3.1 questions Flashcards
Normal Range for Fasting Glucose
3-5.4 mmol/L
Normal Range for random glucose
3-7.7 mmol/L
Normal HbA1c level
4.7-6.1%
Normal pulse in Adults
60-100 BPM
Normal Resp Rate in adults
14
Normal BP in adults
<130/85
Fever
Oral > 37.2
Rectal >37.7
DM diagonostic criteria
Random 1 reading if symptomatic
2 reading if asymptomatic >11.1 mmol/L
Fasting >7.0 mmol/L
or 2 values of oral GGT
Hypokalemia
< 3.5 mmol/L
Serum bilirubin in Jaundice
> 19 umol/L
Hyperkalemia
>5 mmol/L
Excessuve alcohol drinking
Males > 4 /day
Females > 2 /day
Anaemia - Hb
Males < 130 g/L
Females < 115 g/L
Classificaton of BMI
Normal = 20-25
Overweight > 25
Obesity > 30
Important General Questions in history
Fatigue, tiredness or malaise
Fever, sweating, shakes
Weight change esp loss
Pain or discomfort
Any unusual lumps or numps
Any unusual bleeding
Skin problem - rash or itching
Most common cause (bacterial) of traveller’s diarrhoea
Escherichia coli
Campylobacter species
Travel infections transmitted by mosquitoes
Malaria
Yellow fever
Rift valley fever
Japanese B encephalitis
Chikungunya
Dengue fever
Onset of travellers diarrhoea
6-12 hours afters infected food or water
most common cause = water or ice, unclean utensil and so on
Traveller’s Diarrhoea
6-12 hours after ingestion
Last 2-3 days
Symptoms = abdominal cramps, frequent diarrhoea with loose watery stoools and possible vomiting
Very severe with passing of blood or mucus = shigella sp . camplobacter sp and amoebiasis
otherwise think E.Coli, Campulobacter sp, Shingella sp and Slamonella
Treatment = Rehydration
with antimotility Ioperamide (Imodium) or antibiotics (if moderate-severe) like Norfloxaxine or azithromycin
Main 2 cause of presistent diarrhoea
Amoebiasis or giardiasis
Species that cause Malaria
Plamodium Vivax and Plasmodium Ovale
Plasmodium Falciparum = Malignant
Plasmodium Malariae
Plasmodium Kowlesi
Presentation of Malaria
Always think in any returned traveller
Fever + Chills + headache
- High fevers
Malaria Prophylaxsis drugs
Chloroquinine - approved for pregnancy, aggravates psoriasis, causes retinopathy
Doxycycline - Photosensitivity reactions
Mefloquine - cause dizziness, fuzzy head, blurred vision and neuropsychiatric
Atovaquone + Proquanil - avoid in pregnancu, kidney impairement. Causes Gi upsetm headache, dizziness, myalgia
Compulsary two vaccination for visiting ‘high risk’ areas
Yellow Fever
Meningococcus
Yellow Fever
Symptoms, Diagnosis, treamtent
Viral infection spread by Aedes Mosquitoes
- Symptoms - Fever + Bradycardia + Jaundice + bleeding
- Flu like-symptoms with relative bradycardia (THINK YELLOW FEVER IN BRADYCARDIA) =
- Bradycardia = Faget’s sign
- Albuminuria also present
- Bleeding = from the gums and haematemesis
Diagnosis = ELISA testing
Meningococcal infection
Risk
esp risk for trekking through nepal + Haj pilgrimage
Hepatitis A
Risk, prevention
Rural and developing area
Declining level of antibodies to Hep A and adults are at special risk
A blood test to Hep A antibodies
Hepatitis A = 2 injections vaccine (given with Hep B usually)
Avoid contaminated food
Which Hepatitis has a high mortality in pregnant women
Hepatitis E
Japanese B encephalitis
Symptoms, Diagnosis, treamtent
Mosquito-borne flavivirus infection
High mortality
Rice paddies and pig farm = high risk
Febrile illness + Vomiting + Stupor
Rabies
Symptoms, Diagnosis, treamtent
Vaccine recommended, can also be given after bite
Wash immediately with soap
Painful bite + paraesthesia + hydrophobia (pain with drinking)
Main causes of infection in returned traveller
Mostly present within 2 weeks (except HIV)
Common infection = malaria, dengue, giardiasis, hepatitis A and B, gonorrhoea or Chlamydia Trachomatis and Helminthic
Non-infectious = DVT and thromboembolism
Investigation on gastrointestinal system
Mild = microscopy and culture
moderate or prolonged (>3 wks) =
- Stool examination (3 specimens) - microscopy, wet preparation and culture
- Faecal multiplex PCR
- Treat Pathogen
Abnorminal discomfort
- Bloating, intestinal hurry and bornorygmi and often followed by diarrhoea
- usually no pathogen in stool
Important Signs
- Maculopapular - genue, HIV, typhus, syphillis, arbovirus infection, leptospirosis, Q fever
- Petechiae - viral haemorrhagic fever, leptospirosis, dengue
- Rose spot - Typhoid
- Eschar - Typhus (tick and scrub), anthrax
- Chancre - African Trypanosomiasis, syphillis
- Fever - think malaria
Treatment for malaria
- Admit to hospital with infecious disease - rule out G6PD deficiency
- Fluid replacement
- P. vivax, P. ovale, P. malariae - artemether + lumefantrine + primaquine
- P. falciparum - Riamet or quinine + doxycycline / clindamycin
Typhoid fever
Symptoms, Diagnosis, treamtent
Incubation - 10-14 days
- Headache predominates
- Stepladder fever + Abdominal pain (w/ constipation) + relative bradycardia
- Pea soup diarrhoes
- Rose spot rash (later)
Diagonosis - Blood/stool culture, (serology not helpful)
Treatment - Azithromycin or Ciprofloxacin
Cholera
Symptoms, Diagnosis, treamtent
Incudates hours to 5 days
Clinical variable fever + abrupt onset ‘rice water’ diarrhoea
- Causes - electrolyte depletion, intense thirst, oliguira, weakness, shrunken eyes
Diagnosis = Stool microscopy and culture (Vibrio Cholerae)
Treatment
- Strict barrier nursing
- IV fluid and electrolytes
- Doxycycline
Dengue Fever
Symptoms, Diagnosis, treamtent
- sout-east pacific and queensland
- Myalgia and fever <39 dengue > malaria
- Fever + severe aching + rash
Symptoms = abrupt fever, headache, nausea, pain behind eye, severe backache, prostration, sore throat, aching muscles and joing
- subsides in 2 days and then returns
- Maculopapular rubelliform rash on limb or petechial rask
Diagonsis - IgM serology (dengue specific, best on 5 days); PCR; FBE: leukopenia, thrombocytopenia in haemorrhagic form
Treatment - Rest, fluid, analgesics
AVOID antibiotics and corticosteriods
Differentials for fever in returned traveller
Malaria
Dengue (rash)
Chikungunya
Encepalitis (delium, convulsion, coma)
Melioidosis (pneumonia)
Chlorea (rice-water diarrhoea)
Typhoid (stepladder fever + bradycardia)
Clinical Features of uncontrolled diabetes
- Polyuria
- Polydipsia
- Loss of weight (Type 1)
- tiredness and Fatigue
- Propensity for infection - skin and gential (vaginal thrush)
- Vulvovaginitis (inflammation and irritation of vagina)
- Pruritus Vulvae (itchy valva)
- Balanitis (inflammation of head of penis)
- nocturnal enuresis (type 1)
- Blurred vision/visual changes
Secondary causes of diabetes
Endocrine disorder
- Cushing Syndrome
- Acromegly
- Phaeochromocytoma
- polycyctic ovarian syndrome
Pancreatic disorder
- Haemochromatosis
- Chronic pancreatitis
Drug induced
- Thiazide diuretics
- Oestrogen therapy (high dose)
- Corticosteriods
Other transient causes
- Gestational diabetes
- Medical or surgical stress
Symptoms of diabetes complications - may be the presenting complaint
- Staphylococcal skin infections
- Polyneuropathy (tingling or numbness in feet, pain)
- Impotence
- Arterial disease - myocardial ischaemia, peripheral vascular disease
Examination of Diabetes
- General inspection - including skin
- BMI (weight/height)
- Waist circumference
- Visual acuity
- Blood pressure - standing and lying
- Peripheral neuropathy - tendon reflex, sensation (cotton wool, 10g monofilaments)
- Urinalysis - glucose, albumin, ketones, nitrites
Screening for T2D
- People with impaired fasting glucose/impaired glucose tolerance
- Age > 40 years
- Age > 30 with family history (first degree relative with type 2 diabetes), obesity, bmi > 30, hypertension
- Age > 18 in ATSI, pacific islanders
- Previous gestation diabetes or history of large babies
- People with long term steriod use and atypical antipsychotics
- Polycystic ovarian syndrome esp overweight
- CVD and other risk factors
Screen every 3 years
Diagonsis of T2D
- If symptomatic (2 of polydipsia, polyuria, freq skin infection or freq thrush)
- Fasting Blood glucose > 7.0 mmol/L on two occasions
- Random Blood glucose (2hd prandial) > 11.1 mmol/L on two occasions
- HbA1c >6.5%
- If asymptomatic
- at least two seperate values, either fasting or post prandial, or two OGTT
Microvascular complications of T2D
Retinopathy
Nephropathy
Neuropathy
Macrovascular complication of T2D
Ischaemia / coronary heart disease
Cerebrovascular disease
Peripheral Vascular disease
Organs effects KNIVES
Kideney
Nerves
Infection
Vessels
Eyes
Skin
Name 4 Diabeteic metabolic complications
- Hypoglycaemia
- Diabetic ketoacidosis
- Hyperosmolar hyperglycaemia
- Lactic acidosis
Clinical complications of T2D
- Cataracts
- Refractive error of eye
- Sleep apnoea
- Depression
- Musculoskeletal - neuropathic joint damage (Charcot type Arthropathy), tendon rupture
- Foot ulcer
Metabolic syndrome/ Syndrome X/ Insulin Resistance
Upper truncal obesity (waist circumference) > 102 cm M, > 88 cm F
plus any 2 or more of the following
Increased triglycerides > 1.7 nmol/L
Decreased HDL cholesterol <1.0 M, <1.3 F
Fasting glucose > 5.5 mmol
BP > 130/85
Goals for Diabetes
- Diet - normal healthy
- Body mass index 5-10% for overweight or obese
- Physical activity - atleast 30 mins
- Smoking - 0
- Alcohol consumption <2 standard drink
- BGL - 6-8 mmol/L fasting, 8-10 mmol/L postprandial
- HbA1c <7%
- Total cholestrol <4.0
- HDL-C >1.0
- LDL <2.0
- TG <2.0
- BP 130/80
- Urinary albumin < 20
- Vaccination - against influenza and pneumococccal disease and dTPa vaccine
Descrine three Insulin regimens
- Pre-mixed two injection - biphasic system
- Breakfast and evening
- 3 injection per day
- Short acting before breakfast and lunch;
- Intermediate or long-acting before evening
- 4 injections (basal-bolus) system
- Short acting before breakfast, lunch and dinner (bolus)
- Intermediate-acting or long-acting at bedtime (basal)
What are some available types of insulin
- Ultra-short acting (peak 1 hr, duration 3.5-4.5)
- Insulin aspart - NovoRapid
- Short acting (peak 2-5 hr, duration 6-8)
- Neutral - Actrapid
- Intermediate (duration 12-24 hr)
- Isophane - Protaphane
- Long-acting (analouges)
- Insulin glargine - Lantus
- Premixed (short and intermediate or long)
- Novomix
Sick days in Diabetes management during insulin
Never omit insulin dose
More top-up insulin
Maintain glucose
Drugs for Diabetes
- Biguanides
- Metformin
- Side effects - GIT disturbances (diarrhoe, n/v), avoid in hepatic, kidney and cardiac disease, lactic acidosis
- Sulfonyureas
- Gliclazide, Glipizide, Glibenclamide, Glimepride
- Side effects - hypoglucemia (common), weight gain, rash and GIT
- a-glucosidase inhibitor
- Acarbose
- Side effects Flatulence, skin rashes, diarrhoea, liver effects
- Thiazolidnediones (glitazones)
- pioglitazone
- Side effects - caution heart failure, odema, weight gain, heart failure, hepatic effects, fracture risk
- DPP-4 agonist (gliptins)
- Sitagliptin, Vildagliptin
- Side effects - rhinorrhoea, headache hypersensitivity e.g. uticaria, dizziness, fatigue
- SGLT 2 inhibitor
- Canagliflozin, Dapaliflozin
- Side effect - type of diuretic (bewares kidney failure), genitourinary infection, dehydration, dizziness, hypoglycaemia
Control of hypertension in Diabetes
<130/80 = Target
Use ACE-I, ARK and Ca channel blocker
Controls of dyslipidaemia
Target
Total < 4 mmol/L
TG <1.5 mmol/L
HDL > 1 mmol/L
LDL <2 mmol/L
Use - HMG-CoA reductase inhibitor
Resin for hypercholestrolemia
fibrates and resins for dyslipidemia
Hypoglycaemia in diabetes.
Blood glucose level < 3.0 mmol/L
More common in type 1 but can occur in type 2
In type 2 it can happen with Sulphonylureas
Classic warning - sweating, tremor, palpitation, hunger, peri-oral paraesthsia
Rx. Rule of 15
give 15 g of low GI carb (can be 0.5-1 mg of glucagon) - wait 15 mins and then high GI carb
Complications in T2D
Ketoacidosis - anion gap –> metabolic acidosis
Hyperosmonal hyperglycemic state - no anion gap
Prescipitating factors - infection, non-compliant, undiagnosed, change in lifestyle, myocardial infarction, stroke, steriods
Ketoacidosis in T2D
- Preceding polyuria, polydipsia, drowsiness
- Vomiting and abdominal pain
- Hyperventilation (severe acidosis, acidotic breathing) - Kussmal breathing
- Ketonuria
Management
- Urgent hospital admission
- Rapid-acting insuilin IM 10 units
- IV normal saline
(comatose patient requires water, sodium (3L N saline), potassium (KCl) and insulin)
Hyperosmonal hyperglycemia in T2D
- Altered conscious with marked dehydration in absence of ketoacidosis
- Rx - IV fluids, Saline slowly, Insulin lower doses to ketoacidosis
Name the 4 CAGE questionaire suggesting a problem drinker
2 or more positive replies = positive test
- Have you ever felt you should CUT down on your drinking?
- Have people ANNOYED you by critising your drinking?
- Have you ever felt bad or GUILTY about your drinking?
- Have you ever had a drink first thing in the morning to steady your never or get rid of hangover? an EYE-OPENER
Investigation important in indentification of excessive chronic alcohol intake
- Blood alcohol
- Serum GGT - elevated in chronic drinkers
- MCV- > 96 fL
Other cahnges
- Abnormal liver function test (other than GGT)
- Carbohydrate deficient transferrin (specific)
- HDL elevated
- LDL lowered
- serum uric acid elevated
Symptoms of alcohol withdrawal
Hangover (acute)-
- headache
- nausea
- irritability
- mild tremor
Withdrawal (chronic)
- agitation
- prominent tremor
- sweating
- insomnia
- seizures
- delirium tremens (DTs)
Mangement of alcohol withdrawal
- Maintain fluids, electrolytes and nutrition
- Add Vitamin B complex inc thiamine
Medications - Diazepam, Thaimine, Vitamin B
IF psychotic add haloperidol
What is delirium tremens
Serious life-treatening withdrawal state.
Onset - 1-5 days from withdrawal (usually 3-4)
Symptoms - disorientation, agitation, clouding of consciousness, marked tremors, visual hallucination
Signs - sweating, tachycardia, pyrexia, signs of dehydration
Rx- Hospitalisation, correct fluids and electrolyte with IV treatment, treat systemic infection, Thiamine. Diazepam IV slowly
Add Haloperidol if psychotic features present
What are the hormones released by the anterior pituitary
- ACTH
- FSH
- LH
- TSH
- GH
- Prolactin
What are the hormones released by posterior pituitary
- ADH
- Oxytocin
Antibodies raised in Hashimoto thyroiditis
- Antimicrosomal or antithyroid peroxidase antibodies
What are the antibodies raised in Graves
- Antitithyroglobulin
- Antithyroid peroxidase
- TSH receptor
Common organisms causing UTI
Escherichia coli and Staphylooccus saprohyticus
Less common- gram negatice (Klebsiella sp and Prosteus sp.), enterococci sp and gram positive cocci (Streptooccus faecalis and staphylococcus)
Diagonisis/Investigations important in UTI
Mid stream urine collection with microscopy WBC > 10per mL
Dipstick positive for leucocytes (presence of infection) and nitrates (presence of bacteria)
Culture with cound > 10^5 cfu/ml
Other test = FBE, ESR/CRP, blood culture, consider U&E and PSA (in men)
Causes of tremor
- Physiological
- Benign essential tremor
- Anxiety - hyperventilation
- Hyperthyroidism
- Toxicitiy - alcohol, liver failure, uraemia
- Drugs - lithium, narcotic withdrawal
- Parkinson disease
- Drug-induced parkinsons
- Cerebellar disease
- Alzheimer’s disease
- Wilson disease
- Cerebral tumour (frontal lobe)
Causes of flapping tremor (metabolic tremor)
- Wilson’s syndrome
- Hepatic encephalopathy
- Uraemia
- Respiratory failure
- Lesion of red nucleeus of midbrain
Basic Clinical features of Parkinson’s
- Stooped posture
- Failure to swin arm or arms
- Masked facies
- staring expression
- slow, monotonous speech
- pill-rolling tremor at rest
- slow and shiffling gait at rest
- turning by numbers
Classic tetrad of PD
- Tremor at rest
- Rigidity
- bradykinsia (poverty of movement)
- Postural instability (loss of postural reflex)
Differential Diagnosis for PD
- Depression
- Multiple system atropy
- Progressive supranuclear palsy
- Normal pressurue hydrocephalus - MRI ventricular enlargement
- Frontal lobe damage/dementia
- Lewy body dementia - lilliputia
- Huntington’s
- Wilson’s disease
- Drug induced - antipsychotics, anticonvulsants, amiodarone, lithium
- Toxin- CO poisioning, manganese toxicity
Red flags in Parkinsons
- Rapid progresion of gait impairment, need to use wheelchair, dementia, postural instability, falls, dysautonomia, bulbar dysfunction within 5 years onset
- Inspiratory respiratory dysfinction
- Recurrent falls (>1 a year)
- Poor response to L-dopa or DA agonist
- Symmetrical symptoms
- Onset of other treament - antipsychotic
Pharmacology in parkinsons
- Levadopa (converted to dopamine)
- Usually given with dopa decarboxylase
- Dopamine agonist - bromocriptine, pramipexole, ropinirole
- Can add MAO-B inhibitor (Selegilene)
- Can add COMT inhibitor (Entacapone, Tolcapone)
Signs of parkinsons
- Pill rolling tremor
- Increased rigidity - cogwheel
- Akinesia/bradykinesia slow
- micrography
- Postural/gait changes
- Congnitive decline
- Olfactory loss
Differentials for acute vision loss in non-inflammed eye
- Retinal Detachment
- Retinal artery or vein occlusion
- Migraine
- Hyperglycemia
- Amauroxis fugax
- Anterior ischemic optic neuropathy- temporal gaint cell arthritis
- Optic Neuritis - MS
Differentials for chronic vision loss in white eye
- Macular degeneration
- Refractive errors
- Cataracts
- Diabetic retinopathy
- Open angle glaucoma
Red flags in vision loss
- Sudden vision loss
- Vision loss with temporal arteritis symptoms - jaw claudication (pain with chewing), temporal tenderness
- Raised intraocular pressure – ie pain with tender globe and hazy cornea, nausea and fixed dilated pupil
- Pain on eye movement in younger patients 30-50 – optic neuritis
- History of new flashes and floaters
Examinations to be done in vision loss
- Visual acuity
- Visual fields
- Red reflex
- pupil reflex
- Fundoscopy
- Blood pressure
- BGL
Differentials for painless red eye
- chalazion/stye
- subconjuctival haemorrhage
- pteyrium
- eyelid disorders
Differentials of painful red eye
- Conjuctivitis (allergic, bacterial, viral)
- Keratitis
- Corneal trauma
- Keratoconucticitis sicca dry eyes
- episcleritis
- scleritis
- Acute angle closure glaucoma
- endophthalmitis
- uveitis
Emergency conditions causing red eye
- Angle closure glaucoma
- Ketaritis
- Ruptured globe/penetrating eye injury
- Blunt trauma
- Corneal abrasion
- Gonococcal conjuctivitis
What should your uncorrected vision in better eye be better than to drive
6/12
What is true about visual field in regards to driving unconditionally
Binocular with a horizontal extent of at least 110 degrees within 10 degrees above or below the horizontal midline,
If there is significant field loss/ scotoma within a central radius of 20 degrees of foveal fixation
Important questions in history of fever
Travel
Pets
Occupation
Immunosupression
Drugs - cocaine, antimicrobials, anticholinergic, amphetamine
Sexual history
Investigations to differentiate between infectious, malignant and autoimmune causes
Malignant - Weight loss, lymph involvement, CT
Autoimmune- ESR in giant cell, RF in rheumatoid, ANA in SLE, antibodies
LFT to differential Cirrhosis and Hepatitis,
D-dimer for DVT
ACE levels for Sarcoidosis
Name 10 infectious causes of fever
- UTI
- Pneumonia
- sinusitis
- Mengitis
- Bacteraemia
- Tuberculosis
- Abdominal abcess
- Endocarditis
- Osteomyelitis
- cytomegalovirus (CMV), Epstein-barr virus, influenza
Name three malignant cases of fever
Chronic leukaemia
Lymphoma
Metastatic cancer
Name four autoimmune causes of fever
Gaint cell arthritis
Inflammatory bowel disease - Chron’s, ulcerative colitis
Rheumatoid Arthriitis
Systemic lupus erythematosus
Lyssavirus
Symptoms, Examination, Diagnosis
Symptoms - Disoriented, insomnia, ataxia, rapidly deteriorating speech, hallucination, coma
Examination - Hydrophobia and intermittently febrile
Diagnosis - Serology – saliva test for rabies PCR
Brucellosis
Symptoms, Examination, Diagnosis
Symptoms- Remitting relapsing course of fever, Arthralgia, myalgia
Examination - none
Diagnosis - Serology = SAT (serum agglutination test).
Leptospirosis
Symptoms, Examination, Diagnosis
Symptoms - Biphasic illness with septicaemic and immune phase, High fever, headache, myalgia and arthralgia, rash, meningism and vomiting = common
Examination - Meningism, Jaundice
Diagnosis - Serology MAT (microagglutionation testing) or ELISA
Q fever
Symptoms, Examination, Diagnosis
Symptoms - Similar to leptospirosis and brucellosis
Non-specific influenza like illness
Acute fever-myalgia, severe headache
Arthralgia, anorexia and acute weight loss
Examination none
Diagnosis - Serology – repeat 1-2 weeks later because negative at start of fever – PCR
Antibody – 4 fold rise
Prevention - Vaccine in abattoirs
Hydatid disease
Symptoms, Examination and Diagnosis
Symptoms - Right upper quadrant pain or epigastric pain, nausea vomiting
Examination - none
Diagnosis - Stool exam – eggs and proglottids in stool
Serum serology
FBC – moderate eosinophilia, megaloblastic perinicious anaemia
Definition of sepsis
Infection either suspected or confirmed with systemic features of fever, tachycardia, tachypnoea, or elevated white cell count
