30/04/24 Flashcards
What is Glasgow Coma scale?
Glasgow Coma Scale (GCS) is a universal score used in the assessment of conscious levels of a patient. It is a score out of 15. Lowest score can only be 3/15.
A GCS of 8 or below suggests that the patient is unable to maintain their own airway adequately, and warrants urgent assessment by the anaesthetic team.
It assesses:
> motor response
6- obeys commands
5 - localises to pain
4 - withdraws to pain
3 - flexor response to pain
2 - extensor response to pain
1 - no response to pain
> verbal response
5 - oriented
4 - confused conversation
3 - inappropriate speech
2 - incomprehensible
1 - none
> eye opening response
4 - spontaneous
3 - open in response to speech
2 - opens to pain
1 - no eye opening
What is tuberculosis? How is it transmitted?
Tuberculosis (TB) is an infectious disease caused by Mycobacterium tuberculosis.
It is a chronic granulomatous disease.
It is primarily transmitted through the inhalation of infected droplets produced when an infected patient coughs.
How does tuberculosis present?
General symptoms:
- night sweats
- fever
- wt loss
- chronic cough
Different organ systems can present with different symptoms.
Lungs:
- Chronic cough productive of purulent sputum +/– haemoptysis
- May have a large cavity present
- Can get bronchiectasis, pneumonia, fibrosis and pleural effusions
CNS:
- TB meningitis or Tuberculoma due to haematogenous spread of disease into the subarachnoid space (Rich foci) where they rupture to cause CNS disease
- Headache
- Meningism
- Focal neurological signs
- Decreased consciousness
- Very poor outcomes and risks of disability
Genitourinary:
- Causes ‘sterile’ pyuria, kidney pathology, abscesses, salpingitis and infertility, epididymo-orchitis
MSK:
- Arthritis
- Osteomyelitis
- Psoas abscess
- Pott’s disease of the spine
How is tuberculosis diagnosed?
CXR
If CXR shows signs of TB, arrange three sputum samples (one sample should be an early morning sample) for microscopy for acid-fast bacilli, mycobacteria culture, and specialist molecular tests/drug sensitivity testing.
If other systems are affected:
- joint or spinal plain X-rays
- abdominal, renal tract, or lymph node ultrasound scans
- early morning urine samples for dipstick testing, microscopy (looking for sterile pyuria) and Mycobacteria culture
- echocardiogram (pericardial disease)
- CT scans of the chest, central nervous system, or bones/joints
- lumbar puncture (CNS TB).
What specialist screenings are there to identify latent tuberculosis? Describe each screening.
Mantoux test
- a type of tuberculin skin test where tuberculin is injected intradermally. The skin is inspected for signs of a local skin reaction (induration) after 2–3 days, and the test is considered positive at an induration of 5 mm or more, regardless of previous BCG vaccination history.
Interferon‑gamma release assay (IGRA)
- blood test based on detecting the response of white blood cells to TB antigens
What are the risk factors for tuberculosis?
- close contact with active tuberculosis
- immigrants from areas with high tuberculosis prevalence
- people with relatives or close contacts from countries with a high rate of TB
- immunocompromised (e.g., HIV or immunosuppressant medications)
- malnutrition
- homelessness
- drug users
- smokers
- alcoholics
How is tuberculosis managed?
If they have clinical features of TB, don’t wait for the culture results, immediately start tx.
Isoniazid, rifampicin, ethambutol and pyrazinamide for 2 months, then isoniazid and rifampicin for a further 4 months.
Extended duration in TB meningitis, pericarditis and spinal TB (may also require surgery).
Suspected active TB infection, admission or urgent referral should be arranged for specialist assessment and management, depending on clinical judgement.
Stop smoking.
Reduce alcohol intake.
What is dementia?
A syndrome that involves chronic impairment of multiple higher cortical functions such as memory, thinking, orientation, comprehension, and language.
It can be a primary neurodegenerative disorder or secondary to another condition
What are the types of dementia?
Vascular
Fronto-temporal
Lewy body
Alzheimer’s
How does dementia present?
- gradual, progressive, impairment of higher cortical function.
- memory loss
- difficulty with familiar tasks
- language problems
- disorientation (getting lost, losing track of time and date)
- impaired decision making
- increased irritability, anxiety, depression
- decline in social engagement and interest in hobbies
- personality changes
- difficulty in abstract thinking (e.g. managing finances)
What is Alzheimer’s disease?
Common cause for dementia.
A chronic and progressive form of dementia, which is caused by characteristic neuropathological features such as amyloid plaques and tau proteins.
How is Alzheimer’s disease caused?
A build up of amyloid protein deposits around brain cells and tau protein tangles within brain cells.
How does Alzheimer’s disease present?
4 A’s
- Amnesia (recent memories lost first)
- Aphasia (word-finding problems, speech muddled and disjointed)
- Agnosia (recognition problems)
- Apraxia (inability to carry out skilled tasks despite normal motor function)
How is Alzheimer’s disease managed?
Pharmacological treatments may have modest benefits, and include:
- cholinesterase inhibitors rivastigamine, galantamine, and donpezil in mild-moderate dementia
- NMDA inhibitor memantine in severe dementia
The MMSE score: severe: <10; moderate: 10-20; mild: 21-26/30.
What is vascular dementia?
Second most common cause of dementia.
Caused by impaired blood flow to areas of the brain due to vascular damage (i.e. lots of micro-infarcts in someone with cardiovascular disease risk factors).
It can have a ‘step-wise’ progression due to progressive infarcts over time.
