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PACES revision > Acute medicine- station 5 > Flashcards

Acute medicine- station 5 Flashcards

1
Q

What are the steps in the management of asthma?

A
  1. SABA
  2. Add ICS regularly
  3. Add LABA (only continue if benefits), consider increasing ICS to 800mcg/day
  4. Increase dose ICS. Consider adding leukotriene receptor antagonist or LAMA or theophylline or B2 agonist tablets
  5. Oral steroids
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2
Q

What are the criteria for life threatening and severe asthma?

A

Life threatening

  • PEFR <33%
  • Sats <92%
  • PO2 <8kPa
  • Normal or raised PCO2
  • Silent chest
  • cyanosis
  • poor resp effort
  • arrthmyia
  • Exhaustion/altered consciousness

Severe attack

  • PEFR 33-50% predicted
  • RR >25
  • HR >110/min
  • Inability to complete sentences on 1 breath
  • Pts whose PEFR >75% 1hr after initial treatment may be discharged
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3
Q

What are the differential diagnosis of a TIA?

A 
Migraine
Focal epilepsy
Metabolic disturbance eg hyper/hypoglycaemia
Transient global amnesia
MS
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4
Q

What are the risk factors for a TIA?

A 
Age
Previous TIA and stroke
HTN
DM
Dyslipidaemia
Cardiac disease
Obesity
Cigarette smoking
Alcohol
Recreational drug use
Carotid stenosis
AF
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5
Q

What would your investigation plan be for a patient presenting with a possible TIA?

A

Bloods- FBC- polycythaemia/thrombocythaemia
Glucose- exclude hypo/hyperglycaemia
HBA1C
Lipid profile

ECG and 24hr ECG for AF
ECHO- assess for LV dyskinesia or other structural cause of cardioembolism
Carotid artery imaging
Duplex US
CT angiography/MR angiography
Brain imaging= MRI including diffusion weighted imaging and gradient echo imaging

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6
Q

What score do you use to calculate risk in TIA?

A 
ABCD2 score
Age >60yrs= 1
BP >140/90= 1
Clinical features:
    Unilateral weakness= 2
   Speech impairment without weakness = 1
Duration
   10-59mins =1
    >60mins = 2
Diabetes = 1

Score more than or equal to 4 high risk and need specialist assessment and investigation within 24hrs
IF <4 then within 1 week (risk of stroke 1% when score=1-3)

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7
Q

How do you manage a TIA?

A

Commence aspirin and dypiradamole as dual antiplatelet
Start anticoagulation if in AF
Control BP <130/80
Cholesterol <3.5mmol/L
HBA1C <7.5%
Carotid endarterectomy shoul dbe offered within 2 weeks to those with carotid stenosis 50-99%
Lifestyle- reduce salt, sat fat, weight loss, stop smoking, reduce alcohol

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8
Q

What should you advise somebody that has had a TIA?

A 
At high risk of  stroke and they need to ACT FAST.
Facial weakness
Arm weakness
Speech problems
Time to call 999
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9
Q

What are the red flag features of headache?

A 
New headache in patient >50yrs
Develops within minutes- SAH
Inability to move limb or other neurological abnormalities
Mental confusion
Recent trauma
Woken by headache
Worsens with change in posture and straining
Scalp tenderness
Visual loss/abnormalities
Jaw claudication
Neck stiffness
Rash
Fever
Pre-exisiting HIV, cancer, risk factors thrombosis
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10
Q

What are your investigations for headache

A 
FBC, U+E, ESR (GCA), CRP, clotting
WCC/CRP
Brain imaging
LP
Temporal artery biopsy
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11
Q

How would you treat a cluster headache and hemicrania?

A

Hemicrania (constant unilateral headache): indomethacin

Cluster headache: SC/nasal triptans, 100% oxygen

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12
Q

What are the causes of pericarditis?

A

Viral infection: coxsackie, EBV, influenza, Echovirus
Rheumatological: Sarcoid, scleroderma, RA, SLE, PAN, AS
Drugs: hydralazine, procainamide, isoniazid, phenytoin
Neoplastic: sarcoma, mesothelioma, mets
Bacterial: staph, haemophilis, pneumococcus
Other: chest trauma, uraemia, radiation

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13
Q

What investigations would you do of somebody with pericarditis?

A 
ECG- saddle ST elevation
CXR: boot shaped heart
Bloods: U+E, FBC, troponins, ESR/CRP
ECHO- effusion or tamponade or myocarditis
Surgical: percardiocentesis
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14
Q

What criteria would cause you to admit a patient with pericarditis?

A
  • Fever (>38ºC) and leukocytosis.
  • Evidence suggesting cardiac tamponade.
  • A large pericardial effusion (ie an echo-free space of more than 20 mm).
  • Immunosuppressed state.
  • Patients taking warfarin.
  • Acute trauma.
  • Failure to respond within seven days to non-steroidal anti-inflammatory drugs (NSAIDs).
  • Elevated cardiac troponin, which suggests myopericarditis.
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15
Q

How would you manage pericarditis?

A

NSAIDs + PPI

Colchicine

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16
Q

What are the symptoms of hypertensive encephalopathy?

A 
Headache
Drowsy
Confusion
Nausea.vomiting
Visual disturbance

Caused by severe small blood vessel congestion and brain swelling and reversible if BP lowered

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17
Q

Name some causes of hypertension

A 
Renal:
GN
Chronic atrophy pyelonephritis
Adult PCKD
Analgesic nephropathy
Renal artery stenosis
Endocrine:
Conn's
Cushings
Phaeochromocytoma
Acromegaly
Thyrotoxicosis
Hyperparathyroidism
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18
Q

What are the thresholds for treatment of blood pressure

A

Stage 1 hypertension >140/90 (ABPM >135/85) + one or more of the following:
• target organ damage
• established cardiovascular disease
• renal disease
• diabetes
• 10-year cardiovascular risk equivalent to 20% or greater.

If >160/100 offer to anybody

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19
Q

What are the steps in hypertension management?

A

< 55yrs = ACE-I
>55yrs or black= CCB

A+C

A+C+D (indapamide)

Consider adding spironolactone if K+ <4.5 or increasing indapamide

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20
Q

How would you manage somebody with an UGI bleed?

A

Check Hb
IVF + Hb replacement
If platelets <50 then transfuse
FFP if fibrinogen <1g or INR >1.5x normal
Beriplex if on warfarin
PPI prior to endoscopy not currently in NICE guidelines
Endoscopy within 24hrs

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21
Q

What investigations would you do for somebody with GI bleed?

A 
FBC + crossmatch
U+E
LFTs- CLD and varices? 
INR and clotting
Erect CXR and AXR ? perf
Endoscopy
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22
Q

What scores are used in UGI bleeds?

A

Blatchford score: scores are added using the level of urea, haemoglobin, systolic blood pressure, pulse rate, presentation with melaena, presentation with syncope, hepatic disease and cardiac failure. A score of 0 is the cut-off with any patient scoring >0 being at risk of requiring an intervention.

Rockall score
- pre-endoscopy: age, shock, co-morbidity
- post-endoscopy: also uses diagnosis (Mallory Weiss tear=0, all other=1, GI malignancy=2) and evidence of active bleeding. Predicts rebleed and mortality
If >1 need to stay in

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23
Q

What are the causes of haematemesis?

A 
In order of frequency
Peptic ulcer 44%
Oesophagitis 28%
Gastritis/erosions 26%
Erosive duodenitis 
Varices
Portal hypertensive gastropathy
Malignancy
Mallory-Weiss tear
Vascular malformation
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24
Q

Who can be discharged with an UGI bleed?

A

Urea<6.5
Hb>130 in man, >120 in women
SBP >110
Pulse <100

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25
Q

What questions would you ask if somebody presented with palpitations?

A 
Onset, freq, exacerbation
Chest pain
SOB, leg swelling
Exercise tolerance
Syncope/light headed
Fatigue
Vascular risk factors (htn, DM, hyperlipidaemia)
Endocrine: thyroid issues- hot/cold, tremor, anxiety
Drug/alcohol
26
Q

What investigations would you perform for somebody presenting with palpitations?

A 
FBC- anaemia
U+E, calcium, magnesium- electrolyte disturbance
Glucose
Lipids
TFTs
ECG
24hr tape
ECHO
27
Q

Who should be rate controlled and who should be rhythm controlled in AF?

A 
Rate controlled in patients:
>65yrs
with IHD
CI to anti-arrythmics/cardioversion
Without cardiac failure

Rhythm control in patients:
<65yrs who are symptomatic
Presenting with lone AF (no other CV/resp disease)
With AF secondary to treated/corrected precipitant
With cardiac failure

Can consider ablation or pace and ablate

28
Q

How would you rate limit in AF?

A

Beta blockers
Rate limiting calcium antagonists
Digoxin only if sedentary

29
Q

What do you use to decide whether to anti-coagulate in AF?

A

CHADSVASc score

CCF= 1
HTN >140/90 = 1
Age >75 =2
Diabetes= 1
Stroke/TIA = 2
Vascular disease (MI, PVD)= 1
Age 65-74= 1
Sex= female= 1

Offer anticoagulation to anyone except score= 0 or 1 for being females

30
Q

What is the HASBLED score?

A

Risk of bleeding with anticoagulation

Hypertension >160
Abnormal liver or renal function (1 point each)
Stroke history
Bleeding history or predisposition
Labile INR
Elderly >65yrs
Drugs or alcohol (1 point each)
31
Q

What are the causes of AF?

A 
IHD
Rheumatic heart disease
Hypertensive heart disease
Thyrotoxicosis
Acute infection
Electrolyte imablance
Cardiomyopathy (toxic, metabolic, endocrine, collagen disease related, infiltrative, infective, genetic)
Constrictive pericarditis
32
Q

How do you differentiate AF from other pulse irregularities?

A

Irregular pulse due to controlled AF is differentiated from that of multiple extrasystoles by the long pauses which occur in groups of 2 or more, whilst with ectopic beats the compensatory pause follows a short pause because the ectopic is premature. Exercise may abolish extrasystoles but worsen irregularity of AF. AF may be difficult to distinguish from atrial flutter with a variable block, multiple atrial ectopics due to shifting pacemaker and paroxysmal atrial tachycardia with block but only in AF is the rhythm truely chaotic

33
Q

What are the differential diagnoses of pyelonephritis?

A 
Peritonitis
Cholecystitis
Appendicitis
Renal colic
PID
Ectopic pregnancy
Pneumonia
34
Q

What factors predispose to urinary sepsis and pyelonephritis?

A

Mechanical: structural abnormalities of renal tract, vesicourethral reflux, renal calculi, catheter/stent, incomplete emptying
Constitutional: DM, immunocompromised, atrophic urethritis
Behavioural: change in sexual partner
Positive FH

35
Q

How would you investigate somebody with possible peripheral vascular disease?

A

Full examination with assessment of pulses, for ulcers, hair loss, bruits over aorta/iliac/femoral/politeal, assess neuropathy
Buergers test- elevate leg and assess for peripheral pallor
Measure ABPI
Urine dip for glycosuria

FBC, U+E, glucose, HBA1C, lipid, autoantibody
ECG
arterial duplex
angiography

36
Q

How would you manage somebody with PVD?

A

Lifestyle advice and control of vascular risk factors as for TIA
Anti-thrombotic medication (anti-platelets)
Treatment of claudication:
- supervised exercise programme
- pharmacological agents: cilostazol, pentoxifylline
- endovascular tx: stenting, angioplasty
- Bypass surgery

Treatment of critical limb ischaemia:

  • parenteral prostaglandins
  • thrombolysis
  • endovascular tx: stenting, angioplasty
  • surgery
37
Q

What signs/symptoms would encourage you to involve surgeons in PVD?

A

6 P’s pain, paraesthesia, paralysis, pallor, pulselessness, perishingly cold

38
Q

Why do patients with more severe disease often have pain at rest in bed?

A

In bed at night there is physiological decrease in cardiac output and a reactive dilatation of skin vessels to warmth in bed

39
Q

What is phantom limb pain?

A

Pain appearing to come from where an amputated limb used to be. Suggested mechanisms for pain include damage to nerve endings and subsequent erroneous re-growth leading to abnormal and painful dischagre of neurons in stump and altered nervous activity within the brain as a result of loss of sensory input from the amputated limb

40
Q

What are the risk factors for DVT?

A 
Age
Obesity
Immobility/recent long-haul travel
Previous VTE
Pregnancy/puerperium
OCP use
Cigarette smoking
Thrombophilia
Recent surgery
Cancer
CCF
41
Q

Describe the Wells score for DVT

A

Active cancer: 1
Paralysis, paresis or recent plaster immobilisation: 1
Bedridden for >3 days or major surgery in last 12 wks: 1
Tenderness along distribution of deep veins: 1
Entire leg swollen: 1
Calf swelling >3cm compared to other leg: 1
Pitting oedema confined to symptomatic leg: 1
Collateral superficial veins present: 1
Previous DVT: 1
Alternative diagnosis at least as likely as DVT: -2

Likely if 2 or more
Unlikely if 1 or less

42
Q

Describe the Wells score for PE

A

Clinical signs and symptoms of DVT: 3
No alternative diagnosis more likely than PE: 3
HR >100bpm: 1.5
Immobilisation for >3 days or surgery in last 4 wks: 1.5
Previous PE/DVT: 1.5
Malignancy: 1
Haemoptysis: 1

43
Q

How long do you treat a DVT for?

A

Proximal DVT 3 months and reassess, consider continuing if unprovoked
In cancer at least 6 months

44
Q

Which patients need more careful monitoring of warfarin treatment?

A

Drugs: broad spectrum antibiotics
Liver disease
Hyperthyroidism
ETOH

45
Q

What is the triad of nephrotic syndrome?

A

Proteinuria, hypoalbuminaemia and oedema (hyperlipidaemia)

46
Q

What are the causes of nephrotic syndrome?

A

Glomerulonephritis (80%)

  • minimal change
  • Membranous
  • focal segmental glomerulosclerosis
  • mesangiocapillary

Other

  • DM
  • amyloidosis
  • SLE
  • drugs- penicillamine
  • allergies
  • infection
47
Q

What are the complications of nephrotic syndrome?

A

Increased susceptibility to infection- partly due to Ig loss in urine
Thromboembolism- increased platelet abnormalities and clotting factors
Hyperlipidaemia
Hypertension

48
Q

How do you manage nephrotic syndrome

A

Monitor U+E, BP, fluid balance and weight
restrict salt intake
Diuretic- furosemide +/- metalazone or spiro
If chronic ACE-i decrease proteinuria and slow renal deterioration
Treat hypertension with ACE-i

49
Q

What are the causes of nephritic syndrome?

A

Post strep glomerulonephritis (diffuse proliferative)
Infective endocarditis
IgA nephropathy
Membranous GN
SLE (Diffuse proliferative is most common)
HSP
Cryoglobulinaemia

50
Q

What is Goodpastures disease and how do you treat it?

A

Develop autoantibodies to type IV collagen essential component of renal basement membrane
Haemoptysis and macroscopic haematuria

Anti-GBM Ab in serum on ELISA
Biopsy: cresecentic

Tx: plasma exchange, steroids, cytotoxics

51
Q

WHat is the classification in Granulomatosis with polyangitis?

A

ELK
Ears/nose/throat= almost 100%
Lungs- most patients
Kidneys 75%

Rare vasculitis

52
Q

How do they test for HIV?

A

COmbination test of HIV antibodies and p24 antigen (fourth generation test)

Generally accepted need to be rechecked in one month if negative and suspected

53
Q

Name some aids defining conditions?

A 
Oesophageal candidiasis
Candidiasis of bronchi, lung
Invasive cervical cancer
CMV reitine
HIV encephalopathy
Kaposis sarcoma
Toxoplasmosis of brain
Progressive multifocal leukoencephalopthy
PCP
TB
Lymphoma- Burkitts, brain
54
Q

How do you treat HIV?

A

Everyone starts HAART
COmbination of 3 ARTs from at leaxst 2 groups

  • Nucleoside reverse transcriptase inhibitors (NRTI): Tenofovir, Lamivudine, Zidovudine
  • Non-nucleoside reverse transcriptase inhibitors (NNRTI): Efavirenz
  • Protease inhibitors: Indinavir, ritonovir
  • Integrase inhibitors
  • FUsion inhibitors

Atripla can be given once a day

Septrin prophylaxis if CD4 <200

55
Q

What are your differentials of microcytic anaemia?

A

Iron deficiency
Anaemia of chronic disease
Thalassaemia
Sideroblastic anaemia

56
Q

What are your differentials in macrocytic anaemia?

A

Megaloblastic (delayed nuclear maturation in relation to cytoplasm in red blood cells in bone marrow due to defective DNA synthesis)

  • vitamin B12 def
  • folate def
  • drug induced

Non megaloblastic

  • alcohol
  • myelodysplastic syndromes
  • liver disease
  • pregnancy
  • hypothyroidism
57
Q

What are the causes of vitamin B12 deficiency?

A

Low dietary intake- vegans (B12 in meat and dairy products)

Stomach

  • pernicious anaemia
  • gastrectomy
  • congenital def in intrinsic factor

Small bowel

  • ileal disease or resection eg Crohns
  • coeliac disease
  • tropical sprue
  • bacterial overgrowth

Abnormal utilisation

  • nitrous oxide- inactivates B12
  • congenital transcobalamin II def
58
Q

What is pernicious anaemia?

A

Autoimmune condition in which there is atrophic gastritis with loss of parietal cells and hence failure of intrinsic factor production and vit B12 malabsorption

59
Q

What do you need to remember to ask if a patient has a macrocytic anaemia caused by possible B12 def?

A

Neurological features- polyneuropathy, weakness, ataxia, subacute combined degeneration of spinal cord. Dementia and visual distubance

60
Q

How do you investigate a patient with possible pernicious anaemia?

A

Hb
Blood film
vit B12

Anti-parietal cell Ab- sensitive but not specific
Intrinsic factor antibodies- specific but not sensitive (found in 50%)

May be necessary to do

  • bone marrow biopsy
  • Small bowel barium follow through

Schilling test is no longer used

61
Q

If you have a megaloblastic anaemia of underdetermined cause, how do you manage this?

A

Always replace B12 prior to folate so you don’t aggravate the neuropathy

PACES revision (12 decks)

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