AIP Flashcards
1
Q
What is alveolar-arterial O2 gradient used for
A
In type 2 resp failure
- if A-a gradient normal = not due to lung disease
- if A-a gradient is raised = intrinsic lung disease
2
Q
causes of a complete white out on CXR
A
Trachea deviated towards = total lung collapse, pneumonectomy
Trachea central = consolidation (pneumonia), ARDS
Tracheal away = large pleural effusion
3
Q
Electrolyte daily requirements
A
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
4
Q
Signs of dehydration on U&E
A
Hypernatraemia, high haematocrit, raised Hb
5
Q
Transfusion threshold - normally and with ACS
A
70g/L normally
80g/L with ACS
6
Q
G&S vs crossmatch
A
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
7
Q
Blood product thresholds
A
Platelets - bleeding and <30x10^9
Plasma - if bleeding and abnormal coag (APPT ratio >1.5)
Cryoprecipitate - DIC with fibrinogen < 1g/L, von willebrand
8
Q
Immediate immune reactions to transfusion, how they present and management
A
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.
9
Q
Indications for arterial line + what the trace tells us + complications
A
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
10
Q
Causes of raised and low CVP - how it is measured?
A
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
11
Q
Catecholamine drugs used in ICU - what are their target receptor and action
A
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
12
Q
Classes of anti-arrhythmics
A
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
13
Q
Indications for NG tube + when to do a PEG tube
A
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
14
Q
How is TPN given
A
Via a central line
15
Q
Refeeding syndrome
A
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
16
Q
what to give patients in a coma
A
glucose, thiamine IV if cause unclear
may also trial naloxone or flumazenil
raised ICP consider mannitol
fluids + ventilation, nutrition, pressure sores
17
Q
How to confirm brainstem death
A
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
18
Q
What number to call if no signs of life in suspected cardiac arrest
A
2222
19
Q
When to give adrenaline/amiodarone during CPR
A
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
20
Q
Reversible causes of cardiac arrest to treat during CPR
A
4 H’s
- Hypoxia
- Hypovolaemia
- Hypothermia
- Hyper or hypokalaemia
4 T’s
- Tension pneumothorax
- Tamponade
- Toxins
- Thromboembolism
21
Q
Cardiogenic shock - definition, causes, presentation, ix, mx
A
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
22
Q
Hypovolaemic shock
A
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
23
Q
anaphylactic shock
A
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
24
Q
Neurogenic shock - cause, triad of signs and mx
A
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
25
*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
```
26
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
27
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
28
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
29
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
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
31
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
32
Chronic bronchitis definition = part of COPD
chronic productive cough for at least 3m in each of the last 2 years
33
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
34
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
35
Causes of pleuritic chest pain
PE, pleural effusion, pneumonia
36
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
37
*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
38
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
39
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
40
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
41
Treatment in GI perforation
Resus - IV fluids, O2
IV abx
NG tube for decompression
Surgery to repair + washout
42
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
43
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
44
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
45
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
46
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.
47
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
48
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
49
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
50
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)
51
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
52
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
53
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
54
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
55
Collapse when working with arms above head - cause?
Subclavian steel syndrome
56
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
57
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
58
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
59
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
60
How does carotid dissection present
Unilateral head/face/neck pain, horners syndrome, anterior circulation stroke/TIA
61
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
62
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
63
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
64
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
65
Uraemic complications
Pericarditis and encephalopathy
66
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
```
67
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
68
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
69
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
70
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.
71
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
72
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
73
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
74
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
75
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
```
76
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
77
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
78
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
79
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
80
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 -
81
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
82
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
83
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
84
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
85
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
86
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
87
IIH
```
Ix:
MRI/CT - look at size of ventricles (normal, large in hydrocephalus)
LP - assess pressure
Visual field mapping
FBC, CRP, ESR, COAG
```
```
Mx:
Loose weight, lifestyle
Acetazolamide, serial LP can drop ICP
Prednisolone acutely for papilloedema
Surgery - bariatric, CSF shunt, optic nerve fenestration
```
88
Rhino-sinusitis
Diagnosed if have facial discomfort/pain, nasal obstruction or purulent discharge, loss of sense of smell
May consider nasal endoscopy to look for polyps, inflammation, oedema, purulent discharge
CT if atypical or severe disease
Mx
Reassure, most resolve within 3 weeks
Anti-pyretic, nasal decongestant max a week, nasal irrigation with saline, fluid + rest, warm face mask
If >10 days consider 14 days of high dose intranasal corticosteroid
If prolonged beyond this or very severe, or rapid decline may consider Abx, first line = phenoxymethylpenicillin
If recurrent consider endoscopic sinus surgery
89
Trigeminal neuralgia management
| - vascular compression of trigeminal nerve, also: MS, tumours, abnormalities of the skull base, AVM
Ix:
CN exam
Examine face and dental cavity
MRI if diagnostic uncertainty, young, suspect malignancy or MS, not improve with treatment
Tx:
Educate patient, get to understand their triggers e.g. shaving, cold air to face etc
Carbamazepine 1st line - titrate up to effective dose, explain not work immediately
alternatives - baclofen, lamotrigine
Can give botulinum, perform decompression
90
SAH management
berry aneurysm in the Circle of Willis
- sudden onset severe headache, loss of consciousness N+V, signs of raised ICP, meningism
look at subdural vs epidural
```
Ix:
Assess consciousness
Baseline bloods + coag
Do fundoscopy and neuro exam
Do Ct without contrast - if -ve do LP after 12 hrs for xanthochromia
angiography to identify bleed origin
ECG
```
Mx:
Analgesics, antiemetics, supportive care - analgesia, antiemetic, ng tube, intubation
nimodipine 60mg every 4 hours for 21 days - prevent vasospasm and ischaemia
Nitropuriside, labetalol used to maintain bp, keep < 180
CT angiogram to locate aneurysm
Neurosurgical clipping or coiling
Treat hydrocephalus with drain
91
Extradural/ subdural mx
Ix:
CT head - extradural lemon, subdural banana
If small, no sx watch and wait
If large, causing symptoms then consider surgical decompression with burr hole
Manage fall holistically
92
How to differentiate costochondritis from MI or Pleuritic chest pain
Tender on palpation - not in other causes
Costochondritis presents with aching/pressure/sharp pain over ribs/sternum, worse when active/ coughing
Simple analgesia, steroid injection if bad
93
Aortic dissection - Type A vs B (stanford classification)
RF are male, age, HTN, atherosclerosis, smoking, high cholesterol, marfans/ Ehlers danlos, aortic valve disease, FHx
Present with sudden onset central tearing chest pain radiating to the back
- may also have signs of other vessel occlusion e.g. focal neuro signs, anuria, angina
On exam - tachycardia, hypotension, aortic regurg murmur, different pulse, BP and CRT between two limbs
Ix
- Bloods - FBC, U&E, LFT, coag, CRP, troponin, D-dimer
- ABG
- ECG to exclude/ identify MI
- CT aortogram = first line
- Echo can also be used
- CXR may show widened mediastinum
Type A - involves ascending aorta
Type B - not involve ascending aorta
Mx
- O2 as needed
- Analgesia - morphine 2-5mg
- Cross match at least 4 units of blood
- Monitor urine output - end organ perfusion
- IV labetalol to maintain SBP 100-120 and reduce cardiac contractions to prevent further aortic injury
- IV fluids/ noradrenaline if low BP
Type A - emergency open surgery w. graft
Type B - Can manage conservatively with BB - surgery (Thoracic endovascular aortic repair) if leaking, expanding, compressing vital organs or ruptured
Lifelong antihypertensives and monitoring with CT
94
Becks triad in cardiac tamponade
Muffled heart sounds
Raised JVP
Hypotension
95
Pericarditis
Common causes:
- viral - coxsackie/ echovirus
- Post MI - Acute or dresslers (AI - weeks- years)
- Malignant
- Uraemic
- Post surgery/radiotherapy
Ix:
Look for triad of pleuritic chest pain, pericardial rub, serial ECG changes
Do cardiovascular exam, ECG looking for widespread saddle shaped ST elevation
Do FBC, LFT, U+E (creatinine, uraemia), CRP, Troponin (high if myocardium involvement), INR
Do CXR, echo to look for fluid - usually normal
Do blood culture, pericardial fluid culture if unclear cause and suspect bacterial infection
Tx:
restrict physical activity until symptoms resolve or CRP, ECG resolve
NSAID for 4 weeks + PPI (aspirin over nsaid if recent MI due to risk of rupture)
Colchicine for 3 months
steroids if refractory pain
majority as an outpatient unless fever, large effusion, cardiac tamponade, immunosuppressed, due to trauma, on anticoagulation, poor response to treatment
and treat cause - anti-tb for tb, antibiotics if bacterial
pericardiocentesis for symptomatic effusion
96
Presentation, Ix and treatment of cardiac tamponade/effusion
What is presenting triad?
Get light-headedness, SOB, syncope in tamponade due to reduced CO
Tamponade = where pericardial effusion fluid limits filling of the heart
Raised JVP, low BP, muffled heart sounds
Also get cough, pulsus paradoxus = drop in SBP >10mmHg with inspiration - SOB, tachycardia, tachypnoea
Ix:
- Bloods/ culture - uraemia, WCC, CK
- CXR - large pear shaped heart
- Echo - Bouncing of heart in pericardium, fluid
- ECG - small QRS, PR depression, electrical alternans
- CT if located effusions, pericardiocentesis if suspect malignancy or purulent effusion (high CEA = malignancy)
- Pericardial biopsy
Mx:
ICU
Lie with feet up
Treat cause (infection, malignancy, aortic dissection, AI), most resolve on own
IV fluids, O2
Ionotropes e.g. dobutamine
Pericardiocentesis, pericardial fenestration, surgical drainage if malignant/ purulent/ blood
Constrictive pericarditis - raised JVP that doesn't fall with inspiration (kussmauls sign)
97
Boerhaave - presentation and management
Present with retrosternal chest pain, resp distress, subcutaneous emphysema, hx of vomiting
Often septic and haemodynamically unstable
Ix
- bloods + G&S
- CXR may show pneumomediastinum
- CT TAP with contrast is gold standard
- May also do urgent OGD if high level of suspicion
Mx
- Resus with O2 and fluids
- NBM
- Broad spectrum Abx
- Analgesia
- Emergency surgery to repair perforation with insertion of feeding jejunostomy
- If mild/ iatrogenic/ old may be able to treat conservatively with ITU, Abx/ anti fungal, NBM, TPN/ feeding jejunostomy, NG tube and chest drain for drainage
98
Anaphylaxis
Airway swelling, hoarse voice, stridor, SOB, urticaria, signs of shock (tachycardia, hypotension, pale, clammy)
Ix
- Do mast cell tryptase to confirm diagnosis - immediately and after 1-2 hours
- O2 sats, ECG, BP
Mx
- 2222
- ABCDE
- Remove trigger
- lie flat with legs raised
- Ensure patent airway, give O2 aim 94-98%
- IM adrenaline 0.5mg 1in1000 (anterolateral middle 1/3 thigh), repeat after 5 mins if little improvement
- IV fluid challenge - 500ml NaCl over 15 mins
- After stabilisation give IV hydrocortisone and chlorphenamine
Observe for 6-12 hours due to risk of biphasic reaction
Allergy clinic + give adrenaline injector
99
Pleural thickening/ plaques - suspected cause
Asbestosis/ mesothelioma
100
HF - common causes, Ix, Mx
RHF - raised jvp, peripheral oedema, ascites
LHF - pulm oedema, SOB, exercise intolerance, cough (pink sputum), orthopnea, multiple pillows, paroxysmal nocturnal dyspnoea, wheeze
HTN, CAD, Valvular, Myopathies, pericardial, arrhythmia, high output states (anaemia, hypothyroid)
Ix:
Routine obs, cardiovascular examination
Bloods - FBC (anaemia), LFT, U+E, CRP, TFT, Lipids
BNP - >400 do ECHO (look for dilated CM, valve issues)
CXR - batwing (alveolar oedema), kerley B line (interstitial oedema), Bilat effusion, increased heart size, prominent upper lobe vessels
ECG - LVH, HF, Bipid P wave (atrial enlargement)
NYHA score - I no limitation, II some fatigue/SOB with exercise, III gentle activity, not at rest, IV at rest
Tx:
Manage Comorbs, lifestyle - salt, exercise, smoking
Ejection fraction maintained - observe, furosemide as needed
Ejection fraction reduced give ACEi, BB, spironolactone if fluid overloaded/ sx.
Further specialist treatment = digoxin/ ivabradine/ valsartan/ isosorbide dinitrate+hydralazine
Consider statin/ antiplatelet
ICD to prevent sudden cardiac death if prev VT/MI or cardiac resynchronisation therapy if LVEF <35%
101
Lung Ca - types, sx
Small cell, NSC (adenocarcinoma, squamous cell, large cell)
Present with SOB, Cough, worse at night, haemoptysis, Weight loss, Chest pain, finger clubbing, facial engorgement if SVC obstruction
Pan-coast tumour can present with horners syndrome: ptosis, miosis, anhidrosis. Also get pain, weakness, atrophy, oedema in upper limb, hoarse voice
Differential = lung abscess, cervical disc prolapse with concurrent TB, Lung mets
2ww if evidence of cancer on CXR or >40 with haemoptysis
Ix:
Obs, FBC (anaemia), LFT (ALP high in bone mets), U+E, bone profile (Ca may be raised due to PTH or bony mets, Na may be low if SIADH)
CXR, CT TAP, Bronchoscopy with biopsy or CT guided percutaneous biopsy
Paraneoplastic
Squamous - PTH
Small cell - ACTH, SIADH, Lambert eaton (antibodies to voltage-gated calcium channels, prox and ocular weakness better with exercise)
Mx:
Stage fitness with ECOG
Early disease consider surgery (lobectomy)
Consider adjuvant or neoadjuvant chemotherapy (platinum based), especially stage III/ IV
Radiotherapy often used in palliative cases or as alternative to surgery in early disease
Radiotherapy for bronchial obstruction, SVC obstruction, bone pain and cerebral mets
102
Anaemia - how can severe anaemia present, ix, mx
<130 in men
<120 in women
<110 in pregnant
Severe anaemia can present with
- SOB
- Angina
- Peripheral oedema
- Ejection systolic murmur
- Tachycardia
- HF
Ix
- FBC - look at Hb level
- Blood film
- Ferritin - low in IDA, high in ACD
- Transferrin - Opposite to above
- B12/ Folate lvls
- CRP/ESR - chronic disease
- LFT - alcohol/ bilirubin for haemolytic
- Coombs/ haptoglobin - haemolytic
IDA - ferrous sulphate - check lvl 2-4w late, cont for 3m
B12 - Hydroxocobalamin and folic acid
Folate - Folic acid
Severe - transfusion
103
What is the cause of megaloblastic and non-megaloblastic macrocytic anaemia
Megaloblastic - B12, folate
| Non-megaloblastic - alcohol, liver disease, hypothyroid
104
What is pernicious anaemia
= AI condition where patient has antibodies to intrinsic factor preventing the absorption of Vit B12
In B12 deficiency get glossitis and peripheral neuropathy
105
Sudden onset watery diarrhoea with accompanying blood and abdo discomfort. Started 5 days after dose of abx - cause, Ix, mx
Cdiff
Ix
- Bloods
- Stool sample - look for enterotoxins, also MC&S, virology, ova/cyst/parasite
- ABG if suspect sepsis
- CT if complications, endoscopy + biopsy if diagnosis uncertain
- AXR if abdominal distension, suspected perforation/ megacolon
Mx
- report to public health
- Side room
- stop laxatives/ abx/ PPI - do not give anti-motility agents
- Start abx - 1st line oral vanc, 2nd line oral fidaxomicin, if severe oral vanc and IV Metro
- IV fluids
- Surgery for severe colitis, Faecal tranplant
106
Acute diarrhoea ix
- Abdo/ PR exam/ look for clubbing/ ulcers/ masses
- assess hydration status
- temperature
- Bloods
- Stool sample
```
Oral rehydration solution/ IV fluids
Racecadotril
Loperamide
Antispasmodics
Abx if bacterial
```
107
IBS - diagnosis, ix, mx
Differential for chronic watery, non bloody diarrhoea is bile acid malabsorption - bile acid draws fluid and electrolytes into the bowel - treat with low fat diet and cholestyramine
Abdo pain, related to defacation/ altered stool frequency/ altered stool appearance
At least 2 of: altered stool passage, bloating, worsened by eating, rectal mucus, exclusion of alternative conditions
Ix
- FBC, ESR, CRP
- Coeliac serology
- stool sample, faecal calprotectin
- H breath test
- Sigmoidoscopy
- CA125 in women
Mx
- Fluids, exercise, dietician
- Fibre - insoluble for constipation
- OTC probiotics for diarrhoea
- Antispasmodic, TCA for refractory pain
- constipation: bulk forming laxative e.g. fybogel, linaclotide if refractory
- diarrhoea: loperamide
108
NOF #
Intracapsular vs extra capsular vs subtrochanteric
Use garden classification - intracapsular #
- I - incomplete #, minimal displacement
- II - Complete #, undisplaced
- III - Complete #, partially displaced
- IV - complete #, completely displaced
RF - smoking, steroids, age, osteoporosis, alcohol
Inability to weight bear, pain, reduced ROM - Shortened and externally rotated leg
Ix
- Obs
- Try to identify cause of trauma/ fall - Bloods, ECG, urine dip
- Bone profile - Ca, vit D, phosphate, ALP
- Pelvic Xray from multiple planes - AP and lateral
- MRI/ CT if needed
Mx
- Catheter for urine output
- Fluids due to internal bleeding
- Analgesia - Iliac fascial block - LA
- Med review - AKI risk, hold anticoags if need op
- NBM
- Immobilise
Surgery
- gardens I or II - dynamic hip screw
- gardens III or IV - total hip replacement
- Extra-capsular - DHS or intramedullary nail
Post op
- VTE prophylaxis - LMWH
- delirium assessment, screen for infection
- mobility assessment
- physio/ OT, pain relief
- Bisphosphonate if osteoporosis
109
Pelvic # Ix + Mx
Ix
- 3 plane Xray or CT
- Serial Hb for blood loss
- Assess pelvic stability
- Check peripheral pulses - iliac vessel dmg
- LL neuro exam
- Look for blood in urine, dipstick
- Angiography, cystography, urethrogram
Mx
- AtoE
- IV fluids + O2
- Pelvic binder
- If stable/ avulsion treat conservatively with bed rest, VTE and gradual physio
- If unstable, haemorrhage, open or urological injury - surgery
110
Spinal cord injury - types/ consequences + Mx
Ant - loose motor, pain and temp
Post - loose vibration and proprioception
Complete - loss of sensory and motor
Brown-sequard - loss of ipsilateral vibration + proprioception + motor and contralateral pain + temp
Neurogenic shock - injury above T6 can affect sympathetics leading to vasodilation, hypotension, bradycardia and hypothermia
Mx
- Immobilise C spine
- Canadian C spine rules to determine risk - adults do CT (then MRI if see lesion), children do MRI. Do radiology if >66, dangerous mechanism, parasthesia. If none of these and spinous processes not tender, able to rotate head right and left 45 degrees then can clear spine
- T/ L spine - Xray if no neuro signs, CT if neuro signs
- Modified A-E = Catastrophic haemorrhage, A + C spine stabilisation, BCDE
- GCS
- Head blocks, strap to backboard
- IV morphine
- IV fluids
- O2
- Atropine if bradycardia
- catheterisation
- Surgery if progressive neuro sx or unstable + displaced fracture
- Physio
111
TBI
Hx including - mechanism, LOC, amnesia, vomiting, headache, neck pain, anticoags, alcohol intake
Ix
- GCS
- Neuro/ CN exam - balance, motor/ sensory, speech
- Check for base of skull fracture (battle sign behind ear, CSF leak, periorbital haematoma)
- CT - within 1 hour if GCS <13 at initial assessment or <15 after 2 hours, basal skull or open skull fracture, focal neuro signs, seizure, repeated vomiting
- CT - within 8hr if >65, clotting disorder, dangerous mechanism, >30mins amnesia
Mx:
- AtoE - airway support, fluids, O2 as needed
- Immobilise C spine if suspected injury
- Neurosurgical input
- Anti emetics, analgesics
- Nutritional support
- Mannitol if risk of haematoma, oedema
- in emergency with significant swelling consider craniectomy
112
What test is done to identify CSF
Beta transferrin
113
Extradural bleed - what is key about their presentation? Ix, Mx?
Fractured temporal/ parietal bone at pterion damaging middle meningeal artery/vein
Present with initial LOC followed by a lucid interval then further deterioration - headache of increasing severity, vomiting, seizure, dropping GCS
See brisk reflexes, upgoing plantars, limb weakness, aphasia, visual defects, raised ICP (cushings triad)
Ix
- AtoE + obs (GCS, pupils)
- Baseline bloods, coag, G+S/ crossmatch, glucose, bone profile
- CT head - biconcave (lens shaped) haematoma, not cross suture lines
- Angiography if spontaneous - look for AVM
Management
- AtoE
- O2/ fluids - resus - maintain SBP >90
- Reverse or pause anticoags
- IV mannitol or hypertonic saline 2.7% to reduce ICP
- Abx if open fracture
- Levetiracetam for seizure prophylaxis
- for large bleeds > 30cm3, midline shift, focal neuro or GCS< 8 - Burr hole craniotomy
- Alternative is open craniotomy with cauterisation/ ligation
114
Subdural haematoma
Due to bridging veins, blunt trauma
Elderly, alcoholics, HTN, anticoags at increased risk
Slower sx onset than extradural - drowsiness, personality changes, LOC, fluctuating headache
Can have chronic presentation 2-3w post fall
Ix
- AtoE + obs (GCS, pupils, HTN)
- Neuro exam
- Baseline bloods, coag, G+S/ crossmatch, glucose, bone profile
- CT head - crescent shaped haematoma, not limited by suture lines
- Angiography if spontaneous - look for AVM
Mx
- AtoE
- O2/ fluids - resus - maintain SBP >90
- Reverse or pause anticoags
- IV mannitol or hypertonic saline 2.7% to reduce ICP
- If small - monitoring and repeat CT
- for large bleeds > 30cm3, midline shift, focal neuro or GCS< 8 - Burr hole craniotomy
- Alternative is open craniotomy with clot evacuation, cauterisation/ ligation
- For recurrent bleeds - subdural drain
- For chronic bleed that doesn't need surgery - dexamethasone
115
Burns - classification and management
Causes: thermal, chemical, electrical, friction or radiation
Non complex - Not affect face, perineum, genitalia, hands, feet, crossing joints, circumferential. <15% total body surface area. Deep burn < 1%
Complex - opposite to above, any chemical/ electrical
Superficial - Epidermis - red/ painful, no blister, blanches and returns
- Superficial dermal - pale to dark pink, painful, blistered, weeping/ wet, slow to regain colour after blanching
- Deep dermal - Blotchy red, reduced sensation, blistering, non-blanching
- Full thickness - white/ brown/ black, no blisters, dry, painless, non-blanching
- Fourth degree - subcut fat, muscle or bone
Get systemic hypotension due to evaporation and third spacing
Inhalational injury
- Hoarse voice, black mucus, stridor, SOB, burns to face and neck, raised HbCO
Ix
- Rule of nines or Lund and brower chart
- Assess burn depth
- Assess for inhalational injuries
- Establish time of burn
- Bloods - FBC,U&E, CK, LFT, G&S, Crossmatch, HbCO, BM, ABG
- BP (art line), cardiac monitoring, UO
- Trauma CT if needed
- Temp for hypothermia
Mx: Acute severe
- AtoE
- Intubation if inhalational injuries
- High flow O2 - 100% if CO, elevate head
- Escharotomy if circumferential chest burns/ ischaemic limbs
- Fluids if >15% tbsa or >10% in kids - parkland formula - 3-4ml x % tbsa x kg - 1/2 over 8hr then 1/2 over 16
- prevent hypothermia
- IV abx if >10-15% burns - trust guidelines
- IV morphine, sedatives
- NG tube and catheter
- Tetanus
Excise and graft full thickness, other depths: wound care
Fluclox if secondary infection
First aid mx
- rinse under cold tap for 20 mins
- layer cling film over wound
- elevate
Electrical - remove source, check myoglobin/ CK, ECG for arrhythmia, compartment syndrome
Chemical - Remove clothing, brush off and irrigate for 1hr, TOXBASE, poison centre
116
Splenic rupture
LUQ pain following blunt trauma (EBV, haem malignancy place at higher risk), Get hypovolaemic shock, Kehr's sign (shoulder pain due to blood in peritoneum irritating diaphragm)
Ix
- If haemo unstable - laparotomy
- If stable - CT TAP
Mx
If stable - bed rest, fluids, monitor with US
If unstable - laparotomy - splenectomy or splenic salvage
- Pen V and prophylactic vaccinations
117
Anal fisure management
- Anal pain on defecation, severe and sharp, bright red blood on paper, tearing sensation
Primary (no cause) or secondary (constipation, IBD, STI, malignancy)
Mx
Primary care
- Soften stool – fluid, fibre, laxative
- Analgesia (paracetamol/NSAID), warm bath
If not improved within a week:
- GTN ointment BD
- topical lignocaine if extreme pain (max 14d)
- Refer if not resolved within 6-8w
Secondary care
- Topical diltiazem or nifedipine
- Botulinum toxin
- Sphincterotomy
118
Colorectal cancer
L side: bleeding, altered bowel habit
R side: anaemia, weight loss, abdo pain
Ix:
Abdominal and PR exam looking specifically form mass
Routine observations
FBC (anaemia), U+E, LFT (mets), CRP, CEA, CA19-9, BRAF
2ww:
1st line: Colonoscopy with biopsy
2nd line: Barium enema (apple core) or CT colonography
CT TAP - staging and metastatic identification
Liver Ultrasound
PET scan
Trans rectal US
Screening: Faecal immunochemical testing - every 2 years from age of 60-74. If +ve have colonoscopy - remove adenoma, if intermediate risk colonic surveillance
2ww:
>40 with unexplained weight loss and abdominal pain
>50 with unexplained rectal bleeding
>60 with IDA or changes in their bowel habit
Mx:
Remove polyp on colonoscopy and send for histology
Segmental resections with anastomosis or stoma
Radiotherapy
Chemo: FOLFOX, anti-VEGF
Stenting if palliative
119
Oesophageal cancer
Presents with dysphagia, haematemesis, vomiting, weight loss, odynophagia, anaemia, feel lump in throat, virchows LN
RF are alcohol, smoking, barrett's (GORD, achalasia), coeliac
2ww if issues swallowing, or >55 with weight loss and any of: dyspepsia, reflux, upper abdo pain
Ix
- Baseline bloods, Glucose
- Endoscopy + biopsy
- Barium swallow if endoscopy not tolerated
- Look for mets with CXR, liver US
- CT/ PET for staging
Mx
- Endoscopic resection or oesophagectomy
- For palliative consider radiation/ chemo/ stenting, PEG feeding and analgesia
120
Variceal bleed
- dilated veins due to liver disease
Haematemesis/ coffee ground vomit, abdo pain, haematochezia, tachycardia, hypotension
Ix:
- Obs for shock - BP, UO, CRT, HR
- FBC, U&E (raised urea due to bleed), LFT, G&S, crossmatch, coag
- OGD
- CXR if risk of perforation
- CT for liver disease
Assess risk with Glasgow blatchford score >1 - inpatient
Assess risk of rebreeding post procedure with rockall score
Mx
- AtoE
- Assess airway, O2, Look for shock
- IV fluid bolus/ transfusion if needed
- Catheterise - UO as proxy for organ perfusion
- Stop any anticoags/ NSAIDS
- IV terlipressin
- Prophylactic cipro or cef
- Omeprazole
- Band ligation, balloon tamponade if continued bleeding
- Beta blocker for long term prevention
If not controlled with band ligation or recurrent - TIPS
Call on call gastroenterologist for immediate endoscopy post stabilisation if acute shock
121
Causes of increased portal pressure
Pre-hepatic - portal vein thrombosis
Intra-hepatic - hepatitis, cirrhosis idiopathic
Post-hepatic - budd chiari, compression from tumour
122
Hypoglycaemia
= BM < 3.5
Causes -Insulin/SU, Addisons, Insulinoma, Factitious (C-peptide low), post prandial
Presents with dizziness, light headedness, sweating, palpitations, hunger, weakness, vision changes, irritability, anxiety, drowsiness, LOC, seizure
Whipple's triad - low plasma glucose, sx of low glucose, resolution with correction of hypoglycaemia
Ix:
Do BMs = fasting glucose <3
Do neurological assessment and calculate GCS
Do serum insulin - see if due to insulin
C-peptide - high if endogenous cause (insulinoma, SU)
ECG
SU level
Cortisol level to look for adrenal insufficiency
Management:
Get the hypo box
If conscious and able to swallow - 10-20g carbs, retest in 15 mins - jelly babies, glucose tablets
If confused give 2 tubes of buccal glucogel, IM glucagon
Repeat up to 3x times before escalating to below
If cant swallow, low GCS give IM glucagon or IV dextrose- 200ml 10% over 15mins (IM glucagon not effective if malnutrition)
Cant give glucagon if alcoholic, SU, liver disease, malnourished
If due to SU give ocreotide
Important to alert DVLA, refrain from driving until BMs under control
- test BM before driving and then 2hrly throughout the journey
After stable assess hypo awareness with GOLD score
If repeated hypos: Blood Glucose Awareness Training (BGAT) programme
123
DKA management
Present with dehydration, vomiting, abdo pain, polyuria, confusion, hyperventilation
Commonly caused by inadequate insulin therapy or infection
Differentials for ketosis are alcoholics and starvation
Can have normal glucose DKA if taking SGLT-2 inhibitors - treat same, switch from SGLT2 inhib to other drug
Ix:
AtoE assessment
Urine ketones 2+ (dipstick) or blood ketones >3
Blood glucose >11
ABG: Bicarb <15 or pH <7.3
FBC - look for raised WCC, U&E - raised K in acidosis
CXR to exclude pneumonia as cause
Anion Gap >13 (Na – Cl + HCO3)
Beta-HCG if abdo pain - pregnancy can precipitate, are at high risk
Plasma osmolality >320, normal ketones - think HHS
Routine bloods, TFT, CK, amylase, cultures, trops
Mx:
AtoE
Obs - Sats, BP, ECG monitoring, cannula, catheterise to assess urine output
If BP<90 - fluid challenge (500ml over 15 mins), repeat if still low
Following this give 1L over 1st hour then over 2,2,4,4,6hrs
Give fixed rate 0.1 unit/kg/hr act rapid insulin - 50U actrapid in 49.5ml Nacl
- aim for ketone drop of 0.5 per hour, glucose 3/hr, HCO3 increase >3/hr, keep K+ between 4-5.5 - if not enough increase rate by 1U/hr
- when glucose <14 start 10% dextrose IV (1L over 8hrs) alongside normal fluids
Continue long acting insulin
K+ replacement if < 5.5 - 40mmol KCL in second bag of fluid onwards
Treat underlying cause (infection, MI etc), monitor BM, Ketones, K+, urine output hourly
(resolved when ketones <0.6 and pH >7.3)
If eating/drinking can stop and go back to normal regime, if not eating and drinking then switch to variable rate
Aim to get patient eating and drinking on normal insulin regimen and biochemically resolved within 24hrs
124
HHS
Hyperglycaemia (>30), raised blood osmolality (>320), no evidence of ketosis (< 3 in blood)
Present with weakness, exhaustion, dehydration, leg cramps, vision changes, focal neuro signs
Mx
- AtoE
- First line is IV fluid replacement with 0.9% NaCl - not too quick due to risk of cerebral oedema/ central pontine myelinosis (2-3L positive balance + urine output in first 6 hours)
- If glucose not falling by >5mmol/L/hr or ketones rising - start IV insulin 0.05U/kg/hr + start dextrose when glucose <14
- Replace potassium
- monitor U&E, BM, urea, pH, creatinine
Aim drop in osmolality 8/hr
Resolved when glucose <12.2, osmolality <315 mmol/kg
125
Cause of metabolic ketoacidosis with low or normal ketones
Alcohol
126
Metabolic acidosis - causes if high and low anion gap
High anion gap = organic acids e.g. lactic acidosis, ketoacidosis
Normal anion gap = loss of bicarbonate either via diarrhoea, renal tubular acidosis, Addisons, drug causes. Have a high chloride.
127
Insulinoma mx
Immediate potassium and dextrose
Surgery to remove pancreatic endocrine islet cell tumour
Avoid exercise, eat small frequent, high starch meals + diazoxide.
128
Critical illness polyneuropathy
Critical illness leads to diffuse, symmetrical, placid paralysis of limbs and diaphragm - reduced reflexes
```
MRC score
Serum CK
CSF normal
Normal conduction velocity on N studies
muscle biopsy
```
General care, exercises, passive stretching
Can cause difficulty weaning, increased risk of VTE
129
MSCC
```
Ix:
MRI whole spine
PR for anal tone
Bloods - Ca 15-3 for breast cancer, PSA for prostate
Neuro exam
```
```
Tx
Lie flat
Dexamethasone
Catheterise if urinary incontinence
Bisphosphonates
DVT
Analgesics
Laminectomy/ radiotherapy
```
130
Spinal cord compression - presentation + causes
Radicular pain at level of injury, altered sensation, spastic paraparesis below, may be autonomic sx e.g. urinary retention, paralytic ileus, priapism, constipation
Causes
- Trauma
- Malignant spinal cord compression
- Disc herniation
- Epidural/ subdural haematoma
- OA
- cervical spondylitis myelopathy
131
Guillain Barre
Hx of viral illness followed by progressive symmetrical ascending weakness, neuropathic pain, peripheral loss of sensation and reduced reflexes
```
Ix
Clinical diagnosis of ascending weakness, parasthesia and hyporeflexia occurring post infection
Do NCS, EMG
Look for antibodies
Do LP - protein in CSF
Spirometry if suspect resp involvement
Routine bloods
Check Ig levels as if IgA deficient might get anaphylaxis when given IV-Ig
```
Mx:
Immunoglobulins (0.4g/kg/24hrs) and/or plasma exchange
Supportive care - treat resp failure, monitor heart, give analgesics and DVT prophylaxis
Physio, rehab
Splinting to prevent join contracture
Improves over time
132
MG management
Lamber eaton - better with exercise
MS, MND, hypothyroidis, horners sx are other differentials
Often first sign is drooping of eyelid (ptosis) and diplopia, then get muscle weakness that is worse with exertion. Worse at end of day.
Can also get fatiguable chew, dysarthria/ dysphagia, weak breathing, dropped head. No change in tone, reflexes, sensation, no wasting.
Weakness more marked in proximal than distal, arms than legs
Myopathy, eye trauma, third nerve palsy, cyst or swelling
- differentials for MG eye symptoms
Ix:
Do a full neuro exam, assess vision and muscle weakness
Crushed ice on eye for 3 mins, improves ptosis
Ask to count to 50 and see if fatigue
Anti-Acetylcholine receptor antibodies
Repetitive nerve stimulation test or EMG
CT/MRI of thymus to look for thymoma
Tensilon test - rarely done as can cause bradycardia
General bloods, TFTs
Mx:
Myasthenic crisis - intubation, mechanical ventilation + immunoglobulins, plasma exchange and steroids
Treat with acetylcholinesterase inhibitor e.g. pyridostigmine, add steroids +/- azathioprine if not sufficient. Is also rituximab, biologics
TPMT before start azathioprine, not combine with allopurinol
Oral atropine for muscarinic SE of pyridostigmine (diarrhoea, colic, sweats, salivation, lacrimation)
If thymoma present - thymectomy
133
MND - most common = ALS (degen of anterior horn cells and cranial motor nuclei)
- No sensory loss, no sphincter deficits (MS)
- No eye sx (MG)
Limb onset - asymmetrical distal weakness, UMN and LMS signs, no sensory issues - spasticity, wasting, upgoing plantars, reduced reflexes
Bulbar onset - slurring of speech, wasting + fasciculation of tongue, dysphagia
Resp onset - dyspnoea, orthopnea
Ix
- hx and exam show UMN/LMN and no sensory signs
- Neuroimaging and electrophysiological tests exclude other causes
- Bloods to exclude thyroid, b12/folate deficiency, Antibody testing, CK can be raised in MND
- Muscle biopsy to exclude myopathy
- LP to exclude GB
Mx
- patient education
- MDT - physical, occupational and speech therapy - exercise regimes to maximise mobility
- Riluzole - glutamate release inhib - only prolong life by 2-4m
- Hyoscine for drooling
- Quinine (1st line) then Baclofen for cramps
- Baclofen for spasticity
- Analgesics
- Feeding/ speech support (may need NG, gastrostomy when cant feed by mouth)
- Opioids or benzodiazepines for breathlessness
- NIV (BIPAP) may be used overnight
- Hospice care and respite
134
Aortic stenosis
Caused by calcification, bicuspid aortic valve, rheumatic heart disease
Presents with ejection systolic murmur, dyspnoea, angina and syncope
If radiates to carotids, narrow pulse pressure, slow rising, symptoms = stenosis not sclerosis
Displaced apex = LVH
Differential for aortic stenosis - hypertrophic cardiomyopathy (also presents with syncope, dyspnoea, angina)
Ix: Cardio exam, obs, ECG, transthoracic ECHO, CXR
Tx:
Conservative
HF: Diuretic, ACEi
Angina: BB or CCB
TAVI or AVR, or balloon valvuloplasty
- if severe sx, LVEF <50, already undergoing cardiac surgery, pressure gradient >40 on echo
Assess QRISK - Statins, BP etc
135
Polymyositis/ dermatomyositis
Fever, malaise, weight loss
- Proximal weakness (shoulder + pelvis) with distal sparing
- Difficulty combing hair, climbing stairs
- NOT tender
Dermato - heliotrope rash, gottrons sign, shawl sign, mechanics hands
ix
- raised ck
- ESR/CRP raised
- antibody testing - ANA, anti-jo
- EMG - short, low amplitude movements
- Diagnose with muscle biopsy
- regular spirometry to monitor for resp muscle failure
mx
- Rest + exercise programme
- Prednisolone is mainstay – topical in mild up to IV in v.severe
- 2nd line – azathioprine, cyclophosphamide
- IV IG therapy
136
Tests indicative of haemolytic anaemia
Raised LDH
Reduced haptoglobin
Intravascular - haemosiderin urine (brown) - not present in extravascular causes
Intravascular causes include mechanical heart valve, haemolytic uraemic syndrome, DIC, HELPP, acute transfusion reaction,
Extravascular causes - sickle cell, thalassaemia, G6PD deficiency spherocytosis, warm or cold AI haemolytic anaemia, hypersplenism, malaria
137
AI hepatitis
ANA/ anti-sma/ anti-lkm1 +ve, raised IgG, raised ALT/AST, raised PT and low albumin, raised bilirubin, liver biopsy diagnostic
Treat with prednisolone initially and then in combination with azathioprine
Treat for 2 years or until LFTs better for 12m
May require liver transplant
138
PBC management
Dark urine, pale stool and raised liver markers with background of AI conditions
Fatigue common
Vs PSC
Ix:
IgM, AMA +ve, ALP/GGT raised and no other explanation
In late stage disease may see raised PT, low albumin
Do liver biopsy to confirm
Fibroscan can be used to evaluate degree of liver fibrosis
```
Mx
UDCA (obeticholic acid is 2nd option)
Sedating antihistamine or cholestryamine for itching
Rituximab for fatigue
Avoid the pill, HRT
Supportive treatment - fat soluble vitamins, osteoporosis prophylaxis
Steroids and azathioprine
liver transplant if above fail
```
PSC more common in men, younger
- ve AMA, confirm with MRCP or ERCP
- Treat with stent/ balloon insertion, cholestyramine, rifampicin, fat soluble vitamins, avoid alcohol, transplant,
139
NAFLD - alcohol cutoff, presentation, Ix, Mx
- after diagnosis screen for cirrhosis every 2yrs
<2.5 (F), <3.75 (M) units per day
progresses from steatosis to non-alcoholic steatohepatitis to fibrosis then cirrhosis
RF: Obesity, HTN, Type 2 diabetes, Hyperlipidaemia, Smoking
Ix
- LFTs, coagulation screen, albumin
- Lipids/ HbA1c/ FBC
- AMA, ANA, SMA etc
- Caeruloplasmin for Wilson, ferritin for haemochromatosis, alpha 1 antitrypsin
- viral studies
- US to confirm fatty liver
- Enhanced liver fibrosis (ELF) blood test -> fibroscan if signs of fibrosis
- CT/ MRI
- Liver biopsy to confirm diagnosis
Mx
- Patient education
- Diet, exercise, gradual weight loss, alcohol abstinence
- Manage HTN, T2DM, High lipids
- Pioglitazone, metformin, statins may help
- Bariatric surgery, Liver transplant, TIPS
140
Acute liver failure management
Fulminant if no known prev liver disease and altered clotting - onset within 8w of disease onset
Present with jaundice and encephalopathy
Causes
- toxins e.g. alcohol, paracetamol
- viral hepatitis
- Metabolic - Wilsons, alpha 1, haemochromatosis
- NAFLD
- HCC or metastasis
- pregnancy - HELLP, acute fatty liver disease of pregnancy
- Budd chiari or portal vein thrombosis
- AI liver disease
Ix:
Hx - ask about onset of jaundice and encephalitis, ask about toxins and fhx of wilsons etc
Asses consciousness/ mental state and do abdo exam for asterixis/ ascites
Raised PT, low Albumin
Do routine bloods (FBC, LFT, U+E, glucose, INR (>1.5), ammonia) and liver screen (hep b/c, AI, toxicology, ferritin, caeruloplasmin etc)
High ammonia -> encephalopathy
Do G+S, blood culture if suspect infection
ABG for lactate
Liver US + doppler for Budd chiari/ cancer
CT - Assess for cerebral oedema, raised ICP, other causes of altered mental state
EEG to define level of encephalopathy
Investigate for cause
- caeruloplasmin (low), alpha 1 antitrypsin, ferritin (haemochomatosis), ANCA, AI screen, Alcohol, viral
Mx:
Treat cause
Treat in ITU/ HDU due to need for intubation
Fluid resus - fix distributive shock with: CVC line, Fluids/ ionotropes, monitoring urine output, BP
Ascites- restrict fluid, low salt diet. spironolactone +/- furosemide - if large: paracentesis + human albumin solution
Encephalopathy - Lactulose with neomycin, raise head of bed, repeated enemas. Mannitol can reduce ICP, rifaximin can help in prevention
IV 10% glucose
Coagulopathy - clotting factors, plasma, platelets, PPI to stop bleeding
AKI - Correct electrolytes, for hepatorenal type 1 may need terlipressin + albumin, dialysis/ TIPS if needed
Abx prophylaxis
Consider transplant based on kings college criteria if high INR/ PT, quick onset encephalopathy, high bilirubin
141
ALD - alcoholic liver disease
>12.5 units per day for 15-20 years
Do CAGE - cut down, annoyed, guilty, eye opener
Ix
- AST:ALT ratio >2
- Raised GGT/ MCV - indicate alcohol abuse
- Coag screen, albumin levels
- Bloods - FBC, U&E, CRP
- US, fibroscan
- biopsy
Mx
- Alcohol abstinence - Antabuse, acamprosate, naltrexone
- Chlordiazepoxide + pabrinex for acute withdrawal
- counselling, brief intervention psychotherapy, alcoholics anonymous
- Lifestyle
- Steroids can help in acute hepatitis - important
- Transplant
Can commonly revert to normal liver once alcohol stopped
142
Cirrhosis
Causes are - alcoholic, NAFLD, hepatitis B/C, Wilsons, hereditary haemochromatosis, alpha-1-antitrypsin, CF, Budd-chiari
sx - lethargy, weight loss, nausea
on exam - hepatomegaly, asterixis, dupuytrens, gynaecomastia, caput medusae, palmar erythema, leukonychia, easy bruising, clubbing, xanthelasma
In decompensation - jaundice, variceal haemorrhage, encephalopathy (asterixis due to ammonia), ascites, abnormal clotting
ix
- LFT, coag, albumin
- Baseline bloods
- Caeruloplasmin, ferritin, alpha fetoprotein, alpha-1-antitrypsin
- Hepatitis serology
- fibroscan - transient elastography
- CT
- Biopsy
- Ascitic tap - neutrophil >250= SBP
Use child-pugh score to grade cirrhosis, MELD score for prognosis
Mx
- Lifestyle - high protein, low sodium/ fat diet
- Alcohol abstinence
- Colestyramine for pruritis
- treat cause - penicillamine (Wilsons), UDCA (PBC), etc
- Ascites- spironolactone +/- furosemide - if large: paracentesis + human albumin solution - if persistent TIPS
- continued screening for varices - every 3 years, HCC, decompensation, do MELLD score 6 monthly
- Liver transplant based on UKELD score
143
Ascites - how to determine cause, ix, mx
SAAG - serum ascites albumin gradient
- >1.1 = transudate - raised portal pressure
- <1.1 = exudate - normal portal pressure - e.g. due to cancer, infection, pancreatitis, nephrotic syndrome
Ix:
Regular bloods, Clotting, albumin, ascitic tap, liver screen, US, MRI/CT
Perform ascitic tap if suspect SBP - raised WCC and neutrophils (> 250). Treat with abx (cefotaxime/ ceftriaxone) and human albumin solution
Put on a low salt diet - in some this will be enough to resolve
1st line fluid restrict and spironolactone
2nd line furosemide
Aim for no more than 1kg loss a day
If large, refractory or causing resp compromise paracentesis followed by plasma expansion
If persistent - TIPS
Cholestyramine for pruritis
144
Liver cancer - HCC
Mainly caused by cirrhosis or hepatitis B/C infection
Presents with weight loss, fatigue, fever, night sweats, pruritus, jaundice, ascites, encephalopathy, RUQ pain
If hep B/C carrier or have cirrhosis should have 6&12 monthly screening via AFP and US - lesions>2cm should be biopsied and CT scanned
Ix
- Bloods - LFT, FBC, U&E, coag
- AFP
- Ca 19-9 - cholangiocarcinoma/ pancreatic cancer
- US
- CT
- bone scan, look for mets
- biopsy rarely done
Mx
- conservative if elderly
- if singular <3cm, small, confined can consider resection
- Can transplant liver if fit Milan criteria (1 x <5cm, 3 x <3cm, no metastasis and no vessel invasion on CT/ MRI)
- Ablative therapy
- Systemic chemo/ radiotherapy rarely used (transarterial chemoembolization)
145
Pancreatic cancer
Adenocarcinoma
Presents with weight loss, fever, epigastric discomfort/ back ache and progressive painless jaundice
Ix
- routine bloods
- Ca 19-9
- faecal elastase
- glucose levels
- US
- CT
- Biopsy via ERCP or endoscopic US
Mx
- Surgical resection
- pancreaticoduodenectomy with antrectomy (Whipple's procedure)
- chemotherapy
- analgesia, creon, stenting
146
How can gastric tumour affecting pylorus present?
Reflux, early satiety, fullness, vomiting, weight loss, anaemia, melaena
147
Hypertension
<55 or diabetes - ACEi or ARB
>55 or black - CCB
2nd line ACEi + CCB or Thiazide / CCB+ ACEi or thiazide
3rd line - All 3
4th - K < 4.5 - spironolactone, K > 4.5 - alpha or beta blocker
148
Psoriasis - hyper proliferation of keratinocytes
Symmetrical erythematous patches, papules and plaques with overlying silver scale
Differentials - dermatitis, lichen planus, cutaneous lymphoma
Recent alcohol binge -> rash = psoriasis
Ix:
Clinical diagnosis, skin biopsy only if doubt
Auspitz sign - removal of scales causes capillary bleeding
IBD, assess CV risk
Ask about nails (pitting and onycholysis), joints, dactylics (swelling of digit)
Dermatology quality of life index score
Use psoriasis area and severity index (PASI) to assess severity, also assess body surface area affected
Tx:
Educate, is chronic condition, help sx not cure
Identify + avoid precipitants, stop smoking, alcohol, healthy lifestyle diet and exercise
Emollient, salicylic acid for scale/itch
1st line - vit D analogue OD + topical corticosteroid OD
If after 4-8 weeks not gone stop steroid and try vit d analogue BD for 12 w.
If still not better consider corticosteroid BD or coal tar
If ongoing treatment resistant consider referral and dithranol
Dermatology - topical calcineurin inhib, ciclosporin, acitretin, narrow band UVB. If UVB ineffective consider methotrexate, ciclosporin or TNF alpha inhibitors e.g. adalimumab
For joint - do xray (central erosions), bloods, joint aspiration. Treat with NSAID first line, 2nd line corticosteroid injection and if active disease methotrexate, if dactylitis or entheses - adalimumab, NSAID
Guttate psoriasis - rain drop lesions, commonly post strep throat, treat with phototherapy
Pustular psoriasis - acute withdrawal of psoriasis meds - treat with supportive care and systemic management
149
Sepsis
AtoE
Septic shock (distributive) = need for vasopressors to maintain MAP > 65 or hypovolaemia unresponsive to fluids - present as flushed, dry, warm, tachycardia, hypotension
Ix
- FBC - WCC, low platelets (DIC)
- U&E
- LFT
- CRP, ESR, procalcitonin
- Clotting
- ABG (lactate) + cultures
- ECG
- Glucose
- GCS/ neuro obs
Mx
- AtoE
- Sepsis 6 (fluids, abx, O2 (>94%), lactate (+ glucose on A BG), UO (>0.5ml/kg/hr), blood culture
- If not improving, shock consider critical care outreach, central line and admin of noradrenaline 1st line or vasopressin 2nd line.
- Dobutamine, hydrocortisone can be used as ionotropes
- Paracetamol as antipyretic
- NIV, cardiac, renal, liver monitoring
- VTE prophylaxis
- can develop stress ulcer so give omeprazole or ranitidine
150
Peritonitis
Presents often initially with generalised abdominal pain, becomes focal and well localised, fever, tachycardia, tenderness, rebound tenderness and guarding on palpation
Lie with knees flexed
Caused by SBP, perforation, trauma/surgery, AI, leakage of bodily fluids into peritoneum
Ix
- FBC, U&E, LFT, CRP
- AXR/ CXR to look for perf
- urinalysis
- Blood culture
- Peritoneal fluid sample (neutrophil > 250 = SBP)
Mx
- IV fluids
- IV abx
- Exploratory laparotomy if perforation
- For SBP give cefotaxime/ ceftriaxone + human albumin solution and await culture sensitivities
151
PID symptoms and treatment
= Endometritis, Salpingitis, Oophoritis, Tubo-ovarian abscess, Pelvic peritonitis
Uterine, cervical motion tenderness
Lower abdo pain, pain on urination and sex
Uterine bleeding (inter-menstual, post coital or breakthrough)
Abnormal cervical or vaginal discharge
Fever, nausea and vomiting
Ask about recent termination of pregnancy or IUD
Ix:
Bimanual + obs - adnexal tenderness, cervical motion tenderness
Vulvovaginal or high vaginal swab for chlamydia/ gonorrhoea
Urinalysis + culture
Bloods - CRP, ESR, WCC
Pregnancy test - exclude ectopic
Transvaginal US
Tx:
Pain relief
Empirical antibiotics: Ceftriaxone 1mg IM, doxy 100mg BD and metro 400 mg BD for 14 days
Consider removing IUD
If mycobacterium genitalia - moxifloxacin
TOC if chlamydia, gonorrhoea, mycoplasma genitalium
Contract trace all partners in last 6 months, give 7 days doxycycline to all partners
152
Management of chlamydia and gonorrhoea
gonorrhoea - yellow/green discharge
First catch urine/ vulvovaginal swab
NAAT test - 2w window period
Gonorrhoea can also be examined by microscopy and culture - gram-negative diplococci
Transvaginal US, cervical motion tenderness - can be used to identify endometritis and salpingitis of PID
Chlamydia - 7d 100mg doxycycline or 1g azithromycin oral
- also treat partner
- avoid sex until completed course
- partner notification - 1 month or last partner for symptomatic males, 6 months for others
- if under 25 retest in 3-6 months
Gonorrhoea - 1g Ceftriaxone IM
- also treat partner
- abstain from sex until completed treatment
- partner notification - 2w or last partner if symptomatic male, 3m for all else
- Follow up after 1 week to ensure treatment successful, test of cure 2w after
153
Infective endocarditis
Most commonly affected valve = mitral, in IVDU is tricuspid
Due to bacteraemia and abnormal cardiac endothelium
- Get infective vegetation formation
- Causes regurg murmurs and HF
- embolus formation
Normal valve - staph A
Abnormal valve - strep viridens
Prosthetic valve - early: within 2m epidermis, later staph a
Presentation
- May have new heart murmur - pan systolic mitral regurg, early diastolic murmur of aortic regurg
- Fever, chills, weight loss
- Splinter haemorrhages, Roth spots, Janeway lesions (painless, red, on palm) and oslers nodes (red tender nodules on fingers)
- clubbing if longstanding
- CVA, splenic/ renal/ pulmonary abscess
Investigate with DUKE criteria
2 major (2x +ve blood cultures, evidence of endocardial involvement - new murmur, vegetation, abscess)
1 major, 3 minor
5 minor
Minor = IVDU, fever >38, predisposing heart condition, vascular phenomenon, immunological phenomenon (oslers, Janeway, glomerulonephritis, Roth spot), +ve cultures of uncommon pathogen
Ix
- examine for signs + murmur
- FBC, CRP, ABG for infection markers
- Urinalysis - microscopic haematuria - glomerulonephritis
- CXR
- ECG, Echo within 4 hours
- Blood cultures (3 sets, 3 sites, 3 different times)
- Cardiac CT if diagnostic uncertainty
Mx
- native or late prosthetic valve: ampicillin, flucloxacillin and gentamicin
- early prosthetic valve: vancomycin and gentamicin and rifampicin
- Then treat based on organism (staph a = fluclox, MRSA = vancomycin, strep = amoxicillin or ceftriaxone)
- surgery to remove vegetation, repair/ replace valve
154
What model is used for treating schizophrenia?
Biopsychosocial model
- Antipsychotic, general medical care
- CBT, family therapy
- Alcohol, drug management, social skills training, employment opportunities
155
Anxiety
ASK ABOUT SUICIDAL THOUGHTS
GAD 7, GAD2
Persistent worry most days for last 6m, inability to control worrying and associated with at least 3 of: restlessness, fatigue, lack of concentration, irritability, muscle tension, poor sleep.
Ask about how impacting work, school, relationships, social life
Ask about mental and physical symptoms - any panic attacks?
Ask about self harm, risk of suicide
Assess with GAD2, GAD7
Screen for organic causes e.g. hyperthyroid, SVT, anaemia, hypoglycaemia etc.
Step 1 - educate, sleep hygiene, exercise, Beta blocker
Step 2 - Low intensity psychological interventions based on CBT (individual self help)
Step 3 - CBT or drug therapy with SSRI (2nd line SNRI, 3rd pregabalin)
Step 4 - Refer for specialist care, medication
156
Depression hx
PHQ2, PHQ9 - can be used for screening and understanding severity respectively
Organic
- steroid use, DM, hypothyroid, adrenal issues
Open consultation - Acknowledge difficult topic say if want to stop and have a break at any time please say
```
How long been going on for, any triggers?
How much been affecting life - appetite, sleep, exercise, social life, hobbies, mood, libido
How changed over time
Anything your worrying about
Anything pre-occupying your mind
When is it at its worst
What do you feel is getting you through
What is your view of yourself
```
Hows your concentration, how feel about self, how feel about future
Have you ever thought about harming yourself or others
Have you ever felt the opposite to how you are now, particularly high?
What do you think is causing this, anything you're worried about?
Have you ever felt like this before?
Have you ever suffered with mental health conditions before or been on any medication
How are you otherwise, fit and healthy
Any family history of mental health conditions?
```
Do you drink, smoke, take drugs?
Live alone, with family?
Able to look after self?
Relationships?
Support network?
```
If high risk of suicide contact crisis resolution and home treatment team
157
Depression mx
Last at least 2w, no hypo or mania
Core symptoms are low mood, fatigue and reduced energy, loss of interest in activities that are normally pleasurable
Can do routine bloods to screen for organic causes
```
Mx:
Assess suicide risk
PHQ-9
>5 – mild
>10 – moderate
>15 – moderately severe
>20 – severe
```
Sleep hygiene, exercise Crisis team if suicidal
If mild
Discuss concerns, sleep hygiene, regular sleep/wake times
Exercise programmes
Provide information
Active monitoring
Follow up in 2 weeks, make contact if not attend
Mild - mod
low intensity self guided or computerised CBT, second line is group CBT
Mod to severe
High intensity individualised CBT
SSRI first line - continue for 6m post remission
ECT can be considered for fast short term improvement
158
Suicide risk assessment
Before
- Events leading up to incident - any precipitant?
- Was the attempt planned?
- Suicide note/tell anyone?
- Attempts not to be found?
- Affairs put in order?
During
- Exactly what happened including number of tablets, timings
- How they were discovered
- Concurrent use of alcohol or other drugs
- What did they think would happen?
After
- What happened straight after?
- How do they feel now? Any feelings of regret?
- Current mood/current plans of ending their life or self harm
- What would happen if they went home?
159
Eating disorder Hx + Mx
Defined as BMI below 17.5 kg/m2
Ask about binge eating, purging, vomiting, perceptions towards appearance, typical food consumption in a day, how often weigh self or look in mirror, make excuses not to eat. Ask about excessive exercise, any tablets used to loose weight. Lack of insight into own weight loss. Ask about menstrual irregularities, sexual dysfunction, weakness, fainting, fatigue, constipation, changes in skin or hair, seizures?
SCOFF questionnaire
do you make yourself Sick
have you lost Control over how much you eat
lost > One stone in last 3m
Do you believe you are Fat when others say you are thin
would you say Food dominates your life
Routine obs + blood glucose
Sit-up, Squat–stand test - rank difficulty
BMI, FBC, U+E, LFT, CRP, ESR, TFT, Bone profile, Mg
ECG
Pregnancy test
Consider DEXA if <18, >1year
Assess risk with marsipan document
Immediate referral to CAHMs, community mental health team or eating disorder specialist
If high risk, risk of referring syndrome admit
<18 - anorexia focussed family therapy or individual CBT/ psychotherapy second line
>18 - eating disorder based CBT, group therapy
If refuse to eat - NG tube and TPN, consider sedation if refusing, emergency crash team
General
monitor food consumption + U+Es
Avoid QT prolonging drugs e.g. citalopram
If vomiting - dental checkup, rinse mouth with mouthwash after rather than cleaning
Stop excessive exercise/laxatives
Dexa scan, refer to diabetes if insulin misuse
Advise against conception until weight improves, give contraception even if amenorrhoea
160
Peripheral arterial disease - chronic, critical and acute limb ischaemia
Usually affects both sides to some degree
Can get haemosiderin deposits in PAD, chronic venous insufficiency due to DVT, thrombophlebitis (superficial veins) or pregnancy
Most common cause = atherosclerosis
Chronic limb ischaemia - present with intermittent claudication, weak pulses and hairless/ impaired healing
Can develop into critical limb ischaemia if pain at rest, particularly at night and improved by hanging leg out of bed, cold and pale limb, ischaemic lesions or gangrene
Ix
- CV exam + BP + pulses + CRT
- FBC, Glucose (diabetes), lipids
- Thrombophilia test if <50
- ECG
- ABPI - claudication 0.6-0.9, rest pain 0.3-0.6, critical ischaemia/ gangrene = <0.3
- Treadmill test - walk until claudication
- Duplex US especially if considering revascularisation
- CT angiography - gold standard
- MR angiogram or catheter angiogram
Mx
- Stop smoking, exercise, weight loss
- statins, antihypertensives, ACEi, manage diabetes
- Exercise regime + Antiplatelets (aspirin and clopidogrel)
- If exercise regime not improved 2nd line = balloon angioplasty +/- stent, 3rd line = bypass.
- Non surgical alternative is Naftidrofuryl oxalate (vasodilator).
In critical limb ischaemia - always treat as can cause ulcers, necrosis and amputations
- discuss in MDT
- revascularisation without delay
- analgesics +/- laxatives/ antiemetics as needed
- amputation last resort
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Acute limb ischaemia
Most commonly due to an embolus/ thrombotic plaque - can be caused by trauma, popliteal aneurysm thrombosis, aortic dissection, compartment syndrome, iatrogenic
Tends to only affect one side
6 P's - acute limb ischaemia
- pain
- pallor
- perishingly cold
- pulselessness
- parasthesia
- paralysis
Often other leg is normal - or can develop on back of chronic limb ischaemia
Use Rutherford classification to grade acute limb ischaemia
Ix
- Assess arterial disease RF
- FBC, lipids, glucose, ESR (temporal arteritis)
- thrombophilia screen
- Doppler US to assess arterial flow
- CT angiogram 1st line
- MR angiography or Catheter angiography can be considered
- ECG, echo, aortic US, popliteal and femoral US
- ABG for lactate
- ABPI after initial management to assess for chronic ischaemia
Mx
- AtoE
- 15L O2, IV access, immediate heparin bolus followed by infusion, morphine + antiemetic, NBM
- If Rutherford I or IIa can manage conservatively with prolonged course of heparin, monitoring
- Compartment syndrome - fasciotomy
- If embolic: surgical embolectomy, bypass graft, local intra-arterial thrombolysis (streptokinase)
- If thrombotic: intra-arterial thrombolysis, angioplasty or bypass graft
- If irreversible - leg mottled and muscle hard and woody - urgent amputation
- Treat any MI/ AF - consider antiplatelets/ anticoagulant
Post surgery - ischaemic reperfusion syndrome - can cause compartment syndrome, high K+, acidosis, high myoglobin causing AKI
162
Differentials for swollen foot and mx of charcots
Localised: DVT, cellulitis, rheumatoid arthritis, lymphedema, malignancy
Systemic: Heart failure, liver failure, nephrotic syndrome calcium antagonists, NSAIDS, hypothyroid
Have neuropathy, greater than 2 degrees difference in temp between two feet
Charcot foot = red, warm, swollen and deformed
Charcot Mx:
Xray/ MRI and screen for infection and ulcers: involves MDT, nurses, podiatry, diabetes drs, orthopaedics
Immobilisation of the joint in a cast (or with orthopaedic stabilisation), which will usually remain in place for 3 – 6 months (monthly X-Rays are used to assess progress) - takes weight off of foot to allow healing
Surgery is required if foot deformity puts the patient at risk of ulcers or protective footwear (custom braces and orthotic footwear) is not effective. Also if is unstable fractures or dislocations.
Longer term management is with optimisation of diabetic control, including BP and lipids, as well as specialised footwear and education
Important to regularly check the feet for ulcers
May require amputation if not healing and infection
The total process of healing usually takes 1 – 2 years
Give antibiotics as needed,
163
Diabetes management and Annual review
Diabetes is diagnosed as a HbA1c > 48, Fasting >7 or random glucose >11.1
1 +ve result with sx, 2x if no symptoms
First line management is lifestyle, education (DESMOND, X-pert programmes)
- exercise, reduce intake of sugar, low GI foods, reduce alcohol, stop smoking, weight loss, screening
If HbA1c > 48 start metformin 500mg OD, each week increase by 500 to max of 2g
If HbA1c >53 then start then add DPP4, SGLT2, pioglitazone, SU
If still >53 - triple therapy
SU - hypo, gain weight
SGLT2 - (gliclazide) Improve weight, cardio and renal protective (not work if eGFR <60
TZT - contraindicated with haematuria
DPP4 - (-gliptin) not improve weight, use in liver or renal failure
GLP-1 - (-tide) third line, only use if already on triple therapy
If insulin/ SU - aim 53
If others aim 48
Consequences
Microvascular - neuro, nephropathy (peripheral, autonomic e.g. gastroparesis, erectile dysfunction), retinopathy
Microvascular - ischaemic heart disease, stroke, PVD
Annual review
Take a hx, ask about how managing, sx, SE of tablets
Depression and anxiety
Qrisk to look for CV disease - cholesterol, BP, BMI
Do a blood glucose measurement - HbA1c
Diabetic retinopathy screen
Foot exam - check sensation (glove and stocking, pain, tingling), for ulcers, do ABPI, pulses, CRT, inspect footwear
Ask about autonomic SE including erectile dysfunction, gastroparesis
Nephropathy - early morning first pass urine specimen for ACR, also do creatinine level for eGFR
164
Diabetic foot mx
Educate - appropriate footwear, check feet daily, report any injuries that dont heal, no barefoot walking
Charcot - immobilisation, realignment arthrodesis/ surgery
Ulcers - off-loading/ bed rest - therapeutic shoes, wound management, diabetic control
Infection- swab, blood culture, xray for osteomyelitis, IV abx
Painful neuropathy - bed foot cradles, analgesia (TCA first line) alternatives = gabapentin, carbamazepine
PAD - exercise, antiplatelets, revascularisation
Last resort = amputation
165
Foot ulcers - appearance,
Venous
- granulated, shallow, irregular
- medial malleolus
- painful, worse at end of day + when standing
- Age, obesity, prev VTE, pregnancy
- thrombophlebitis, haemosiderin, atrophie blanche, lipodermatosclerosis, oedema
- Duplex US for venous insufficiency, ABPI to rule out arterial, swab if infection
- Raise leg, exercise, weight loss, compression bandaging (only if ABPI >0.6), emollients, endovascular treatment of varicose veins, abx if infection
Arterial
- punched out, well defined, deep, necrotic base, little granulation, at pressure points
- foot cold, reduced pulse, painful (better if hang out of bed at night)
- Obese, smoker, DM, HTN, hyperlipidaemia
- Hx of intermittent claudication, PAD: hair loss, necrotic toes, cold, reduced pulses
- Do ABPI, duplex US, angiography, swab for infection, xray for osteomyelitis
- debridement, wound care, graft,
- Treat PAD - exercise, antiplatelets, endovascular surgery e.g. balloon angioplasty/ stent
Neuropathic
- Punched out, painless, loss of sensation in glove and stocking, warm foot, good pulses
- burning/ tingling neuropathic pain in legs
- DM, B12, Charcot marie tooth
- Do BM's, bloods, assess sensation, ABPI for accompanying PAD, swab/ xray if infection
- Optimise diabetes, diet, exercise, podiatrist, foot hygiene, manage CV risk factors, may need debridement/ surgery.
166
Pressure sores Management
Ix:
Assess cause, location, grade, size, infection, odor, exudate
Waterlow risk assessment
Grade based on appearance and depth
Tx:
Pressure redistribution, nutrition, analgesia, dressing (-ve pressure)
Rotate position, address incontinence, malnutrition, regular skin assessment
Debridement
6w fluclox if osteomyelitis
Plastic surgery
167
DVT
Unilateral throbbing pain worse when standing or walking, swollen, red calf/ leg, warm and tender to touch
Cellulitis, thrombophlebitis, PAD/ Acute ischaemia, ruptured baker cyst are differentials
Measure calf circumference 10cm below tibial tuberosity, if >3cm difference suspect DVT
Ix
- Bloods - FBC, U&E, LFT, CRP, coag
- Wells score
- If wells >1 - Doppler US within 4hrs (if cant be done do D dimer and give interim apixaban)
- If wells <1 - D dimer (if cant be done within 4hrs start apixaban) - If positive do US, negative stop anticoagulant
Mx
- 1st line apixaban/ rivaroxaban
- Alternative LMWH then warfarin
- 3m if provoked (transient risk factor e.g. surgery, immobility, pregnancy), 6m if unprovoked
- if unprovoked offer thrombophilia, cancer testing
Consider thrombolytic treatment if illiofemoral DVT
IVC filter if repeated DVT/ PE or non responsive to anticoagulant
Can develop post thrombotic syndrome: chronic venous hypertension and varicose veins causing: limb pain, swelling, hyperpigmentation, dermatitis, ulcers, venous gangrene, and lipodermatosclerosis
- exercise, leg elevation, compression
168
Virchows triad - DVT
venous stasis, hypercoagulable state, endothelial injury
169
Cardiac arrest: Pulseless VT/ VF
- Causes, management and investigations post management
4h's and 4t's
Hypoxia, hypothermia, hypo/hyperkalaemia, hypovolaemia
Thrombus, tamponade, Tension pneumothorax, Toxins
Pulseless: CPR + non-synchronised DC defibrillation
- High flow O2 - 15L, secure airway
- IV fluid resus
- Adrenaline 1mg 1in10000 and amiodarone 300mg after 3rd shock
- Repeat adrenaline dose every 3-5 mins
- Further 150mg amiodarone after 5th shock
- If PE - Thrombolytic therapy, continue CPR for 60-90 mins
- once resolved amiodarone 900mg over 24 hours
- Post arrest care in ITU
Ix
- Trops
- Temperature
- ABG, U&E for electrolytes/ hypoxia
- CXR for pneumothorax/ tamponade, HF
- Toxin screen
- Drug levels e.g. digoxin
- ECG for MI, long QT etc
- TFTs
- Coronary angiography
170
VT with pulse monomorphic and polymorphic management
| VF is always pulseless
Monomorphic, Unstable: synchronised defib up to 3 attempts, followed by 300mg amiodarone over 10-20mins
- then can re-shock or consider procainamide or sotalol as needed
- once resolved amiodarone 900mg over 24 hours
Monomorphic, Stable: amiodarone 300mg IV over 10-20 mins
- once resolved amiodarone 900mg over 24 hours
- Alternative = flecainide or synchronised cardioversion/ pacing
Polymorphic - torsades de pointes
- Stop any drugs prolonging QT - citalopram, erythromycin, ondansetron, ciprofloxacin etc
- Correct any electrolyte imbalances e.g. hypokalaemia
- IV MgSO4 2g over 10-15mins
- If refractory - increase HR to reduce QTc using adrenaline if hypotension or dobutamine if normotensive
- Can consider transcutaneous/ transvenous pacing
- If congenital - long term treatment with BB
Following VT consider ICD fitting to prevent further events, beta blocker + amiodarone can be given in addition or as alternative
ICD acts like a pacemaker but can also shock to reset heart rhythm if needed
171
PEA/ Asystole - cardiac arrest
Causes = 4H's 4T's
Non shockable
- Give adrenaline immediately and continue chest compressions
- repeat adrenaline every 3-5 mins
- recheck rhythm every 2 mins
- Secure airway, IV fluids
172
Sinus bradycardia - when and how to treat
Can be normal in sleep, athletes
Can be caused by hypothermia, cushings triad (raised ICP), MI, anorexia
Treat if any adverse features (MI, shock, syncope, HF) or if risk of asystole (recent asystole, mobitz type II or complete heart block, ventricular pauses >3s)
1st give 500mcg IV Atropine
In not improved
- repeat above to max of 3g
- isoprenaline 5mcg/min IV
- Adrenaline 2-10mcg/min IV
- Or transcutaneous pacing
173
SVT - presentation, Ix, Mx
AVNRT, AVRT e.g. WPW (short PR, wide QRS, delta wave)
Palpitations, Fatigue, Pre-syncope/syncope , Chest pain
Ix
- Thorough clinical history
- ECG, echo
- response to adenosine/ vagal manoeuvres
Mx
- Haemo unstable: defibrillate
- Haemo stable: 1st vagal manœuvres (Valsalva, carotid massage - not if recent stroke), 2nd 6mg adenosine via wide bore cannula (verapamil if asthma), 12mg if no improvement after 2 mins, repeat once more. 3rd line is DC cardioversion
Long term: Depends on cause
- BB or CCB's
- Flecainide, sotalol or amiodarone may also be effective
- Catheter ablation - AVRT (WPW - remove accessory pathway), AVNRT
- stop smoking, alcohol, caffeine, drugs that might be precipitating
174
Atrial flutter
Due to re-entry circuit around tricuspid valve in most cases
Atrial rate of 250-350, 2:1 conduction ratio with ventricular rate around 150
On ECG:
- multiple p (f waves) waves per QRS
- regular QRS intervals
- Loss of flat isoelectric line
- Flutter waves have saw tooth appearance
- Regular rhythm tachycardia
Suspect if vagal manoeuvres/ adenosine for treatment of SVT haven't worked
Mx - 3 options
- If haemo unstable - cardioversion, can also do if stable and within 48hrs of presentation (if not need to anticoagulant for 3w)
- Best treatment - catheter ablation
- If not suitable for above - pharmacological cardioversion with amiodarone, sotalol, digoxin, verapamil, flecainide
Important to also treat underlying cause e.g. alcoholism, obesity, hyperthyroid
Long term anticoagulation often needed - apixaban or warfarin - risk of thromboembolism
175
AF management
Absent P waves,
Admit to hosp if:
HR >150bpm and/or
BP <90
Loss of consciousness, severe dizziness, chest pain, or breathlessness
Complications: stroke, TIA or acute HF
Onset within 48h? Options to refer CDU for immediate cardioversion without need for anticoagulation or manage in primary care if stable
Doac - better stroke risk reduction, but shorter half life so need better adherence, less monitoring
Aim for pulse rate of 60-80 on rate control
Paroxysmal - >30s <7d
Persistent - >7d or <7d but need pharm/ elect cardioversion
Permanent - longstanding (>1yr), failed to cardiovert, cardiovert but revert within 24hrs
Most common causes = IHD, HTN, Valvular heart disease, Hyperthyroidism
Ix: Pulse, ECG, holter monitor or event recorder if paroxysmal, Bloods, ECHO, TFT
Tx:
If present with collapse or are haemodynamically unstable - O2, fluid, airway adjunct, emergency cardioversion
If new, young, reversible, HF - Cardiovert with DC if within 48hrs or after 3w of anticoagulation. Alternative = pharmacologically with rhythm control
Treat cause e.g. hyperthyroid
If paroxysmal - pill in pocket (sotalol or flecainide) or catheter ablation
Long term:
Rate - BB (propanolol), CCB (diltiazem) or digoxin (if pt sedentary). If monotherapy fails combine BB and CCB
Rhythm - BB, flecainide (if no structural heart disease), amiodarone
Left atrial catheter ablation, AVN ablation or pacing can be considered
```
CHADVAS vs HASBLED
- Offer anticoagulant if chadvas >2
- Consider Anticoagulant in men with Chadvas >1
Hasbled >3 - at risk of bleeding
- DOAC or warfarin
```
176
Heart block types and mx
Commonly caused by MI, drugs e.g. CCB/ BB/ digoxin/ flecainide, endocrine e.g. hyperkalaemia, Addisons, hyper magnesia
1st degree - prolonged PR >0.2s or 3-5 small squares
2nd degree
- Mobitz type 1 - prolonging PR until QRS dropped
- Mobitz type 2 - QRS dropped every 2/3 P waves, constant PR
3rd degree - no relation between P wave and QRS
Present with fatigue, dyspnoea, syncope, chest pain/ nausea/ palpitations
- Type 2/3 can present with stokes Adams attacks causing syncope - last seconds
Mx
Look for + treat reversible causes
Type 1
- If young, no sx - no need to treat
- Avoid disopyramide, flecainide, propafenone, beta-blockers, calcium-channel blockers, digoxin and magnesium
- Annual ECG
Type 2
- Ix with 24hr ECG, echo, cardiac catheterisation
- Avoid above drugs
- If low HR - 1st atropine or 2nd pacing
- Permanent pacemaker for mobitz type 2
Type 3
- If low HR/ haemo unstable - 1st atropine, noradrenaline, dopamine, if refractory - transcutaneous pacing may be needed
- Avoid above drugs
- Permanent dual chamber pacemaker
177
When need a pacemaker + when is a biventricular pacemaker used
Use temporary if only expect arrhythmia to be temporary or as temporary treatment until permanent pacemaker is put in place
Complete or mobitz type 2 heart block
Symptomatic bradycardia - non respondent to atropine
Sick sinus syndrome
HF (cardiac resynchronisation therapy) - use biventricular (RA, RV, LV) - can also add defib (CRT-D) if NYHA class III or IV
Drug resistant SVT/ arrhythmias
Post MI
178
HEADSS - suicide/ general teenage assessment - what stand for
```
Home and environment
Education
Activities
Drugs and alcohol
Sexuality
Suicide
```
179
Paracetamol overdose - what to ask in hx, specific Ix and Mx
Presents with N+V followed by signs of hepatic necrosis after 24 hours - encephalopathy, RUQ pain, change in consciousness, hypoglycaemia, haemorrhage, jaundice.
Hx
- Why taken
- Accidental, deliberate or therapeutic
- How much, other drugs/ alcohol
- When
- Staggered or all at once
- Risk will happen again?
- Suicide hx if deliberate
- What happened, sx
```
Ix:
Take plasma paracetamol lvl 4 hours post ingestion or immediately if ingestion unknown/ staggered
U+E, LFT as baseline
Regular BM for hypoglycaemia
Clotting screen, INR
ABG for Acidosis
```
Mx:
AtoE
Charcoal 1g/kg if within 1 hour of ingestion
If lvl above treatment line, no vomiting, occurred <24hrs before start IV N-acetylcysteine
If unclear about when taken/ staggered start immediately
Also start immediately if 8-24 hours ago and taken >150mg/kg - not want to delay tx
Regime
- Bag 1 over 1 hour: 150mg/kg in 200ml 5% glucose
- Bag 2 over 4 hours: 50mg/kg in 500ml 5% glucose
- Bag 3 over 16 hour: 100mg/kg in 1000ml 5% glucose
Stop when level <10, bloods normalise
If pH <7.3, Lactate, creatinine or INR high, high grade encephalopathy consider transplant
180
Epilepsy causes, ix and management
= >2 unprovoked seizures occurring more than 24 hours apart within a year of each other
Can be triggered by alcohol, sleep deprivation, drugs, flashing lights, infections, medication
Frontal lobe seizures - motor sx, jacksonium march
Temporal lobe seizures - deja vu, motor sx, hallucinations, vertigo
Tonic clonic - stiff then rhythmic jerking
Myoclonic - Brief, 'shock-like' involuntary single OR multiple jerks
Atonic - loss of all tone causing a fall
Absence - loss of awareness and a vacant expression for 10s before returning abruptly and continuing as though nothing has happened
Causes:
- Idiopathic
- Trauma
- Mass effect lesions
- surgery
- vascular e.g. stroke
- Genetics
- Infection
- electrolytes
- glucose
Ask about before, during and after
```
Ix:
CV, neuro, MSE - identify injuries
Routine obs
FBC, U+E, LFT, CRP, BM (hypoglycaemia), urea, Ca (bone profile), thiamine (alcohol withdrawal)
AED levels
Raised prolactin and CK
ECG - long QTc can precipitate epilepsy
MRI - look for structural cause
EEG
```
Mx:
Advise on water safety (shower not bath, buddy system), not swim alone, no machinery, 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, record seizure - support head, remove dangerous objects. Once stop seizing check airway and put in recovery position.
1st seizure - 6months for car 5 years for HGV
After diagnosis of epilepsy (second seizure) - 1 year for car, 10 years for HGV
Start after diagnosis (2nd seizure)
Focal - carbamazepine, lamotrigine
Tonic-clonic seizures: sodium valproate or lamotrigine.
Absence seizures: ethosuximide or sodium valproate
Tonic, atonic and myoclonic seizures: sodium valproate or topiramate
vagal n stimulation can also help
Status epilepticus = seizure >30 mins or recurrent without regaining consciousness (treat at >5mins)
AtoE
- O2 sats, ABG, bloods, cultures, AED levels, BMs
- secure airway and high flow O2
- IV access, start fluids to help lower lactate
- D: Check GCS, pupils, BM temp
- E: check for injuries, rash, infection, liver signs of alcohol abuse
Cont existing AED
Lorazepam 4 mg IV, if unavailable;
Diazepam 10 mg PR, if unavailable;
Midazolam 10 mg buccal
If after 10 mins (5 mins later) no improvement give 2nd dose, if not work give phenytoin 15mg/kg loading dose then 50mg/min (give in ITU as need ECG monitoring)
If phenytoin not work transfer to ITU for GA
Last choice - RSI, propofol, midazolam
Repeat AtoE once seizure stopped
Afterwards
- CT head, EEG, LP, Neuro review, MRI, Discharge after 48hrs
181
Facial nerve palsy - CBD
UMN - forehead sparing
LMN - non forehead sparing
Assess facial movements against resistance, ask about changes in taste (ant 2/3) and intolerance to load noises
Can grade degree of paralysis by House-Brackmann
LMN causes - Idiopathic bells palsy, parotid tumour, base of skull fracture, cholesteatoma, acoustic neuroma, herpes (Ramsey hunt), GB
UMN causes - brainstem stroke, MS, tumour, HIV, syphilis
Refer if suspected cause or red flag features (cancer, UMN, ENT sx etc)
Mx:
Eye care - Refer to ophthalmology: lubricating eye drops, patches, taping, eye weights, botulinum, surgery
Give steroids if present within 72 hours, cont for 10 days. Most resolve spontaneously. If refractory consider facial nerve decompression surgery or reanimation surger
182
Hyperaldosteronism - how presents and what investigation is first line
Presents with hypertension and hypokalaemia
| - First line investigation is aldosterone/renin ratio
183
Palliative prescribing, presentation in dying
Secretions, Agitation, Pain, N/V, Constipation, Abdo cramps, SOB, Drowsiness
Meds: Give subcut
- Haloperidol, midazolam for agitation/ confusion
- Levomepromazine, metoclopramide
- Hyoscine butylbromide - cramps and secretions
- Morphine
184
TB
Ix:
CXR - apical opacification, effusion, millet seed
Early morning sputum sample for AFB, culture
NAAT
Antibiotic sensitivity
HIV test
```
Tx
Notify infection control body, place in ventilated side room
Isoniazid (pyridoxine)
Ethambutol
Rifampicin
Pyrazinamide
```
All for 2m then I+R for 4m (10m if CNS)
Contact trace, screen others with Mantoux and IGRA
185
Ear discharge CBD
Otitis media
Sx: Earache, fullness, hearing loss, fever
Ix: Otoscopy to look for bulging, redness of TM, fluid level or perforation, impedance audiometry to measure pressure in middle ear, do nasal endoscopy to check the openings of eustachian tubes, audiometry if hearing loss
Mx: Analgesics, warm compress, most self limiting. If severe, <2yo, bilateral: oral amoxicillin
Consequences include mastoiditis, facial nerve palsy, meningitis, cerebral abscess.
If mastoiditis - IV abx, consider CT (if consider surgery or abscess, have headache, lethargy etc) and mastoid air cell clearance.
Otitis media with effusion - due to closure of Eustachian tube. Get negative pressure in middle ear, draws fluid in from middle ear. hearing loss, poor speech development, ear popping, imbalance
If effusion - fullness, hearing loss persists after infection treated. Observe for 6-12 weeks for spont resolution, if ongoing, limiting development, bilateral consider grommets, adenoidectomy
If perforation persists (Chronic otitis media) - antibiotics and surgery to fix eardrum
Otitis externa
Sx: Ear pain, itch, discharge often post water based activity. If unrelenting pain that interferes with sleep, hearing loss, FN involvement, fever think necrotising otitis externa (do CT, CRP, ESR)
Ix: otoscopy - red swollen external auditory canal, ear swab if recurrent, if necrotising do CT/ MRI
Mx: Clean ear, analgesic, often self limiting - if severe: ear wick, topical antibiotic (aminoglycoside e.g. gent or ciprofloxacin) +/- hydrocortisone drops, keep ears dry. Acetic acid for prevention. For necrotising, same day referral to ENT, 6w oral ciprofloxacin
Cholesteatoma
Sx: Non resolving unilateral offensive discharge thats unresponsive to antibiotics
Ix: Retraction of pars flaccida on otoscopy, if facial nerve involvement or planned surgery do an MRI
Tx: Surgical removal often required - canal wall up mastoidectomy
Also want to rule out CSF if base of skull fracture - test for glucose and beta 2 - transferrin
186
Osteoarthritis management
Ix
Assess level of pain and limitations of activity - on exam see stiffness and limitation of ROM
Assess psychological impact
Do examination of joint and one above/below
Calculate BMI
Bloods: FBC (WCC), U+E (before starting on NSAID), LFT as baseline, CRP/ESR (identify inflammation)
Do Xray of the joint
- Loss of joint space
- Osteophytes
- Subchondral sclerosis
- Subchondral cysts
Consider joint aspiration to rule out gout, septic arthritis
Hand signs:
- Sparing of the metacarpophalangeal joints
- Bony enlargement of the proximal interphalangeal joints known as Bouchard’s nodes
- Bony enlargement of the distal interphalangeal joints known as Heberden’s nodes
- Squaring of base of thumb
- Reduced functional movement (e.g. reduced grip strength)
Diagnostic criteria
- >45yo
- activity related joint pain
- no morning stiffness or stiffness lasting <30 mins
Mx
Educate, weight loss, exercise, physio, hot/cold compress, stop smoking, foot wear, psych, TENS
WHO pain ladder
- topical NSAID
- Topical NSAID + paracetamol
- NSAID, paracetamol and topical capsaicin
- Above + opioid
Joint replacement or arthrodesis (fusion)
187
Rheumatoid arthritis management
Sx - weight loss, night sweats, fever, malaise, low appetite, weakness, joint swelling/ red/ hot/ painful, joint stiffness worse in morning, better with exercise, lasts >30mins - 1hr.
Affects >5 joints, is symmetrical - affect metacarpo-phalangeal joints
Refer if:
Small joints of hands/feet are affected
>1 joint affected
Been delay of more than 3 months between symptom onset and seeking advice
look for rheumatoid nodules on skin, ask about previous eye conditions e.g. anterior uveitis
Can cause baker cysts
increased risk of atherosclerosis
Can also cause pleural effusion, lung fibrosis
Ix
Examination and history - systems review
FBC, U+E, LFT, CRP/ESR, RF, Anti-CCP, ANA
Xray - bony erosions, joint space narrowing, soft tissue swelling, juxta-articular osteoporosis
US - look for effusion and thickening/blood flow in synovial membrane
Joint aspiration if suspect septic
Assess disease activity with DAS28
Hand signs
- boutonnieres
- Swann necking
- Z thumb
- ulnar deviation
Mx
Educate, lifestyle, psych
Assess psych wellbeing
NSAID for pain relief
Corticosteroid if flare - up to 3x a year
1st Line: cDMARD e.g. methotrexate, if palindromic hydroxychloroquine. Bridge with glucocorticoid.
2nd Line: bDMARD (if 2x above ineffective) e.g. TNF inhibit adalimumab, Anti CD20 rituximab
3rd line: surgery
Drug SE
Steroids - Infection, osteoporosis, DM, cushings
Methotrexate – liver toxicity, pneumonitis, oral ulcers
188
Gout
Common causes are hereditary, alcohol, renal impairment, NSAID, Diuretic (thiazide), purine rich foods,
Fever, collapse, Recent infections, trauma, rashes, weight loss
History of acute attack of pain, swelling, redness and warmth. Commonly 1st metatarsophalangeal joint
May have tophi on extensor surfaces of limbs, ears and achilles tendon
Ix:
Hx - ask about prev attacks, diet, alcohol
Often clinical diagnosis
Do joint aspiration to confirm (urate crystals)
Do uric acid lvl 4-6w post attack
Xray to exclude other causes
Screen for CV and renal disease
Mx:
Discuss lifestyle changes - loose weight, reduce purine in diet (red meat, seafood), reduce alcohol consumption
Rest, ice, elevate
1st line: NSAID (naproxen + PPI) or colchicine
2nd line: oral or corticosteroid injections
Prevention - once acute attack resolved
- Weight loss, reduce alcohol, reduce purine in diet
- allopurinol - titrate dose to reduce uric acid <300. Give colchicine alongside for first 6 months. Can cause rash/fever, if renal impairment monitor U+E
- 2nd line febuxostat
189
BPH - present with LUTS
Storage
- frequency
- nocturia
- incontinence
- urgency
Voiding
- Poor flow
- Hesitancy
- Dribbling
- incomplete emptying
```
Hx ask about these things +
- fever
- Pain/ backache
- Weight loss
- problems passing stool
- Any burning when go to the toilet
- Any pain
-
```
Ix:
IPSS - int. prostate symptom score
DRE
Dipstick - Diabetes, UTI
Blood tests including PSA, U&E, FBC
Urodynamics - flow rate <10mls = obstruction (or neuro/DM)
Bladder, kidney US to look for chronic retention (recurrent UTI, CKD, hydronephrosis, stones, overflow incontinence)
May do MRI, CT KUB, flexible cystoscopy in secondary care
Mx:
If mild - reassure and reduce alcohol/caffeine, incontinence pads, bladder training, follow up
If moderate - Alpha blockers (tamsulosin - relax neck of bladder and prostate - dizziness and issues with ejaculation), 5-alpha reductase inhibs (finasteride - reduce size of prostate), catheters
If severe (recurrent UTI, haematuria, acute retention) - surgery -Transurethral resection of prostate
Complications
Acute urinary retention - catheterise
Bladder diverticular
Chronic urinary retention and hydronephrosis
190
Domestic abuse
Signs include
- withdrawn
- downplaying symptoms
- large bruises in shape of hand/ fist
- repeated attendance
- delayed attendance
- multiple bruises of different ages
Safeguarding, social services
Ask about home life, ask directly if there has been any physical abuse or threats, ask if they are scared of their partner
Reassure about patient privacy, safety and confidentiality
Ask about
- physical - ever hurt you
- sexual - ever made you do sexual things you don't want to do
- emotional - try to belittle or control you
Who is it - do they drink/take drugs, psych health conditions? convictions?
How often happen, how long been going on for, is it getting worse
How have you been coping, have you tried anything to get away, tried to get help before
Anyone else in the house
Who live with
Any weapons in the house
Do they have a safety plan
Do they work
Assess risk
- currently in danger? what happen if went home?
- thoughts of hurting self or others?
Offer advice and support
acknowledge was difficult to disclose and next part is probably hardest step, prepared to support the person to take it in their own time
Say not their fault
```
Family/ friends for support?
counselling, support, helplines - give leaflet
Refuge if cant go home
Refer to
- police
- local domestic abuse services
- counselling/ support
- social services if child involved
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191
BCC, SCC
Refer on 2ww for SCC
Routine referral for BCC
Ix:
Biopsy, dematoscopy, CT if suspect spread, FNA of local nodes
RF - UV exposure, fair skin, weakened immune system, personal or family history
SCC looks wet, sloughy, ulcer, from keratinocytes. Comes on more quickly, tender, more common on back of hand, may be nearby actinic keratitis
BCC from hair follicles - pearly, nodular, depression in middle, telengectasia, non tender
Superficial BCC - patch/plaque, pale ping, Clear rolled edge
High risk
Diameter >2 cm
Location on the ear, vermilion of the lip, central face, hands, feet, genitalia
Elderly or immune suppressed patient
Histological thickness greater than 2 mm, poorly differentiated histology, or with the invasion of the subcutaneous tissue, nerves and blood vessels
Tx:
Excision with 4mm margins
If complex, deep or unclear boarders do MOHs
Radiotherapy alternative if not want surgery (increased scarring),
For superficial BCC or actinic keratitis or Bowens disease - cryotherapy, photo-dynamic therapy , curettage, 5-FU, immiquimod
Actinic Keratosis - Diclofenac
192
Types of dementia - key features
How to investigate, treatment of AD
AD: early impairment of memory. Manifests as short-term memory loss and difficulty learning new information.
VD: typically a ‘stepwise’ decline in function. Predominant gait, attention and personality changes. May have focal neurological signs (e.g. previous stroke)
DLB: parkinsonism (tremor, rigidity, bradykinesia, postural instability). Fall, syncope and hallucinations predominant feature
FTD: marked personality change and behavioural disturbances. Memory and perception relatively preserved.
What to ask in hx
- when start
- gradual or step wise
- any triggers
- associated depression, psych sx, behavioural change, sleeping pattern, cognitive changes, parkinsons like features, sensory changes, fluctuating awareness
- head injury, psych hx, vascular disease, diabetes, parkinsons
- focal neuro, vision etc (vascular)
- medication
- fhx
- shx - who live with, who looks after, work, can they perform AODL, work/drive, smoking/ alcohol/ drugs
- assess risk to self - ever done anything that put themselves at risk
- ICE
```
Investigate with cognitive tests
- Abbreviated mental test score
- Mini mental state exam
Refer to memory clinic then:
- MOCA (26/30)
- Addenbrookes
```
DSM-V Diagnosis - functional impairment, affect >2 cognitive domains, no other cause (depression, delirium)
Do Brain MRI
Mx:
Advanced planning, capacity, care plan, end of life care
Supportive care
Physical and mental health
Inform DVLA
Exercise, group cognitive stimulation programmes
Mild to moderate - acetylcholinesterase inhibitors e.g. rivastigmine or donepezil
Moderate to severe - NMDA antagonist e.g. memantine
193
Vertigo CBD
Ask: how long for? Tinnitus, hearing loss, what makes better, what makes worse, headaches, visual changes?
If seconds to minutes, comes on when turning head, no tinnitus or hearing loss: BPPV
- diagnose with dicks hall pike manoeuvre (rotary nystagmus)
- treat with epley manoeuvre
- educate, advise against sudden head movements and sit/lie down in stages
- no driving until condition under control
If >20 mins to hours, fullness in ear, sensorineural hearing loss, tinnitus, N+V = Menieres
- do audiology to confirm sensorineural deafness
- inform DVLA - not drive until under control
- limit salt, alcohol, caffeine, chocolate, smoking as can trigger
- avoid dangerous activities like driving
- prochlorperazine for vertigo and nausea
- beta-histone as prophylaxis, diuretics in 2dry care
- hearing aid for hearing loss
If spont vertigo lasting days = acute labyrinthitis (hearing loss) or vestibular neuritis (no hearing loss). Often post viral infection.
- resolves on own in few weeks
- start moving as soon as possible
- not drive when dizzy
- if severe consider antihistamine/ antiemetic e.g. prochlorperazine
- give antiemetics, hydration, vestibular rehab
If central (also sx of dysphagia, dysarthria, diplopia, dysmetria) - brainstem lesion or acoustic neuroma
194
Atypical antipsychotic counselling
Schizophrenia is caused by problems with dopamine receptors in the brain
Onlanzapine works by blocking receptors in the brain that are involved in transmitting these messages between cells
Comes in a daily tablet form or in a depot injection every 2-4w
- depot often used if issues with compliance
Start at a low dose and built up over a week or two depending on individual response
Once started is likely will return on the medication long term unless it isn't helping in which case switch to another drug
Will need to measure LFTs, lipids, weight, HbA1c levels prior to starting. Lipids, weight, HbA1c, prolactin, U&E, LFT, FBC, ECG will be monitored regularly throughout treatment
Important to inform doctor if want to become pregnant
Some side effects include
- weight gain
- high prolactin causing - low libido, menstrual issues, gynaecomastia, sexual dysfunction
- sedation
- HTN
- Glucose intolerance
- Anticholinergic se e.g. dry mouth, constipation, dry eyes, urinary retention
- orthostatic hypertension
- less risk of extrapyramidal SE
Is a risk of neuroleptic malignant syndrome in overdose so if think have taken too many tablets or develop fever, muscle rigidity, tremor, altered mental status visit GP/ A&E
Is also a risk of agranulocytosis and increased rate of infections
Can have withdrawal symptoms so let dr know if want to stop
195
Schizophrenia explanation/ counselling
ICE, ask patient what already know
Info - schizophrenia is a long term condition that affects peoples ability to distinguish between abnormal thoughts and reality. This can mean experiencing hallucinations, paranoia, loss of interest in doing things.
Does this resonate with you?
Cause - the cause of schizophrenia isn't clear, each person is different. However it commonly affects young people like yourself. Some things can trigger or worsen schizophrenia, these include significant stress or drugs. Does this apply to you?
Effect on life - Schizophrenia will always be there however with medication most people can make a recovery. There may be times when the symptoms come back and this is called a relapse. Having schizophrenia puts you at increased risk of other mental health disorders like depression and suicide. If you feel like this or your symptoms are getting worse and you think you might be having a relapse please tell someone. We hope however that with continued treatment this won't happen.
Do you understand all this?
Treatment - long term medication that you will need to continue even if your symptoms stop. Are things you can do and things I can do however:
You - healthy lifestyle, exercise, avoid drugs and alcohol as they can make your condition worse. Is important you attend your appointments
Us: Antipsychotics, manage in combination with GP, can also use talking therapies . Put in touch with other services for employment, finances etc.
Summarise
196
Lithium counselling - check photo on phone
ICE
Do you have any questions about your condition or what's happened so far
Alters signals in the brain to help stabilise your mood
Comes in tablet and liquid form. If taking the tablet form is important to swallow with lots of water
Take the tablet once a day - usually recommend to take in the evening so that monitoring is easier - need to assess levels 12 hours after taking dose - not strict - but must take at same time every day
Can take 1-2w to work - if miss a dose and <6hrs since normal time then take, if after this skip dose and return to normal the next day - do not double dose
Important not to stop suddenly and not to change dose without speaking to DR first
Will receive a lithium monitoring book - this can be used to keep track of blood tests, appointments and can be used in emergencies
Can take several weeks to months for lithium to start working - will need to take a blood sample every week to get appropriate level - once stable this can then go to monthly and then 3 monthly
Will also need to monitor some blood levels including thyroid function tests, urea and electrolytes and calcium
Lithium can have some side effects including
- increased thirst, nausea, increased urination, diarrhoea, tiredness, weight gain, tremor, metallic taste
- usually resolve with time
It is also important you are aware of symptoms of lithium toxicity - these can be life threatening so need to seek urgent medical help
- confusion
- drowsiness
- vision changes
- difficulty speaking
- seizures
- vomiting, tremor
Can affect kidneys leading to renal toxicity, neophrogenic diabetes insipidus, hypothyroidism, hyperparathyroidism, hypercalcaemia
Should not take NSAIDs as increase lithium level
Are risks of birth defects associated with pregnancy when taking lithium so important on a reliable form of contraception, speak to psychiatrist if want to start a family
197
Peripheral venous exam
Varicose veins present with itching, discomfort and heaviness of the legs, night cramps, oedema, burning sensations, paraesthesiae, exercise intolerance, or restless legs
- may have a dull ache worse when standing
Tx
- weight loss, exercise, avoid prolonged standing, keep legs elevated when possible
- consider compression stockings if intervention not appropriate - do ABPI first
- Endothermal ablation
- Sclerotherapy
- Excision
General inspect - body habitus, oedema, scars, ulcers, medical equipment, mobility aids
Inspection of legs - scars, venous eczema (red, blotchy), haemosiderin (brown/red), atrophy blanche (white, lack of pigment), lipodermatosclerosis
- Look for venous ulcers over medial malleolus
- saphena varies - dilation of saphenous vein at its junction with femoral vein in the groin - put hand over and ask to cough
assess for arterial disease
- temp
- pulse - femoral, popliteal, ant tibial, dorsalis pedis
- pallor
- cyanosis
- cap refil
- hair loss, ulcers
Great saphenous - medial leg
Lesser saphenous - lateral to posterior leg
Assess varicosities
- temp - increased temp = phlebitis
- palpate - tender = phlebitis, hard and tender = thrombophlebitis
Assess for pitting oedema - go up leg to find level stops (HF)
tap test - finger on SFJ (4cm inferolateral to pubic tubercle), tap varicose vein and feel for thrill - if felt shows valve insufficiency
Listen with Steph for bruit
Venous duplex scan
Tourniquet test - lie flat, life leg, milk veins, place tourniquet at level of SFJ then get to stand up, look for filling of veins. Go lower by 3cm each time, when filling stops are at level of incompetent valve
perthe's test - apply tourniquet to mid thigh whilst standing, get patient to walk around for 5 mins. If veins less distended is no deep venous issues, if veins more distended or same is superficial and deep venous issues
Do doppler, duplux US, ABPR, arterial vascular exam, abdo exam
198
Discharge planning - what to include
Patient details
- name, DOB, hosp number, address, GP details
- Hospital stay - ward, consultant name, admission and discharge date, discharge destination
- Date written and personal signature
Clinical details
- Admission details - PC - hx and exam
- Investigations - results and any awaited tests/ results
- Diagnosis and Comorbs
- Management - how managed/ treated, any complications
Plan
- Plan for post discharge
- Follow up
- Actions for GP
Medication
- Changes to regular medication
- Medication to continue post discharge - drug, dose, form, frequency, length (qqt)
- PRN meds
- write meds in handwriting, include pt name and address, dose written as 5 (five) mg, total amount as 10 (ten)
199
BCC/SCC management
Refer on 2ww for SCC
Routine referral for BCC
Ix:
Biopsy, dematoscopy, CT if suspect spread, FNA of local nodes
RF - UV exposure, fair skin, weakened immune system, personal or family history
SCC looks wet, sloughy, ulcer, from keratinocytes. Comes on more quickly, tender, more common on back of hand, may be nearby actinic keratitis
BCC from hair follicles - pearly, nodular, depression in middle, telengectasia, non tender
Superficial BCC - patch/plaque, pale ping, Clear rolled edge
High risk
Diameter >2 cm
Location on the ear, vermilion of the lip, central face, hands, feet, genitalia
Elderly or immune suppressed patient
Histological thickness greater than 2 mm, poorly differentiated histology, or with the invasion of the subcutaneous tissue, nerves and blood vessels
Tx:
Excision with 4mm margins
If complex, deep or unclear boarders do MOHs
Radiotherapy alternative if not want surgery (increased scarring),
For superficial BCC or actinic keratitis or Bowens disease - cryotherapy, photo-dynamic therapy , curettage/ cautery, 5-FU, immiquimod
Actinic Keratosis - Diclofenac
200
Melanoma Mx
Ix:
Do a dermatological exam - ABCDE, determine classification (superficial, nodular)
Use Glasgow 7 point checklist = ABCDE + looking for inflammation, itch, oozing
Dematoscopy
Biopsy - excisional with 2mm margins
Breslow (depth in mm), Clarkes (layer of skin descends to, not part of staging), ulceration, mitotic index give indicator of prognosis
Do CT if suspect metastatic spread, assess for BRAF mutation
```
Mx:
Wide local excision with margin based on breslow thickness
insitu - 5mm
<1mm - 10mm
1-2 - 10-20
2-4 - 20-30
>4 - 30mm
+/- lymphadenectomy/ sentinel LN biopsy
Can also do electrochemotherapy
```
If metastatic - BRAF inhib, immunotherapy e.g. ipilimumab, chemo, interferon alpha
201
Warfarin counselling
Warfarin is a blood thinner that helps stop clots from blocking blood vessels within the body. It does this by blocking the function of vitamin K
It can be taken to treat people who have had a previous blood clot or those at high risk due to AF or prosthetic heart valve
The action of warfarin can be rapidly reversed with an antidote of activated vit k called phytomenadione
It is taken once a day in the tablet form - at same time each day to keep level steady
- different colour tablets indicate the dose
If you miss a dose for any reason take as soon as you remember, if the next day then just take a single tablet, do not double dose
Takes 2-3 days to begin working, on these days re given a higher loading dose
INR is a measure of how long it takes the blood to clot in health people it is 1 - as we want to reduce your risk of clots we aim for 2-3
- to get your medication dose to the right level we need to monitor your INR every 3-4days at first until we reach the correct dose with 2 consecutive readings in range, then every 1-2 weeks until same then can measure 3 monthly
- will record results in a yellow book
2. 5 +/- 0.5 for PE/DVT
3. 5 +/- 0.5 for recurrent PE/DVT and already on anticoag or if prosthetic heart valve
take 3m for DVT
take 6m for PE
Lifelong AF
Wear warfarin alert bracelet
It is common for you to bleed a little more than normal e.g. heavier periods, gum bleeding when brush teeth, nose bleeds, easy bruising, prolonged bleeding if cut self
However if experience blood in urine/ stool/ vomit, large bruises without cause, nose bleeds lasting >10 mins, sever headaches or fits, changes to eye sight or ams. legs need to seek medical help
Some side effects include - mild rash, hair loss, nausea, diarrhoea
Can interact with medications including over the counter like St johns wart - read information leaflet and inform pharmacist when purchasing medication, same when starting medication at the drs
Avoid foods high in Vit K including liver, spinach, cranberry. Avoid alcohol binges. Avoid contact sports.
Carry alert card, take yellow book to any appointments
Contraindicated in pregnancy - need to be on a reliable contraceptive
202
ECG interpretation
Name and DOB
Date and time
Look at rate - number x6 or 300/ large squares
Look at rhythm - irregularly irregular/regularly irregular
Look at axis - highest in II = norm, III right, I left
Look at p wave - present, absent, followed by QRS, shape, duration
Look at PR interval (3-5 small squares or 0.2s - longer = heart block)
Look at QRS (<3 squares), look for wide (BBB, abnormal depolarisation), Q wave (>20% height of R wave), hypertrophy, RSR in V1 = RBBB, RSR in V6 = LBBB
Look for ST elevation (>1mm in >2 contiguous limb Leeds or >2mm in >2 chest leads)
Look for T wave tenting (>5mm in limb leads, >10mm in chest), inversion (ischaemia, PE, LVH, HOCM), biphasic in hypokalaemia
Look for U wave
203
ABG
WIPE
Check contraindications - infection, peripheral vascular disease, AV fistula (relative = impaired coag)
Allergies - Chlorhexadine
Allens test - get to clench fist, occlude both arteries, check blanched, release ulnar a colour should return within 5-15s
Palpate and clean for 30s
insert at 45 degrees until flashback
remove, remove needle and dispose, expel air and invert
add cap and patient label
Apply pressure over site for 3-5mins
204
Prescribing
Identify the therapeutic indication
Identify the patient’s perspective of medication use
Document the name, date of birth and address of the patient, hosp number
Document the name of the medication
Document the appropriate dose of the medication (how many mg etc per dose)
Document the strength and formulation of the medication
Document the quantity of the medication - total amount of tablets for entire course
Sign the prescription and include your GMC number
Document your address and contact details
Document the date of the prescription
Advise the patient how to use the medication
Explain how the medication with be monitored if relevant
205
BM
WIPE
- explain: Today I need to measure your blood glucose level, which involves taking a very small blood sample from your fingertip. You will experience a sharp scratch when I take the sample, but this should be very brief
Ask if any pain, allergy, consent
```
Clean if dirty
Turn on machine
Check strips are in date
Place in machine
take cap off lancet, draw blood and place strip to blood
Apply gauze and tape
```
206
Cannulation
Indications
- drug therapy
- fluids
- blood products
- emergency drugs
Is a risk of infection if not wear gloves, not wash hands, touch key parts
WIPE
- allergies
- indication
Clean tray and gather equipment
- cannula, flush, syringe, blunt needle, octopus, tourniquet, bandaging, gauze
Do not cannulate if prev cannulation site, bruising, haematoma or infection
Clean for 30s
Insert cannula
Clean port on octopus before and after flushing
Assess 8hrly and VIP score calculated - pain, erythema, swelling, induration, palpable venous cord, pyrexia
Tell patient to speak to member of the team if becomes painful or start bleeding/ discharging
207
Inhaler technique
Explain what been started on and why
Show inhaler and its components
Explain why that type of inhaler is used and when
(rinse mouth out if steroid)
Happy with everything I have said so far, any questions?
Before use if not used in last 5 days take lid off shake and do one test spray
Look at dose counter and ensure not empty
Check expiry date
Hold upright, check nothing in mouthpiece, shake
sit up straight put chin up, breath out till lungs empty, form a tight seal. Breath in slow and steady while push canister, continue to breath in till lungs full. Remove inhaler from mouth and hold breath for 10s, breath out
If second puff do after 30 seconds, put back on cap after
Assess their technique
Spacer - increase drug to lungs and reduce SE
Prep, attach, breath out away from inhaler, form seal, puff once then breath in and out 2-3 times
Wash with detergent once a month, air dry. Do not wipe as causes static
If in asthma attack not improve after 10 puffs then call 999
leaflet, follow up
208
Blood cultures
Gel hands, confirm patient ID, ensure indication, gain
consent and check allergies.
Clean equipment tray as per guidelines
Collect equipment
Ensure packaging intact and within expiry date
Prepare bottles: Mark 10mls above fluid line, remove caps off bottles, disinfect tops with a sepa-rate 2% CHG in 70% IPA wipe for a minimum of 30 secs, allow to air dry.
Re-apply tourniquet and palpate and select appropriate vein
Loosen tourniquet
Decontaminate site with 2% CHG in 70% IPA cleansing for 30 seconds, allow to air dry
Do not re-palpate site
```
Puncture vein with winged collection system
Take cultures prior to other samples.
Aerobic First
Fill each bottle with 10mls
Keep bottles vertical
```
Release tourniquet
On removal of needle apply pressure.
Dispose of sharps immediately into sharps bin, apply gauze, remove gloves and apron
Gel hands
Label appropriately and according to trust/local policy
Dispose and clean equipment as policy
Wash hands
Document procedure, indication and treatment plan in patient’s notes
209
Suicidal hx
If no immediate risk of harm to patient - refer to community mental health team
If immediate risk of harm refer to crisis
210
Bisphosphonate
Introduce
Ask if know why starting
Brief Hx
- Prev fractures
- Menopause
- Reflux, any other meds
- Alcohol, smoking
Explain osteoporosis = bone thinning and function of bisphosphonates
Taken 1xweekly on same day each week
Take 2 hours before food in morning, plenty of water, sit upright for 30 mins after
Can take 6m to have affect
Work in background - important to continue
Can cause heartburn, nausea, GI upset and some muscle pain - tends to resolve. More serious SE include gastric ulcers - blood in vomit or stool, osteonecrosis of jaw - pain on chewing and facial swelling - problems swallowing
Important not to take alongside NSAIDS e.g. ibuprofen
Important to remain active, eat leave green veg, nuts, fish, stop alcohol and smoking
May give calcium supplements alongside
Conclude
211
GP tired station
In hx ask to identify any causes
- low mood/ depression
- hypothyroid
- anaemia
- CO
- sleep
Council on exercise, diet, wellbeing/ lifestyle
Consider testing for organic causes above
Review in 4w
212
CKD
```
1 - >90
2 - 60-89
3a - 45-59
3b - 30-44
4 - 15-29
5 <15
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Counselling
- CKD is a lifelong condition where the kidneys don't work as well as they should - it is commonly associated in getting older. Sometimes there is a clear cause like high blood pressure, diabetes, infections, or autoimmune conditions but in others there isn't one.
- People with CKD can experience symptoms such as tiredness, shortness of breath, swelling of their feet and ankles, blood in their urine, nausea, have you experienced any of these
- We diagnose CKD via blood tests like the ones you had,
- CKD can get worse over time to the point where the kidneys stop working (kidney failure), this is uncommon (1in50 cases) and many people live healthy long lives. Its important to be aware however that having CKD increases your risk of strokes, heart attacks
- It is treated by a combination of lifestyle changes and some medication including drugs to lower your blood pressure and cholesterol levels. In later stages some people need treatment with dialysis or transplants.
- Lifestyle changes include: stop smoking, healthy balanced diet, restrict salt intake to <6g/day, do regular exercise 150min a week, reduce alcohol to <14, loose weight, avoid NSAIDS.
- Medication include: ACEi to keep BP < 140/90, statins, water tablets for swelling, erythropoietin for anaemia
- We will review you after starting the medication and then follow up long term with 6-12 monthly appointments
- Can have pneumococcal vaccine and yearly influenza vaccines
- Support is available in the form of CKD groups, counselling services and leaflets
ACEi: U+E and BP check in 2 w
Statin: LFT check at 12w, 12m
213
HTN
Aim for a 40% drop in non-HDL cholesterol over 3 months
>140/90 in clinic do ABPM or home BP measurement
>180/120 - consider immediate treatment for malignant hypertension
Based on ABPM
- <135/85 - no need to treat
- >135/85 = stage 1 - start if >80, <60 or between two with end organ damage, raised Qrisk >10%, diabetes
- >150/95 = stage 2 - start treatment
- >180/120 = stage 3 - start treatment
End organ dmg - Eyes, heart, kidneys
- LVH on ECG - S wave in V1 + R wave in V5/6 >35mm
- Fundoscopy - arteriolar narrowing, retinal haemorrhages, papilloedema
- Raised ACR, abnormal U&E, protein/albuminuria
Discuss what is hypertension
Risks - Renal damage, stroke, CVD
<55 or diabetes - acei
>55 or black - CCB e.g. amlodipine
If still high - ACEi + CCB/ thiazide like or CCB + Acei/ thiazide like
If still - All 3
If still - confirm resistant hypertension, check for postural, discuss adherence
- low-dose spironolactone4 if blood potassium level is ≤4.5 mmol/l
- alpha-blocker or beta-blocker if blood potassium level is >4.5 mmol/l
In <80 - BP <140/90
In >80 - BP <150/90
214
Back pain management
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Fit note - patient can self certify for 7 days
Write
- Cause of symptoms
- Date of assessment
- Timeframe
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Can decide if not fit for work or if fit with:
Phased return to work
Altered hours
Amended duties
Workplace adaptations
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Self help is very important – PIL or video back exercises, avoid bed rest
Explain that movement helps improve the back, and pain doesn’t equal harm
Best to pace – frequent short bouts rather than overdoing things
Going to need pain relief and possible diazepam initially if spasms (although NICE doesn’t recommend this CKS does) or
Acute analgesia; Paracetamol PLUS ibuprofen, codeine, diazepam 2mg tds
Add amitriptyline or duloxetine only if neuropathic pain (sciatica)
Applying heat pads may help
No evidence for paracetamol alone, or opioids, or SSRIs, or gabapentin
Acupuncture may help some people (but evidence is poor and may not be available) is not recommended (although some patients may find it he
215
Clozapine
Liquid or tablet
SE: sedation, weight gain, hypersalivation, tachycardia, constipation
Serious SE: reduce seizure threshold, cause neutropenia and increase risk of infections, cardiomyopathy
Monitoring
- BM, ECG, BP
- FBC, U&Es, LFTs, prolactin, HbA1c and lipids. For clozapine, a baseline troponin is also requested.
First 18w - test FBC weekly then every 2w until 1year then monthly
Not smoke! or change smoking habit
216
Look at rheumatoid
On NHS
