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PACES Revision Cards > Acute Medicine > Flashcards

Acute Medicine Flashcards

1
Q

Headache Red Flags

A

Thunderclap = sudden onset, maximal within 5 minutes

New onset neurological deficit

New cognitive dysfunction/personality change

History of malignancy (especially if < 20)

Immunosuppression e.g. HIV

Impaired GCS

Recent head injury (< 3 months)

Triggered by cough/valsalva
Worse on waking/lying down

+ sudden LoV/painful eye (?GCA ?AACG)

Substantial change in usual headaches

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2
Q

Differentials for Thunderclap Headache

A

Subarachnoid haemorrhage
Internal Carotid Artery Dissection
ICH
Pituitary Apoplexy

CVST

Reversible Cerebral Vasoconstriction Syndrome
Acute hypertensive crisis
Posterior Reversible Leucoencephalopathy

Primary cough, sexual, and exertional headache

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3
Q

Causes/RFs for SAH

A

85% of non-traumatic SAH = due to aneurysms in the circle of Willis

5% = AVMs/Tumours/ Vasculitides/Arterial dissection

RFs
- FHx
- PKD
- CTD e.g. Ehler Danlos, Marfan’s, Pseudoxanthoma elasticum
- Vascular RFs = HTN, smoking
- Cocaine/meth use
- IE with mycotic aneurysms

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4
Q

Investigating SAH

A

CTH
- if <6 hours after onset and negative = excluded!
Lumbar Puncture
- >6 hours onset
CT Angiogram if xanthochromia/RBC positive LP but CTH negative

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5
Q

Management of SAH

A

ABCDE
Depends on cause
Refer to neurosurgical team - ?coil vs clip
BP control
Supportive Rx (?ICU/HDU)

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6
Q

Complications of SAH

A

Vasospasm (4-10days post)
Hydrocephalus (20%)
- Raised ICP = CN palsies, reduced GCS, Cushing’s Triad
Rebleeding (17%)
Seizuers
Arrhythmias
Hyponatraemia (SIADH vs Salt-wasting)
Death

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7
Q

When to perform a CT head prior to LP (for meningitis)?

A

Consider CTH prior to LP if:
- > 60
- Focal neurology deficit
- Reduced GCS
- Seizures
- Features of raised ICP e.g. papilloedema
- History of SoL/cancer/immunosuppression

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8
Q

Indications for Non Traumatic CT Head

A

Confusion/Reduced GCS and known ICH/cerebral infarct/SoL/CNS infection

New focal neurological deficit e.g. stroke

Thunderclap headache

New headache and features of raised ICP e.g. papilloedema

New/worsening headache and history of cancer/immunosuppresion/pregnancy or >50

1st Seizure or change in seizure pattern

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9
Q

Management of Migraines

A

CONSERVATIVE
- Avoid exacerbating factors/triggers e.g. cut out all caffeine
- Sleep hygiene
- Education/reassurance

MEDICAL
- Prophylatic Rx e.g. propanolol, candesartan, topiramate (avoid if trying to get pregnant!)
- Rescue Rx = simple analgesia, triptans (avoid if IHD)
- Do NOT give COCP

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10
Q

Management of Cluster Headache

A

Acute Attack = triptans (SC or nasal), ?high flow oxygen

Prophylaxis = verapamil or lithium

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11
Q

Definition of HTN

A

> 135/85 = Stage 1 Hypertension (confirmed with ambulatory/home BP monitoring)

> 150/95 = Stage 2 Hypertension

> 180/120 = Severe/Malignant HTN (depends if features of End Organ Damage present)

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12
Q

When would you treat stage 1 HTN?

A

1) If > 80

2) If <80 AND
- Evidence of end organ damage
- CVD
- Renal disease
- Diabetic
- Q Risk >10%

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13
Q

Outline the management of Stage 2 HTN

A

If < 55 or T2DM
- ACEI first line

If >55 / Afro-Caribbean ethnicity
- CCB first line

2nd line = ACEI + CCB / ACEI + diuretic

3rd line = ACEI + CCB + diuretic

4th line = refer to specialist ?spironolactone ?alpha blocker ?beta blocker

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14
Q

When should we consider Secondary HTN?

A

If <40 and lack risk factors for HTN (e.g. CKD) or their HTN is resistant to treatment

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15
Q

Causes of Secondary HTN

A

ENDOCRINE
- Primary hyperaldosteronism (Conn’s)
= Most common cause
- Cushing’s syndrome
- Phaeochromocytoma
- Acromegaly
- Thyrotoxicosis
- Congenital Adrenal Hyperplasia

RENAL
- Glomerulonephritis
- Adult PKD
- Renal artery stenosis

Carcinoid syndrome

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16
Q

How would you investigate someone for Secondary HTN?

A

Bedside
- ECG
- Fundoscopy
- Urine dip

Bloods
- Routine FBC, U&Es, glucose, lipids

Renal USS

Further Ix tailored by underlying suspicion of cause
- Renin:Aldosterone ratio
- Dexamethasone Suppression Test
- TFTs
- OGTT & IGF1
- ?Renal angiogram

17
Q

Define Acute Severe Hypertension.

How would you manage a patient with Acute Severe HTN?

A

BP > 180/120

No evidence of acute end organ damage/grade III or IV retinopathy

Rx =
1) 24 hour ambulatory/home BP monitoring
2) Arrange follow up within 7 days
3) If confirmed persistent HTN = start treatment

18
Q

Define Malignant HTN

How would you manage a patient with Malignant HTN?

A

A.k.a Accelerated HTN

BP >180/120 with signs of retinal haemorrhage +/- papilloedema

No other signs of Acute End Organ damage

Rx
1) Start treatment e.g. amlodipine
2) Shared decision making with patient - most can be discharged home with follow up e.g on ambulatory care with home BP monitoring

19
Q

Outline features which would make you concerned for a Hypertensive Emergency

A

Chest pain (?ACS)

(?Hypertensive encephalopathy/ICH/Stroke/SAH)
- Confusion
- Seizures
- Reduced GCS

Proteinuria
New AKI/deterioration in renal function

20
Q

HTN in Pregnancy

A

= Systolic >140 or diastolic > 90
(or increased by >30 (s) / >15 (d) since booking BP)

PRE-EXISTING HTN
- History of HTN before 20 weeks

GESTATIONAL HTN
- HTN occurring after 20 weeks
- Usually resolves after birth

PRE-ECLAMPSIA
- HTN & proteinuria > 20 weeks
- High risk pts given Aspiring 75mg OD from 12 weeks

21
Q

Features of Pre-eclampsia

A

Hypertension
Proteinuria
Headache
Visual disturbance, papilloedema
RUQ pain
Brisk reflexes

Seizures = ECLAMPSIA

22
Q

Treatment of Pre-Eclampsia

A

PO labetalol/nifedipine if BP >160/110

Optimum timing of delivery

If develop eclampsia = IV magnesium 4g

23
Q

Well’s Score - DVT

A

0 - DVT unlikely
1-2 = Do d-dimer
>3 = DVT likely, request USS

Active cancer (1)
Bedridden > 3 days/Major surgery <12 weeks ago (1)
Previous DVT (1)
Paralysis/plaster cast of that leg (1)

Calf swelling > 3cm (1)
Collateral (non varicose) superficial veins (1)
Entire leg swollen (1)
Tender along deep venous system (1)
Pitting oedema (1)

If alternative diagnosis as/more likely = - 2 points

24
Q

Wells Score - PE

A

<4 = PE unlikely, do d-dimer
>5 = PE likely, do CTPA

Previous DVT/PE = 1.5 points
Immobilisation >3 days/surgery in last 4 weeks = 1.5 points
Malignancy (received treatment in last 6 months/palliative) = 1

Clinical signs of DVT = 3
HR > 100 = 1.5
Haemoptysis = 1

If PE is number 1/equally likely diagnosis = +3

25
Q

CHA2DS2S Vasc Score

A

Determines risk of stroke with AF

C - CHF
H - HTN
A - Age: 65-74 = (1), >75 = (2)
D - Diabetes
S2 - Stroke/TIA = (2)
S - Sex: M = (0), F = (1)

Vasc = Vasculopathy e.g. IHD, PVD

                                 M            F Low Risk                      0             1 Moderate Risk            1             2 High Risk                     2             3
26
Q

What is the ORBIT score?

A

Score used to assess bleeding risk for patients on anticoagulation for AF

5 components
1) Hb - if < than normal range = 2 pts
2) Age > 74 = 1 pt
3) Bleeding history = 2 pts
4) eGFR < 60 = 1 pt
5) Already on antiplatelets = 1 pt

Max 7 points

27
Q

How would you assess a patient in whom you suspect TIA?

A

ABCD2 Score - high risk if >4
Age >60
BP > 140/90
Clinical features
Duration > 1hr vs 10-60 minutes
Diabetes

Bedside
- BP
- ECG (?AF) and 24 hour ECG monitoring

Bloods
- Routine FBC, U&Es, LFTs, coag
- HbA1c, glucose, lipid profile
- ?thrombophilia screen if young

Imaging
- Consider CT head/MRI head (esp if already on anticoag)
- Carotid Doppler USS
- Echocardiogram

Refer to TIA clinic, for assessment within 24 hours
Consider admitting if crescendo TIAs

28
Q

How would you manage a patient with TIA?

A

CONSERVATIVE
- Stop smoking
- Reduce alcohol intake
- Lifestyle measures

MEDICAL
- ?Antihypertensive agents
- Statin
- Aspirin + clopidogrel

SURGICAL
- Refer for carotid endartectomy if carotid stenosis 70-99% on symptomatic side

29
Q

DVLA Advice for Stroke/TIA

A

Group 1 Drivers =
- Stop driving for 1 month
- Review with doctor

Group 2 Drivers =
- Stop driving for 1 year
- Review with doctor

30
Q

DVLA Advice for Seizures

A

Group 1 Drivers =
- Cannot drive until seizure free for 1 year

Group 2 Drivers =
- Cannot drive until seizure free for 5 years AND haven’t been on AEDs for 5 years
- If multiple seizures = must be seizure free for 10 years

31
Q

Management of Atrial Fibrillation

What agents can be used for Rhythm Control?
When is rhythm control preferred?

A

Agents = Amiodarone, Flecainide (cannot use if HF or IHD)

Preferred if:
- < 65
- Symptomatic/paroxysmal
- 1st presentation
- AF secondary to precipitant e.g. infection

32
Q

Management of Atrial Fibrillation

What agents can be used for Rate Control?
When is rate control preferred?

A

Agents = Beta blockers, CCBs, Digoxin

Preferred if:
- >65
- History of IHD
- Permanent AF

33
Q

How would you investigate a patient with new AF?

A

ABCDE

History

Bedside
- BP
- ECG/telemetry

Bloods
- FBC, U&Es, LFTs
- Coag
- TFTs (REMEMBER thryoid!!!!)
- Extended electrolytes
- Glucose, lipids

Imaging
- Echocardiogram (exclude valvular disease)

34
Q

How would you manage a patient with AF?

A

ABCDE - determine if haemodynamically stable or not
- haemodynamically unstable = cardioversion!

1) Rate vs rhythm control
2) Assess for precipitants/reversible causes
3) ?Anticoagulation (CHADSVasc)
4) ?Elective cardioversion (REFER TO CARDIOLOGY)
- if onset < 48 hours = heparinise and cardiovert as inpatient
- if onset > 48 hours = 3 weeks of anticoagulation prior to cardioversion

35
Q

What is Sickle Cell Disease?

A

Autosomal recessive condition of abnormal Hb synthesis

Definitive Ix = haemoglobin electrophoresis, genetic testing

36
Q

How might a patient with Sickle Cell Disease present?

A

1) Thrombotic “painful” crises
- Usually precipitated by infection/dehydration
- Thromboses in various organs e.g PEs, AVN of hip
- Rx = transfusions/transfusion exchange/analgesia

2) Sequestration = hypovolaemic shock
- Pooling of blood in spleen/lungs

3) Acute Chest = fever, SoB, tachycardic, hypoxia, chest pain
- May need transfusion exchange

4) Aplastic Crisis = pancytopaenia = anaemia, infection, thrombocytopaenia

5) Infection
- At increased risk of infection due to hypo/asplenism (esp encapsulated bacterium)

37
Q

Outline the long term management of Sickle Cell disease

A

MDT approach - haematology, respiratory, geneticists

Antibiotics prophylaxis and immunisations (pneum, flu, mening)

Folic acid (reduces risk of BM aplasia)

Hydroxycarbamide
- Can reduce incidence of crises
- Indicated if >3 vaso-occlusive crises in 1 year OR stroke OR recurrent acute chest syndrome

PACES Revision Cards (9 decks)

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