21 - Vertical Themes (Uni Days) Flashcards
What is a standard LFT panel?
Look at clinical picture, often LFTs are isolated on their own and this is common and normal
What are the different ducts in the HPB system?
What LFTs are raised in hepatocellular injury and cholestasis?
Hepatocellular Injury: infection, malignancy, autoimmune, alcohol, drugs, NAFLD
Cholestasis: pregancy, drugs, biliary atresia, primary biliary cholangitis, gallstones
What are some extender liver screening tests?
What are the different types of jaundice and the causes?
How does haemostasis occur?
Primary clot: see image
Secondary clot:
- Initiation
- Amplification
- Propagation
- Termination
How does post hepatic obstructive jaundice present?
Pale stools and dark urine
What is included in a basic clotting screen?
PT/INR: extrinsic clotting. FVII, V, X, prothrombin and fibrinogen
APTT: FVIII, IX, XI, XII, V, X, prothrombin and fibrinogen
Bleeding Time: platelets
Thrombin time: how long for fibrinogen to fibrin
ALWAYS TAKE FBC TO LOOK AT PLATELETS WITH CLOTTING SCREEN
What are some causes of abnormalities on clotting screens?
- Inherited deficiency of a clotting factor
- Inherited deficiency of or defective von Willibrand factor
- Consumption – clotting factors used up by DIC
- Dilution – massive blood loss when replacement is with IV fluids and red cells only
- Vitamin K deficiency or antagonism (affects factors II, VII, IX and X)
- Liver disease
- Anticoagulants
All clotting factors apart from two are made by the liver, which are these?
vWF
Factor 8
How will clotting screens (PT, APTT, fibrinogen, platelets) be affected in the following:
- Haemophillia A or B
- DIC
- End stage liver disease due to cirrhosis
Platelets adhere to vWF
How will clotting screens (PT, APTT, fibrinogen, platelets) be affected in the following:
- Over anticoagulation with warfarin
- Patient on therapeutic dose LMWH for DVT
What are the different types of followers in the Kelley leadership study?
What empirical antibiotic should you sue for meningitis?
- IV Ceftriaxone
- If over 60 use Ceftriaxone and Amoxicillin for listeria cover
- If allergy use Meropenem
Once cultures have come back can switch to narrower spectrum antibiotic
Why is vancomycin not used for meningitis?
Poor penetration through the BBB
What are some risk factors for a C.Diff infection?
- Recent broad spectrum abx use
- Prolonged hospital stay
- >65
- PPI therapy
- Immunosuppressed
- Chemotherapy
What antibiotics are used for cholecystitis?
- Co-amoxiclav or Metronidazole+Ciprofloxacin or Meropenem
- Also give IV fluids, analgesia and arrange for cholecystectomy
Is meropenem safe in penicillin allergy?
Has a beta lactam ring so can still cause some reactions
Check if patient has true penicillin allergy
How long doe patients need to take antibiotics for acute cholecystitis?
- If no surgery due to being too frail then 4-6 weeks
- If cholecystectomy and no perforation none needed after surgery
- If perforation then 5 days post operatively
IV fluids, analgesia, antibiotics
What is evidence based medicine?
Incorporates value based medicine
What are the benefits of value based medicine?
Never assume you and the patient hold the same values!!!
What is the difference between a sign and symptom?
Sign: objective that can be viewed by another person
Subjective: subjective that is only felt by the patient
If asked in an exam what symptoms by the examiner use jargon, if asked to ask the patients about their symptoms DO NOT use jargon
What investigations would you order for this patient?
- Bloods: FBC, U+Es, LFTs, CXR, eGFR, HbA1c, Lipid profile, NT-proBNP
- ECG
- Echocardiogram
- CXR
What signs will you see on a CXR for a heart failure patient?
- Cardiomegaly
- Pulmonary oedema (bilateral infiltrates/Batwing)
- Fluid in right fissure
- Pleural effusion
When do you refer to secondary care for suspected heart failure?
- Refer for echo within 2/52 if NT-proBNP >236
- Refer straight for echo if previous MI
What are the two options for gall bladder removal?
- Laparoscopic cholecystectomy
- Open cholecystectomy
What can you include in your management plan apart from the treatment?
- Self help advice e.g monitor BM, stop smoking
- Escalate to senior
- Analgesia and antiemetic
What do you need to remember to report on a CXR before A-D?
RIP!!!!
(check for equal distance between clavicles and spinous process
What is a silhouette sign?
If you lose a key line then there is consolidation in a specific place
What is this x-ray showing?
Veil Sign
Left upper lobe collapse
What is the exposure with a AXR and what review system should you use?
From diaphragm to pubic symphis
B - Bowel gas pattern
B - Bones (metastatic deposits)
C - Calcification e.g renal calculi, phleboliths
ALWAYS CHECK LUNG BASES
What should you be looking at on a pelvic x-ray?
Joints are SI and pubic symphis
What should you always look for when given an x-ray of a joint?
A second view of the joint!
What two layers is an epidural and spinal anaesthesia between?
Epidural: dura mater and arachnoid mater
Spinal Anaesthesia (subarachnoid space): arachnoid mater and pia mater
What conservative action can be taken for hip OA?
- Mobility aids
- Physio
- Activity modification
- Weight loss
What is dalteparin and how does it work?
LMWH
Works by binding to factor Xa and inactivating it and binding to ATIII to potentiate it’s action
How does dabigatran and rivaroxaban work?
Dabigatran: binds to factor II (thrombin) and inactivates it
Rivaroxaban: binds to factor Xa and inactivates it
What malignancy and non-malignant diseases are related to obesity?
OBESITY IS A RISK FACTOR FOR
- Cancer: bowel, ovarian, breast, endometrial
- Non-malignant: stroke, OA, T2DM, MI
What joints in the hand does RA usually affect?
- PIPJ
- MCP of thumb
What are some examples of macrogols?
- Movicol
- Laxido
What do you need to tell someone that is starting on the pill?
- Does not protect against STI
- What to do with missed pill
- Vomiting and diarrhoea
- Interaction with antibiotics
How do you treat BPPV?
- Dix Hallpike to diagnose and should resolve spontaneously
- If does not resolve then use Epley
What is the mechanism of aspirin?
Irreversible COX inhibitor and TXA2 inhibitor
What are some contraindications for the pill?
- Breast cancer
- >35
- Raised BMI
- Previous VTE
- Migraine with aura
What procedure should you use for hydronephrosis?
Percutaneous nephrostomy
What are the side effects of ethambutol and pyrazinamide?
Ethambutol - Retrobulbar neuritis
Pyrazinamide - Gout so joint aches, hepatitis
What are some extra-articular features of RA?
- Pulmonary nodiles
- Pericarditis
- ILD
- Lymphadenopathy
- Carpal tunnel syndrome
- Splenomegaly
- Dry eyes/mouth
- Scleritis
Where do you find the deep inguinal ring?
Halway between ASIS and pubic tubercle
What is the role of a healthcare visitor?
Offer support to families through early years from pregnancy and birth to school years
What are some features of poorly controlled asthma?
- Difficulty sleeping due to asthma
- Asthma interfering with normal daily activities
- Using salbutamol >once a week
- Declining PEFR
How can you teach a patient to improve their asthma control?
- Review inhaler technique
- Avoid triggers
- Smoking cessation
- Self management plan
- Step up drugs
How do you perform the Dix-Hallpike test?
- Ask patient to sit upright on couch and focus on a point keeping eyes open
- Lower head and torso down to level of bed
- Move head directly below level of bed and turn head left or right
- Watch for nystagmus for 30-60 secs
- Repeat on opposite side
How is BPPV managed?
- Avoid sudden change in position
- Adequate hydration
- Advise not to drive whilst symptomatic
What are some risks of not treating hypernatraemia?
- Seizures
- Thrombotic episode
- Stroke
- Loss of consciousness
What is a waterlow score?
Estimated risk of development of a pressure sore in a patient
- What is the treatment for LRTI in a bronchiectasis patient?
- What is the likeliest organisms in a diabetic leg ulcer?
- What should you check before startin azathioprine?
- Amoxicillin for 14 days
- E.Coli
- TPMT levels
What is the murmur like in AS, what are the symptoms, how does it appear on ECG and how is it managed?
- Ejection systolic loudest in aortic area radiating to carotids
- SOB, Syncope, Palpitations, Chest pain
- LVH, AF, Heart block
- TAVI if elderly, cardiac surgery if young and fit
What are some questions you should ask if a patient has ascites?
- Alcohol history
- Risks for viral hepatitis e.g IVDU, blood transfusions
- Obesity
Why is the INR prolonged in alcoholic liver disease?
- Liver not able to produce clotting factors
- Vit K deficiency from alcohol
How is falciparum malaria treated?
IV artesunate
How should you treat nephrotic syndrome initially and when in CKD are people consider for RRT?
- Diuretics
- Anticoagulation
- Stage 4
What rhythm can adenosine TERMINATE?
Narrow complex tachycardia
(NOT atrial and sinus tachycardia)
What is a side effect of alendronic acid?
- GORD!!!!
Why do you need an ABG in sepsis?
Lactate!!!!!
What antibiotics should you give for bacterial meningitis?
- Benzylpenicillin stat dose at GP
- Ceftriaxone definitive
- Dexamethasone with bacterial meningitis
How do the LP parameters vary for bacterial, viral and fungal meningitis?
Appearance: cloudy and turbid in bacterial, clear in viral, clear or cloudy in fungal
Opening pressure: rasied in bacterial, normal or raised in viral, raised in fungal
WBC: raised in all, mostly in viral
Glucose: low in bacterial and fungal, normal in viral
Protein: elevated in all
What are some investigations and management you should do for a patient in post op with a suspected PE?
Ix:
- Bedside: ECG
- Bloods: Trop, D-dimer,
- Imaging: CTPA
Mx
- Start rivaroxaban
- Oxygen
- IV fluids
- Analgesia
- Stop any precipitating medications
What are some differentials for tiredness?
- Hypothyroidism
- Anaemia
- Coealics
- Cushings
- Diabetes
- OSA
Where should you insert a chest drain?
At the top of the rib
What are some signs and symptoms of ILD?
Symptoms: dry cough, SOB on exercise that is progressive
Signs: clubbing, fine inspiratory crackles, reduced chst expansion
What are some signs of lung cancer?
- Horners
- SVC obstruction
- Paraneoplastic syndromes
- Signs of metastases: jaundice, ascites, bone pain, hepatomegaly
- Night sweats
- Hoarse voice
- NOTHING
When can’t you use a V/Q scan for a PE?
Obstructive lung disease e.g COPD, Asthma
What are some causes of pulmonary artery hypertension?
- PE
- Hypoxia
- LVH
- Idiopathic
How do you work out the causes of hyponatraemia?
Pseudo: check serum osmolality, if normal then due to hyperlipidaemia, mannitol, TURP or high BM
Hypervolemic: CCF, Nephrotic syndrome, Cirrhosis
Euvolemic: SIADH (ADH stops RAAS and aldosterone production so Na goes into urine)
Hypovolemic: Diuretics, vomiting, addisons, sweat, diarrhoea
What is the pathophysiology of dementia?
- Amyloid plaques extracellularly
- Neurofibillary tangles intracellularly
What are some reversible causes of a dementia like presentation?
- Polypharmacy with anticholinergics
- Thiamine deficiency
- Normal pressure hydrocephalus
- Syphilis
Why does CKD-BMD develop?
- Active Vit D not being hydroxylated by kidneys
- Low Ca
- Raised PTH
- Takes Ca from bone
Mx: phosphate binders, calcimimmetics, vit D replacement, parathyroidectomy if tertiary hyperPTH
What is seen on fundoscopy of diabetic retinopathy? (IMPORTANT)
1. Background retinopathy: microaneurysms and hard exudates
2. Pre-proliferative retinopathy: cotton wool spots, haemorraghe
3. Proliferative: new vessels form, urgent referral
4. Maculopathy: decreased visual acuity
What is seen on fundoscopy with hypertensive retinopathy?
Grade:
I = silver wiring
II = AV nipping
III = flame haemorraghes and cotton wool spots
IV = papilloedema
What is the dose of adrenaline for anaphylaxis?
IM 1:1000 500 mcg
What are some symptoms of hyperthyroidism?
Can you DC cardiovert someone who has hyperthyroidism with AF?
No they need to be euthyroid for 8-10 weeks
Why do people with CKD get hyperK+?
- Impaired GFR plus a frequently high dietary potassium intake
- Extracellular shift of potassium caused by the metabolic
acidosis
- Treatment with K+sparing drugs e.g. ACEi/ARBs
What are some non-pharmacological interventions for delirium?
After completeing an A-E assessment, how should you manage this patient?
CONTROLLED OXYGEN
What are some pathophysiological features of asthma?
