BIG THREE Flashcards
Non-urgent endoscopy referral criteria
-Patients with haematemesis
-Patients aged >= 55 years who’ve got:
treatment-resistant dyspepsia or
-upper abdominal pain with low haemoglobin levels or
raised platelet count with any of the following: nausea, vomiting, weight loss, reflux, dyspepsia, upper abdominal pain
nausea or vomiting with any of the following: weight loss, reflux, dyspepsia, upper abdominal pain
Urgent endoscopy referral criteria
-All patients who’ve got dysphagia
-All patients who’ve got an upper abdominal mass consistent with stomach cancer
-Patients aged >= 55 years who’ve got weight loss, AND any of the following:
upper abdominal pain
reflux
dyspepsia
Managing patients who do not meet referral criteria (‘undiagnosed dyspepsia’)
This can be summarised at a step-wise approach
1. Review medications for possible causes of dyspepsia
2. Lifestyle advice
3. Trial of full-dose proton pump inhibitor for one month OR a ‘test and treat’ approach for H. pylori
if symptoms persist after either of the above approaches then the alternative approach should be tried
Testing for H. pylori infection
initial diagnosis: NICE recommend using a carbon-13 urea breath test or a stool antigen test, or laboratory-based serology ‘where its performance has been locally validated’
test of cure:
there is no need to check for H. pylori eradication if symptoms have resolved following test and treat
however, if repeat testing is required then a carbon-13 urea breath test should be used
Atrial fibrillation: rate control
Rate control should be offered as the first‑line treatment strategy for atrial fibrillation except in people:
whose atrial fibrillation has a reversible cause
who have heart failure thought to be primarily caused by atrial fibrillation
with new‑onset atrial fibrillation (< 48 hours)
with atrial flutter whose condition is considered suitable for an ablation strategy to restore sinus rhythm
for whom a rhythm‑control strategy would be more suitable based on clinical judgement
Medications
Agents used to control rate in patients with atrial fibrillation
beta-blockers
a common contraindication for beta-blockers is asthma
calcium channel blockers
digoxin
Digoxin is not considered first-line anymore as they are less effective at controlling the heart rate during exercise
should only be considered if the person does no or very little physical exercise or other rate‑limiting drug options are ruled out because of comorbidities
may have a role if there is coexistent heart failure
Atrial fibrillation: rhythm control
Agents used to maintain sinus rhythm in patients with a history of atrial fibrillation
- beta-blockers
- dronedarone: second-line in patients following cardioversion
- amiodarone: particularly if coexisting heart failure
Atrial fibrillation: catheter ablation
NICE recommends the use of catheter ablation for those with AF who have not responded to or wish to avoid, antiarrhythmic medication.
Technical aspects
the aim is to ablate the faulty electrical pathways that are resulting in atrial fibrillation. This is typically due to aberrant electrical activity between the pulmonary veins and left atrium
the procedure is performed percutaneously, typically via the groin
both radiofrequency (uses heat generated from medium frequency alternating current) and cryotherapy can be used to ablate the tissue
Anticoagulation
should be used 4 weeks before and during the procedure
it should be remember that catheter ablation controls the rhythm but does not reduce the stroke risk, even if patients remain in sinus rhythm. Therefore, patients still require anticoagulation as per their CHA2DS2-VASc score
if score = 0: 2 months anticoagulation recommended
if score > 1: longterm anticoagulation recommended
Outcome -notable complications include cardiac tamponade stroke pulmonary vein stenosis -success rate around 50% of patients experience an early recurrence (within 3 months) of AF that often resolves spontaneously longer term, after 3 years, around 55% of patients who've had a single procedure remain in sinus rhythm. Of patients who've undergone multiple procedures around 80% are in sinus rhythm
Patient on Mesalazine (Ulcerative colitis) feeling unwell. Most important 1st test and why
FBC - as mesalazine (an aminosalicylate) causes many haematological adverse effects, including agranulocytosis
1st line treatment of C difficile
Oral vancomycin
1st line treatment of life-threatening C.difficile
Oral vancomycin + IV metronidazole
Treatment of recurrent C. difficile
Prescribe oral fidaxomicin - recommended if the patient presents with a recurrent episode of C.difficile within 12 weeks of symptoms resolution. Recurrence of C.difficile infection within 12 weeks may indicate that the organism is resistant and thus requires fidaxomicin.
Should this fail provide oral vancomycin + IV metronidazole
Pulses: pulsus paradoxus
greater than the normal (10 mmHg) fall in systolic blood pressure during inspiration → faint or absent pulse in inspiration
severe asthma, cardiac tamponade
Pulses: slow rising/plateau
aortic stenosis
Pulses: collapsing
aortic regurgitation
patent ductus arteriosus
hyperkinetic states (anaemia, thyrotoxic, fever, exercise/pregnancy)
Pulses: Pulsus arternans
regular alternation of the force of the arterial pulse
severe LVF
Pulses: bisferiens pulse
‘double pulse’ - two systolic peaks
mixed aortic valve disease, HOCM
Aortic dissection - investigation of choice
CT angiography: pelvis/chest/abdomen (depending on stability of patient) Transoesophageal echocardiography (TOE) more suitable for unstable patients who are too risky to take to CT scanner
Budd-chiari syndrome classic triad
The features are classically a triad of:
abdominal pain: sudden onset, severe
ascites → abdominal distension
tender hepatomegaly
Budd-Chiari syndrome is a condition characterized by obstruction to hepatic venous outflow. It usually occurs in a patient with a hypercoagulative state (e.g. antiphospholipid syndrome) but can also occur as a result of physical obstruction (e.g. tumour). The venous congestion can cause hepatomegaly and portal hypertension which can can also result in splenomegaly and ascites.
Severe exacerbation of asthma
The features of acute severe asthma are: PEFR 33-50% best or predicted, inability to complete full sentences, RR >25/min and pulse >110 bpm
Moderate exacerbation of asthma
PEFR 50-75% best or predicted
Speech normal
RR < 25 / min
Pulse < 110 bpm
Life-threatening asthma
PEFR < 33% best or predicted Oxygen sats < 92% 'Normal' pC02 (4.6-6.0 kPa) Silent chest, cyanosis or feeble respiratory effort Bradycardia, dysrhythmia or hypotension Exhaustion, confusion or coma
Indicator of HOCM
Ventricle thickening
Tall R waves in V4-6
Deep q waves common
HOCM management (ABCDE)
A- Amioderone B- Beta-blockers or verapamil for symptoms C- Cardiac defibrillation D- Dual chamber pacemaker E- Endocarditis prophylaxis
HOCM - Drugs to avoid
Nitrates
Ace-inhibitors
Inotropes
Why transferrin saturation, total ferritin is high but total iron-binding capacity is low in Haemochromatosis
Haemochromatosis is an iron storage disorder therefore binding capacity in the blood is unaffected
HOCM ECG findings
T wave inversion
LVH - tall r waves
Deep ST depression
VIT C deficiency signs/symptoms
involved in connective tissue (collagen) synthesis thus associated with poor wound healing
involved with iron absorption thus can have iron deficiency anaemia (pale, pale conjunctiva,bleeding gums,fatigued)
Klebsiella pneumonia A’s
Alcoholism, Aspiration pneumonia (affects upper lungs) and Abscesses (empyema)
Also presents with red jelly-like sputum
also more common with diabetics
Asbestos & Asbestosis
- Commonly affects lower lobes (typically)
- Length of exposure can relate to the severity
- Crocidolite (blue) asbestos is the most dangerous form.
- Causes pleural thickening
- Causes pleural plaques (benign and do not undergo malignant change).
- Can cause mesothelioma.
