Acute Medicine Flashcards
What is acute medicine?
Acute medicine refers to immediate and early management of adults in hospital who require urgent or emergency care. Although it is closely linked to emergency medicine and critical care, it is firmly rooted in the principles of general internal medicine. Mostly based in AMUs etc.
What are the key aspects of the job of acute medicine?
Reviewing patients admitted from A&E and GP. Including diagnosis, initial management and treatment. Need to decide who is admitted and discharged, who needs specialist review and who needs escalation to critical care/HDU
(key role of acute medicine is to convert presenting complaint into differential diagnosis)
What are the typical presentations seen in acute medicine?
- Chest pain
- SOB
- Abdominal pain
- Vomiting/haematemesis
- Sepsis
- Confusion
What score is used to predict the outcomes in patients with a PE?
PESI - pulmonary embolism severity index
What is the treatment for someone with a CURB65 score of 0-1?
Consider outpatient treatment and single antibiotic
What is the treatment for someone with a CURB65 score of 2?
Short in-patient treatment and dual antibiotic
What is the treatment for someone with a CURB65 score of 3?
In-patient treatment and IV therapy
What is the treatment for someone with a CURB65 score of 4-5?
These patients have a mortality rate of 41-57%. The treatment is in-patient therapy HDU/specialist care dual antibiotics
What does SNOUT and SPIN refer to?
SNOUT means a negative test rules out and SPIN means a positive test rules in.
So the SNOUT is sensitive and the SPIN is specific
When is a fat embolism more likely to occur?
With broken bones
What are the symptoms of PE? (5)
- SOB
- Chest pain - pleuritic in nature
- Cough
- Associated leg swelling
- Haemoptysis (rarely)
What are the signs of PE? (5)
- Tachycardia (most common)
- Hypotension (only happen if massive PE)
- Raised JVP
- Pleural rub (rare)
- May have no signs
What are the risk factors for PE? (8)
- Previous DVT/PE
- Current DVT
- Immobility
- Major surgery
- Long bone fracture
- Acute malignancy
- Oral contraceptive pill
- Pregnancy
What are the differential diagnoses for PE? (7)
- Pneumonia
- LRTI
- ACS
- Pleurisy
- Pericarditis
- MSK chest pain
- Upper GI symptoms (GORD)
What is it called when the PE is across the bifurcation in the pulmonary artery?
Saddle PE
What is the initial treatment for a PE?
- Low molecular weight heparin
- Option of warfarin or DOAC or longer-term LMWH
- Treatment options depend on whether provoked or unprovoked
Other considerations - duration of treatment and further investigations required
1 in how many patients on warfarin are at risk of intra-cerebral haemorrhage?
1 in 200
What is a D-Dimers sensitivity and specificity in terms of %s?
Sensitive 95%
Specific 50%
(because can be positive due to many causes - but won’t miss PE)
There is a WELLs score for PE and DVT. What are the elements of WELLs score for calculating PE? (7)
- Clinical signs/symptoms of DVT
- PE is first diagnosis or equally likely
- Heart rate >100
- Immobilisation at least 3 days or surgery in the previous 4 weeks
- Previous, objectively diagnosed PE or DVT
- Haemoptysis
- Malignancy w/treatment within 6 months or palliative
If there is a possibility of PE, what is the flow chart to decide upon performing a CTPA?
PE possible –> WELLS score –> if high risk 4 or more –> CTPA.
If WELLS score is low <4 –> D-Dimer –> positive then CTPA, negative PE excluded
When would someone with a PE require admission to HDU/CCU/ARCU? (what signs/symptoms)
Massive - hypotension - cardiac arrest - patients receive Alteplase Sub-massive - hypoxia - cardiac ECHO/ECG - positive cardiac biomarker - troponin
Which anti-hypertensive is most likely responsible for a patient with deranged bloods including hyperkalaemia and AKI?
ACE inhibitors
Of the following drugs, which are most likely important to withhold in someone with an AKI? Amlodipine Metformin Simvastatin Ramipril Aspirin
Ramipril
Metformin
Amlodipine
Why is VBG useful in someone with AKI?
Measures:
acidosis
lactate
potassium
What is the treatment for someone with high potassium?
Calcium gluconate, insulin and dextrose (be careful as patients with diabetes are prone to a hypo - need careful monitoring)
What are the ECG signs of hyperkalaemia? (6)
- Flattened P waves
- Broad bizarre QRS
- Sloping ST
- Tented T waves
- Sine wave ECG
- Any arrhythmia
What does the calcium gluconate do in the treatment of hyperkalaemia?
It is cardioprotective
What is the emergency management of hyperkalaemia?
- Calcium gluconate IV (10ml 10% bolus)
- Salbutamol 5mg NEB
- Insulin dextrose (10 units actrapid in 50ml 50% dextrose) IV over 20 min
- Haemofiltration/dialysis if not responding to the above (uraemic symptoms (confusion, twitchy, itchy), hyperkalaemia not responding, flash pulmonary oedema, pericardial effusion, metabolic acidosis not responding)
- may need cardioversion if BP <100 systolic
What are the indications for haemofiltration/dialysis?
- Uraemic symptoms
- Hyperkalaemic not responding with treatment
- Flash pulmonary oedema
- Pericardial effusion
- Metabolic acidosis not responding with treatment
What questions can be asked to assess the severity of COPD? (5)
- Usual exercise tolerance/functional status
- Weight loss (unexplained)
- Use of long term oxygen therapy
- Previous need for NIV
- Number of admissions for COPD and number of courses of ABX/steroids for COPD in last 12 months
What is the chronic management of COPD? (6)
- Stepwise progression of inhalers; SABA, LAMA, combination of steroids and LABA
- Carbocysteine
- Nebulisers
- Home oxygen
- Pulmonary rehab
- Vaccinations
What is the management of acute exacerbation of COPD? (7)
- Nebs
- Steroids
- Antibiotics (if infection)
- Oxygen
- Consider other causes e.g. MI
- Assisted ventilation; NIV, mechanical ventilation
- Consider level of care and DNACPR if appropriate
What type of infections can produce symptoms of confusion?
- Pneumonia
- UTI
- Cellulitis
- Gastro
- Neuro
What are the commonest causes of delirium/confusion?
- Infection
- Drugs
- Electrolyte disturbance
- Pain
What are the 3 indications for dialysis in someone with AKI?
- Pericarditis - if someone has developed pericarditis (will present with chest pain that improves upon leaning forwards and worse on inspiration)
- Uraemic encephalopathy - hallucinations and confusion
- Metabolic acidosis after attempts at treating - the dialysis will remove excess acid / same with hyperkalaemia if not responding to treatment
What needs to be assess immediately in a paediatric patient with fever?
- Patent airway
- Breathing
- Circulation
- Consciousness
What signs/symptoms of a child puts them at high risk for serious illness? (9)
- Pale/mottled/ashen/blue skin, lips or tongue
- No response to social cues
- Appearing ill to a healthcare professional
- Does not wake or if roused does not stay awake
- Weak, high-pitched or continuous cry
grunting - Respiratory rate greater than 60 breaths per minute
- Moderate or severe chest indrawing
- Reduced skin turgor
- Bulging fontanelle
What needs to be measured/assessed in a routine assessment of a child with a fever? (4)
- Temperature
- Heart rate
- Respiratory rate
- Capillary refill
What NEWS scores correspond to low, intermediate and high risk?
Low = 1-4 Intermediate = 5-6 (or a red score) High = 7 or more
What are the 6 physiological parameters included in the NEWS score?
- Respiratory rate
- Temperature
- Heart rate
- Blood pressure
- Oxygen saturations
- Level of consciousness (AVPU/GCS)
What clinical features increase the chances of a diagnosis of asthma? (8)
At least one of the following: wheeze, cough, difficulty breathing, chest tightness …particularly if these symptoms occurs:
- Frequently/recurrent
- Worse at night/early in the morning
- Triggers; exercise, animal hair, cold/damp hair, emotions
- Occur separate to colds
- Personal history of atopy
- Family history of asthma/atopic disorder
- Widespread wheeze heard on auscultation
- History of improvement of symptoms in response to adequate treatment
What clinical features would decrease the chances of a diagnosis of asthma? (6)
- Symptoms only occurring in conjunction with colds
- Isolated cough without wheeze or difficulty breathing
- Prominent dizziness, light-headedness or peripheral tingling
- Repeatedly normal physical examination of chest when symptoms present
- Normal PEFR
- No response to asthma treatment
What are the various causes of shock? (6)
- Cardiogenic
- Hypovolaemic
- Obstructive
- Septic
- Anaphylactic
- Neurogenic
What are the cardiogenic causes of shock? (6)
- MI
- Dissection of the thoracic aorta
- Cardiac arrhythmias
- Acute valvular failure or acute VSD
- Drug overdose
- Myocarditis
What are the causes of hypovolaemic stroke? (4)
- Haemorrhage (GI tract, aortic dissection, ruptured AAA, trauma)
- Fluid losses (diarrhoea, vomiting, polyuria, burns)
- 3rd space fluid losses (acute pancreatitis)
- Adrenal failure
What are the causes of obstructive shock? (3)
- Cardiac tamponade
- Pulmonary embolus
- Tension pneumothorax
What is the initial assessment of shock?
- If BP is unrecordable, call the cardiac arrest team and begin basic life support and establish venous access
- Check the airway is unobstructed. Give highflow O2
