3rd Yr Med Flashcards
Stable Angina Features:
No pain at rest
No raised Trop
No ECG changes
Unstable Angina Features:
Pain at rest
No raised Trop
Transient ECG changes (ST Depress, T wave Invers)
nSTEMI Features:
Pain at rest
Raised Trop
ECG changes (ST Depress, T wave Invers)
STEMI Features:
Pain at rest
Raised Trop
ECG changes (ST Elev, LBBB)
Stable Angina Mx
Aspirin 75mg ACEi/ARB SL GTN Statin (Rate control: Beta-blocker, CCB, Ivabradine)
Unstable Angina/nSTEMI Mx
Morphine + Antiemetic O2 Fondaparinux SL GTN Aspirin 300mg Stat (75mg OD) Repeat ECG + Angiography
STEMI Mx + Tx
Morphine + Antiemetic O2 LMWHep SL GTN Aspirin 300mg Stat (75mg) Repeat ECG + Angiography
Tx:
(w/ in 90mis): PPCI (w/ Prasugrel)
Thrombolysis (IV Alteplase)
(Aspirin continued indefinitely, Prasugrel/Clopidogrel continued for 12 months)
HF Class
NYHA:
1: No limitations
2: Mild limitations
3: Severe limitations
4: Sx at rest
HF Ix
BNP/ANP
Echo (Trans-oesophageal)
CXR
(ECG, Trop)
HF Meds
Cardiac meds:
Beta-blockers, CCB (Diltazem, Verapamil), Ivabradine (Slows HR w/out drop in BP)
Diuretics:
Furosemide, Thiazides, ACEi/ARB (If HT), Spironolactone (If Hypokalaemic)
Venodilators:
CCB (Amlodipine), GTN/Nitrates, Hydralazine
ECG Analysis
Rate Rhythm Axis (LAD, RAD) P waves QRS PRi (0.12-0.2s) QRS (0.12s) QT (0.2s) R -> S Progress (L/RBBB) ST Elev/Depress T wave (Tall/Flat/Invers)
AF Mx
Rate control:
Beta-blocker, CCB, Digoxin
Rhythm control:
Beta-blocker, Amiodarone
(If < 48hrs: DC Cardioversion)
Anti-coag:
Rivaroxaban 15mg BD (21 days), 20mg OD
Bradyarrhythmia Mx
SAN ( + Sx): Pacemaker
AVN:
1/2T1 + Syncopal: Cardiac Monitor
2T2/3 + Sx: Permanent Cardiac Pacemaker
Tachyarrhythmia Mx:
SVT
VT
SVT:
Vasovagal manoeuvres
IV Adenosine 6mg (If NSR: Re-entry - Anti-arrhythmic, If no NSR: AF)
Cardioversion (DC, Amiodarone)
VT:
Amiodarone
DC Cardioversion
HT Mx
< 55yo, Diabetic:
ACEi/ARB (+/- CCB +/- Thiazide-like D)
> 55yo, Black:
CCB (+/- ARB/ACEi +/- Thiazide-like D)
Features: AS AR MR MS
AS: (D, Carotids, Holding breath)
Eject-Syst, Cres-decres, Rad to Carotids
AR: (D, Leant forward, Exp)
Early Diast, Decres
MR: (D, L, Exp)
Pan-Syst, Blowing, Rad to Axillae
MS: (Bell, L, Exp)
Opening snap, Mid-Diast, Rumbling
Non-funct Pit Adenoma Mx
Prolactinoma Mx
Non-funct Pit Adenoma Mx:
Surg/RadioTx w/ HRT (GH, HC, Oestrog/Prog/Test, Thyroxine)
Prolactinoma Mx:
D2 (Dopamine) Agonists: Cabergoline, Bromocriptine
Acromegaly Ix
Raised IGF-1, PRL (Co-secreted w/ GH) Failed OGTT (Fails to Supp GH)
Acromegaly Mx
Surg
GHIH (Somatostatin)
GH Antag
Dopamine Agonists (Prevent Release of GH)
DI Features
Polydipsia
Polyuria (Large Vol, Diluted Urine: > 3L/day), Nocturia
Low Urine Osmolality (< 300)
High Serum Osmolality (> 295)
DI Mx
Cranial:
Vasopressin (Exogenous ADH)
Nephrogenic:
Reduced NaCl/Protein Intake +/- Diuretic
(Carbamazepine: Sensitises Renal Tubules)
SIADH Sx + Mx
Fluid Retention (Small Vol, Concentrated Urine)
Mx:
Fluid restrict (+/- Diuretic)
Demeclocycline/Tolvaptan (ADH Antag)
Cushings D Patho + Complications
Pit Adenoma secreting ACTH
+/- DM, HT, Osteoporosis
Cushings D Ix
Raised ACTH/Cortisol, Low CRH, (Raised Glu, BP)
Raised 24hr Urinary Cortisol
Failed Dexamethasone Supp Test (Low-dose does not Supp ACTH)
Cushings D Mx
Trans-sphenoidal Surg
Cause of Secondary Adrenal Insuff + Sx
LT Steroid use => Supp of ACTH => Low Cortisol
Hypoglycaemia, (Normal Aldosterone: Normal BP)
Weakness, Fatigue
Immunosupp
Secondary Adrenal Insuff Mx
Stop Steroids
HRT: Cortisol Supp (HC)
Addisons Patho, Features + Complication
Auto-Immune Adrenal Destruction (Ald Def):
Low Ald/Cortisol (HypoT/HypoGlyc) Low Adrenals (Hair loss, Reduced Libido) High ACTH (Hyperpigmentation)
Addisonian Crises during stress/illness
Addisons Ix
9am ACTH/Cortisol levels
(-) SynACTHen Stim Test (Low Cortisol)
U+Es (Hyponatraemia, Hypokalaemia, Raised Urea), HypoGlyc, Anaemia
Addisons Mx
HRT: Fludrocortisone, HC (Double dose when ill)
Steroid card
(Reg Fluids - IV Dextrose + HC when ill)
Bilat Adrenal Hyperplasia Patho + Features
Adrenal Enlargement => Excess Aldosterone/Cortisol
HT, Raised ICP
Cushings Synd
Bilat Adrenal Hyperplasia Mx
Spironolactone (Aldosterone Antag)
Bilateral Adrenalectomy
Klinefelters Features
(47, XXY):
Tall, feminised Man (Infertility, Gynaecomastia)
Small, male Ext Genitalia (Hypogonadism)
Turners Features
(45, XO)
Small, androgynous, Woman (w/ webbed neck)
Ambiguous Ext Genitalia
AIS Features
(Test Def/Insens):
Ambiguous Genitalia + Undescended testis
Amenorrhoea, Infertility
CAH Features
(21-Hydroxylase Def):
Ambiguous Genitalia
Excess Test (Male characteristics/Virilisation: Deep voice, Hair growth, Cliteromegaly, Acne, Amenorrhoea)
Cortisol/Aldosterone Def (Addisonian/Cushing Crisis)
Pheochromocytoma Sx
Headache
Palpitations/TachyC
Sweating
(Anxiety/Panic, HT, HyperGlyc)
Pheochromocytoma Ix + Mx
24hr Urinary Metanephrines + Catecholamines CT CAP (Mets)
Mx:
Alpha-block (Phenoxybenzamine, Doxazocin)
Beta-blocker
Surg
Causes of HypoTh
Hashimotos (Anti-Th AB’s)
Diet (I2 Def)
Med (Amiodarone, Lithium)
Post-partum Thyroiditis, Sheehans Synd
HypoTh Ix + Mx
T3/4, TSH
Th-Peroxidase AB’s
Mx:
Levothyroxine
Causes of HyperTh
Graves (Auto-AB’s Stim TSH-R)
Nodular D
Thyroiditis (Viral Inf, Amiodarone, Post-partum)
HyperTh Ix
T3/4, TSH
TSH-R AB’s
Thyroid USS (Confirm Nodules)
Nuclear Tc/I2 Uptake Scan (Assess Act): Uniform (Graves), Single (Nodule), None (Thyroiditis)
HyperTh Mx
Beta-blocker (Control Sx)
Carbimazole (Th Peroxidase Antag)
Radioactive I2
Thyroidectomy
HypoTh vs HyperTh Sx
Weight changes HR (Brady/Tachy) GI (Constipation/Diarrhoea) Cold/Heat Intolerance Depression/Anxiety Hypo/Hyper-reflexia
Specific Sx:
HypoTh
Graves
HypoTh:
Myxoedema (Puffy Eyes)
Graves:
Proptosis (Eyes protrude)
Pre-tibial Myxoedema
Hypercalcaemia Causes + Sx
Primary Hyper-PTH/Osteoporosis,
RCC/Squamous CLC (Secreting PTHrP) =>
Stones, Moans, Groans, Bones, Psych
ECG changes
Polyuria/Polydipsia (Nephrogenic DI)
Hypercalcaemia Ix + Interpretations
PTH (High: HyperPTH, Low: Malig)
(PTH => Bone Turnover): High ALP, Low Phosphate
Hypercalcaemia Mx
IV Fluids (w/ careful electrolyte monitoring)
Hypocalcaemia Causes + Sx
Diet/Hypo-Mg2+ (Low Ca2+),
Renal D/Lack of Sunlight (Low Vit D)
=>
ECG changes
Myalgia/Paraesthesia
Spasms (Laryngomalacia, Carpo-pedal)
Seizures
Hypocalcaemia Mx
Ca2+ Supp
DM Diagnosis Criteria
Fasting Glu: > 7mmol
Random: > 11mmol
HbA1c: > 6.5 (48mmol)
DKA Def/Criteria
HyperGlyc (> 11mmol)
Ketones (> 3mmol)
Acidosis (pH < 7.33)
DKA Ix + Mx
Hourly Glu + Ketones
FRII (IV Actrapid 0.1 Units/Kg/hr)
IV 0.9% NaCl (+/- Dextrose, K+)
HHS Def/Criteria
HyperGlyc (> 30mmol w/out Ketoacidosis)
HypoVol
Serum Osmolality > 320 (2Na + Glu+ Urea)
HHS Ix + Mx
Hourly Glu + Ketones
IV Fluids (1L/hr, 1L/4hr, 1L/4hr) +/- K+
LMWHep
DM Complications:
ST
LT
ST:
Lipodystrophy
Hyper/Hypo Episodes
LT:
Microvasc: Nephropathy, Retinopathy, Periph Neuropathy, Immunosupp (UTI, Pneumonia, Thrush)
Macrovasc:
Stroke/TIA,
CVS D/HT,
Ulcers/Gangrene (Periph Ischaemia - PVD)
Oesophageal Dysmotility Types + Features
Achalasia: (Non-distensible LOS):
Bird-beak (Ba Swallow)
Diffuse Oesophageal Spasm: (No control of Peristalsis):
Corkscrew (Ba Swallow)
Hypercontractile:
Nutcracker (Ba Swallow)
Oesophageal Dysmotility Ix + Mx
Ba Swallow
Endoscopy
Manometry
Mx:
SM Relaxants (CCB: Nifedipine, Nitrates)
Myotomy
Pneumatic Baloon Dilation
GORD Mx
PPi
H2 Antag (Ranitidine)
Alignates (Gaviscon)
Mallory-Weiss Tears Patho
Excess Vomiting => Tears w/in Endothelium of Oesophagus
=> Bleeding
UGIB Mx
Variceal: Fluid Resus IV PPi IV ABx + Terlipressin (ADH Antag) OGD (Band/Stent)
Non-Variceal: Fluid Resus IV PPi OGD (+/- Radioembolization/Surg) Post-OGD PPi
SB vs LB Obstruct Ix
Erect CXR:
Air under Diaphragm
AXR: SB: > 3cm, Central, Valv Conniventes (All the way across)
LB:
> 6cm,
Periph,
Haustra (Part way across)
Contrast CT:
ID Level of Obstruct
SB/LB Obstruct Mx + Surg Indications
NBM (Bowel Rest)
IV Fluids (+ Electrolytes)
NGT (Bowel Decompress)
(Stop Opiates)
Surg (Strangulated Hernia/Reversible Cause, > 48hrs, Ischaemia, Perf)
Coeliacs D Patho, Ix + Mx
Auto-Immune React to Gluten w/in S Intestine
=> Lymphocytic Infiltration + Villous Atrophy
Ix: Raised Tissue Transglutaminase (tTG)
Mx:
Gluten-free Diet
Appendicitis Ix
FBC, U+Es, LFTs, CRP Amylase/Lipase (Excl Pancreatitis) Urinalysis (Excl UTI) ECG, Trop (Excl MI) Preg test (Excl Preg)
Appendicitis Mx
Opiates + Antiemetic
Appendectomy
(If Perf: ABx)
PBC Eped + Features
Middle-aged Women
Early: Asymptomatic, Fatigue + Pruritus
Late: Cholangitis (Granulomatous Inflamm of Bile Ducts) => Cirrhosis
PBC Mx
Cholestyramine (Reduce Pruritus)
Ursodeoxycholic Acid (Improves Survival)
Liver Transplant
PSC Eped + Features
Younger men w/ Autoimmune D
Early: Progress Obstruct Jaundice
Late: Cirrhosis, Cholangiocarcinoma
PSC Mx
Cholestyramine (Reduce Pruritus)
Ursodeoxycholic Acid (Improves LFTs)
Liver Transplant
Biliary Colic vs Acute Cholecystitis vs Ascending Cholangitis
Biliary Colic: RUQ Pain (1-5hrs after meal), N+V
Acute Cholecystitis:
RUQ Pain, N+V, Fever, TachyC
Ascending Cholangitis: Charcots Triad (RUQ Pain, Fever, Jaundice), Reynolds Pentad (+ Confusion, HypoT)
Biliary Colic/A Cholecystitis/Asc Cholangitis Ix + Mx
LFTs, ERCP
Mx:
Stone removal
Cholecystectomy (w/ Bile Salt replacement)
ERCP (w/ Biliary Decompress)
IV ABx (If Asc Cholangitis: Tazocin 4.5g TDS)
Pancreatic Ca Features:
Head
Tail
Head:
Painless, Obstruct Jaundice
Vague Epigastric Pain/Mass
Tail:
DM Sx
Loss of Enzymes (Malnutrition, Loose Stools)
Pancreatic Ca Ix
Amylase, Lipase, LFTs
ERCP/MRCP
AXR
CA19.9, CEA, aFP
Causes of Pancreatitis
G: Gallstones E: Ethanol T: Trauma S: Scorpion/Spider Venom M: Mumps A: Autoimmune S: Steroids H: Hyperlipidaemia, Hypercalcaemia, Hypothermia E: ERCP D: Drugs
Pancreatitis Ix
FBC, U+Es, LFTs
Raised Amylase/Lipase (More Sens)
AXR
ERCP/MRCP
Pancreatitis Mx
Reduce Sx (Stop Alcohol, Remove Stones, Opiates) Tx Cause (Electrolytes, ERCP, Steroids => Inflamm) Exocrine Support (DM Insulin)
Colon Ca Features
L:
LIF
Constipation, Tenesmus, Late Diarrh
Anaemia (Blood of Surf + mixed)
R:
RIF
Diarrh, Late Constipation
Anaemia (Blood mixed)
Colon Ca Ix
AXR, CT
CEA, aFP, LDH
IBD Features (UC vs CD) - 5
UC: Rectum -> back (Continuous) Submucosal Inflamm No Granulomas Cobblestone, friable mucosa No Perianal D
CD: Ileum (LIF, Skip lesions) Transmural Inflamm Non-caseating Granulomas Fissuring Ulcers, Crypt Abscesses Perianal D (Fistulas , Fissures, Strictures)
IBD Ix - 5
Faecal Calprotectin, Stool Cult (Excl: C.Diff)
FBC, U+Es, LFTs, CRP/ESR
Coeliac Serology (Anti-tTG)
Serum Ferritin/B12/Folate/Vit.D (Malabsorption => Def)
Sigmoidoscopy/Colonoscopy (+/- Biopsy)
IBD Mx
Steroids, Azathioprine, Sulfasalazine
LMWHep
(Acute: IV HC 100mg QDS)
Haemorrhoids Features
Prominent Vessels (Vascular bundles)
Above (Painless)
Below (Painful)
Haemorrhoids Classification
1: No Prolapse
2: Reduce Spontaneously
3: Reduce Manually
4: Unable to Reduce
Haemorrhoids Mx
GTN/CCB Cream
Staples, Bands, Incision
TB Screening
Immigrants from highly Prevalent (Endemic) Countries
Healthcare workers
HIV (+) Pt’s
Pt’s beginning Immunosuppression
Latent TB Tx
Rifampicin + Isoniazid (with Pyridoxine) 3 months or
Isoniazid (with Pyridoxine) 6 months
(Avoid w/ Pt’s > 35yo or at risk of Hepatotoxicity)
Active TB Features
Non-resolving Cough
Unexplained Persistent Fever
Drenching Night Sweats
Unexplained Weight loss (Cachexia)
Other: Clubbing Lymphadenopathy Hepatosplenomegaly Erythema Nodosum Pleural Effusion Pericarditis
Active TB Ix + Findings
Sputum samples (3x AAFB + TB test), (If no Sputum: Bronchoscopy)
CXR (Cavitating Pneumonia, Pleural Effusion), CT/MRI
LN Biopsy + Histology (Caseating Granulomatous Inflamm)
LP (Raised Proteins, Reduced Glu, Lymphocytosis)
Active TB Mx
2 months of RIFATER (RIPE)
4 months of RIFINAH (RI)
Active TB Mx SE
RIP: Hepatotoxicity (Baseline LFT’s)
I: Periph Neuropathy (Pyridoxine)
E: Retrobulbar Neuritis (Visual Acuity)
TB Paradoxical Reaction + Mx
Tx cause Bact to die => Inflamm
Mx:
Steroids (esp Pericardial + CNS): Prevent Inflamm
HIV Tx:
ARVTx
ARVTx: 2 Nucleoside Reverse Transcriptase Inhib \+ 1: Non-nucleoside Reverse Transcriptase Inhib, Boosted Transcriptase/Protease Inhib, Integrase Inhib
HIV Tx:
Prophylaxis
Vaccinations
Prophylaxis: (Falling CD4):
CD4 < 200: Cotrimoxazole (PCP)
CD4 < 50: Azithromycin (Mycobacterium)
Vaccinations:
Hep B
Pneumococcus
Annual Flu Vaccine
Skin Inf Org + ABx
If MRSA:
If Penicillin Allergy:
Strep + Staph: Flucloxacillin
If MRSA: Vancomycin
(If Penicillin Allergy: Doxycycline, Meropenem)
MSK Inf Org + ABx
Strep + Staph: Tazocin
Resp Inf Org + ABx
Atypical
Viral
S Pneumoniae, H Influenzae: Amox, Co-amox, Doxy
Atypical (Legionella): Doxy, Fluoroquinolone
Viral (Rhino/Adeno/Entero): Oseltamivir
GI Inf Org + ABx
Salmonella: Ceftriaxone, Azithromycin
C Diff: PO Vancomycin, Metronidazole (IV)
Enterobacteria (Campylobacter, E-coli, Shigella): Ciprofloxacin
GUN Inf Org + Mx
Gonorrhoea: IM/IV Ceftriaxone
Chlamydia: Doxy
CNS Inf Org + ABx
Meningitis (N. Men, S Pneum, H Influenzae): IV Ceftriaxone + Dexamethasone
Viral (HSV): Aciclovir
CVS Inf Org + ABx
IE
Cult (-)
IE (S Viridans): Benzylpenicillin
IE (S Aureus - IVDU): Flucloxacillin
IE (Enterococci): Amox
(Cult - ): Ceftriaxone
Dementia Types + Features Vascular D D w/ Lewy Bodies PD w/ D FT D
Vascular:
Stepwise Progress w/ Risk Factors
D w/ Lewy bodies:
Gradually Progress (+/- PD Sx)
Persistent, Realistic A+V Hallucinations
PD w/ Dementia: PD Sx (Bradykinesia, Rigidity, Tremor) precedes Dementia
FT Dementia:
Early-onset, Complex problems (Loss of Social Inhib)
Delirium Mx
Reverse Cause: Hypoxia - O2, Electrolytes - Fluids, Inf - ABx, Obstruct/Retention - Laxatives/Catheter)
Orient to Time/Place
Family members
Avoid sedatives/anticonvulsants/Intoxicants
Confirming Death
Pupils fixed + Dilated
No Resp to Pain
No Breath/Heart Sounds (> 1min)
K+ Sparing and Non-K+ Sparing Diuretic Examples + SE
K+ Sparing:
ACEi/ARB, Spirnolactone => Hyper-K+
Non-K+ Sparing:
Thiazides (Inhib NCC in DCT)
Loop (Inhib NKCC in Loop of Henle)
=> Hypo-K+
Causes of Hyper-K+
CKD +/- K+-rich Diet Drugs (K+-sparing, NSAIDs, Digoxin, Hep, Trimethoprim, Cyclosporin) Intracellular Shift: Decreased SNS (Beta-blockers) Decreased Insulin Decreased pH (Acidosis) Decreased Aldosterone (Addisons) Rhabdomyolysis/Haemolysis/Lysis
Hyper-K+ ECG changes
Tall, Peaked T waves
Prolonged QRS
Loss of P waves (=> Asystole)
Hyper-K+ Mx
Cardiac protection:
IV 10ml 10% Ca2+ Gluconate (10mins)
Shift K+ Intracellularly:
IV Actrapid 10 Units + 50ml 50% Dextrose
Neb Salbutamol 10mg
(If Acidotic: IV 500ml 1.4% NaHCO3)
Remove Excess:
PO/PR Ca2+ Resonium
IV 80mg Furosemide
Causes of Hypo-K+
Losses (Renal: Diuretics, GI: Reduced Intake, Vom/Diarrh)
Intracellular Shift:
Increased SNS (Beta-agonists, Adren)
Increased Insulin
Increased pH (Alkalosis)
Increased Aldosterone (Hyperaldosteronism/Cushings, Hyper-RAAS)
Hypo-K+ ECG changes
Small T waves
U wave (after T)
Increase in PRi
Hypo-K+ Mx
(PO/IV) K+ and Mg2+ Supplements w/ IV Fluids
Causes of Hyper-Na+
Hypervolaemic:
Hyperaldosteronism/Cushings
Euvolaemic:
DI, Hypodipsia
Hypovolaemic:
Diuretics, Diarrh, Sweating
Hyper-Na+ Mx
Hypervolaemic: (Chronic): Fluid restrict +/- Furosemide, (Nutritional Support)
Euvolaemic: IV Dextrose
Hypovolaemic: (Acute): IV NaCl 0.9%
Causes of Hypo-Na+
Hypervolaemic:
3rd Spacing (HF, Cirrhosis, Nephrotic Synd)
Polydipsia
Euvolaemic:
SIADH
HypoTh
Preg
Hypovolaemic:
Fluid loss (Vom/Diarrh, Bleeds, Diuretics, Burns)
Pancreatitis
Hypoaldosteronism (CAH/Addisons)
Hypo-Na+ Mx
IV NaCl 0.9%
AKI Classification
1: Serum Cr x 1.5-2
2: Serum Cr x 2-3
3: Serum Cr x > 3, UO < 0.5ml/Kg/hr
Causes of Pre-renal AKI
Hypoperfusion:
Hypovolaemia
HF
Impaired Auto-regulation (ACEi/ARB, NSAIDs)
Pre-renal AKI Ix + Mx
FBC, U+Es, BP, RAAS
Mx:
Stop meds
Tx Hypovolaemia/Sepsis/Anaemia
Causes of Renal AKI
Drugs (Nephrotoxins)
Inflamm (GN, Vasculitis), Inf
Trauma (HT, Sepsis/Ischaemia)
Renal AKI Ix + Mx
Urinalysis, Renal Biopsy, CRP/ESR, USS-KUB
Mx: Stop Nephrotoxicity meds Tx Cause Assess Fluid balance Steroids (Reduce Inflamm)
Def ATN + Mx
Fluid-resistant AKI
Mx:
Stop IV Fluids (+/- => Pulmon Oedema)
Fluid restriction + Diuretics
Cause of Post-renal AKI, Ix + Mx
Obstruction
USS-KUB
Mx: Surg
RRTx Indications
Uraemic Pericarditis/Encephalopathy
Intoxicants (Antifreeze, Methanol, Lithium)
Fluid-overloaded despite Diuretics
Hyperkalaemia, Metabolic Acidosis despite Tx
CKD Causes
Diabetic
HT
APCKD
Diabetic CKD Ix
Raised Urin Albumin : Cr (Raised PCR): > 2.5 (Females)/ > 3.5 (Males)
Glu on Dipstick
(Evidence of poorly-controlled DM: Retinopathy, Nephropathy, Neuropathy)
HT in CKD Ix
Urin metanephrines (Phaeochromocytoma) Aldosterone : Renin (Hyperaldosteronism) Dexamethasone Supp test (Cushings) T3/4, TSH (HyperTh) MR Angiography (Renal A Stenosis)
DM/HT CKD Mx
ACEi/ARBs (HT + Proteinuria)
Statin (Reduce CVS Risk Factors)
Screening (Microvascular Complications)
APCKD Ix + Mx
(+) FHx
USS (Kidneys + Liver)
Mx:
ACEi/ARBs (HT + Proteinuria)
Tolvaptan (ADH Antag: Reduce Cysts)
CKD Classification
eGFR
1: > 90
2: 60-90
3a: 45-60
3b: 30-45
4: < 30
CKD Complications (Anaemia) Patho - 5
Anaemia: Reduced EPO Blood loss + Reduced lifespan of RBC's Uraemic Myelosuppression Fe Def (Absolute: Reduced Absorption, Funct: Inflamm => Raised Hepcidin) Vit B12/Folate Def
CKD Complications (Min Bone D)
Min Bone D:
Increased Excretion of PO4-
Reduced Synthesis of Vit D (=> Reduced Absorption of Ca2+)
Hypocalcaemia => Rise in PTH
Hyper-PTH => Increase in ALP (Increase Bone Turnover + Osteoclast Act) => Rise in Serum Ca2+
(Tertiary Hyper-PTH: High PTH + Ca2+) =>
Vascular/Soft Tissue Calcification + Skeletal PTH Resistance (Osteodystrophy)
Causes of Nephrotic Synd
Min change D (M Common in Children)
Focal Segmental Glomerulosclerosis
Membranous Nephropathy
Nephrotic Synd Features
Proteinuria
Hypoalbuminaemia
Ascites, Oedema
(Hyperlipidaemia)
Nephrotic Synd Mx
Tx Cause ACEi/ARB (HT, Proteinuria) Diuretics (Reduce Oedema) LMWHep Statins (Hyperlipid)
Causes of Nephritic Synd
Autoimmune/Inflamm (SLE, Vasculitis, IgA)
Inf (HIV, Hep B/C, IE, Post-strep)
Nephritic Synd Features
Oliguria, AKI (Drop in eGFR)
Haematuria
Proteinuria
HT
Nephritic Synd Mx
Tx Cause ACEi/ARB (HT, Proteinuria) Diuretics (Reduce Oedema) LMWHep Steroids (Reduce Inflamm)
Blood Gas Features:
Alkalosis
Acidosis
Alkalosis (pH > 7):
Resp (pCO2 Low)
Metabolic (BE High)
Acidosis (pH < 7):
Resp (pCO2 High)
Metabolic (BE Low)
- Anion Gap: Na - (HCO3 + Cl) = 8-12 (H+ added: AG > 12, HCO3- lost: AG < 8)
Causes of Alkalosis + Acidosis
Resp Alkalosis: Hyperventilation
Metabolic Alkalosis: Loss of Acid (GI/Renal Loss)
Resp Acidosis: Poor Ventilation
Metabolic Acidosis: Gain of Acid (Toxins + Renal Fail, Lactic Acidosis, DKA), Loss of Base (GI/Renal Loss)
Fluid Routine maintenance
H2O: 25-30ml/Kg/day
K+/Na+/Cl-: 1mmol/Kg/day
Glu: 100g/day
Fluid Resus Indications + Mx
Syst BP < 100 HR > 90 RR> 20 CRT> 2s NEWS > 5
Mx:
IV 0.9% NaCl 500ml over 15mins
Asthma Mx
1: SABA (Blue Reliever)
2: ICS (Brown Preventer)
3: + LTRA (Montelukast)
4: + LABA (w/ SABA, Remove LTRA)
5: LABA + ICS (MART) - Begin Increasing dose of ICS
6: MART + LTRA
7: + Aminophylline/LAMA (Ipratropium)
Severe vs Life-threatening vs Near-fatal Asthma
Severe:
Cannot complete sentences
RR > 25, HR > 110, PEFR: 33-50%
Life-threatening:
Silent Chest, Cyanosis
RR < 12, HR < 60, PEFR: < 33%, SpO2 < 92%
Near-fatal:
Hypercapnia + Hypoxia (T2RF)
Req Mech Ventilation
Acute Asthma Exacerbation Mx:
If Severe/Life-threatening/Near-fatal
ABCDE O2 Neb Salbutamol 5mg PO Pred 40mg (If Severe: Neb Ipratropium 500 micrograms) (If Life-threatening: IV Aminophylline) (If Near-fatal: Mech Ventilation)
Asthma Safe Discharge
Off Nebs > 24hrs Peak Flow > 75% Nurse R/v PO Pred 40mg 5 days GP f/up w/in 2 days OTP Asthma Clinic w/in 4wks Peak Flow Meter + Written Action Plan
Inadequate Asthma Control Sx - 5
Rescue meds > twice a week Sx > twice a week Awakening w/ Sx Excessive SE's or Sx => Activity limitation FEV1: < 80%
Acute COPD Exacerbation Mx - 6
ABCDE O2 (88-92%) via Venturi mask Neb Salbutamol 5mg Neb Ipratropium 500 micrograms PO Pred 30mg STAT + OD (7 days) (If Inf: CXR, IV Abx + f/up)
COPD Mx:
Care bundle - 2
Med - 5
Surg - 1
Care bundle:
Pulmon Rehab
Smoking Cessation
Med: Bronchodilators (Beta-Agonists) Antimuscarinics (Ipratropium) Steroids, Mucolytics LTOT (Non-smokers w/ SpO2: < 7.3KPa, < 8KPa w/ CP)
Surg:
Lung Vol Reduction (Lobectomy)
Bronchiectasis Sx
Large Vol of Clear Sputum
Chronic Cough/SOB
Obstruct LD
Bronchiectasis Ix + Findings
HR CT (Signet rings: Thickened Alveolar Walls) CXR (Lobar Collapse/Atelectasis, Intercurrent Inf)
Bronchiectasis Mx - 6
Physio (Improve Mucus Clearing)
(If MRC Dyspnoea Score > 3: Pulmon Rehab)
Bronchodilators
Flu Vaccine
Reg ABx (After 3 Exacerbations and + Cult)
(If Inf Exacerbation: ABx for 14 days, may need to change class if already taking Reg)
MRC Dyspnoea Score - 5
1: No Sx
2: SOB walking up hill
3: SOB => Slower walking
4: SOB => Stop after 100m or 2mins
5: SOB => Immobility
Pneumonia Scoring
CURB-65: Confusion Urea > 7mmol RR > 30 BP < 90 (Syst) Age > 65yo
Causes of Non-resolving Pneumonia Inf
C: Complication (Abscess, Empyema) H: Host (Immunosupp) A: Abx (Inadequate) O: Org (Atypical, Resistant) S: Secondary Diagnosis (PE, Cancer)
Haemoptysis Mx + Ix - 6
ABCDE O2 Lie Pt on side of Lesion IV/PO Tranexamic Acid (Antifibrinolytic) Stop Anticoags + NSAIDs
CT Aortogram
Haemoptysis Ddx
Inf (TB, CF, Bronchiectasis, Fungal, Pneumonia)
Malig (Primary, Mets)
Bleeding D (Vasculitis, Coagulopathy, PE, Arterial Erosion)
Tension Pneumothorax Criteria
Pleuritic Chest Pain
SOB
Silent Lung, Hyperresonance, Asymmetrical Chest Expansion
Shock (TachyC, HypoT)
(Deviated Trachea + Mediastinal Shift Away)
Tension Pneumothorax Mx
Large Bore Cannula + Chest Drain (2nd IC Space MCL, Above Rib)
Anaphylaxis Mx
ABCDE O2 + Secure Airway Remove Trigger IM Adren 0.5mg (Repeat every 5mins) IV HC 200mg + Chlorpheniramine 10mg
PE Sx + Signs
Sx:
Sudden, Constant, Severe Pleuritic Chest Pain
SOB, Cough (+/- Haemoptysis)
Signs:
(Recent DVT)
Shock (TachyC, HypoT)
Pulmon HT, RV Strain
PE Mx + Ix
ABCDE O2 Anticoag IV Alteplase (Thrombolysis) (Confirm RV Strain: CT/Echo/ECG)
Def FEV1 + FEVC
FEV1: Vol of Air expelled in 1s after Max Inspiration
FEVC: Total Vol of Air expelled after Max Inspiration
Obstructive vs Restrictive Lung Function
Obstruct: (FEV1:FEVC 50%)
Normal/Low FEVC
Reduced FEV1
Restrict: (FEV1:FEVC 90%)
Reduced FEVC
Reduced FEV1
TB Supp Mx - 4
Admit to SR
Specialist TB Nurse
Notify Public Health
Start ABx
CF Advice - 8
No Smoking Annual Flu Vaccine Avoid other CF Pt's or Pt's w/ Pneumonia Avoid Smokers Avoid Animals/Composts (Aspergillus) Avoid Jacuzzis (Pseudomonas) Clean + Dry Nebulisers Regularly Frequent fluids + NaCl Tablets (esp during Illness/Exertion)
Lung Ca Sx + Complications
Hoarse Voice, Dysphonia
SOB, Dry Cough, Haemoptysis
B Sx
Lymphadenopathy
SVCO (Facial Oedema, Engorged Neck Veins, Airway Compromise)
Horner’s Synd (Miosis, Anhidrosis, Ptosis, Enopthalmos)
Lung Ca Paraneoplastic Syndromes
Anaemia, Clubbing
SIADH (Small Cell LC)
Cushings (Small Cell LC)
Hyper-PTH/Hypercalcaemia (Squamous Cell LC)
Lung Ca Ix
CXR
Staging CT (Spiral Thorax + Abdo)
US-guided FNA of LN
ILD Sx - 4
SOB
Dry Cough
Restrictive Lung Pattern (Reduced FEV1 + FEVC)
Weight loss
Transudate vs Exudate
Transudate: (Prot < 30g/L):
HF
Cirrhosis
Hypo-Albumin
Exudate: (Prot > 30g/L):
Inf (HIV, TB)
Malig
Inflamm
Pleural Effusion Ix
US-guided Pleural Aspiration:
Biochem (Protein, LDH, pH, Cytology)
Microbiology (Microscopy, Culture + Sensitivity)
Added Lung Sounds Features: Crackles Wheeze Stridor Pleural Rub
Crackles:
Inspiratory (Opening of Alveoli)
Fine (Fibrosis) + Coarse (Effusion, Consolidation)
Wheeze:
Continuous, Musical
High-pitch (Bronchospasm) + Low-pitch/Rhonchi (Secretions)
Stridor:
Inspiratory, High-pitch Whistle (Large Airway Obstruct)
Pleural Rub:
Inspiratory, Grating (Friction of Inflamm Pleura)
OA Xray changes
Loss of Joint space
Osteophytes
Subchondral Sclerosis
Subchondral Cysts
RA Xray changes
Loss of Joint Space
Erosions
Soft Tissue swelling
Soft Bones (Osteomalacia)
OA Mx
OT/PT
Walking Aids
Analgesia (NSAIDs, Paracetamol, Opiates)
Surg (Joint Replacement/ Fusion)
RA Mx:
Conservative
Med
Surg
OT/PT +/- Walking Aids
Analgesia (Opiates)
DMARDs
(After 2 Failed DMARDs: Monoclonal AB’s - Rituximab: CD20 Inhib)
Surg (Joint Replacement)
Sero (-) Spondyloarthropathies Types + Features
(+) HLA-B27, (-) RhF
Psoriatic
Enteropathic
Reiters
Ankylosing Spondylitis
Psoriatic Features
R: Rheumatoid Arthritis (Hands + Wrists) O: Oligo (2-4 Joints) A: Arthritis Mutilans (Erosions => Deformities) D: Dactylitis (Sausage-shaped fingers) S: Sacroiliac Back Pain (Psoriatic Plaques)
Enteropathic Features + Mx
IBD
Asymmetrical Arthritis of Digits
Mx:
DMARDs + Anti-TNF
(Avoid NSAIDs - IBD)
Reiters Synd Features, Ix, Mx
(Knee) Arthritis following Urethritis (STI) + Conjunctivitis
Severe, Unilat Pain (Unable to Flex/Ext Passively/Actively)
Fever, Raised WCC
Ix: Joint Asp
Mx:
IV ABx 6wks
Ankylosing Spondylitis Features - 3
Back/Buttock Pain (Radiates Up)
Spinal Deformities (Kyphosis, Scoliosis) + Reduced/Asymmetrical Chest Wall Expansion
LL Weakness/Paraesthesia
Sjogrens Sx + Ix
M: Myalgia A: Arthritis D: Dry Eyes F: Fatigue R: Raynaud's E: Enlarged Parotids D: Dry Mouth
Ix:
Raised Anti-Ro/La, RhF
Sjogrens Mx
Anti-Inflamm
Frequent fluids, Eye Lubricants
SLE Sx
S: Serositis (Pericarditis, Pleurisy)
O: Oral Ulcers
A: Arthralgia
P: Photosensitive Rash
SLE Ix
Normal CRP, Raised ESR/PV
Anti-Ro/La, Anti-dsDNA
Haem changes (Anaemia, Thrombocytopaenia, Leukopaenia + Low Complement Proteins)
SLE Mx
Anti-Inflamm (DMARDs)
Sun Protection
PMR Sx + Ix
Widespread Pain (Shoulders, Neck/Spine, Hips)
Fatigue, Fever, Weight Loss
Headache (Associated w/ GCA)
Ix:
Raised CRP/ESR
(+) ANA/ANCA
PMR Mx
No Improvement
15mg Prednisolone, (Methotrexate: Steroid-sparing)
If no Improvement w/in 18 month: Reconsider Ddx - Cancer, RA
GCA Sx
Jaw Claudication Scalp Tenderness Unilat Throbbing/Pulsating Headache Vision changes (Diplopia, Blindness) (Associated w/ PMR)
GCA Ix + Mx
Temple A Biopsy (Giant Cell Granulomas + Necrotising Vasculitis)
Mx:
Prednisolone 60mg 2wks
Aspirin (Prevent VTE)
(If Vision changes: IV Methylpred 1g)
Osteopaenia/Osteoporosis Features + Ix
Rib/Vertebral #’s w/out Trauma
Ix: Dexa scan (T: < -1)
Vasculitis Sx - 6
Fever Fatigue Weight loss Rash Haematuria SOB
Vasculitis Mx
ID Cause, Stop Drugs
Steroids/DMARDs (Excl Inf before starting)
Gout vs Crystal Arthropathy
Gout: (-) Bifringent Crystals
Crystal Arthropathy: (+) Bifringent Crystals
Gout Mx
Diet/Lifestyle changes (Reduce Meat/Alcohol, Avoid Dehydration)
Acute: NSAIDs, Colchicine
Prophylaxis: Allopurinol
Crystal Arthropathy Mx
Acute: NSAIDs
Prophylaxis: Colchicine
Fibromyalgia Triad + Sx
Pain, Poor sleep, Fatigue
Vague, Widespread Pain (Above + Below, Bilat)
Fibrofog (Diff Conc)
Diff Sleeping, Exercising
Fatigue, Fever, Weight loss
Fibromyalgia Ix
Normal Ix (No Raised CRP/ESR/PV) Normal Exam
Fibromyalgia Mx
Education
CBT
Amitriptyline
Scleroderma Patho, Sx + Ix
Fibrosis of CT => Raynauds, Calcinosis, HT
Ix:
+) ANA
(Normal CRP/ESR/PV
Scleroderma Synd
C: Calcinosis Cutis R: Raynauds E: Oesophageal Dysmotility S: Sclerodactyly T: Telangiectasia
Scleroderma Mx
Scleroderma: Methotrexate
(Flares: Prednisolone)
Calcinosis: Ca2+ Antagonist
HT: ACEi
Dermamyositis/Polymyositis Sx + Ix
Acute + Symmetrical M Weakness (=> SOB)
Photosensitive Rash
Raynauds
Ix:
Raised CK, ALT
Normal CRP
Bisphosphonates Indications, Info, SE
Indications: Osteoporosis, (Co-prescribed w/ Steroids)
(Ca2+, Vit D Co-prescribed)
Taken weekly, w/ water on empty stomach, whilst standing/sitting upright + for 30mins after
+/- Oesophagitis (Discontinue)
Monoclonal AB’s Info
Require TB test
Increased risk of Intracellular Pathogens (Viral/Parasite)
Sulfasalazine Contraindications
Aspirin Allergy
Do not take w/ NSAIDs => Kidney Fail, Peptic Ulcers
Azathioprine Info
Assess TPMT Act (+/- => Myelosuppression)
Reg weekly FBC test for 8wks
+/- Skin sensitisation (Sunscreen)
Methotrexate Info
Require Contraception + Preg test (Teratogenic)
Weekly doses w/ Folic Acid Supplements
Inflamm vs Mech Pain
Inflamm:
Improves w/ Activity
Fatigue + Syst Sx
Mech:
Better w/ Rest (Shorter morning Stiffness)
No Fatigue/Syst Sx
HF (w/ Reduced EF) Mx
ACEi
Beta-blocker
+/- Spironolactone
(Annual Flu Vaccine, One-off Pneumococcal Vaccine)
HF CXR Signs
A: Alveolar oedema (Bat wing opacities) B: Kerley B lines (Horizontal lines) C: Cardiomegaly D: Dilated upper lobe vessels (Pulmonary Congestion) E: Effusion (Pleural)
BPH Mx
Alpha-1 Antag (Tamsulosin)
5a-Reductase Inhib (Finasteride)
TURP
Post-MI Complications
Death Arrhythmia Rupture Tamponade HF Valvular D Aneurysm Dressers (Pericarditis) Embolus Recurrence
COPD Diagnosis + Ix
Post-bronchodilator FEV1 < 0.7
PEFR/Spirometry
CXR (Emphysema: Bullae, Hyperinflation: Flattened Diaphragm + Barrel-chest A-P on Lat)
FBC (Anaemia/Polycythaemia, Eosinophil Count)
BMI
(Serum alpha1 Anti-trypsin Def)
Asthmatic/Steroid-Responsive Features
Diagnosis of Asthma/Atopy
Raised Eosinophil Count
Diurnal variation of PEFR
Variation of FEV1
COPD Step-up Mx
1: SABA/SAMA
2: (If no Asthmatic/Steroid-Resp):
SABA + LABA + LAMA (Discontinue SAMA)
+/- ICS
2: (If Asthmatic/Steroid-Resp):
SABA + LABA + ICS
+/- LAMA (Discontinue SAMA)
(Prophylactic ABx: Azithromycin)
COPD Staging
S1: (Mild): FEV1 > 80%
S2: (Mod): FEV1 50-70%
S3: (Sev): FEV1 30-50%
S4: (V.Sev): FEV1 < 30%
GI Tract Blood Supply
Coeliac Trunk (Comm Hep, Splenic, L Gastric)
Sup Mesenteric (Middle Colic, Right Colic, Ileocolic, Jejunal + Ileal)
Inf Mesenteric (L Colic, Sigmoid, Sup Rectal)
GI Anatomy affected by Ulcers
Post Gastric: Splenic A, Pancreas
L Curvature: L Gastric A
Duodenal: Gastroduodenal A
Virchows Triad of Clotting
Hypercoaguability (Surg/Trauma, Malig, Preg, Sepsis, Inflamm/Auto-Immune) Endothelial Inj (Atherosclerosis, Vasculitis, Thrombophlebitis) Haemostasis/Turbulent Blood flow (Immobility, AF/Arrhythmias, BradyC/HypoT, Venous Obstruct)
Acute LVHF Mx
(Sit Pt up) Morphine + Antiemetic O2 IV Furosemide 80mg SL GTN (+/- Isosorbide Nitrate +/- CPAP)
Stroke Ix + Mx
Non-contrast CT Head:
- If Haem: Refer to Neurosurg (Do not give Aspirin/Thrombolysis), Reverse Anticoags
- If Ischaemic: Aspirin 300mg
(If < 80yo + Pc < 4.5hrs => Thrombolysis: IV Alteplase)
