24/10/21 Flashcards
PERC Rule (8 points)
Age <50yo HR <100 SP > 95% No Haemoptysis No Oestrogen Use No Surgery or Trauma requiring hospitalisations within 4 weeks No Hx of VTE - > DVT or PE No Unilateral Leg Swelling
Wells Criteria for PE (8 points)
Clinical Signs of DVT
PE most likely diagnosis
HR >100bpm
Immobilisation for at least 3 days of surgery within the past 4 weeks
Hx of DVT or PE
Haemoptysis
Hx of Malignancy within 6 months or Palliative
Investigations of women with abnormal PV bleeding.
- Post-Coital, Pre-Menopausal
- Inter-Menstrual Bleeding
- Post-Menopausal
- Abnormal vaginal bleeding (signs or symptoms suggestive of cervical cancer) → HPV + LBC, symptomatic (see algorithm below)
- Post-coital bleeding
- If single episode of post-coital bleeding, clnically normal cervix + HPV not detected and LBC negative DO NOT need colposcopy
- Need to consider STI in all women with post-coital bleeding
- Inter-menstrual bleeding → refer for gynaecological assessment regardless of result
- Post-menopausal → refer for gynaecological assessment regardless of result
- Post-coital bleeding
Clinical Presentation of Subcutaneous Emphysema
- Crepitus → if extensive, may cause soft tissue swelling and discomfort
- The gas itself does not need treatment BUT its importance lies in the fact that its presence indicates possibly serious injuries that require urgent management
- Gas can track along fascial planes and enter the head, neck, limbs, chest, abdomen and scrotum
Treatment of Subcutaneous Emphysema
- Directed at the underlying cause
- Subcutaneous gas is absorbed by the body over time
- If compromising overlying soft tissue or causing compartment syndrome → surgical management may be required to release the gas
Discuss management of mild-moderate pain in a palliative care setting. Role of Paracetamol and NSAIDs.
- Paracetamol
- First line because of favourable safety profile
- MSK or Soft tissue pain
- Can also reduce the overall daily doses of NSAIDs or opioids required which in turn reduces the risk of adverse effects
- NSAIDs
- Mild to Moderate pain
- Inflammation, Tissue Injury, Metastatic Bone Pain, Malignancy-related Fever and Post-Operative Pain
- Avoid in patients with moderate to severe kidney impairment
DSM-5 Criteria for Depression (9 points + timeframe + specific criteria)
At least 5 of the following symptoms have been present for a 2 week period and represent a change from previous functioning. At least 1 has to be either 1 or 2.
- Depressed Mood - most of the day, nearly every day
- Anhedonia - most of the day, nearly every day
- Weight Changes
- Sleep Disturbances
- Psychomotor Agitation/Retardation
- Fatigue/Loss of Energy
- Feelings of worthlessness or excessive or inappropriate guilt
- Diminished ability to think/concentrate or indecisiveness
- Recurrent tthoughts of death/suicidal ideation
Investigations for Latent TB Infection. Explain the mechanism of both. In which patient demographics should we be considering either test.
Tuberculin Skin Test (TST aka Mantoux Test) - measures inflammation (dermal induration) in response to injection of purified protein derivative → measure response 72 hours later. preferred in children <5yo to prevent venepuncture
- Interferon Gamma Release Assay - a blood test that measures patients WBC Cytokine Release secondary to tuberculosis antigens
- preferred in patients who have a history of BCG vaccination as this test is non-reactive to BCG vaccine
What needs to occur prior to diagnosing LTBI? Do the investigations, distinguish between LTBI and active TB?
Neither test distinguishes between active TB or LTBI → clinical features and other investigations are required to exclude active TB before diagnosing LTBI
Clinical Features of Active TB (4) + 1 base investigation used to rule out active TB.
- Clinical Features: fever, cough, weight loss, lymphadenopathy + Chest Xray
Treatment of Latent TB (1 point) Side Effects of Medication (4 points + 1 bonus)
- Isoniazid 300mg (10mg/kg) for 6-9 months
- Generally well tolerated. Side Effects: GIT upset, Acne, Hepatotoxicity, Peripheral Neuropathy (co-prescription with Vit B6 usually given)
In women NOT seeking to conceive, what is the first line therapy for heavy menstrual bleeding?
- 52mg Levornogesterol-Releasing IUD - Mirena → most effective therapy for heavy menstrual bleeding
- bleeding can be expected in the first few months following insertion but if bleeding has not settled by 6/12 - for specialist review
- note that the 19.5mg LNG IUD (Kylena) is not indicated for HMB
What is the management strategy in women seeking to conceive and as a second line for women NOT seeking to conceive?
- Tranexamic Acid - antifibrinolytic drug that inhibits clot breakdown by preventing activation of plasminogen and plasmin. It reduces blood loss more than NSAIDs and progestogens.
- Tranexamic Acid 1-1.5mg PO, Q6-8H for first 3-5 days of each cycle
- NSAIDs → decreased prostoglandin concentration in the endometrium, thereby reducing menstrual blood loss. Less effective than tranexamic acid in reducing blood loss but can reduce concurrent dysmenorrhoea.
- Ibuprofen 200-400mg PO TDS, start before or at onset of menstrual cycle and continue for up to 5 days
- Mefenamic Acid 500mg PO, TDS, start before or at onset of menstrual cycle and continue for up to 5 days
- Naproxen 500mg PO initially then 250mg every Q6-8H, start before or at onset of menstrual cycle and continue for up to 5 days
When should you refer to a specialist in the context of HMB?
If no improvement in 6/12 → for specialist referral
Indications for referral <6/12
- Concurrent severe dysmenorrhoea at baseline or concurrent dysmenorrhoea that does not improve after 3/12 of pharmacotherapy
- Concerns regarding fertility → e.g endometriosis or adenomyosis
- FIbroids >3cm
- Endometrial Polyps
- Increased Risk of Endometrial Cancer
Risk Factors for Endometrial Cancer? (7 points)
- Oligomenorrhoea
- PCOS
- PHx or FHx of endometrial or colon cancer
- Use of unopposed oestrogen or tamoxifen
- Obesity → especially if associated with diabetes or HTN
- Age >45yo
- Radiological Findings → endometrial thickness >12mm in premenopausal or ≥5mm in perimenopausal women
Order of options for treatment of HMB in women NOT seeking to conceive.
- Mirena
- NSAIDs or Transexamic Acid
- COCP
- Oral progestegen or Depot methoxyprogesterone
Definition of Boxer’s Fracture. Clinical Presentation of Boxer’s Fracture.
4th or 5th Metacarpal Neck Fracture with volar displacement of the metacarpal head
Occurs in 20% of patients who have punched a hard object → pt may be reluctant to disclose the mechanism of injury
Presents with pain or tenderness centred around a specific location on the hand corresponding to one of the metacarpal bones, around the knuckle
Initial Management of Boxer’s Fracture
- RICE + Simple Analgesia
- X-ray → AP and Oblique View
- Open Fractures - ABx
- Severe Fractures → if >45degree angulation or >20degree rotation → refer to hand surgeon for external fixation
What kind of splint is required for a Boxer’s Fracture?
Ulnar Gutter Splint can be used for immobilisation → 70-90degree flexion at the MCP joint, slight flexion at the PIP and DIP and mild wrist extension.
First Aid for Snake Bite (3 points of management)
- Manage Airway, Breathing and Circulation
- Arrange urgent transfer to hospital → hospital must have adequate antivenom and critical care facilities in which the antivenom can be safely administered and anaphylaxis can be treated
- In cases presenting <4hours → apply pressure bandage with complete immobilisation of the affected limb
- Apply a broad bandage (15cm) over the bite site then wrap distally and proximally to cover the whole affected limb
- Pressure bandage should only be removed if antivenom therapy as started OR clinical and laboratory assessment confirms no evidence of systemic envenoming
