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4th Year > ACC > Flashcards

ACC Flashcards

1
Q

Things to do in A (5)

A 
Airway patency - suction and maintain
Are they talking?
15L/min O2
C-spine check
Tracheal position
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2
Q

Things to do in B (8)

A 
Chest injuries and expansion
Respiratory Effort
RR
O2 Sats
Auscultate and percuss
ABG
CXR
PEFR
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3
Q

Things to do in C (7)

A 
Cap refill
Urine output (+confusion)
Pulses
BP
Auscultate
IV access - bloods and fluids
ECG (+ echo)
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4
Q

Likely bloods needed (8)

A 
FBC
U+E
LFT
Clotting
CRP
X-match
Group and Save
Cultures
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5
Q

Things to do in D (4)

A

GCS
BGL
Pupils
Temperature

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6
Q

Things to do in E (3)

A

Quick exposure
Abdo/neuro/spinal exam
Get help etc.

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7
Q

STEMI Management

A

MONAP

Morphine 1-10mg + Metoclopramide 10mg
Oxygen
GTN spray 2 puffs
Aspirin 300mg
PCI within 12hrs/90mins of Dx - give Ticagrelor and LMWH (Fondaparinux) before
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8
Q

What if PCI is impossible?

A

Fibrinolysis with Altepase and LMWH

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9
Q

NSTEMI Management

A

MONAG

Morphine 1-10mg + Metoclopramide 10mg
Oxygen
GTN spray 2 puffs
Aspirin 300m
Grace Score
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10
Q

What does the Grace score tell us?

A 
<1.5% = Clopidogrel 300mg
1.5-3% = Fondaparinux 2.5mg
>3% = PCI within 96hrs with Clopidogrel, LMWH and IV Eptifibatide
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11
Q

Post N/STEMI Management

A

COBRAS + lifestyle

Clopidogrel 75mg OD
Omega 3
Bisoprolol 2.5mg OR
Ramipril 2.5mg OD
Aspirin 75mg OD
Statin (Atorvastatin 80mg OD)
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12
Q

Which LMWH should be used with renal impairment?

A

Enoxaparin

NOT Fondaparinux

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13
Q

Post-PCI anticoagulation

HAS-BLED 0-2

A 
0-6m = Warfarin, Aspirin, Clopidogrel
6-12m = W + A or C
Lifelong = Warfarin/NOAC?
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14
Q

Post-PCI anticoagulation

HAS-BLED >2

A 
0-4wks = W, A, C
1-12m = W + A or C
Lifelong = Warfarin?
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15
Q

When to PCI (4)

A

<12hrs since onset
New LBBB or ongoing chest pain after Tx
ST elevation >1mm in 2 limb leads
ST elevation >2mm in 2+ consecutive chest leads

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16
Q

Blood markers for MI

A

Troponin T & I - increases at 3hrs, peak at 24hrs, can’t perform within 2hrs (might be 6hrs), <5 rules out MI
Creatinine Kinase - increases at 4-8hrs, peaks at 24hrs

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17
Q

Aortic dissection Sx

A

Sudden, severe, tearing chest pain
Radiates into back
Syncope
Dyspnoea

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18
Q

Types of Aortic Dissection

A 
70% = Ascending Aorta = Type A (35% mortality)
30% = Descending Aorta = Type B (15% mortality)

Debakey I = Asc + Desc
Debakey II = Asc only - associated with MI + neuro Sx
Debakey III = Desc only - associated with AKI

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19
Q

Aortic Dissection risk factors

A

Male >50yrs
HTN
Aortic stenosis/bicuspid valve

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20
Q

Aortic Dissection CXR findings (5)

A 
Wide mediastinum
Double knuckle aorta
R-side tracheal deviation
Pleural effusion L>R
Separated aortic wall
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21
Q

Diagnostic test for Aortic Dissection

A

CT angiogram

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22
Q

Aortic Dissection management

A

Treat as shock
IV Beta-blocker
Type A = open stent graft repair
Type B = endovascular repair

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23
Q

Signs of acute severe asthma

A

PEFR 33-50%
HR >110
RR >25
Incomplete sentences

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24
Q

Signs of acute life-threatening asthma

A 
PEFR <33%
Sats <92%
Silent chest
Poor respiratory effort
Cyanosis
Confusion
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25
Q

Sign for near fatal asthma

A

PaCO2 >6 = may need mechanical intervention

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26
Q

Management of Acute Asthma

A

O SHIT ME

Oxygen 15L
Salbutamol 5mg O2-driven nebs, repeat every 10-15mins
Hydrocortisone 200mg/Prednisolone 40mg
Ipratropium bromide 500mcg neb if severe/life-threatening
Theophylline 5mg/kg IV bolus if no improvement
Mag Sulph 2g IV

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27
Q

Management of COPD exacerbation

A

O SHIT

Oxygen 15L - careful not to drive sats too high
Salbutamol 5g + IpBromide 500mcg air-driven nebs, repeat 10-15mins
Hydrocortisone 200mg IV/Prednisolone 40mg
Aminophylline 5mg/kg bolus if no improvement (CO2 increasing, GCS decreasing)

BiPAP if unable to expel adequate CO2 -> pH increasing

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28
Q

Infective exacerbation of COPD Abx

A

Amoxicillin, Doxycycine or Erythromycin

Often A+D 7 days

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29
Q

CAP organisms

A 
Strep pneumoniae
Mycoplasma
Moraxella catarrhalis
S aureus
HiB
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30
Q

HAP organisms

A

Gram -ve enterbacteria
S aureus
Pseudomonas
Klebsiella

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31
Q

What is CURB65?

A 
Confusion - AMTS <8
Urea >7
RR >30
BP <90 systolic
>65yrs old
0-1 = Home
2 = Admit
3+ = ICU
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32
Q

What is temporal arteritis?

A

Immune-mediated vasculitis of posterior ciliary arteries

Associated with polymyalgia rheumatica

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33
Q

Why is temporal arteritis important to diagnose?

A

Can cause ischaemic optic neuritis -> vision loss

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34
Q

Who should you suspect temporal arteritis in?

A

> 50yr old with new acute headache

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35
Q

What are the features of temporal arteritis?

A

Diffuse superficial headache and scalp tenderness, esp over temporal artery
Jaw claudication - worse with eating
Distended throbbing temporal artery
Transient vision loss

Nausea
Fever
Sweat

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36
Q

What investigations do you need for temporal arteritis?

A

Temporal artery biopsy = definitive

ESR and CRP both increased

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37
Q

What is the management of temporal arteritis?

A

Oral prednisolone 60mg daily
Vision changes = seen same day
No vision changes = assess response in 48hrs
Reduce dose over several months, Tx for 1-2yrs

Also start Aspirin and PPI daily

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38
Q

What is a venous sinus thrombosis?

A

Thrombosis in brain venous channels

Most commonly sagittal sinus (47%) and transverse sinus (35%)

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39
Q

Who is at risk of a venous sinus thrombosis?

A 
Thrombophilia
Nephrotic syndrome
Pregnancy
COCP
Malignancy
Chronic inflammation etc.
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40
Q

What are the features of a venous sinus thrombosis?

A 
Headache
Vomiting
Seizures
Increased ICP - papilloedema, risk of herniation
Vision changes

May present like stroke
May cause haemorrhage

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41
Q

What investigations are needed for a venous sinus thrombosis?

A

Head CT/MRI
D-dimer
APTT
Clotting/thrombophilia screen

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42
Q

What is the management of venous sinus thrombosis?

A

LMWH then Warfarin (INR 2-3)

Thrombolysis with altepase if not resolved in 2(?) days

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43
Q

What is likely to cause an extradural haemorrhage?

A

Temporal bone fracture -> damage to Middle Meningeal Artery

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44
Q

What happens with MMA bleed?

A

Lose consciousness, return to full consciousness, deteriorate again with raised ICP

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45
Q

Where is a subdural haemorrhage most likely to occur from?

A

Bridging vein between brain and dura

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46
Q

5 signs of basal skull fracture

A

Panda eyes - orbital bruising
Battle sign - mastoid bruising (takes days to appear)
Subconjunctival haemorrhage
Bleeding from auditory meatus/haemotympanum
CSF otorrhoea/rhinorrhoea

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47
Q

When should you perform a head CT within <1hr following head injury? (7)

A 
GCS <13 initially
GCS <15 2hrs post-injury
Suspected skull fracture
Signs of basal skull fracture
Focal neurological deficit
Post-trauma seizure
>1 episode of vomiting
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48
Q

When should you perform a head CT within 8hrs following head injury? (5)

A

Age >65yrs
Hx of bleeding/clotting disorders
On Warfarin
Dangerous mechanism of injury eg. high fall, hit by car
>30mins retrograde amnesia of events prior to injury

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49
Q

When should you perform a head CT within <1hr following head injury on a CHILD? (8)

A 
Suspicion of NAI
GCS <14 initially
GCS <15 <1yr old or 2hrs post-injury
<1yr with bruise/swelling/laceration >5cm on head
Suspected fracture or tense fontanelle
Focal neurological deficit
Post-trauma seizure
2+ of: drowsy, LoC, amnesia >5mins, 3+ episodes of vomiting, dangerous mechanism
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50
Q

What is Cushing’s reflex?

A

Triad of:

  • Increased BP
  • Irregular breathing
  • Bradycardia

Late sign of raised ICP - may indicate imminent brain herniation

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51
Q

What pupil signs may you get with raised ICP?

A

Ipsilateral pupil dilation

Due to temporal lobe herniation pressing on oculomotor nerve

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52
Q

What are the high risk factors for C-spine injury? (3)

A

> 65yr old
Dangerous mechanism
Extremity paraesthesia
(Any of these = 3-view C-spine X-ray within 1hr)

‘Sixty five, Fast drive, Sense deprive - Image if alive’

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53
Q

What are the low risk factors for C-spine injury? (5)

A 
Simple rear-end MCV
Delayed neck pain
Sitting in ED
Ambulatory at ANY TIME
Absence of midline tenderness
(Any of these = low risk, none of these = C-spine X-ray)

‘Slow wreck, Slow neck, Sitting down, Walking ‘round, C-spine fine - Range the spine’

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54
Q

What is if they are low-risk for C-spine injury?

A

Range of movement
Can they rotate their neck 45 degree each way
Yes = fine, No = C-spine X-ray

‘If you can look both ways, you can cross the road… without imaging’

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55
Q

What is the prognosis of a space-occupying lesion?

A

<50% survival at 5yrs

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56
Q

What are the features of primary brain tumours?

A

Headache - worse when lying, bending, coughing, wakes patient up
Vomiting
Increased ICP - papiloedema, I/L pupil dilation etc
Decreased GCS (late)
Focal neurology - CN VI palsy most common (Lateral Rectus palsy)
Behaviour changes
Visual disturbances
Seizures <50%

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57
Q

What investigations are necessary for a brain tumour?

A

CT +/- MRI

Avoid LP due to coning risk

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58
Q

What is the management of brain tumours?

A

Dexamethasone 4mg TDS for raised ICP
Surgical removal if possible + chemo-radiotherapy
Seizure prophylaxis

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59
Q

What would localise a lesion to the temporal lobe? (4)

A

Amnesia
Hallucination of sound/smell
Dysphasia
Contralateral homonymous hemianopia

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60
Q

What would localise a lesion to the frontal lobe? (4)

A

Contralateral hemiparesis
Personality change
Broca’s aphasia
Unilateral anosmia

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61
Q

What would localise a lesion to the parietal lobe? (3)

A

Contralateral hemisensory loss
Astereogenesis - inability to recognise objects from touch alone
Sensory inattention

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62
Q

What would localise a lesion to the occipital lobe?

A

Contralateral visual field loss

Diplopia/polyopia

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63
Q

What would localise a lesion to the cerebellum?

DASHING

A 
DASHING
Dysdiadochokinesis + past-pointing
Ataxia
Slurred speech
Hypotonia
Intention tremor
Nystagmus
Gait abnormalities
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64
Q

What is meningitis?

A

Inflammation of the meninges

Often viral/bacterial

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65
Q

What are the common bacterial causes by age-group?

A 
Neonate = Group B Strep
>3m = N. Meningitidis, Strep pneumoniae, HiB
Adults = N. Meningitidis (G-), Strep. pneumoniae (G+)
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66
Q

What are the common viral causes?

A

Enterovirus
HSV1
Coxsackie

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67
Q

What are the features of meningitis?

A

Headache
Photophobia
Neck stiffness
Purpuric non-blanching rash (septic)

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68
Q

What are the features of meningitis in an infant?

A 
Drowsy/decreased GCS
Vomiting
Irritable
Feverish
Seizures
Opisthotonus
Bulging fontanelle
High-pitched crying
Not feeding
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69
Q

What will an LP show for viral meningitis?

A

Clear CSF
Normal plasma glucose ratio
Normal protein
15-1000 LYMPHOCYTES

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70
Q

What will an LP show for bacterial meningitis?

A

Cloudy CSF
Low glucose, <50% of plasma
High protein, >1g/L
10-5000 NEUTROPHILS

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71
Q

What will an LP show for TB meningitis?

A

Cloudy CSF with fibrin web
Low glucose, <50% of plasma
High protein, >1g/L
10-1000 LYMPHOCYTES

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72
Q

What is the management of bacterial meningitis?

A

Benzylpenicillin IM in the community

<3m = IV 2g cefotaxime + IV ampicillin (Listeria cover)
>3m = IV 2g cefotaxime + dexamethasone once confirmed bacterial with LP
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73
Q

What is the management of viral meningitis?

A

Supportive

Self-limiting after 4-10 days

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74
Q

What is the San Francisco Syncope Rule?

A

CHESS

CHF Hx
Haematocrit <30%
ECG abnormality
SoB
Systolic BP <90

Any of these = high-risk of adverse outcome

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75
Q

What types of stroke are there?

A 
85% = ischaemic
15% = haemorrhagic
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76
Q

What are the features of a stroke?

A

Sudden onset focal neurology lasting for >24hrs

BEFAST
Balance problems
Eye - visual disturbance
Face drooping
Arm weakness
Speech slurred
Time to call 999
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77
Q

What is the Rosier score? (7)

A 
One point for each of:
Contralateral arm weakness
Contralateral leg weakness
Ipsilateral facial weakness
Slurred speech
Visual field defect
Seizure (-1)
LoC/syncope (-1)

1+ = likely having a stroke

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78
Q

What bloods do you need if you suspect a stroke?

A 
FBC
U&amp;E
LFT
Glucose
Lipids
Clotting
Cardiac enzymes
Group and Save
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79
Q

When do you need a head CT within 1hr if you suspect a stroke? (5)

A 
<4hrs since Sx - thrombolysis window
GCS <13
Risk of bleeding - oral anticoagulation or bleeding disorder
Severe headache at onset
Evidence of raised ICP
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80
Q

What else might you need if you suspect and anterior circulation stroke? (3)

A

Echo
Carotid doppler
24hr ECG

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81
Q

What is the initial management of a stroke?

A

Head CT
Thrombolysis if <4hrs with Altepase 900mcg/kg (max 90mg) IV over 60mins
SaLT to assess swallow, NBM in meantime
Admit to stroke ward

Haemorrhagic = some suitable for surgery

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82
Q

What is the management of a TIA?

A

Within 1 week = 300mg Aspirin and urgent assessment

>1 week ago = assessment with 7 days

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83
Q

What is secondary prevention of strokes?

A 
Triple anti + lipids
Antiplatelet = Clopidogrel 75mg OD
Anti-HTN = BP control
Anti-coagulation = Warfarin/NOAC
Lipids = Statin

Influenze vaccine
No driving for 1 month

84
Q

What is in the HAS-BLED score?

A 
Hypertension
Abnormal renal or liver function
Stroke Hx
Bleeding disorder
Labile INR
Age >65
Drugs or alcohol

Max score = 9, >2 = high risk of bleeding

85
Q

How does DKA arise?

A

Lack of insulin -> Low cellular glucose uptake -> Ketone metabolism used

86
Q

Who gets DKA?

A

Younger females, unknown diabetes Hx

87
Q

What are the features of DKA?

A 
Polyuria and polydipsia
Severe dehydration
Nausea and vomiting
Hyperventilation - Kussmaul breathing
Pear-drop breath
Cramps
Drowsiness
88
Q

What investigations should you do if you suspect DKA?

A

Blood Glucose - very high
U&E - raised urea, raised Na+, raised/lowered K+
FBC - may have raised WCC
Plasma osmolarity
ABG/VBG - metabolic acidosis with respiratory compensation
Urine - shows ketones +++
ECG, CXR, MSU, cultures

89
Q

What is the broad management of DKA?

A

ABCDE

Fluid replacement
Insulin infusion

90
Q

What is the fluid replacement regime for DKA?

A 
1L 0.9% NaCl over 1hr
1L NaCl + K+ over 2hrs
1L NaCl + K+ over 2hrs
1L NaCl + K+ over 4hrs
Continue until rehydrated

K+ = 40mmol/L KCl provided K+ 3.5-5.5
When glucose <14, add 10% glucose 125ml/hr

If Na+ >160 = consider 0.45% saline for first 3L
K+ given to prevent insulin-induced hypokalaemia

91
Q

What is the insulin infusion regime for DKA?

A

50 units ACTRAPID insulin IV at 0.1 units/kg/hr

92
Q

When can you transfer a DKA patient to recovery?

A

pH >7.3

Blood ketones <0.6mmol/L

93
Q

What is the management of a seizure lasting >5mins in an adult?

A

IV Lorazepam 4mg over 2mins OR PR Diazepam 10mg
Repeat at 10mins if no effect

If alcoholism/malnourished = Pabrinex 2 pairs IV over 10mins

94
Q

What is the management of a seizure lasting >20mins in an adult?

A

IV Phenytoin 20mg/kg over 20mins OR IV Phenobarbital 10mg/kg over 10mins

Call anaesthetist

95
Q

What is the management of a seizure lasting >40mins in an adult?

A

Rapid Sequence Induction with Thiopentone

96
Q

What causes a subarachnoid haemorrhage?

A

Rupture of Berry aneurysm in Circle of Willis

5% of all haemorrhagic strokes

97
Q

What are the features of a SAH?

A

Thunderclap headache - sudden and severe, worse upon bending neck
Radiates behind occiput
Nausea, vomiting
Impaired consciousness/drowsy
Early focal neurology - most often CN III palsy

98
Q

What is the Hunt and Hess scale?

A

Assesses severity of SAH
Grade 1 = asymptomatic, <5% mortality
Grade 2 = mod headache, no neurological deficit except for CN palsy
Grade 3 = drowsiness, confusion, mild focal deficit
Grade 4 = stuporous, mod hemiparesis, early decerebrate
Grade 5 = deep coma, decerebrate, 70% mortality

Surgery for grades 1 and 2

99
Q

What investigations may be useful for SAH?

A

Head CT with contrast = 95% diagnostic within 24hrs
LP >12hrs after onset if Hx suggestive but CT -ve - shows bloody than xanthochromic CSF
CT angiogram - identify location of aneurysm

100
Q

What is the immediate management of SAH?

A

Urgent neurosurgery

Correct hypotension
Nimodipine to reduce vasospasm
IV mannitol 200ml of 10% to reduce ICP

101
Q

What are the features of vasovagal syncope?

A 
Onset over a few seconds
LoC usually <2mins
Preceding visual disturbance, light headedness, sweating
Prompt full recovery
Cannot occur lying down
102
Q

What investigations are necessary for a vasovagal syncope?

A

ECG - exclude arrhythmias
FBC, U&E, BGL
CVS + neuro exam
Lying and standing BP

103
Q

What are the ECG red flags following LoC? (3)

A

Conduction abnormality eg. BBB, heart block
Long or short QT
ST or T wave abnormalities

104
Q

What are the red flags following LoC? (6)

A 
ECG red flags
Hx or signs of heart failure
Transient LoC on exertion
New unexplained breathlessness
FHx of sudden cardiac death <40yrs
Heart murmur

Any of these = urgent CV assessment within 24hrs

105
Q

What are the features of an uncomplicated faint? (3 P’s)

A

Posture - prolonged standing
Provoking factors - pain, medical procedure
Prodromal Sx - hot, sweating

106
Q

What are the features of simple alcohol withdrawal?

A 
Within 12hrs of stopping
Anxiety and restlessness
Tremor
Tachycardia
Insomnia
Sweating
107
Q

What are the features of Delirium Tremens?

A 
72hrs after stopping
Same as simple withdrawal + autonomic hyperactivity
Hyperreflexia
Gross tremor
Dilated pupils
Confusion
Hallucinations
108
Q

What is Wernicke’s disease?

A

Triad of:

  • Ophthalmoplegia (nystagmus, CN VI palsy)
  • Ataxia (cerebellar)
  • Confusional state
109
Q

What is Korsakoff’s syndrome? (4)

A

Confusion
Pyschosis
Amnesia
Confabulation

110
Q

What is alcoholic ketoacidosis?

A

Stop drinking -> repeated vomiting and starvation -> dehydration and fatty acid breakdown

111
Q

What are the 7 signs of alcohol dependency?

A

TWRPCHR

Tolerance
Withdrawal
Repertoire
Primacy
Compulsion
Harm
Reinstatement
112
Q

What is the treatment of alcohol withdrawal?

A

Chlordiazepoxide 10-30mg decreasing daily over 7 days
Pabrinex to prevent WKS
- Nourished and well = 300mg thiamine oral daily
- Malnourished = IM OD 3-5 days

113
Q

What is the treatment of delirium tremens?

A

In hospital
IV diazepam PRN for sedation
IV pabrinex to prevent WKS
Treat seizures as per

114
Q

What drugs are available to maintain alcohol abstinence?

A

Acamprosate - reduce cravings

Disulfiram - adverse alcohol reactions

115
Q

How is paracetamol usually metabolised?

A

Inactivated by conjugation in the liver

116
Q

How does paracetamol OD become toxic?

A

Overruns conjugation
Produces NAPQI which is inactivated by glutathione
When glutathione runs out = toxic NAPQI remains
Causes necrosis of liver and kidney tubules

117
Q

What are the features of paracetamol OD?

A

1st 24hrs = asymptomatic or N&V
After 24hrs = hepatic necrosis -> RUQ pain and jaundice
Then encephalopathy, hypoglycaemia, oliguria, renal failure

118
Q

When should you check paracetamol level?

A

4 hours after OD

119
Q

What blood test best predicts liver damage?

A

INR

120
Q

What is the treatment regime for paracetamol OD?

A 
Wait 4hrs/for paracetamol level then give Parvalex
1st bag over 1hr
2nd bag over 4hrs
3rd bag over 16hrs
Continue until INR <1.3
121
Q

When do you stop treatment of paracetamol OD?

A

INR <1.3

122
Q

What do you do if they present <4hrs post-paracetamol OD?

A

Wait until 4hrs then measure levels and start Tx

123
Q

What do you do if they present 4-8hrs post-paracetamol OD?

A

Wait for levels and start Tx

Maximum Parvalex efficacy in this window

124
Q

What do you do if they present 8-15hrs post-paracetamol OD?

A

Take paracetamol levels and start Tx before getting them back

125
Q

What do you do if they present >15hrs post-paracetamol OD?

A

Give Parvalex

Levels mean nothing here

126
Q

What do you do if they’ve had a staggered paracetamol OD?

A

Give Parvalex

Levels mean nothing here

127
Q

When to consider liver transplant after paracetamol OD?

A

pH <7.3
Lactate >3 after fluids, strongly consider if >3.5
All 3 of: Creatinine >300, INR >6.5, Grade III/IV encephalopathy

128
Q

What do you do if the patient has an allergic reaction to Parvalex?

A

Stop infusion
Give anti-histamine
Wait 30mins
Restart with a reduced dose

129
Q

What are the 6 P’s of ischaemic limbs?

A 
Pain
Pallor
Pulseless
Paraesthesia
Paralysis
Perishingly cold
130
Q

What would suggest an embolus as opposed to thrombus in acute ischaemic limb?

A

Acute onset
Suggestive source eg. AF
Clear ‘end’ to ischaemic area
No previous claudication

131
Q

What would suggest a thrombus as opposed to embolus in acute limb ischaemia?

A

Slow onset
No suggestive source
Previous claudication

132
Q

What is the management of acute limb ischaemia?

A 
Thrombus = heparinisation followed by angioplasty
Embolus = prompt embolectomy
133
Q

When must revascularisation occur by in acute limb ischaemia?

A

4-6hrs to prevent permanent necrosis and rhabdomyolysis, causing liver failure

134
Q

What investigations are important in acute limb ischaemia?

A 
Bloods - FBC, U&amp;E, CK, Coag
ECG
CXR
ABG
Urinalysis
Echo/angiogram if thrombus suspected
135
Q

What are the features of cellulitis?

A

Warm red painful skin with well-defined margin

136
Q

What are the serious complications of periorbital cellulitis? (4)

A

Central retinal vein occlusion
Optic nerve compression
Cavernous sinus thrombosis
Meningitis

137
Q

What organism would a would swab be likely to grow in cellulitis?

A

S aureus

138
Q

What is the treatment of localised cellulitis?

A

Oral flucloxacillin

2nd line = Clindamycin

139
Q

What is the treatment of systemic/above knee cellulitis?

A

IV fluclox/co-amox + benzylpenicillin

140
Q

What is the treatment of paediatric periorbital cellulitis and why is it important?

A

IV ceftriaxone

To prevent posterior spread causing meningitis, orbital cellulitis or cavernous sinus thrombosis

141
Q

What investigation do you need if you suspect orbital cellulitis?

A

MRI to assess spread

142
Q

What are the features of a DVT?

A 
Leg pain
Calf swelling >3cm larger than contralateral
Warmth
Tenderness
Dilated superficial veins
143
Q

What investigations do you need for a DVT?

A

Measure calves
D-Dimer
Well’s score - determines need for USS
USS

144
Q

What are the components of the Well’s score? (10)

A 
Cancer (active or last 6m)
Recent immobilisation/paralysis
Bed-ridden for 3 days or major surgery in last 12wks
Localised tenderness over deep veins
Entire leg swollen
Calf swelling >3cm
Pitting oedema in Sx leg only
Nonvaricose collateral superficial veins
Previous DVT
Alternate Dx at least as likely (-2)

0 = low risk, 1-2 = moderate, 3+ = high-risk

145
Q

What is the treatment of DVT?

A

LMWH for 1 week

Oral anticoagulants for 3 months

146
Q

What is gout?

A

Deposit of crate crystals in a joint

90% caused by impaired excretion

147
Q

What is a Tophi?

A

Deposit of crate crystals and other substances at the surface of joints, typically seen in gout

148
Q

What are the features of gout?

A

Sudden agonising red swelling and pain of big toe MPJ

149
Q

What are some precipitating factors of gout? (6)

A 
Dehydration
Diuretic
Too much food
Trauma
Surgery
Infection
150
Q

What investigations do you need for gout?

A

Joint aspirate
Serum urate >600mmol
Joint xray
Bloods - FBC, LFT, ESR, CRP

151
Q

What does the joint aspirate of gout show?

A

Yellow fluid
WCC 2,000-50,000
Bifringent crystals

152
Q

What does the joint xray of gout show?

A

Lytic lesions

153
Q

What is pseudo gout?

A

Sx of gout but joint xray shows chonedrocalcinosis = single white line
Caused by calcium pyrophosphate crystals

154
Q

What is the initial treatment of gout?

A

NSAIDs eg. diclofenac
PPI
Colchicine
Steroids - for patients who cannot take NSAIDs or Colchicine

155
Q

What is the prophylaxis for gout?

A

Allopurinol - may trigger an attack so wait 3wks before starting

Avoid purine-rich foods eg. red wine, alcohol, fish, red meat
Avoid aspirin

156
Q

What is a major risk of septic arthritis?

A

Complete joint destruction within 24hrs

157
Q

What organism causes septic arthritis?

A

S aureus

158
Q

What organism causing septic arthritis would cause pustules on distal limb and polyarthralgia?

A

N. gonorrhoea

159
Q

What are the features of septic arthritis?

A

One hot red swollen immobile joint, extremely painful

Systemic features eg. fever, rigors

160
Q

What investigations do you need with septic arthritis?

A

Synovial fluid MC+S
Blood cultures
Bloods - FBC, CRP
Joint xray - may show destruction

161
Q

What is the initial management of septic arthritis?

A

Drainage +/- prosthesis removal
Splinting
IV flucloxacillin 4-6wks
(IV Cefotaxime if gonococcal)

162
Q

What is an abdominal aortic aneurysm?

A

Permanent dilation of aorta >3cm

163
Q

Where are most AAAs?

A

Generally infrarenal

Often saccular/fusiform

164
Q

Who gets AAAs?

A

Male smokers >50 with HTN and hyperlipidaemia

165
Q

What are the features of a ruptured AAA?

A 
Abdominal pain radiating into back/groin
Expansile and pulsatile abdominal mass
Grey-Turner's and Cullen's signs = Retroperitoneal bleeding
Drowsy/reduced GCS
Low BP and absent femoral pulse
Shock
166
Q

What investigations do you need for an AAA?

A

USS
FBC, U&E, LFT, G&S, X-match, ESR, CRP
CXR
ECG

167
Q

When do you repair an unruptured aneurysm?

A

If >5.5cm on USS

  1. 0-4.5cm = US annually
  2. 5-5.5cm = US 3 monthly
168
Q

How is an AAA repaired?

A

Prophylactic surgery = EVAR

Ruptured surgery = aortic clamping and Dacron graft

169
Q

What are 4 causes of bowel perforation?

A

Intestinal obstruction
Peptic ulcer disease
Diverticulitis
Appendicitis

170
Q

What are the features of bowel perforation?

A

Rapid onset sever abdominal pain
Acute pyrexia and vomiting
Peritonitis
May have absent bowel sounds

171
Q

What does an abdominal xray of a perforated bowel show?

A

Pneumoperitoneum = air under diaphragm

172
Q

What investigations do you need for a bowel perforation?

A

CXR/AXR
ABG - acidotic
Bloods - increased WCC, amylase, lactate
Urgent CT once stable

173
Q

What is the initial management of a bowel perforation?

A 
Fluids
Morphine
Cyclizine
Abx - co-amoxiclav + metronidazole (?cef,met,gent)
NBM - NG tube
Surgical repair
174
Q

What causes an appendicitis?

A

Obstruction of lumen -> inflammation and oedema (6-12hrs) -> necrosis and perforation (24-36hrs) -> peritonitis

175
Q

What are the early features of an appendicitis?

A

Central colicky pain worse with movement
N, V & D
Mild fever

176
Q

What are the later features of an appendicitis?

A 
McBurney's sign = RIF pain
Rigid abdomen with involuntary guarding
Rovsing's sing
Mucus-coated faeces
Swinging pyrexia
177
Q

What investigations may be useful for appendicitis?

A

Urine dip = increased nitrates + WCC
Bloods = increased WCC, CRP + neutrophilia >75%
USS = 90% sensitive

178
Q

What is the treatment of acute appendicitis?

A

Abx = cef+met +/- gent
Appendectomy

Fluids, analgesia, antiemetic, NBM

179
Q

What are the causes of pancreatitis?

I GET SMASHED

A 
Idiopathic
Gall stones
Ethanol
Trauma
Steroids
Mumps
Autoimmune
Scorpions
Hyperlipid/Ca/TF -aemia
ERCP
Drugs eg. diuretics, tetracyclines
180
Q

What are the features of acute pancreatitis?

A

Constant epigastric pain radiating to back
Worse with alcohol, relieved by sitting forward
Epigastric guarding + rigidity
Anorexia & vomiting
Decreased bowel sounds
GT and Cullun’s signs

181
Q

What is diagnostic of acute pancreatitis?

A

Amylase >600

182
Q

What may an AXR show with acute pancreatitis?

A

Retroperitoneal fluid = no psoas shadow

183
Q

What is the modified Glasgow Score?

A

PANCREAS

PaO2 <8
Age >55yrs
Neutrophils >15
Calcium <2
Renal function: urea >16
Enzyme: amylase >600
Albumin >32
Sugar: glucose >10
184
Q

What is the initial management of acute appendicitis?

A 
Fluids + O2
IM Pethidine/other analgesia
Antiemetic
Abx
Catheter
NBM + NGT
LMWH
Surgery
185
Q

Where do bowel obstructions occur?

A

Sigmoid colon = young

Caecal volvulus = old

186
Q

What will an AXR show in a small bowel obstruction?

A

Step ladder appearance = regular bands

187
Q

What will an AXR show in a large bowel obstruction?

A

Haustral fold and faecal mass

188
Q

What will an AXR show win all bowel obstruction?

A

Distended loops
Gas absent distal to blockage

Air in billiary tree = gallstone ileus

189
Q

What are the features of a bowel obstruction?

A 
Sever colicky abdominal pain
Distended abdomen
Tinkling bowel sounds
Constipation - absolute
Empty rectum on PR
N&amp;V - may be bilious
190
Q

What causes a small bowel obstruction? (3)

A

Adhesions
Hernia
Tumours

191
Q

What causes a large bowel obstruction? (3)

A

Malignancy
Diverticular disease
Volvus

192
Q

What is the management of a bowel obstruction?

A

DRIP and SUCK
NBM + NG tube to decompress bowel
IV fluids to rehydrate

IV morphine and cyclizine (avoid metoclopramide)
Neostigmine in paralytic obstruction?

193
Q

What is acute cholecystitis?

A

Acute inflammation of the gall bladder

90% due to gallstones at neck of GB

194
Q

What are the classic risk factors for gallstones?

A 
Fair
Fat
Female
40
Fertile
195
Q

What do the bloods of cholecystitis show?

A

Increased WCC, CRP, glucose, amylase

Derranged LFTs

196
Q

What is the most important investigation for cholecystitis?

A

USS
Shows dilated CBD >5cm, gallstones and thickened GB wall
Tender on pressing probe

197
Q

What causes cholangitis?

A

Biliary stasis from stones (90% cholesterol stones)

Causes infection, generally E. coli, Klebsiella, S faecalis, anaerobes

198
Q

What age range is generally associated with cholangitis?

A

50-60yrs

199
Q

What is Charcot’s Triad?

A

RUQ pain
Fever
Jaundice

200
Q

What is Reynolds Pentad?

A 
RUQ pain
Fever
Jaundice
Shock
Altered mental state
201
Q

What are the features of cholecystitis?

A

RUQ colicky pain radiating to R shoulder and worse with fatty foods
Murphy’s sign = breathing in while pressure on RUQ increases pain
Fever
N&V
Sometimes obstructive jaundice

202
Q

What is the initial management of cholecystitis?

A

NBM, analgesia
Abx = co-amoxiclav
Consider urgent cholecystectomy or T-tube drainage

203
Q

What is the initial management of cholangitis?

A

Essentially the same as cholecystitis

Drainage is the definitive Tx

204
Q

When is biliary colic worse?

A

In the mornings and after food

205
Q

What 3 types of gallstones are there?

A

Cholesterol
Bile pigment - from bile stasis = brown, from haemolytic = black
Mixed

206
Q

What are the features of obstructive jaundice?

A

Yellow
Dark urine
Steatorrhoea

4th Year (15 decks)

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