26/05 Flashcards
Widened QRS or arrhythmia in tricyclic overdose
give IV bicarbonate
management of tricyclic overdose
Consider gastric lavage only if within one hour of a potentially fatal overdose.
Give 50 grams of charcoal if within one hour of ingestion.
Give sodium bicarbonate (50 ml of 8.4%) if:
- pH <7.1
- QRS >160 ms
- Arrhythmias
- Hypotension
bilateral hilar lymphadenopathy
tuberculosis
Progressively worsening headache with higher cognitive function impaired
urgent imaging
headache red flags
- immunocompromise
- under 20 with history of malingnacy
- brain mets
- vomiting
- worsening headache +fever
- sudden onset
- new onset neuro deficit
- now onset cognitive dysfunction
- change in personality
- impaired consciousness
- head trauma (3/12)
- obvious pressure trigger
- changes with posture
- symptoms of GCA or glaucoma
pharmacological cardioversion for new onset a-fib
> flecainide or amiodarone if there is no evidence of structural or ischaemic heart disease
OR
> amiodarone if there is evidence of structural heart disease.’
side effects of standard heparin
Bleeding
Heparin-induced thrombocytopaenia (HIT)
Osteoporosis
side effects of LMWH
> Bleeding
> Lower risk of HIT and osteoporosis with LMWH
monitoring of LMWH
Anti-Factor Xa (although routine monitoring is not required)
monitoring of standard heparin
Activated partial thromboplastin time (APTT)
heparin overdose
protamine sulphate
massive PE + hypotension
thrombolyse - alteplase
persistent pyrexia of unknown origin, lymphadenopathy and high WCC
lymphoma
causes of PUO
neoplasia
- lymphoma
- hypernephroma
- preleukaemia
- atrial myxoma
Infections
- abscess
- TB
connective tissue disorders
how do SGLT2 inhibitors work?
in renal proximal tubule- inhibit sodium-glucose co=transporter to reduce glucose reabsorption and increase urinary glucose excretion
examples of SGLT2 inhibitors
canagliflozin
dapaglflozin
empagliflozin
flashers + floaters
posterior vitreous detachment
features of lambert eaton
> repeated muscle contractions lead to increased muscle strength (in contrast to myasthenia gravis)
> limb-girdle weakness (affects lower limbs first)
> hyporeflexia
> autonomic symptoms: dry mouth, impotence, difficulty micturating
how to differentiate between pseudogout and gout on x-ray
chondrocalcinosis
acute hypophosphataemia
mild (∼0.64–0.80 mmol/L), moderate (∼0.32–0.64 mmol/L)
severe (<0.32 mmol/L).
acute hypophosphataemia management
mild/mod= effervescent tabs
severe/symptomatic= phosphate polyfusor IV
patients on warfarin undergoing emergency surgery
> If surgery can wait for 6-8 hours - give 5 mg vitamin K IV
> If surgery can’t wait - 25-50 units/kg four-factor prothrombin complex
digoxin toxicity signs
> generally unwell, lethargy, nausea & vomiting, anorexia, confusion, yellow-green vision
arrhythmias (e.g. AV block, bradycardia)
gynaecomastia
management of digoxin toxicity
- Digibind
- correct arrhythmias
- monitor potassium
chancroid cause
Haemophilus ducreyi
people aged 60 and over with hypercalcaemia or leukopenia and a presentation that is consistent with possible myeloma.
> very urgent protein electrophoresis and a Bence Jones protein urine test (within 48 hours) to assess for myeloma
features of myeloma
> bone disease: bone pain, osteoporosis + pathological fractures (typically vertebral), osteolytic lesions
> lethargy
> infection
> hypercalcaemia
> renal failure
other features: amyloidosis e.g. Macroglossia, carpal tunnel syndrome; neuropathy; hyperviscosity
investigations in myeloma
> monoclonal proteins (usually IgG or IgA) in the serum and urine (Bence Jones proteins)
> increased plasma cells in the bone marrow
> whole-body MRI
> X-rays: ‘rain-drop skull’ (likened to the pattern rain forms after hitting a surface and splashing, where it leaves a random pattern of dark spots).
Note that a very similar, but subtly different finding is found in primary hyperparathyroidism - ‘pepperpot skull’
diagnostic criteria for myeloma
one major and one minor
OR
three minor
Major criteria;
> Plasmacytoma (as demonstrated on evaluation of biopsy specimen)
> 30% plasma cells in a bone marrow sample
> Elevated levels of M protein in the blood or urine
Minor criteria;
> 10% to 30% plasma cells in a bone marrow sample.
> Minor elevations in the level of M protein in the blood or urine.
> Osteolytic lesions (as demonstrated on imaging studies).
> Low levels of antibodies (not produced by the cancer cells) in the blood.
why is there hypercalcaemia in myeloma?
1ry- increased osteoclastic bone resorption
other- impaired renal function, increased renal tubular calcium reabsorption and elevated PTH-rP levels
management of hypercalcaemia
> rehydration with normal saline, typically 3-4 litres/day.
Following rehydration bisphosphonates may be used.
They typically take 2-3 days to work with maximal effect being seen at 7 days
calcitonin - quicker effect than bisphosphonates
steroids in sarcoidosis
presentation of hep A
flu-like symptoms, RUQ pain, tender hepatomegaly and cholestatic LFTs
incubation of hep A
2-4 weeks
spread of hep A
Faecal-oral
who should get hep A vaccine
- going to endemic areas
- chronic liver disease
- haemophilia
- MSM
- IVDU
- occupational risk
what is NHL
lymphoma without reed stenberg cells
what cells are affected in NHL
B or T cells
NHL is ____ common than HL
NHL is much more common than HL
burkitts lymphoma
starry sky appearance
most common type of NHL
diffuse large b cell lymphoma
who is affected by burkitts lymphoma?
young or immunosuppressed
management of PR bleeds
if haemodynamically stable- supportive
common peroneal nerve lesion
> foot drop
weakness of foot dorsiflexion
weakness of foot eversion
weakness of extensor hallucis longus
sensory loss over the dorsum of the foot and the lower lateral part of the leg
wasting of the anterior tibial and peroneal muscles
management of haemothorax
> Patients should all have a wide bore 36F chest drain.
> Indications for thoracotomy include;
- loss of more than 1.5L blood initially or
- ongoing losses of >200ml per hour for >2 hours.
untreated hyponatraemia
cerebral oedema
management of acute hyponatraemia with severe symptoms
hypertonic saline (3% NaCl)
diagnostic features of kawasaki
fever >5d with 4 of the following criteria:
A) Conjunctival injection
B) Mucous membrane changes (dry cracked lips, strawberry tongue)
C) Cervical lymphadenopathy D) Polymorphous rash
E) Red and oedematous palms/soles, peeling of fingers and toes.
what is the ciliary ganglion
parasympathetic ganglion of the eye
anisocoria worse in bright light
inability of pupil to constrict
parasympathetic = constriction therefore problem with parasympathetic merves
fragile x testes
big testes
most common form of prostate cancer
adenocarcinoma
1st line for maintenance remission in chrons
azathioprine or mercatopurine
management of red man syndrome
> cessation of the infusion, and when symptoms have resolved, recommencement at a slower rate.
> In patients who are more symptomatic antihistamines can be administered, and may require intravenous fluids if the syndrome is associated with hypotension.
immunisations at birth
BCG if risk factors
-Tuberculosis in the family in the past 6 months
2 months vaccines
> 6-1 vaccine (diptheria, tetanus, whooping cough, polio, Hib and hep B)
oral rotavirus
men B
3 months vaccine
> 6-1 vaccine
oral rotavirus
PCV
4 months vaccine
> 6-1 vaccine
> Men B
12-13 months vaccine
> Hib/MenC
MMR
PCV
Men B
2-8 years vaccine
flu vaccine (annual)
3-4 vaccine
4 in 1 pre-school booster (diptheria, tetanus, whooping cough, polio)
MMR
12-13 years vaccine
HPV
13-18 years vaccine
3 in 1 teenage booster (tetanus, diptheria and polio)
Men ACWY
scintigraphy reveals patchy uptake
toxic multinodular goitre
investigation of SUFE
hip x-ray
investigation of breech neonates
ultrasound
painful limp (perthes) investigation
mri
normal pCO2 in acute severe asthma
life-threatening
negative result on spirometry for asthma
refer for fractional exhaled nitric oxide testing
discharge and vaginal pH <4.5
candidiasis
AKI criteria
> increased creatinine (>26 umol/L in 48hrs)
increased creatinine >50% in 7 days
decreased urine output of <0.5ml/kg/hr for more than 6 hours
oesophageal cancer in GORDo
oesophageal adenocarcinoma
Bell’s palsy is a _____ motor neuron condition. Unlike ___ conditions of the face, in ____ conditions the entire side of the patients face is affected
Bell’s palsy is a lower motor neuron condition. Unlike UMN conditions of the face, in LMN conditions the entire side of the patients face is affected
maintenance fluid calculation in children
100ml/kg for the first 10kg, 50ml/kg for the next 10kg and 20ml/kg for every subsequent kg.
side effects of SERM
Tamoxifen
> menstrual disturbance: vaginal bleeding, amenorrhoea
hot flushes - 3% of patients stop taking tamoxifen due to climacteric side-effects
venous thromboembolism
endometrial cancer
side effects of aromatase inhibitors
Anastrozole and letrozole
> osteoporosis NICE recommends a DEXA scan when initiating a patient on aromatase inhibitors for breast cancer > hot flushes >arthralgia, myalgia >insomnia
A 2-week-old infant with a small chin, posterior displacement of the tongue and cleft palate
pierre-robin syndrome
Supravalvular aortic stenosis is found in a 3-year-old boy with learning difficulties
william’s syndrome
A 9-week-old is noted to have a small chin and rocker-bottom feet
edward’s syndrome
rocker-bottom feet without small chin
patau’s
investigation for PSC
ERCP/MRCP
marfans mutation
fibrillin-1
Acute viral labrynthitis
sudden onset horizontal nystagmus, hearing disturbances, nausea, vomiting and vertigo
In acute testicular pain, a unilateral swollen and retracted testicle, with loss of the cremasteric reflex, is characteristic of…
testicular torsion
Gestational diabetes: if the fasting plasma glucose is < 7 mmol/l a …..
trial of diet and exercise should be offered for 1-2 weeks
most common type of breast cancer
invasive ductal carcinoma
ank spon x-ray findings
subchondral erosions, sclerosis
and squaring of lumbar vertebrae
Globus, hoarseness and no red flags
laryngopharyngeal reflux
bilateral grittiness
blepharitis
Complete heart block following a MI?
right coronary artery lesion
In suspected SBP- diagnosis ….
is by paracentesis. Confirmed by neutrophil count >250 cells/ul
carpal tunnel vs C6 entrapment
More proximal symptoms would be expected with a C6 entrapment neuropathy e.g. weakness of the biceps muscle or reduced biceps reflex.
Pepperpot skull
hyperparathyroidism
type I hypersensitivity
- Antigen reacts with IgE bound to mast cells •
> Anaphylaxis
Atopy (e.g. asthma, eczema and hayfever)
type II hypersensitivity
IgG or IgM binds to antigen on cell surface
- Autoimmune haemolytic anaemia
- ITP
- Goodpasture’s syndrome
- Pernicious anaemia
- Acute haemolytic transfusion reactions
- Rheumatic fever
- Pemphigus vulgaris / bullous pemphigoid
Type III hypersensitivity
Free antigen and antibody (IgG, IgA) combine
> Serum sickness
Systemic lupus erythematosus
Post-streptococcal glomerulonephritis
Extrinsic allergic alveolitis (especially acute phase)
Type IV hypersensitivity
T-cell mediated
> Tuberculosis / tuberculin skin reaction
Graft versus host disease
Allergic contact dermatitis
Scabies
Extrinsic allergic alveolitis (especially chronic phase)
Multiple sclerosis
Guillain-Barre syndrome
Type V hypersensitivity
Antibodies that recognise and bind to the cell surface receptors.
This either stimulating them or blocking ligand binding
> Graves’ disease
Myasthenia gravis
encephalopathy, jaundice and coagulopathy
liver failure
causes of acute liver failure
> paracetamol overdose
alcohol
viral hepatitis (usually A or B)
acute fatty liver of pregnancy
features of acute liver failure
>jaundice
>coagulopathy: raised prothrombin time
>hypoalbuminaemia
>hepatic encephalopathy
>renal failure is common ('hepatorenal syndrome')The PTH level in primary hyperparathyroidism may be…
normal
