Amir Sam DPD Flashcards
60M, presenting with 4 hr Hx of tight chest pain, nausea, sweating, SOB, HTN, DH: Amlodipine
Myocardial infarction
Investigations on suspicion of MI?
ECG, Troponin (if positive, coronary angiography, if negative, exercise tolerance test - ETT), Echo
Cardio, resp, GI and musc Ddx of chest pain?
ACS, stable angina, aortic dissection, pericarditis, pneumonia, PE, pneumothorax, oesophageal spasm, oesophagitis, gastritis, costochondritis
Where is the ST elevation seen in a lateral MI and what artery is affected?
V5, V6, I, aVL, circumflex artery
Ddx of collapse?
Hypoglycaemia - ABCDEFG
Cardio - vasovagal, arrhythmia, outflow obstruction, postural hypotension
Neuro - seizure
How to investigate Ddx of collapse?
Arrhythmias - ECG (see if there is long QT), cardiac monitor, 24 hour tape Outflow obstruction (aortic stenosis, HOCM on the left, PE on the right) - low volume/slow rising pulse, ejection systolic murmur, Echo Postural hypotension - lying/standing BP
What is long QT syndrome and what can cause it?
Abnormal ventricular repolarisation
Congenital: mutations in K+ channels, FHx of sudden death
Acquired: low K+/Mg2+ drugs
45M, fever, malaise, IV drug use, afebrile, Osler nodes, raised JVP, pansystolic murmur louder in inspiration, hepatomegaly
Infective endocarditis, mitral regurgitation
Ddx of raised JVP
Right HF - secondary to LHF, pulmonary HTN (PE, COPD) Tricuspid regurgitation (valve leaflets, R ventricle dilatation) Constrictive pericarditis (infection e.g. TB, inflammation e.g. connective tissue disease, malignancy)
65M, SOB, palpitations, HTN, DH Bendroflumethiazide, afebrile, irregular and fast pulse, dull percussion and coarse crackles L base
Pleural effusion secondary to HF
Pneumonia
ECG will show sinus tachycardia
What does sinus tachycardia indicate on ECG?
Sepsis, hypovolaemia, endocrine (thyrotoxicosis, phaechromocytoma)
What does SVT indicate?
Re-entry circuit
AVRT - short PR, delta wave, accessory pathway
AVNRT - circuit within AVN
What does AF indicate?
Thyrotoxicosis, ischaemia (muscle, valve, pericardium), chest infection (pneumonia, PE, cancer), alcohol
What does VT indicate?
Ischaemia, electrolyte abnormality, long QT
What is the management for SVT?
Vagal manoeuvres, adénosine (cardiac monitor), DC cardio version if haemodynamically compromised
Management for AF
Rhythm control - if onset over 48 hours, anti-coagulate for 3-4 weeks before cardioversion
Rate control - beta blocker, digoxin
Management of VT
If no haemodynamic compromise: IV Amiodarone
Look and treat underlying cause
ICD
Pulseless VT: defibrillate
What does S3 indicate?
S3 = poor ventricular filling
What does S1 and S2 indicate?
S1 = closure of mitral valve S2 = closure of aortic valve
What is the fixed wide splitting of S2
Fixed wide splitting of S2.= atrial septal defect
What is S4?
Associated with ventricular hypertrophy
65F, SOB, few hours, orthopnoea, 2 MIs in past, DH: aspirin, simvastatin, ramipril, bisoprolol, raised JVP, S3 heart sound, fine crackles, peripheral oedema
Acute HF
Management of acute HF?
Sit up, oxygen, IV furosemide, treat underlying cause
78M, unconscious, not breathing, no carotid pulse, low temp, ECG shows VF, what is the management?
Shock, CPR (2min), assess rhythm, adrenaline every 3-5min, amiodarone after 3 shocks, treat reversible causes
What is the treatment for asystole/PEA
CPR (3min), adrenaline every 3-5min, correct reversible causes
Ddx of pleuritic chest pain?
Pericarditis, PE, pneumonia, pneumothorax, pleural pathology
60m, SOB, sudden onset, COPD, on Symbicort and tiotropium, high pulse, raised JVP, scattered wheeze and creps, peripheral oedema, low O2 stats, low Hb
Pneumothorax
SOB Ddx dependent on timing?
Seconds: pneumothorax, PE, foreign body
Mins/Hrs: airways (inflammation/obstruction), chest infection (pus), acute HF (fluid)
Days/weeks: chronic of the above, ILD, malignancy/large pleural effusion, neuromuscular, anaemia/thyrotoxicosis
Management of pneumothorax
Primary:
<2 cm: discharge, repeat CXR
>2 cm: aspiration, if unsuccessful, chest drain
Secondary:
<2 cm: aspiration
> 2cm: chest drain
How to determine axis deviation
Look at I and II: is either of them overall negative? If yes, axis deviation
Look at aVL, is it overall positive?
Yes: left axis deviation
No: right axis deviation
Ddx of progressive SOB, dry cough and clubbing with normal FEV1/FVC ratio
Idiopathic fibrosing alveolitis
Connective tissue disease, RA
Drugs
Asbestosis (ship builder)
How to interpret CXR?
PA/AP CXR of name, DOB, taken on (date/time), RIPE (rotation, inspiration, penetration, exposure)
Look at each zone
Follow the periphery - pneumothorax, pleural thickness, costophrenic angles, diaphragm, heart, mediastinum
Types of shadowing seen on CXR?
Interstitial/alveolar shadowing
Reticulo-nodular shadowing
Homogenous shadowing
Masses/cavitations
What should be looked for in the hands in an abdomen exam?
Asterixis (liver flap) Bruising Clubbing Dupuytren's contracture Erythema Leuconychia
What can be seen on the chest in an abdo exam?
Gynaecosmastia, hair loss, excoriation marks, spider naevi
What can be seen on the abdomen in an abdo exam?
Abdo distention, caput medusae, scars
What does a right subcostal (Kocher’s) incision indicate?
Biliary surgery
What does a Mercedes-Benz incision indicate?
Liver transplant
What does a midline laparotomy incision indicate?
GI or any major abdo surgery
What does a McBurney’s (Gridiron) incision indicate?
Appendicectomy
What does a J-shaped (hockey stick) incision indicate?
Renal transplant
What does a low transverse (Pfannenstiel) incision indicate?
Gynaecological procedures?
What does an inguinal incision indicate?
hernia repair, vascular access
What does a loin incision indicate?
Nephrectomy
What can cause hepatomegaly?
Cancer (primary or secondary deposits)
Cirrhosis (early, usually alcoholic)
Cardiac: Congestive cardiac failure, constrictive pericarditis
Infiltration: fatty infiltration, haemochromatosis, amyloidosis, sarcoidosis, lymphoproliferative diseases
What are the causes of splenomegaly?
Portal hypertension, Haematological, Infection, inflammation
75M, epigastric and back pain, high pulse, low BP
Ruptured aortic aneurysms
What are the Ddx for epigastric pain?
Acute pancreatitis, good, Barrett’s oesophagus, peptic ulcer, gastritis (retrosternal, ETOH), malignancy
Above: MI
Below: ruptured AAA
Right: cholecystitis, hepatitis
How do you tell the difference between acute and chronic pancreatitis?
Acute: pain, high amylase
Chronic: pain, wt loss, loss of exocrine and endocrine function, normal amylase, faecal elastase
Ddx of RUQ pain
Acute cholangitis, cholecystitis, biliary colic, hepatitis (alcoholic, AI, NASH, hep B/C), cirrhosis, liver abscess Above: basal pnuemonia Below: appendicitis Left: peptic ulcer, pancreatitis Right: pyelonephritis
Ddx of RIF pain
Crohn’s, appendicitis, UC, Coeliac, ovarian, colon cancer, mesenteric adenitis
Ddx of suprapubic pain
cystitis, urinary retention
Ddx of LIF pain
Diverticulitis, malignancy, ovarian cyst/twist/rupture, IBD
DDx of diffuse pain
Peritonitis, SBP, obstruction, IBD, mesenteric ischaemia
Medical: DKA, Addisons, hypercalaemia, porphyria, lead poisoning
Causes of transudate ascites?
Cirrhosis, cardiac failure, nephrotic syndrome
Causes of exudate ascites?
Malignancy (abdo, pelvic, peritoneal mesothelioma), infection (TB, pyogenic), Budd-Chiari syndrome (hepatic vein thrombosis), portal vein thrombosis
Causes of pre-hepatic jaundice?
Haemolysis, Gilbert’s syndrome
Causes of hepatic jaundice?
Alcohol, AI, Drugs, Viruses
Conjugated bilirubin enters duodenum and leaks out of hepatocytes - causes dark urine
Causes of post-hepatic jaundice?
Gallstones in CBD, strictures, pancreatic cancer
Conjugated bilirubin cannot enter duodenum, causes dark urine and pale stool
Causes of bloody diarrhoea?
Infective colitis (Campylobacter, Haemorrhagic E coli, Entamoeba histolytica, Salmonella, Shigella), Inflammatory colitis (young, extra-GI manifestations), Ischaemic colitis (elderly), diverticulitis, malignancy
How do you manage in acute GI bleed?
ABC, IV access, fluids, G&S, X-match blood, OGD
Variceal bleed - Abx, Terlipressin
How do you investigate and manage an acute abdomen?
Investigations: FBC, U&Es, LFTs, CRP, clotting, G&S, X-match
Erect CXR, CT
Management: NBM, fluids, analgesia, anti-emetics, Abx, monitor vitals and urine output
Management for ascites
Ascitic drain, albumin solution, dietary sodium and fluid restriction, diuretics, monitor weight daily
Appropriate drug for encephalopathy
Lactulose, phosphate enemias, avoid sedation, treat infections, exclude GI bleed
What does a SAAG score of more than 11 g/L indicate?
Cirrhosis, cardiac failure
What does a SAAG score of less than 11 g/L indicate?
TB, Cancer, nephrotic syndrome
What is the presentation and treatment of a perianal abscess?
Tender, red swelling, incision and drainage
What is the presentation and treatment of an anal fissure?
Rectal pain, stool coated with blood, advice re diet, GTN cream
What are UMN signs?
Hypertonia, decreased power, hyperreflexia, positive plantar reflex
What are LMN signs?
Hypotonia (flaccid), decreased power, hyporeflexia
What are the cerebellar signs?
DANISH
Dysdiadochokinesia, ataxia, nystagmus, intention tremor, slurred speech, hypotonia
What are the toxic/metabolic causes of peripheral neuropathy?
Drugs, alcohol, B12 deficiency, diabetes, hypothyroidism, uraemia, amyloidosis
What are other causes of peripheral neuropathy?
Infection - HIV
Inflammation - Vasculitis, connective tissue disease, inflammatory demyelinating neuropathy
Tumour - paraneoplastic, paraproteinaemia
Hereditary - hereditary sensory motor neuropathy
What is seen in optic neuritis?
Blurred optic disc margins, blurred vision, pain on eye movement
What is meralgia paraesthetica and what is the treatment for it?
Compression of the lateral femoral cutaneous nerve
Reassure, avoid tight garments, lose weight
If persistent - carbamazepine, gabapentin
What is radiculopathy?
Disease of the nerve roots e.g. lumbosacral - pain in the buttock, radiating down the leg below the knee Compression by: - Disc herniation - Spinal canal stenosis
What is the triad for Parkinsons?
Tremor, rigidity, bradykinesia
What are the signs of progressive supranuclear palsy?
Parkinsonian features, upgaze abnormality
What are the signs of Lewys body dementia?
Features of Alzheimers, Parkinsons and hallucinations
What are the other causes of confusion apart from Parkinsons?
Post-ictal
Dysphasia - receptive or expressive, other features of stroke/TIA
Dementia - vascular, alcoholic
What are the other causes of confusion apart from Parkinsons?
Post-ictal
Dysphasia - receptive or expressive, other features of stroke/TIA
Dementia - vascular, alcoholic, Alzheimers, Inherited (Huntington’s)
Depressive pseudo dementia - elderly, withdrawn, poor eye contract, precipitating factor
What are the Ddx for confusion and LOC?
Hypoglycaemia
Vascular:
Bleed: headache, collapse
Subdural haematoma (fall, fluctuating consciousness)
Infection - temp, intracranial, extracranial
Inflammation
Malignancy
Metabolic/Toxic: drugs, U&Es, LFTs, vitamin deficiencies, endocrinopathies
What are the differentials for headache in the ED?
Meningitis - fever, neck stiffness, Kernig’s sign
SAH - sudden onset, CT, LP
Giant cell arteritis - polymyalgia rheumatica (shoulder girdle pain, stiffness, constitutional upset), ESR, Steroids, over 50, Biopsy
Migraine - throbbing, vomiting, photophobia, FHx, aura
What is the management for stroke?
Less than 4.5 hours: CT: no haemorrhage Thrombolysis if not contraindications More than 4.5 hours: CT head (exclude haemorrhage) Aspirin 300mg, swallow assessment Maintain hydration, oxygen
What is the management for a TIA?
Aspirin Don't treat BP acutely unless over 220/120 or other indication ECG, Echo Carotid Doppler RF modification
List 3 atypical organisms in CAP
Mycoplasma pneumoniae
Chlamydia pneumonia
Legionella pneumophilia
What are the Ddx for bloody diarrhoea?
infective colitis, UC/Crohn’s, ischaemic colitis (older pts), malignancy, diverticulitis
What are the complications of portal hypertension?
Encephalopathy
Ascites
SBP
Variceal bleed
What do investigations show in DIC?
Reduced platelets and fibrinogen
Increased PT/APTT
Increased D-dimer/fibrin degradation products
What do investigations show in Haemolytic Uraemia Syndrome?
Haemolysis (low Hb, high bilirubin)
Uraemia
Low platelets
What do investigations show in TTP?
HUS + fever + neurological manifestations
What are the types of hereditary haemolytic anaemia?
Red cell membrane (hereditary spherocytosis)
Enzyme deficiency (G6PDD)
Haemoglobinopathy (SCD, Thalassaemia)
What are the types of acquired haemolytic anaemia?
AI, drugs, infection, microangiopathic haemolytic anaemia (DIC, HUS, TTP)
What are the causes of hypovolaemic hyponatraemia?
Diarrhoea
Vomiting
Diuretics
Test: low urine sodium
What are the causes of euvolaemic hyponatraemia?
Hypothyroidism
Adrenal insufficiency
SIADH
Test: TFTs, short synACTHen test, plasma and urine osmolality
What are the causes of hypervolaemic hyponatraemia?
Cardiac failure
Cirrhosis
Nephrotic syndrome
Check: fluid overloaded, low urine sodium
What are the causes of SIADH?
CNS pathology
Lung pathology
Drugs (SSRI, TCA, PPIs, carbamazepine)
Tumours
What are the causes of onycholysis
Trauma
Thyrotoxicosis
Fungal infection
Psoriasis
What are the complications of diabetes?
Microvascular:
- Retinopathy
- Neuropathy (foot ulcers)
- Nephropathy
Macrovascular:
- MI/stroke/PVD
Metabolic:
- DKA/HHS/Hypoglycaemia
Where is ALP made and what is it raised in?
Sources: liver and bone
High in obstructive liver disease and bone disease (malignancy, fracture, Paget’s disease)
normal in myeloma
What are the 4 signs of multiple myeloma?
Calcium (polyuria, polydipsia, constipation) Renal impairment (urea, creatinine) Anaemia (SOB, lethargy, FBC) Bone (Fracture, bone pain, DXA) Infection, cord compression
What are the causes of a caveatting lung lesion?
Infection (TB, Staph, Klebsiella, e.g. alcoholics)
Inflammation (RA)
Infarction (PE)
Malignancy
What are the signs of nephrotic syndrome?
Increased permeability of glomerular basement membrane to protein, proteinuria, hypoalbuminaemia, oedema
What is hereditary haemorrhagic telangiectasia and how does it present?
Autosomal dominant
Recurrent GI and nose bleeds
Abnormal blood vessels in skin, mucous membranes, lungs, liver, brain
What are the causes of microcytic anaemia?
Iron deficiency (diet or blood loss, low ferritin) Beta thalassaemia heterozygosity
What are the causes of normocytic anaemia?
ACD (RA, normal/high ferritin)
What are the causes of macrocytic anaemia?
Alcoholics May Have Liver Failure
Alcohol (Hx, GGT)
Myelodysplasia (pancytopenia, bone marrow)
Hypothyroidism (Hx, low T4, high TSH)
Liver disease (Hx/Exam)
Folate/B12 deficiency (Hx of small bowel disease, gastrectomy)
What is the presentation for polycythaemia?
Headache Pruritus after hot bath Blurred vision (hyperviscosity) Tinnitus Thrombosis (stroke, DVT) Gangrene Choreiform movements
What does a sickle cell anaemia crisis present as?
Acute painful crises
Stroke
Sequestration crises (RBC pooling) - Lung (SOB, cough, fever), Spleen (exacerbation of anaemia)
Gallstones, chronic cholecystitis
What is the management of a sickle cell anaemia crisis?
Analgesia, O2, IV fluids, antibiotics for acute painful crises
Stroke - exchange blood transfusion
Spleen - splenectomy for repeat episodes of splenic sequestration
Gallstones and chronic cholecystitis - cholecystectomy
What does anaemia with a high reticulocyte count indicate?
Haemolytic crises
Ddx: haemorrhage
What does anaemia with a low reticulocyte count indicate?
Parvovirus B19 infection
Aplastic crisis in pts with SCA
Blood transfusion
How is a diagnosis of diabetes made?
Fasting > 7
Random > 11
IGTT - 75g OGTT, 2-hour glc: 7.8-11
What is seen in a history and exam for thyroid cancer?
Lump
RFs: radiation, FHx, rapid enlargement, lymphadenopathy
Mets (lung, follicular thyroid cancer)
What is the investigation and management for thyroid cancer?
USS, FNAC (uptake scan: cold nodules), MDT
Surgery: papillary, follicular, medullary, anaplastic
Thyroxine, radioiodine
What are the discriminatory signs for Cushing’s syndrome?
Bruising, thin skin
Myopathy
Purple striae
DM, HTN, osteoporosis at a young age
What are the causes of amenorrhoea/oligomenorrhoea and how do you investigate them?
Pregnancy (urine beta-hCG)
Hypothalamus (excessive exercise, low BMI)
Pituitary (excess prolactin, low LH/FSH)
Thyroid (hyper/hypo) - TFTs
Ovaries (PCOS, ovarian failure) - excess androgens, high FSH
What is the presentation for hypokalaemia?
Weakness
Arrhythmia
Polyuria
What is the Ddx for hypokalaemia?
GI: vomiting
Diuretics
Primary hyperaldosteronism (bilateral adrenal hyperplasia or Conn’s - aldosterone: renin ratio)
