AIP Flashcards
What is alveolar-arterial O2 gradient used for
In type 2 resp failure
- if A-a gradient normal = not due to lung disease
- if A-a gradient is raised = intrinsic lung disease
causes of a complete white out on CXR
Trachea deviated towards = total lung collapse, pneumonectomy
Trachea central = consolidation (pneumonia), ARDS
Tracheal away = large pleural effusion
Electrolyte daily requirements
Na - 1-2 mmol/kg/24hr
Cl - 1 mmol/kg/24hr
K - 0.5-1 mmol/kg/24hr (max safe dose is 10mmol/hr)
(1 of each)
Glucose - 50-100g
Water - 25-30 ml/kg/24hr (20-25 if elderly, HF or CKD)
When doing maintenance fluids for obese patients - use ideal bodyweight based on BMI and use lower end of range e.g. 25 ml/kg/24hr
Signs of dehydration on U&E
Hypernatraemia, high haematocrit, raised Hb
Transfusion threshold - normally and with ACS
70g/L normally
80g/L with ACS
G&S vs crossmatch
G&S - just looks at patients blood - identifies Rhesus status, ABO blood group and antibodies present
- no blood is issued
- used if no current blood loss, anticipate might be needed in future
Crossmatch - assesses transfusion by mixing small amount of patient and donor blood to look for a reaction
- following testing blood is issued
- need a G&S before hand
Blood product thresholds
Platelets - bleeding and <30x10^9
Plasma - if bleeding and abnormal coag (APPT ratio >1.5)
Cryoprecipitate - DIC with fibrinogen < 1g/L, von willebrand
Immediate immune reactions to transfusion, how they present and management
ABO incompatibility - fever, tachycardia, hypotension, anxiety, may have red urine. Treat by stopping transfusion, starting IV fluids and giving platelets/ other blood products as needed to prevent DIC.
TRALI - transfusion related acute lung injury - present with fever, SOB, hypoxaemia, hypotension. Diffuse infiltrates on CXR. Stop transfusion, give O2, IV fluids and ionotropes (dobutamine or adrenaline)
Anaphylaxis - itchy rash, angioedema, SOB, vomiting, light headed, hypotension. Stop transfusion, IM adrenaline 0.5mg every 10 mins, salbutamol nebs, O2. Steroids, chloramphenamine 2nd line/ post initial stabilisation.
Not a reaction but can get fluid overload causing SOB, bibasal creps, hypoxia, tachycardia, raised JVP. Treat with IV furosemide and O2.
Indications for arterial line + what the trace tells us + complications
Continuous real time monitoring of BP, need for repeat ABG’s
Tells us:
- blood pressure
- myocardial contractility - gradient of upwards curve
- volume status - narrow waveform = hypovolaemia
Complications:
- bleed - apply 3-5 mins of pressure post removal
- thrombus
- emboli
- infection
- accidental drug injection
Causes of raised and low CVP - how it is measured?
High - fluid overload, RHF, pulmonary hypertension, tricuspid disease, SVC obstruction
Low - hypovolaemia, distributive shock
Measured using central venous catheter e.g. central line, Hickmann, picc line
Catecholamine drugs used in ICU - what are their target receptor and action
Noradrenaline - Acts on alpha 1 - cause peripheral vasoconstriction increasing SVR and CO
Adrenaline - Acts on alpha 1 (high doses) doing same as above and acts on Beta 1 (low doses) causing increased SV, HR, CO
Dopamine - same as adrenaline
Dobutamine - Acts on Beta 1 and Beta 2 - causes increased HR, SV, CO but causes vasodilation
Classes of anti-arrhythmics
Class I - sodium channel blocker e.g. lidocaine, phenytoin, quinidine, flecainide
Class II - Beta blocker e.g. propanalol
Class III - K+ channel blocker e.g. amiodarone
Class IV - calcium channel blocker e.g. verapamil, diltiazem
Indications for NG tube + when to do a PEG tube
Feeding
- dysphagia or unsafe swallow due to neuro issue
- reduced consciousness
- protect stomach after surgery
- insufficient oral intake
Removal of gastric contents
- bowel obstruction for immediate decompression
- For resting of the bowel in bowel obstruction
Do a PEG tube when need long term feeding e.g.
- burns
- oesophageal carcinoma
- coma, stroke
- Crohn’s
- fistulae
How is TPN given
Via a central line
Refeeding syndrome
Malnutritioned patients get energy by breaking down existing tissues, hence have low vitamin, electrolyte levels
Occurs when high amount of carbohydrates are given to a malnourished patient. Causes for high insulin secretion,
Insulin leads to K+, PO4, Mg movement into cells, causing a significant drop in levels and an increased extracellular fluid volume
Get an increase in O2 demand leading to increased cardio and respiratory effort
Can cause rhabdomyolysis, cardiac/resp failure, seizure, coma
what to give patients in a coma
glucose, thiamine IV if cause unclear
may also trial naloxone or flumazenil
raised ICP consider mannitol
fluids + ventilation, nutrition, pressure sores
How to confirm brainstem death
First need to meet two criteria
- evidence that condition due to irreversible structural brain damage
- all reversible causes of coma excluded
Then:
- Pupils fixed and unresponsive to bright light
- Absent corneal reflexes
- Absent vestibulo-ocular reflexes (irrigation of the ear with ice-cold water, dolls eye reflex)
- No motor response to trigeminal pain response. An example of this would be no facial grimace to nail bed pressure
- No gag or cough reflex
- Apnoea
What number to call if no signs of life in suspected cardiac arrest
2222
When to give adrenaline/amiodarone during CPR
Give 1mg IV adrenaline and amiodarone 300mg IV after 3rd shock. Then give adrenaline every 3-5 minutes after
Give an additional 150mg amiodarone after 5 shocks
If not shockable give 1mg IV adrenaline as soon as IV access
Reversible causes of cardiac arrest to treat during CPR
4 H’s
- Hypoxia
- Hypovolaemia
- Hypothermia
- Hyper or hypokalaemia
4 T’s
- Tension pneumothorax
- Tamponade
- Toxins
- Thromboembolism
Cardiogenic shock - definition, causes, presentation, ix, mx
Caused by failure of heart to achieve required cardiac output
Causes include: HF, MI, acute dysrhythmia, acute mitral regurg, cardiomyopathy, thyrotoxicosis, severe valvular disease
Defined as SBP <90 for >30 mins or poor peripheral/ end organ perfusion (<0.5ml/kg/hr urine output)
Present as pale, mottled, cold skin. Prolonged CRT. Cold peripheries. Tachycardia, hypotension. Often pulmonary oedema, raised JVP (signs of HF)
Ix: bloods (U&E for renal failure, FBC for anaemia, LFT), ABG, BNP (low can help rule out), ECG, Echo, cardiac enzymes (trops)
Another cause is obstructive e.g. PE, tension pneumothorax, tamponade - do CXR, CTPA
Mx:
O2 to maintain sats >94% (check vs 96%)
250ml fluid boluses if intravascular volume depletion
Monitor with - cardiac monitoring, BP via central line, CVP via central line, catheter for urine output
Treat cause e.g. thrombolysis, percutaneous intervention for MI
vasopressors - dobutamine
Intra-aortic balloon pump - increases cardiac output and improves coronary artery blood flow
Hypovolaemic shock
Presents with dizziness, fainting, cold/clammy/confused. Skin pale, sweaty. Prolonged CRT, hypotension, tachycardia.
Causes include blood loss, burns, excessive exercise, diarrhoea and vomiting
Ix: AtoE Bloods - Hb, U&E, FBC, LFT, Coag, crossmatch, G&S ABG Urine output US can differentiate from cardiogenic CVP monitoring
Mx: AtoE Look for cause - try to stop bleeding Oxygen - keep sats 94 Fluid boluses - 500ml over 15 mins Blood as needed IV pain relief Tranexamic acid If non responsive to fluids may consider vasopressors
If needed:
Resuscitative endovascular balloon occlusion of the aorta
Surgery to stop bleeding
anaphylactic shock
Present with SOB, angioedema, urticaria, itching
serum mast cell tryptase - use to confirm diagnosis
Mx:
2222
Lie flat with legs raised, secure airway, give O2
0.5mg IM adrenaline - repeat after 5 mins if no improvement
Fluid challenge - 500ml over 5-20 mins
Chlorphenamine 10mg, hydrocortisone 200mg after initial resus
further deterioration treat as acute asthma
observe for 6-12 hours
Neurogenic shock - cause, triad of signs and mx
Cause is cervical and upper thoracic injury (above T6)
Loss of sympathetic tone that causes vasodilation and bradycardia
Can also be caused by iatrogenic spinal anaesthesia placement
Develop triad of bradycardia, hypotension and hypothermia
Mx:
IV fluids
Treat cause
Atropine if haemodynamically significant bradycardia
Vasopressors e.g. dopamine, dobutamine may be needed if fluid resus not effective
*Asthma - cough, breathlessness, wheeze, chest tightness
Hyper-inflated chest, wheeze, tachypnoea on exam
Worse at night or in early morning, diurnal variation
Worse in cold air, dust, allergens, when exercising
Hx of atopy
Ix:
FeNO - eosinophil inflammation (>40)
Spirometry w. bronchodilator - FVC increase by 200ml, FEV1 by 12%
Peak flow - >50-75% mod, 33-50% severe, <33% life threatening 20% diurnal variation
Bronchial challenge test
Tx:
Educate - lifestyle
ABCDE + ABG Oxygen (>94%) Salbutamol neb 5mg Hydrocortisone 100mg IV or pred 40mg PO Ipratropium bromide neb 500mcg Magnesium sulfate 1.2-2g IV IV Aminophylline Escalate if pH <7.3, Intubate
Be stable on discharge meds for 12-24hrs before discharge
Long term: SABA SABA+ICS (if using >3x a week, waking once at night) SABA+ICS+LTRA SABA+ICS+LABA +/- LTRA MART Intermediate dose ICS Thophylline
Definition and causes of type 1 resp failure
- polycythemia can indicate long term hypoxia
PO2 < 8kpa
Causes = problems with diffusion at alveoli level
Hypoxia present with
- Signs of respiratory distress
- Cyanosis
- Restlessness, agitation
- Confusion
- Tachycardia and cardiac arrhythmias
Causes:
- pneumothorax
- pneumonia
- pleural effusion
- pulmonary oedema
- R-L shunt
- PE
- Lung fibrosis
Definition and causes of type 2 resp failure
- symptoms of hypercapnia
PO2 < 8kpa
PCO2 > 6kpa
Causes = issues with ventilation
High CO2 present with:
- headache due to cerebral vasodilation
- flushing
- warm peripheries
- bounding pulse
- CO2 retention flap
- Drowsiness, confusion, coma
- Acute asthma attack (exhaustion)
- Severe COPD
- Foreign body inhalation, CF or bronchiectasis secretions
- Chest wall deformity
- Kyphoscoliosis
- Neuromuscular disease - GB
- Opioid overdose, stroke - brainstem resp depression
Start on 24% Venturi due to risk of hypoxic drive, repeat ABG at 20 mins, if PaCO2 has risen by >1.2 consider invasive ventilation
What imaging sign is needed to diagnose idiopathic pulmonary fibrosis + how to treat
Can lead to pulmonary HTN and heart failure
Honeycombing without any clear cause
On CT see ground glass/ honeycombing
Restrictive pattern on spirometry
Can confirm with lung biopsy
Tx
- acutely - high dose steroids
- Long term - Pulmonary rehab, exercise, stop smoking, PPI, pirfenidone/ nintedanib, opiates for cough, LTOT, lung transplant
Only use drugs if FVC 50-80% predicted, stop if drop in FVC >10% in a year
Cause of fine vs coarse crackles
Fine crackles - commonly pulmonary fibrosis (>45yo)
- associated with dry cough, SOB, chest discomfort, end inspiratory crackles, clubbing, weight loss, restrictive pattern on spirometry
Coarse crackles = fluid due to oedema, pneumonia, chronic bronchitis, bronchiectasis, aspiration
30 yr old black female presents with SOB, cough, painful red nodules on shin. CXR reveals bilateral hilar lymphadenopathy, pulmonary infiltrates - What are the two top differentials?
What findings on blood tests would point towards diagnosis
How is diagnosis confirmed
How treated
Sarcoidosis - serum ACE, calcium level raised - long term
Diagnosis confirmed by biopsy - non-caseating granulomata with epithelioid cells
Majority get better on own - may need corticosteroids. High dose for 4-6w then taper over course of a year. Give bisphosphonate. If needed give IV Methylpred or immunosuppressants e.g. methotrexate
Lofgrens syndrome - acute form of sarcoidosis - triad of bilateral hilar lymphadenopathy, erythema nodosum and polyarthralgia - NSAID, steroid, colchicine
Pleural effusion
Cough, SOB, pleuritic chest pain
Empyema presents with above + fever, rigors, productive cough
On exam looking for stony dullness, reduced breath sounds, reduced chest expansion, reduced vocal resonance
Take detailed history to elucidate cause
Do CXR, bloods to differentiate causes (D-dimer, LDH, protein, amylase, WCC), ABG, CT if suspect malignancy, ECG/echo for HF
Important take a sample of pleural fluid using US to differentiate cause - look at protein, LDH. Not needed if bilateral effusion typical of transudate
if asymptomatic - 50ml, if symptomatic aspirate till sx improve
Send for biochem (pH, protein, LDH, glucose), cytology (blood), microbiology (gram stain and culture)
If protein >35 = exudate (unilateral) - cancer, infection, PE, AI, pancreatitis
If <25 = transudate (bilateral) - HF, LF, RF, hypo-albumin, peritoneal dialysis
Can also be haemothorax, chylothorax, empyema (pH <7.2)
If blood do haematocrit, if >1/2 of level in peripheral blood = haemothorax
If between the two use lights criteria - is exudate if
Protein pleural: blood >0.5
LDH pleural:blood >0.6
LDH pleural >2/3 upper limit of normal for serum
pH<7.2 = empyema until proven otherwise
Treatment
If transudate - treat underlying failure - diuretics etc
If exudate
- small - observe
- infection - Abx, antipyretics
- Large - therapeutic aspiration (no >1.5L), chest drain
- If recurrent - long term chest drain or pleurodesis using talc or pleurectomy
Chronic bronchitis definition = part of COPD
chronic productive cough for at least 3m in each of the last 2 years
COPD
Ix: Respiratory exam Peak flow Spirometry with bronchodilator - restrictive picture (FEV1 <80%, FEV1/FVC <0.7) CXR for cor pulmonale If acute exacerbation do sputum culture, ABG Sputum culture if purulent MRC dyspnoea score - activity limitation BODE index - prognosis GOLD staging
Tx
Lifestyle modification and patient education, stop smoking
Acute: O2 (start on 15L, reduce to 24% venturi if hypoxic drive), salbutamol, ipratropium, prednisolone, Abx, physio, NIV (if academia/ rising CO2, pulmonary oedema, tiring T1 failure), Theophylline
Start on SAMA or SABA
Add either LABA + LAMA or LABA +ICS
LAMA + LABA + ICS
COPD rescue pack
- prednisolone - if increasing breathlessness
- Amoxicillin/ doxy/ clarithro - if change in sputum colour
- Salbutamol - extra incase needed
Long term oxygen therapy
if PO2 <7.3 or between 7.3-8 and have secondary polycythaemia, peripheral oedema or pulmonary HTN
Long term abx prophylaxis = azithromycin
Consider mucolytic if bronchiectasis
Pneumonia
Criteria:
Symptoms of acute LRTI (cough and at least one other LRT symptom)
New focal chest sign on exam
At least one systemic feature (sweating, temp of >38, shivers, aches, pains)
No other explanation for the illness
Most common CAP = s pneumoniae, H influenzea in COPD
HAP - 48hrs post admission, within 5d most likely s pneumoniae, after 5 most likely H influenzea, MRSA, pseudomonas
Ix: Respiratory exam O2 sats CXR FBC, U+E, LFT, CRP, ABG Lung function test Blood + sputum culture Sepsis 6 is suspect systemic infection, dropping vitals Procalcitonin to monitor
Do CURB 65 - who needs admission
Confusion, Urea >7, RR >30, BP <90/60, >65
home: 0-1, hosp >2, ITU assessment >3
Tx: Educate, stop smoking Fluids Oxygen if hypoxic Analgesics for pleuritic pain Start on antibiotics - low severity: amoxicillin 5-7d - Mod: amoxicillin + clarithro 5-7d - severe: co-amox + clarithro 7-10d
If suspect aspiration -> metronidazole
For hospital acquired - co-amox for mild, tazocin for severe
Do repeat CXR 6w after symptom resolution - look for malignancy hid by consolidation/ effusion
Causes of pleuritic chest pain
PE, pleural effusion, pneumonia
Pneumothorax mx
- sudden onset pain, SOB, reduced breath sounds, hyper-resonance on percussion, tachycardia
If >50 and smoke or evidence of lung disease on exam/ CXR -> secondary
Tension - haemodynamically unstable, compromised CO, mediastinal shift
Ix:
- CXR - erect
- US if supine
- CT if diagnostic uncertainty, not clear from CXR/US
- ABG
Pleural surface to Lung edge at hilum - measure
Primary <2cm AND no breathlessness = discharge with outpatient x-ray
Primary, >2cm OR breathless = percutaneous aspiration and oxygen then 2nd x ray to confirm gone
Secondary <1cm = oxygen and admit for 24 hours
Secondary 1-2cm = aspiration (if fails then chest drain)
Secondary >2cm OR breathless = chest drain (if fails then discuss with thoracic surgeon)
Do chest drain for any ventilated, tension, bilateral or if haemo unstable
Tension = needle decompression in 2nd IC space MC line, oxygen then chest drain in triangle of safety
Refer for pleurodesis if recurrence or surgery for open thoracotomy and pleurectomy or video-assisted thoracoscopic surgery with pleurectomy and pleural abrasion (better tolerated than open surgery)
Catamenial pneumothorax is around time of menstruation due to endometriosis forming necrotic holes in the diaphragm
*Bowel obstruction - causes and management
Can be mechanical - e.g. due to volvulus, intussusception, hernia, cancer, adhesions, strictures, diverticular disease. Or can be paralytic - e.g. post op, due to drugs such as opioids, gastroparesis, hypokalaemia, bowel ischaemia
Sx
- Diffuse abdominal pain, worse on movement
- third spacing causes diarrhoea and water loss
- vomiting (contains bile, faeces), dehydration
- abdominal distension
- no stool passage
- if perforation - guarding, tenderness
- tympanic percussion, high pitch bowel sounds
Ix
- Assess for dehydration
- ABG if suspect sepsis, abnormal electrolytes
- FBC, U&E, LFT, G&S, crossmatch for surgery
- Abdo xray - bowel dilation, air-fluid levels, no distal gas
- CT
- CXR if suspect perforation (air under diaphragm)
- MRI/ US can be helpful
Mx
- NBM
- Drip and suck - NG tube for aspiration and drainage of stomach, IV infusion for rehydration
- Analgesia, antiemetic
- Monitor urine output as marker of dehydration - catheter
Laparotomy may be essential if diagnosis unclear, signs of ischaemia, closed loop obstruction or perforation
For volvulus may be reducible with sigmoidoscopy/ flatus tube insertion
For malignant obstruction - endoscopic stenting in palliative care
For adhesions do gastrografin imaging and either treat conservatively or with adhesiolysis.
Neostigmine for acute colonic pseudo-obstruction
Mesenteric ischaemia triad - presentation, ix, mx
Often due to thrombus
CVD, high lactate, abdomen soft but tender
Pain disproportionate to clinical findings, limited abdo tenderness with lots of pain
Presents with mild to moderate colicky pain or constant poorly localised pain, loose bloody stools, N+V. Later stage get sepsis, peritonism, ileus.
Ix
- ABG showing metabolic acidosis and FBC showing raised WCC can raise suspicion
- AXR to rule out other causes
- CT angiography is gold standard to identify occlusive event
- normal CT may show pneumatosis intestinal, Mesenteric oedema, bowel dilation
- ECG/ Echo to identify cardiac RF/ cause
Mx
- NBM, IV fluids, oxygen, broad spectrum Abx, NG for decompression, analgesia
- Start IV unfractionated heparin
- May use local thrombolytics if angiography performed
- Surgery to remove necrotic bowel or revascularise bowel
Chronic mesenteric ischaemia
Due to atherosclerosis
Presents with weight loss, abdominal pain after eating, fear of eating on background of CV risk factors
Ix:
Angiography
Mesenteric duplex US to assess blood flow
Tx
- asymptomatic - smoking cessation and antiplatelets
- symptomatic - endo-vascular or open revascularisation
Ischaemic colitis - often due to hypovolaemia
Mild, colicky abdominal pain typically in LIF, N+V, prominent bloody diarrhoea -> dehydration, shock, metabolic acidosis
Ix:
- ABG show metabolic acidosis
- Colonoscopy show blue mucosa, limited bleeding
- AXR shows gas surrounding bowel
- Barium enema shows thumb printing sign
Mx
- correct cause of hypovolaemia - often resolves
- broad spectrum abx
- If ileus NG tube
- surgery if guarding and rebound tenderness, fever, uncontrollable bleeding or paralytic ileus indicating possible infarction of the colon
Treatment in GI perforation
Resus - IV fluids, O2
IV abx
NG tube for decompression
Surgery to repair + washout
What classifies as AAA, indications for surgery
- all men over 65 in uk are offered abdo US to look for AAA
> 3cm = AAA, >5.5cm = surgery
If 3cm-5.4cm refer to vascular to be seen within 12w, monitor via US
- 3-4.4 - yearly US
- 4.5-5.4 - 3 monthly US
BP control with beta blocker, control CV risk factors e.g. stop smoking, exercise
If 5.5 or greater refer to vascular to be seen within 2w
Surgery if >5.5 or >4 and expanding at rate of >1cm per year
Can do open or endovascular repair
AAA rupture - Ix/ Mx
what is triad of abdominal rupture presentation
Thoracic - retrosternal/ central back pain, haemoptysis, collapse - often causes rapid cardiac tamponade
Abdominal - flank or back pain, hypotension and a pulsatile, expansile abdominal mass
- signs of shock - hypotension, tachycardia, collapse, weak thready pulse
Ix:
- Bloods - FBC, U&E, LFT, clotting
- G&S, Crossmatch 6U
- Portable US if unsure
- If not yet ruptured: CT/ CT angiogram
- ECG if thoracic to identify MI
Mx:
- AtoE
- High flow O2
- IV access
- O-ve blood
- Aim SBP <100
- Prophylactic Abx - Cefuroxime and metronidazole
- If stable do CT angio
- If unstable emergency theatre
<70 - open
>70 or women or Comorbs consider end-vascular repair
Acute cholecystitis/ cholangitis management - how present, Ix and Mx
Biliary colic - RUQ pain after eating fatty food
Acute cholecystitis - fever + RUQ pain, N+V
Ascending cholangitis - fever + RUQ pain + jaundice (+ shock + mental confusion)
If swinging pyrexia = gallbladder empyema
Ix:
Do a GI exam - look for jaundice, Murphy’s sign +ve
FBC, U+E, CRP, LFT (ALP/GGT/billirubin), amylase/lipase (pancreatitis)
ABG, culture if suspect sepsis
US gallbladder
ECRP, MRCP or HIDA cholescintigraphy if US -ve
Contrast CT for cholangitis or if suspect complication e.g. perforation
Mx:
Acute cholecystitis:
Monitor BP, pulse, urine output
NBM, IV fluids
Analgesics - diclofenac or opioid
IV abx - trust guideline (cefuroxime and metro)
Laparoscopic cholecystectomy - Nil by mouth, IV fluid, analgesia, ondasteron
Cholangitis - Ecoli
Monitor BP, pulse urine output
NBM, IV fluids
Analgesics - diclofenac or opioid
IV abx - trust guideline (cefuroxime and metro)
ERCP to remove stone or can stent/lithotripsy
Cholecystectomy
Ureteric stone
- present with sudden onset severe loin to groin pain
- lasts mins to hours
- may be haematuria
Ix:
Bedside - urinalysis and Mc&S (look for haematuria)
Bloods - urate and calcium levels, FBC, U+E, LFT, CRP, bone profile, Ca, PTH (exclude high ca as cause), uric acid
Imaging - US for hydronephrosis, CT KUB within 24hr
Stone analysis
Struvite stones - stag horn calculi
Mx:
Advice to increase fluids, loose weight, reduce salt/urate/oxalate/protein in diet
At home if <5mm
- fluids, pain relief (Paracetamol/ tramadol), antiemetic
- Watchful waiting - most pass on own within 3w
- Refer to stone clinic
Can help passage with CCB (nifedipine) or alpha blocker (tamsulosin) if 5-10mm
In hosp if >10mm AtoE, give IV fluids IM diclofenac, antiemetic If hydronephrosis - stent, nephrostomy, catheterise Treat infection Shock wave lithotripsy Percutaneous removal Uretero-renoscopy
Prevention - potassium citrate, thiazide diuretics for calcium stones
Diverticular disease
- LLQ pain worse on eating, better after stool
- Change in bowel habit, bloating, intermittent signif bleeding
- rectal mucus
Diverticulitis:
- N+V
- may have fever/ tachycardia
- may have urgency of urination as can irritate bladder
Ix:
Routine obs + bloods
CXR - look for air under diaphragm (perforation)
CT of abdomen
Barium enema
Sigmoid/colonoscopy - not do in diverticulitis due to risk of perforation
Mx:
If asymptomatic diverticulosis - reassure, suggest lifestyle changes and increase fibre in diet (aim 30g a day)
Diverticular disease - 30g fibre a day, bulk forming laxatives 2nd line, give paracetamol and antispasmodics. Avoid NSAIDS and opioids (increase risk of perforation)
Diverticulitis - Co-amoxiclav, if complications admit for IV fluids, Abx, analgesia. Consider surgery if peritonitis or sepsis, percutaneous drainage if abscess.
Appendicitis
Umbilical pain that worsens and migrates to RIF over 24-48 hours. Worse on movement, low grade fever, N+V, change in bowel habit
On exam:
- Rovsing’s sign - pain in RIF when push in Left
- Psoas sign - lie on left side, extend right hip, causes RIF pain
- often walk slowly, bent over, holding RIF
Ix
- Bloods - FBC, U&E, LFT, CRP
- Urine dipstick + mc&s to exclude renal cause
- US to exclude suspected gynae differentials e.g. ovarian cyst
- Pregnancy test to exclude ectopic
- CT to confirm prior to surgery
Mx
- NBM
- IV fluids
- IV abx
- laparoscopic appendicectomy
Pancreatitis
Acute abdominal pain in epigastric/ LUQ. Radiates to back, better when in foetal position, N+V, fever, peritonitis, flank and periumbilical bruising
Main causes are gallstones, alcohol, steroids
Ix:
Serum lipase/amylase (also high)
Obs
Blood sugar, ECG, pregnancy test
FBC, U&E, LFT (cholestasis), CRP + bone profile + LDH
Do blood gas for grading
Do US, if negative consider MRCP for gallstones
AXR/ CXR can rule out bowel obstruction/ perforation
CT only if diagnostic uncertainty or nor improving after 10-14days
Do Glasgow score in first 48hrs to assess severity - greater or equal to 3 = severe - refer to ITU PaO2 <8 Age >55 Neutrophils >15 Calcium <2 Renal function, Urea >16 Enzymes - LDH >600, AST >200 Albumin <32 Sugar >10
Mx:
Cut down on alcohol, review meds
IV fluids (Hartmans) - 1L stat then 1L over 2, 4, 6, 8 hrs
Analgesia - paracetamol, codeine, oramorph
Nutritional support
Antiemetics (ondansetron)
Catheterise to monitor urine output
Manage gallstones, Abx if infected/ necrosis - ERCP |+/- lap cholecystectomy
If suspect pancreatic necrosis - aspirate and culture - may need surgery
Other complication is retroperitoneal bleed
ARDS is complication if become breathless - may need CPAP
Chronic pancreatitis
Presents as chronic epigastric/ RUQ pain, N+V, reduced appetite and progressive endo/exocrine insufficiency e.g. steatorrhoea, weight loss, malnutrition, DM
Ix:
Bloods, obs (FBC, U&E, creatinine, LFTs, calcium, amylase (usually normal))
Blood glucose, HbA1c
If suspect malnutrition do serum trypsinogen and faecal elastase
Secretin stimulation test - if impaired exocrine function
CT first line investigation
Endoscopic US or secretin enhanced MRI alternatives
Mx
Lifestyle - weight loss, stop smoking/ alcohol, dietician
Pain relief - pain ladder + ERCP stents
Pancreatic enzyme replacement - Lipase e.g. creon
Steroids if AI
DM management + screening
Surgery for complications e.g. pseudo-cyst
Coeliac
In kids - failure to thrive and below: Weight loss Fatigue Weakness Abdominal pain Bloating Flatulence Loose stools Steatorrhoea
Associated with dermatitis herpetiformis
Ix
confirm individual eaten gluten twice a day over last 6 weeks
- IgA Ttg and Total IgA, (2nd line IgG Ttg/ IgA EMA)
- If +ve send to GI for endoscopy and duodenal biopsy - villous atrophy and crypt hyperplasia
- stool culture, MC+S
- FBC (anaemia), U+E, LFT, CRP, ESR, Vit b12/ folate
- Skin biopsy if rash
Mx
Avoid gluten - dietary counselling, referral to dietician
No wheat, barley, rye
Vit D, Ca supplements if insufficient in diet
Assess and manage osteoporosis risk
Yearly follow up, assess sx, BMI, diet adherence, blood tests
If refractory - refer to dietician, specialist and consider short term prednisolone
Complications are dermatitis herpetiformis and Enteropathy-associated T-cell lymphoma (EATCL)
Dyspepsia CBD - differentials and mx
GORD:
Heartburn - worse post meal when lying flat or leaning forwards, acid regurg, bloating, early satiety
Peptic ulcer:
Present with Abdominal fullness, heartburn, nausea, belching, epigastric pain, heartburn, malaena, coffee ground vomit
Eating worsens gastric, improved duodenal
GORD Peptic ulcer Hiatus hernia Gastroparesis - DM Malignancy Drugs lactose intolerance Coeliac
Lifestyle - smaller more regular meals, lift head in bed, eat meals earlier, weight loss, avoid trigger foods, smoking, reduce alcohol, stress/anxiety
GORD:
Ix - 4w PPI trial, OGD if any alarm symptoms (anorexia, anaemia, loss of weight, IDA, melaena)
Mx
Consider a month trial of PPI to help the oesophagus heal, if severe 2months. If recurrent put on lowest effective dose long term
stop any exacerbating drugs
If persistent, oesophagitis - consider doubling PPI dose or adding ranitidine
If ineffective consider laparoscopic fundoplication
Peptic ulcer:
Ix - Hpylori breath test or stool antigen test (not have taken PPI for 2w or Abx for 4), OGD with biopsy (urease testing), FBC for anaemia due to blood loss,
Mx
Review meds (aspirin, bisphosphonates, corticosteroids, potassium supplements, SSRIs, cocaine)
Ask about prev Abx that could affect H pylori tx
7d - Omeprazole, clarithro/metro and amoxicillin
Retest endoscopy and breath or stool test as TOC at 6-8w
If due to NSAID give 2month PPI
If NSAID + H pylori - 2month PPI then eradication
If bleeding consider clipping, thermal coag, adrenaline
Interventional radiology if not improve with endoscopic management, surgery if not available
Hiatus hernia/ malignancy - Barium swallow or endoscopy
Crohns management
- mouth ulcers
- Diarrhoea (nocturnal)
- abdo pain
- Blood in stool
- B12 deficiency (malabsorption in terminal ileum), tingling in fingers
Skip lesions, transmural, entire GI tract
Ix: GI exam, PR and Oral examination FBC (anaemia), U+E, LFT, CRP, ESR, ferritin, B12, folate Stool sample - culture and calprotectin ASCA +ve, pANCA -ve Colonoscopy + biopsy from terminal ileum OGD to differentiate from peptic ulcer Bowel CT/ MRI to look for fistula
Mx:
Induce remission with corticosteroid e.g. prednisolone/ budesonide (modified release steroid) or 5-ASA if steroids CI/ not tolerated
If >2 acute episodes in last 12 months add azathioprine or mercaptopurine
If severe induce with IV hydrocortisone, consider parental nutrition, Abx and blood transfusion
Maintain remission with azathioprine/mercaptopurine, second line methotrexate
To treat diarrhoea
- loperamide
- antispasmodic e.g mebeverine
- bulk forming laxative
- bile acid sequestrant e.g. cholestyramine
Surgery if obstruction, stricture, perforation, abscesses, enterocutaneous fistula - colectomy, segmental repair, widen stricture, stoma
Strictures, fistuae, obstruction are complications
Management of UC
Bloody diarrhoea, tenesmus, LLQ pain often improved on defecation, urgency/ incontinence,
Only LI, superficial, crypt abscesses
Ask if eye, skin, MSK, hepatobilliary
Admit if systemically unwell Ix: FBC (blood loss, anaemia), U+E (dehydration), ESR, CRP Stool sample to exclude infection, do calprotectin Colonoscopy + Biopsy pANCA +ve, ASCA -ve CT to stage, look for complications Abdo xray- lead pipe
Assess severity with true love and Witts
Tx:
Induce remission with 5ASA either topical or oral, if resistant can add corticosteroids, if still not improving over 2w start biologic e.g. adalimumab
If severe episode consider IV steroids + PPI supplemented with IV ciclosporin if no improvement over 72 hours, also IV fluids, Abx, VTE prophylaxis
Maintenance use ASA topical or oral, if >2 relapses in last 12mo that required steroid treatment add azathioprine or mercaptopurine
Protocolectomy - 1st line surgery
Subtotal colectomy with end ileostomy, preservation of rectum - if malignancy, toxic megacolon, failure of medical mx
Don’t give loperamide - risk of toxic megacolon
Avoid NSAIDs
UC associated with increased risk of colorectal cancer and PSC
Causes of cardiovascular syncope
Pale before, become flushed after collapse, lasts seconds
Physical exertion is often a trigger, often no prodrome (unlike vasovagal, have lightheadedness, sweating, nausea)
sudden uncontrolled fall to ground (slow and controlled in vasovagal)
Structural heard disease: CAD, valve disease, tamponade, cardiomyopathy, dissection
Pulmonary disease e.g PE
Sudden onset headache and collapse - SAH
If complete heart block - stokes Addams attacks
Collapse when working with arms above head - cause?
Subclavian steel syndrome
Epilepsy Hx and management
> 2 unprovoked seizures occurring more than 24 hours apart – within a year of each other
Ix: CV, neuro, MSE - identify injuries Routine obs FBC, U+E, LFT, CRP, BM (hypoglycaemia), toxicology screen, blood cultures if think infection, lactate, Raised prolactin and CK ECG MRI - look for structural cause EEG
Mx:
Advise on water safety (shower not bath, buddy system), leave bathroom door unlocked, fire safety and cooking, environment and work safety. Care with heights, high risk activities and consider contraception for certain meds. Advise family and carers.
1st seizure - 6months for car 5 years for HGV
epileptic seizure 1 year for car
>1 seizure - 10 years for HGV
Focal - carbamazepine
Tonic-clonic seizures: sodium valproate or lamotrigine.
Absence seizures: ethosuximide or sodium valproate
Myoclonic seizures: sodium valproate or topiramate.
Status epilepticus = seizure >30 mins or recurrent without regaining consciousness (treat at >5mins)
AtoE
Lorazepam 4 mg IV, if unavailable;
Diazepam 10 mg PR, if unavailable;
Midazolam 10 mg buccal
if 2 doses of above 10 mins apart, if not work give phenytoin
If phenytoin not work transfer to ITU for GA
Loss of consciousness hx + Ix
Triggers, what happening before - exercising? flashing lights? arms above head? lying/standing?
Prodrome - light headed, dizzy, nausea, sweating if vasovagal, none if cardiac, deja vu, hallucination, feeling of doom if seizure
Look pale before, sudden, without warning, on exertion = cardiac
Remember hitting floor - if so is a fall not collapse
How collapse - sudden and uncontrolled = cardiac, slow and controlled = vasovagal
Motor symptoms?
Duration - seconds = cardiac, 30 seconds = vasovagal, mins = seizure
Tongue biting, incontinence
Time till recovery - seconds = cardiac/ syncope, seizures can be longer, can have post-ictal drowsiness, amnesia, transient focal paralysis (Todd’s paralysis)
Relieving factors - better when sat down?
Any injuries/ any pain/ vomiting
Then look for cause - any resent sx (fever (meningitis), chest pain (PE), headache, rashes, weight loss (SOL), DM)
PMH, drug Hx, FHX, Social hx
Investigations:
- BP, HR, tilt table test
- Echo/ ECG for cardiac issues
- ABG - lactate raised in seizure
- EEG for seizure
- Bloods - U&E, FBC, LFT, blood glucose, AED levels
TIA management
Definition = Transient neurological dysfunction caused by focal brain, spinal cord, or retinal ischaemia, without evidence of acute infarction or tissue injury
usually last 10-15 mins
Ix:
Do neurological examination
Do routine obs (BP often rise), perform a GCS, listen to carotids for bruit
Can use FAST screening tool in primary care
Refer to specialist centre for appointment within a day
FBC, ESR, U+E, LFTs (including PT, INR), TFT, cholesterol, ECG/ echo if cardiac cause
MRI preferable for identifying small infarcts, do CT head if suspect haemorrhage
Carotid doppler to look for stenosis
Assess risk of stroke using ABCD2 score - no longer recommended by nice
Mx:
300mg aspirin loading dose immediately (unless risk of bleed) Cont. for 2w
After 2w give 300mg clopidogrel loading dose then continue on 75mg a day long term
Discuss lifestyle: diet, exercise, smoking, alcohol, no driving for 1 month
Treat CV risk factors e.g. BP, cholesterol, AF (anticoagulant)
If >70% stenosis - carotid endarterectomy
Ischaemic stroke
Difference between total anterior circulation stroke and partial:
Total = 3/3 Partial = 2/3 - hemiparesis/hemiplegia - problem with higher mental function (aphasia, apraxia, inattention) - hemianopia
Lacunar stroke - motor/sensory impairment but no change in higher cerebral function
A-E
CV exam, ECG (24hr for AF)
Always do BMs
FBC, U&E, LFT, Coag, Cholesterol, antiphospholipid syndrome
Toxicology
Imaging - CT head within 24 hrs to exclude haemorrhage, CT angiography or magnetic resonance angiography if considering thrombectomy, CT perfusion scan can show salvageable tissue
Carotid US doppler
general - oxygen (sats>95%), blood glucose, swallow assessment, nutrition screen, mobilise, consider for carotid endartectomy - >50% on US
<4.5 hours - alteplase infusion, 300mg aspirin after 24 hrs for 2 weeks then clopidogrel long term
+ thrombectomy if <6hrs and confirmed prom anterior circulation occlusion on CTA or MRA, or 6-34hrs if above + salvageable tissue on CT perfusion scan
> 4.5 hours - aspirin 300mg for 2 weeks then clopidogrel long term
If cant tolerate clopidogrel - Aspirin 75 mg daily with modified-release dipyridamole 200 mg twice daily
manage comorbidites such as lipids etc
Confirm size of infarct, check for any complications of thrombolysis with CT at 24hrs
If haemorrhage = poor prognosis, supportive care, manage BP, contact neurosurgery
Rehab, physio
How does carotid dissection present
Unilateral head/face/neck pain, horners syndrome, anterior circulation stroke/TIA
Haemorrhagic stroke
A-E, CV exam Always do BMs FBC, U&E, LFT, Coag, Cholesterol Toxicology FAST rapid assessment CT - haemorrhage = white If suspect SAH do a lumbar puncture (do after 12 hours, look for xanthochromia)
Mx
Oxygen (sats>95%), blood glucose, swallow assessment, nutrition screen, mobilise
BP control - aim for 130 to 140 mmHg with IV labetalol
swallow assessment
Stop any anticoagulants
Early mobilisation
Falls risk assessment
Decompressive hemicraniectomy (do within 48hrs if meet NIHSS based criteria)
Rehab, physio
What is pyramidal weakness, when is it seen
= UMN damage, seen commonly in CVA, have fixed flexion of upper limbs and extension of lower limbs
PE management
Massive PE = >50% obstruction and SBP <90
Provoked: flight, immobility, surgery, trauma, pregnancy, COCP, HRT, malignancy
SOB, pleuritic chest pain, tachypnoea, cough up blood
Ix:
Calculate the wells score
- >4 -> CTPA
- <4 -> Ddimer, if +ve do CTPA
Start apixaban/ rivaroxaban while await result
If allergic to contrast, GFR <30 or pregnant do V/Q SPECT
Do FBC, U+E, CRP, LFT, Coag, thrombophilia
ABG
Do ECG to identify AF, PE changes (S1,Q3, T3)
CXR to exclude other causes
Screen for cancer if >40, unprovoked
Mx:
AtoE
Give O2, analgesia, iv access, assess circulation (BP)
If low risk, outpatient anticoagulant
If high risk, admit to hosp
1st line: rivaroxaban or apixaban
Or LWMH for 5 days then dabigatran or edoxaban
Or LMWH for 5 days with warfarin until INR normal then warfarin alone
If renal failure - LMWH or warfarin
3 months for provoked, 3-6 months provoked with cancer, 6 months for unprovoked
Massive PE (SBP <90 or drop by 40) - continuous UFH infusion and consider thrombolytic with alteplase
If repeated: IVC filter or pulmonary embolectomy
Meningitis
most common bacterial cause is strep pneumoniae, N meningitidis causes meningococcal septicaemia
Ix:
Assess GCS
If suspect raised intracranial pressure do CT before LP
LP within an hour - WCC, gram stain, glucose, protein, lactate, culture, PCR, Ziehl-Neelson
If cant LP do: FBC, CRP, coag, culture, PCR, BM, ABG
non blanching rash, headache, photophobia, neck stiffness, fever, hypotension/shock, bulging fontanelle,
Kernigs and brudzinski signs
differential if altered mental status - encephalitis, usually herpes, treat with acyclovir
Mx:
Raised ICP -> ITU -> fluids, analgesics, antiemetics, antipyretic
Viral - often self limiting, may give acyclovir
Bacterial - IM or IV benzylpenicillin immediately (only if meningococcal rash). When in hosp start ceftriaxone if >3mo old, add ampicillin or amoxicillin if >60 yo. Give dexamethasone asap, continue for 4 days if pneumococcal
Length of treatment depends on cause
Cryptococcal - fluconazole, amphoteracin B
Consider prophylaxis of contacts - ciprofloxacin
If TB - RIPE for 2m then I+R for 10m (4 normally) + IV dexamethasone
Uraemic complications
Pericarditis and encephalopathy
Adrenal insufficiency (Addisons) management + adrenal crisis presentation/ management
Hypotension (postural), fatigue, weight loss, GI/MSK sx, hyperpigmentation, pubic/ axillary hair loss, salt craving, low libido
Ix:
Early morning serum cortisol - <100
Synacthen test < 550
Test ACTH level to differentiate primary and secondary - high in primary
Electrolytes - low sodium, high potassium
test glucose lvl
Mx:
Educate that it is a chronic condition, will need to take medication for the rest of their life. Is important they take the medication every day, not suddenly stop. Ensure they know how to recognise an adrenal crisis (hypotension, hypovolaemic shock, low blood glucose, N+V, abdo pain, low grade fever)
Treatment involves a combination of hydrocortisone taken 3x daily 10mg on waking, 5mg at noon and 5mg in the evening and fludrocortisone
Can get all their medications for free
Wear a medic alert bracelet
Educate on sick rules
- mild to mod (fever, Abx) - 2x dose for 2 days
- severe - 2x dose, cont until better
- vomit - if vomit within 30 mins, double dose again immediately, if again then 100mg hydrocortisone inject
- minor surgery - double dose on day
- maj surgery - cont infusion
If go abroad take enough for double doses + injection kit
Addisonian crisis - hypotension resistant to fluids, high K, low Na, vomiting, weight loss - do ACTH, cortisol level, ABG (metabolic acidosis), BMs
AtoE Identify cause, screen for infection, cardiac monitoring Iv hydrocortisone 100mg-200mg IV fluid rehydration Monitor BMs
Hypothyroid + when to treat subclinical
Causes:
- Congenital
- Hashimoto
- thyroidectomy, radiotherapy
- iodine deficiency
- carbimazole/ptu
- subacute (de quervains) thyroiditis - viral - hyperthyroid first then hypo
2ndry - pituitary tumours, surgery, radio, infarct (Sheehan)
Ix:
TFTs - TSH high, T3/T4 low
Anti thyroid peroxidase, antithyroglobulin antibodies, US if goitre
MRI if suspect secondary cause
Also check cholesterol (raised), FBC (pernicious anaemia), HbA1c (T1DM), CK (myopathy)
Tx:
Levothyroxine - titrate until TSH normalises
For secondary - transphenoidal surgery
Myxoedema - IV levo, IV steroids, IV fluids, warming
Treat subclinical if TSH > 10
Hyperthyroid
Causes
- graves - eye signs + pretibial myxoedema
- toxic multi nodular goitre
- subacute (painful thyroid) - viral
Secondary
- HCG - multiple pregnancy, molar pregnancy, gestational thyrotoxicosis
- Pituitary adenoma
Ix: TFT: TSH low, T3/T4 high TSH receptor antibodies US of goitre, radio-iodine scan (diffuse vs hot nodules) Biopsy if suspect neoplasm ECG for AF CRP/ ESR - subacute
Tx:
Carbimazone, propylthiouracil - titration block or block replace
Beta blocker for tremor
Radioactive iodine treatment - not recommended in orbitopathy, 3w radio protection after tx, contraception for 6m (4m for men)
Surgical removal
Eyes - steroids, prism glasses, covers, artificial tears, decompressive surgery
Thyrotoxic storm Cool, fluids, resp support Hydrocortisone Carbimazole or propylthiouracil Beta blocker Iodine after 4 days
Treat subclinical if <0.1
CO poisoning - what to ask in Hx and how to treat
Low dose - dizziness, headache, N+V
Higher - confusion, LOC, resp failure, MI
C - anyone else in house affected
O - better when outdoors
M - maintenance of heating/ cooking equipment
A - Alarm (do they have a CO alarm)
Ix
- exhaled CO using breath test on site
- carbon monoxide pulse oximeter (bedside) or a HbCO blood analysis
- ABG
Mx
- Give 100% O2 until HbCO levels are < 3% in non-smokers or <10% in smokers
- if cerebral oedema give mannitol 1g/kg IV
- Monitor ECG
Alcohol
- questionnaires?
- ix?
- managing withdrawal
- drugs to help maintain abstinence
+ how does wernicke’s (triad)/ Korsacoff/ DT present?
CAGE or AUDIT questionnaire
Ix
- FBC (MCV often raised)
- LFT (GGT raised), clotting, U&E
- Amylase if suspect pancreatitis
- Blood glucose
- Breath/ blood levels
Withdrawal
- CIWA-Ar score
- IV fluids - glucose only after thiamine
- IV or oral thiamine - prevent wernicke’s
- Tapering dose of chlordiazepoxide over 5-7 days, confirm abstinence with breath test
- MgSO4 can reduce seizure/ arrhythmia risk
Abstinence
- Disulfram/ Antabuse - headache, N+V, flushing when drink
- Acamprosate - reduces cravings
- Naltrexone - reduces high associated with drinking
Delirium tremens = most severe form of withdrawal - after 72hrs- delirium (clouding of consciousness, delusions), tremor and hallucinations + haemodynamic instability
Wernicke’s triad = mental confusion, ataxia, ophthalmoplegia
Korsakoff - longstanding confusion after withdrawal - anterograde amnesia (no new memories), confabulation (says something not true but with conviction), telescoping (says something in past happened recently), personality change, no clouding of consciousness.
Delirium - causes + DSM-V criteria +
Ix
Do 4AT or AMT
Causes: Pain Infection Nutrition Constipation Head injury, hypoxia Endocrine + electrolyte - altered pH, hypo/hyper Na+ Ca++, acute liver or renal failure, hypoglycaemia Stroke Medication and alcohol Environment
Ix:
Take a Hx from person and third party
Baseline
Cognitive assessment based on DSM-V (inattention, cognitive change, acute/fluctuation, physiological cause) criteria or a 4AT or CAM, AMT10
Admit for investigations for above causes
- assess for fractures
- FBC, CRP, CXR, urinalysis, blood culture, sputum sample, examine for skin infections
- B12, Folate
- Rectal exam, AXR, GI exam
- Assess for dehydration, U&E
- U&E, glucose, LFT (encephalopathy), TFT, ECG, calcium, bone profile
- Neuro exam, ABG
- Medication hx, Drug lvls
- home hazard review
confusion screen: FBC, LFT, CRP, U+E, ABG, Coag, TFT, Bone profile, Mg, b12, folate, ferritin
Mx:
Treat cause
Optimise treatment of Comorbs, medications
Reorientation strategies
Quiet side room, normalise sleep/wake cycle
Home comforts
PT/OT assessment, safe mobility
Home hazard assessment
Give haloperidol or benzodiazepines as sedation may be used if very agitated
Explain diagnosis to carers
AKI
Prerenal - hypo perfusion due to haemorrhage, low blood pressure, sepsis, renal artery occlusion (embolus, infarct, stenosis), reduced cardiac output (HF, MI, PE
Intrinsic - rhabdomyolysis (+ve blood on dipstick), myeloma, ATN (drugs), glomerulonephritis, haemolytic uraemic syndrome (anaemia)
tubular interstitial nerphritis - abx (penicillin), ppi, chemo, nasi
Post renal - bilateral renal stone, lymphoma, bladder outflow obstruction (tumour, stricture, stone), tumours, BPH, neurogenic bladder
Stage 1 - Creatinine >26.5, 1.5-1.9x baseline, urine <0.5 ml/kg/hr for 6-12 hrs
Stage 2 - Creatinine 2.0-2.9x baseline <0.5ml/kg/h for >12 hours
Stage 3 - Creatinine >3x baseline <0.3ml/kg/h for >24 hours OR anuria for >12 hours
hospital acquired AKI - after 48 hours post admission
Ix:
Observe urine output
Do lying/standing BP
urine dip + urinalysis (looking for raised protein, blood, casts), MSU, PCR, PSA
U+E, bicarb, inflam markers, nephritic/MM screen
ABG (pH - metabolic acidosis)
USS KUB
Admit if stage 3, urgent treatment for cause e.g. obstruction, hypovolaemic, complications e.g. pulmonary oedema, sepsis, unknown cause
Tx Catheter + daily U&Es Correct high K+ If hypovolaemic - fluid challenge and maintenance, stop BP meds - aim SBP > 100mmHg If hypervolaemic - furosemide, diamorphine and nitrate plus fluid restrict - or dialysis If acidosis - sodium bicarbonate Relieve obstruction, remove stones etc If sepsis - sepsis 6
Stop DAAAMN- Aminoglycosides, NSAID, ACEi, Metformin, Amphoteracin, Diuretics, Lithium, Digoxin
Insulin renally cleared - if develop AKI reduce dose by 10-20%
ATN - prerenal or post renal cause to an extreme
TIN - sensitivity reaction to Abx, NSAID - give steroids
When to initiate dialysis
Hyperkalaemia unresponsive to medical treatment or in an oliguric patient
Pulmonary oedema unresponsive to medical treatment
Uraemic complications such as pericarditis, encephalopathy
Severe metabolic acidosis (pH <7.2 or base excess below –10)
Fluid overload
Causes of hypernatraemia (>145)
+ management (incl diabetes insipidus)
Hypovolaemic - diarrhoea, vomiting, dehydration, burns, loop diuretics, osmotic diuresis (DKA, mannitol), ATN
Euvolaemic - Diabetes insipidus (low ADH due to reduce production in pituitary or effect in kidneys e.g. CKD) - polyuria + polydipsia - water deprivation/ desmopressin test
Hypervolaemic - too much saline, abx containing sodium, conn’s (primary aldosteronism, high Na, low K), cushings
Urine osmolality
- high = burns or vomiting as water los via other means
- isotonic = diuretic use or osmotic diuresis
- low = diabetes insipidus, conns, cushings
Tx
- Hypovolaemic - IV NaCl
- Hypervolaemic (primary hyperaldosteronism) - Spironolactone, IV dextrose and diuretics
- Isovolaemic (DI) - Increase fluid intake, IV dextrose 5% slowly IV (not too quick as risk of cerebral oedema), desmopressin if cranial, desmopressin/ thiazide/ NSAID if nephrogenic
- if very high consider dialysis
Hyponatraemia/ SIADH - to do
= Na <135
Hypovolaemic (dehydrated)
- low urine osmolality = diarrhoea/ vomiting/ burns
- high urine osmolality = diuretics
Euvolaemic
- urine osmolality/ Na low = acute water load, anorexia, hypothyroidism
- urine osmolality/ Na high = SIADH or Addisons/ CAH
Hypervolaemic
- low urine Na - cardiac failure, low albumin (cirrhosis)
- high urine Na - renal failure
Tx
- hypovolaemic - give NaCl 0.9% slowly to avoid central pontine myelinosis
- SIADH - fluid restrict to 500ml-1L per day + demeclocycline or vaptans
- hypervolaemic - treat cause, loop diuretics
If acute/ severe sx - 3% hypertonic saline
SIADH can be caused by meningitis,GBS, MS, small cell lung cancer, SSRI, carbamazepine
Present with fluid overload, sx of hyponatraemia (N+V, headache, muscle cramp, confusion, seizure)
Differential if K+ raised = Addisons
Ix:
U+E
Confirm true hyponatraemia with finding of low serum osmolality
Plasma and urine osmolality (high in urine, low in blood)
Urine sodium
TFT, synatchen test or early morning cortisol
Mx of SIADH: Treat cause Fluid restrict Demeclocycline Vaptans
Hyperkalaemia - causes, presentation and ECG
= >5.5
Increased intake: dietary, IV fluids, blood transfusion,
Decreased excretion: K+ sparing diuretic, ACEi, spironolactone, Addisons, AKI/ CKD
Extracellular shift: Acidosis (DKA), TLS, Rhabdo, burns
Presents with Fatigue Generalised weakness Chest pain Palpitations SOB
Ix:
Full set of bloods - U&E for K+ level/ AKI, CK for rhabdo, cortisol for Addisons
ABG - see electrolyte levels, metabolic acidosis
Urinalysis
ECG - tented T wave, prolonged PR/ flattening of P waves, wide QRS, VF
Mx:
ABCDE
Cardiac monitoring
Protect myocardium - calcium gluconate - 10ml 10% over 10 mins
Reduce K+ with insulin/dextrose solution - 10U act rapid in 50ml 50% dextrose
Nebulised salbutamol - back to back 5mg nebs to 10-20mg max dose
Dialysis if needed
Chronically - calcium resonium and lactulose
Hypercalcaemia
Causes = hyperparathyroidism, cancer (bone mets, myeloma, squamous cell lung cancer)
Myeloma, Squamous cell carcinoma (PTHrP)
Bone metastasis in lung, breast, renal, prostate (increase osteoclast action and bone resorption
Hodgkins lymphoma (active vit D - increase gut absorption)
Present with Ca >2.6 Stones Thrones - constipation, polyuria Groans - abdo pain, N+V Bones - Bone pain Psychic moans - depression, anxiety, cognitive dysfunction Cardiac - HTN, Bradycardia, arrhythmia
Want to rule out hyperparathyroid hormone as a cause
Ix:
Rapid onset - malignancy
PTH - high = hyperparathyroidism, low due malignancy
Do relevant exams and CT to look for malignancy
Plasma electrophoresis - raised plasma protein in MM
ECG, bloods including Bone profile, LFTs
Can confirm with:
Then test PTHrP and Vitamin D/Calcitriol lvl
Phosphate - low in hyper, high in malignancy
Raised ALP - bone mets
ECG - short QT interval
US of parathyroids
Renal, breast, PR, Resp exams
Mx:
Admit if Ca >3 or symptoms
Rehydration - IV saline to increase renal excretion
Bisphosphonate e.g. Zoledronic acid used to reduce bone turnover. Alternative is calcitonin
If concurrent kidney disease consider dialysis
For hyperparathyroidism - surgery can be considered if symptomatic
For cancer - chemo/radio therapy
Hypocalcaemia - causes
Most common causes
- vit d deficiency
- hypoparathyroidism - surgery, radiotherapy, AI
- CKD
- hypomagnesia
- pancreatitis
- bisphosphonate
- rhabdo/ TLS
Ix
- Do PTH, Vit D, Ca lvls
- High PTH, low Ca = Vit D deficiency, vit D receptor issues or CKD
- Low PTH, low Ca = primary hypoparathyroidism, congenital, hypomagnesia
- Also do U&E for CKD, ECG for long QT, amylase, CK, phosphate
Tx
- 10ml 10% calcium gluconate slow IV
- correct low Mg
- Oral vit D
- If persistent give oral calcium supplements
Acute angle closure glaucoma
Sudden onset red painful eye with associated headache. Blurred vision, haloes around light, N+V, fixed mid-dilated pupil with hazy cornea
Precipitated by watching TV in dark room, reading at night
Ix
- gonioscopy - trabecular meshwork not visible
- slit lamp
- Tenometry
- Humphrey’s visual fields
Tx
- lie patient on back, face up with no pillows
- one drop of pilocarpine (2% if blue eyes, 4% if brown)
- 500mg oral acetazolamide
- analgesia/ antiemetic as needed
- laser irridotomy in both eyes once acute event resolved
POAG
Can present with gradual onset of fluctuating pain, headaches, blurred vision and halos appearing around lights, particularly at nighttime
Ix:
Fundoscopy - cupping of optic disc (>0.4), notching, retinal haemorrhage
Vision assessment - scotoma, loss of peripheral vision (Humphrey visual field)
Tonometry (>21mmhg)
Goniometry - exclude AACG
Slit lamp
MRI scan of orbit if suspect graves or orbital cellulitis
Tx:
1st line - latanoprost (prostaglandin analogue) or timolol (beta blocker)
2nd line - switch, combine or add pilocarpine, acetazolamide, bimonidine
Laser trabeculoplasty, trabeculotomy, aqueous shunt
Monitor yearly for rest of life -
Raised ICP
Sx - headache worse on bending over, vomiting, visual changes
Signs
- Cushing triad - hypertension/ wide pulse pressure, bradycardia, irregular breathing
- unilateral ptosis
Ix
- Bloods - U&E, coag, FBC, LFT, glucose, osmolality
- fundoscopy - blurring of disc margins
- CT/MRI
- LP for opening pressure/ diagnosis
- ICP monitoring
Tx
- General - fluid restrict, raise head of bed, analgesics (morphine reduces coughing), sedation (propofol)
- treat cause e.g. bleed, tumour
- manage seizures
- CSF drainage
- IV Mannitol, Hypertonic NaCl 2nd line
- hyperventilation
- avoid pyrexia/ active cooling
- decompressive craniectomy
Angina Stable/Unstable
Unstable if
- new onset
- deteriorating
- occurs at rest
Ix:
Take history and perform cardiac examination
Do an ECG to look for ST elevation, Q wave or LBBB
Take serial troponins
Do routine bloods: FBC, U+E, LFT, CRP, CK, myoglobin, lipids, TSH, blood glucose
CXR, echo
Consider exercise stress test (Echo), CT angiogram or Coronary angiogram to investigate angina Sx and degree of CAD
Mx: (acute) O2 if sats less than 94% Morphine, metoclopramide 10mg of each Nitrates Aspirin 300mg Ticagrelor according to Chadvas/hasbled Fondaparinux - if going for PCI within 24hrs give unfractionated heparin instead Glycoprotein inhibs if high risk of CV events
Use grace score to decide the risk of MI and need for PCI
Discuss lifestyle risk factors e.g. diet, exercise, smoking, alcohol
Evaluate CV risk factors and start on BARDS = acei, BB, aspirin/clopidogril, rehab, statin
For stable angina:
Stop smoking, activity, weight loss, diet, alcohol
Provoking factors e.g. stress, exercise, cold, large meal
1st line - rest +GTN (up to every 1/2 hour) - take second dose at 5 mins if not improved, if second not help call 999
2nd line - Beta blocker or CCB (verapamil/diltiazem)
3rd line - Beta blocker + CCB (bisoprolol and nifedipine)
4th line - Add in long acting nitrate (isosorbide mononitrate), nicorandil, ivabradine, ranolazine
+
Secondary prevention: 3A’s: aspirin (75mg OD), atorvastatin (80mg OD), ACEi (e.g. ramipril, titrated up to max dose) + statin if cholesterol >4mm/l
Stemi
Ix:
Hx, Exam
O2 sats
Serial troponin, CK-MB, myoglobin if recent MI
ECG - look for ST elevation, new LBBB, Q wave
ECHO/ CXR
Bloods - FBC look for anaemia, U+E to check renal function for contrast, BNP
O2 sats
Mx Morphine +metoclopramide 10mg each IV O2 if sats <94% Nitrates - GTN sublingual, IV if not enough Aspirin 300 Relocate to cardiac intensive unit Ticagrelor 180 Unfractionated heparin - give for max of 5 days, stop post PCI - if possible within 90 mins
PCI with stent (or CABG if multi vessel disease) within 90 mins, if not possible within 120 give thrombolysis w. alteplase or streptokinase
If low CO consider ionotrope e.g. dobutamine
Post MI discuss lifestyle - smoking, alcohol (<14), exercise (150 mins a week, weight training at least 2days), cardio protective diet (reduced salt and fat, more fruit, seeds and nuts, more fish).
Start on ACEi Beta blocker Antiplatelet - aspirin + ticagrelor - 12m, after this cont aspirin, stop ticagrelor Rehab Statin
Antianginals - give ranolazine if low BP
Migraine
Unilateral, throbbing 4-72hrs
have to lie down in dark room
Associated N+V, aura, photophobia and photophobia
Ask about prodrome and postdrome
Cant carry out normal daily life
For diagnosis
- without aura need 5 characteristic headaches
- with aura need 2 headaches with associated visual, sensory or speech/language aura
Ix:
Comprehensive history
Visual assessment, fundoscopy if eye signs
Neuro exam/CN exam if neurological symptoms
Take drug history to identify if medication overuse
Mx:
Educate, do headache diary to understand triggers and avoid them.
Limit standard analgesics
Optimise Comorbs e.g. OSA, insomnia, depression
Take off oral contraceptive pill
1st - Ibuprofen, aspirin, paracetamol
+ metoclopramide
+ sumatriptan - take at start of headache not aura
Prevention: Propanalol (1st line in women of childbearing age), Topiramate, amytriptalline
- start if 2 or more attacks a month that last 3 or more days, or significant effect on quality of life
In pregnancy - 1st line = paracetamol
If linked to menstruation consider mefanamic acid or a combination of aspirin, paracetamol and caffeine
Consider mindfulness, acupuncture, riboflavin
GCA
Ask about joints (polymyalgia rheumatica), tender scalp, vision, jaw, resp tract/ ENT sx
Ix:
Exam, bloods: FBC (normochromic normocytic anaemia and an elevated platelet count) , U+E, LFT (raised ALP), ESR, CRP
Fundoscopy (CRAO - painless sudden loss of vision with RAPD)
Biopsy
Duplex US
PET
PMR - >50, bilateral shoulder/ pelvic girdle ache, last >2w, raised ESR/CRP, morning stiffness >45 mins
Mx:
If strong clinical suspicion start high dose corticosteroids immediately prior to confirmation with biopsy
- IV Methylpred if eye
- 60mg pred if jaw, 40mg if no jaw
- Assess response after 48 hrs
- Taper and continue for 1-2 years
Start aspirin 75mg daily unless contraindications
+ PPI
If recurrent/ contraindications to steroids - tocilizumab, methotrexate
cluster headache
Tx:
Avoid triggers such as alcohol and smoking
Acute: 100% O2 via non rebreathe and sumatriptan subcut, metoclopramide if nausea
Prevention: verapamil 1st line, lithium alternative. prednisolone can help break cluster
