CCT Flashcards
What are the 4P’s of personalised medicine?
- Prediction and prevention of disease
- Precise diagnosis
- Targetted and personalised preventions
- Participation of patients
How much adrenaline should be given in anaphylaxis?
500mcg IM 1:1000 units
- pain/pins and needles in thumb, index, middle finger
- unusually the symptoms may ‘ascend’ proximally
- patient shakes his hand to obtain relief, classically at night
= typical hx of what?
Carpal tunnel
Carpal Tunnel causes wasting of what?
THENAR emminence
Examination signs of carpal tunnel syndrome?
Thenar wasting
Weakness of thumb abduction
+ Phalens and Tinnels
Carpal tunnel causes:
- idiopathic
- pregnancy
- oedema e.g. heart failure
- lunate fracture
- rheumatoid arthritis
- Acromegaly - bilateral cause
Management of carpal tunnel?
Conservative 1st for moderate
Wrist splints for transient e.g pregnancy
Corticosteroid injections
Surgery - division of flexor retinaculum
What are the causes of hypovolaemic hyponatraemia?
The causes of hypovolaemic hyponatraemia include burns, sweating, diarrhoea, vomiting, fistulae, and Addison’s disease.
What are the causes of euvolaemic hyponatraemia?
The causes of euvolaemic hyponatraemia include the syndrome of inappropriate ADH release (SIADH) and hypothyroidism.
What are the causes of hypervolaemic hyponatraemia?
The causes of hypervolaemic hyponatraemia include renal failure, heart failure, liver failure, and nephrotic syndrome.
What tests are required to confirm/exclude SIADH?
The tests required to confirm/exclude SIADH include urea and electrolytes (while not on diuretics), urine and plasma paired osmolalities (while not on diuretics), urine sodium (while not on diuretics), urine dip, TSH, and cortisol.
What is the management for hypovolaemic hyponatraemia?
The management for hypovolaemic hyponatraemia includes IV normal saline and treating the underlying cause.
What is the management for euvolaemic hyponatraemia due to SIADH?
The management for euvolaemic hyponatraemia due to SIADH includes fluid restriction, ADH receptor antagonists, oral sodium and furosemide.
What is the management for euvolaemic hyponatraemia due to hypothyroidism?
The management for euvolaemic hyponatraemia due to hypothyroidism is levothyroxine.
What is the management for hypervolaemic hyponatraemia?
The management for hypervolaemic hyponatraemia includes fluid restriction and treating the underlying cause.
What is the risk when correcting sodium faster than 12mmol/L/day?
Correcting sodium faster than 12mmol/L/day leads to a significant risk of central pontine myelinosis because of fluid shifts.
SIADH is what type of hyponatraemia?
Euvolaemic
Management of SIADH?
Management revolves around offloading this excess water:
- Fluid restriction (up to 750ml/day) and treat underlying cause
- ADH antagonists (e.g. tolvaptan, deomeclocycline)
- Oral sodium and furosemide
ADH aka
vasopressin
What does ADH do?
ADH stimulates water reabsorption from thecollecting ductsin the kidneys.
Common cause of SIADH?
Posterior pituitarysecreting too much ADH or the ADH may be coming from somewhere else, for example, asmall cell lung cancer.
Urine findings in SIADH
The urine becomes more concentrated as less water is excreted by the kidneys therefore patients with SIADH have a “highurine osmolality” and “highurine sodium”.
Symptoms of hyponatraemia
- Headache
- Fatigue
- Muscle aches and cramps
- Confusion
- Severe hyponatraemiacan cause seizures and reduced consciousness
Read short list of SIADH causes:
- Post-operative from major surgery
- Infection, particularly atypical pneumonia and lung abscesses
- Head injury
- Medications (thiazide diuretics, carbamazepine, vincristine, cyclophosphamide, antipsychotics, SSRIs, NSAIDSs,)
- Malignancy, particularly small cell lung cancer
- Meningitis
How are SIADH investigations approached?
In a way, SIADH is a diagnosis of exclusion as we do not have a reliable test to directly measure ADH activity. Clinical examination will showeuvolaemia. U+Es will show a hyponatraemia. Urine sodium and osmolality will be high.
Other causes of hyponatraemia need to be excluded:
- Negativeshort synacthen testto excludeadrenal insufficiency
- No history of diuretic use
- No diarrhoea, vomiting, burns, fistula or excessive sweating
- No excessive water intake
- Nochronic kidney diseaseoracute kidney injury
What type of cancer is associated with SIADH?
- Small cell lung cancer
Also:
- Pancreatic cancer
- Prostate cancer
- Thymoma
- Lymphoma
What is CPM?
Central pontine myelinolysis(CPM) is also (and more accurately) known as “osmotic demyelination syndrome”. It is usually a complication of long termsevere hyponatraemia(< 120 mmols/l) being treated too quickly (> 10 mmol/l increase over 24 hours).
Read summary of symptoms and management of CPM
First phase: this is due to the electrolyte imbalance and the patient presents as encephalopathic and confused. They may have a headache or nausea and vomiting. These symptoms often resolve prior to the onset of the second phase.
Second phase: this is due to the demyelination of the neurones, particularly in the pons. This occurs a few days after the rapid correction of sodium. This may present asspastic quadriparesis,pseudobulbar palsy andcognitive and behavioural changes. There is a significant risk of death.
Preventionis essential as treatment is onlysupportiveonceCPMoccurs. A proportion of patients make a clinical improvement but most are left with some neurological deficit.
What are the two types of diabetes insipidus?
- A lack ofantidiuretic hormone(cranial diabetes insipidus)
- A lack ofresponsetoantidiuretic hormone(nephrogenic diabetes insipidus).
Function of ADH and where it acts!
ADH stimulates water reabsorption from thecollecting ductsin the kidneys.
What is primary polydipsia?
Primary polydipsiais when the patient has a normally functioning ADH system but drinks excessive amounts of water, leading to excessive urine production (polyuria). This is notdiabetes insipidus.
Explain the presentation of diabetes insipidus:
With diabetes insipidus, the kidneys are unable to reabsorb water and concentrate the urine, leading to:
- Polyuria(excessive amounts of urine)
- Polydipsia(excessive thirst)
Read common causes of nephrogenic diabetes insipidus:
Nephrogenic diabetes insipidusis when the collecting ducts of the kidneysdo not respondtoADH. It can beidiopathic, without a clear cause, or it can be caused by:
- Medications, particularlylithium(used inbipolar affective disorder)
- Genetic mutationsin theADH receptor gene(X-linked recessive inheritance)
- Hypercalcaemia(high calcium)
- Hypokalaemia(low potassium)
- Kidney diseases(e.g., polycystic kidney disease)
Explain the production of ADH:
Made in the hypothalamus. Then secreted by the posterior pituitary.
CF treatment for allergic bronchopulmonary aspergillosis
Oral glucocorticoids are the treatment of choice for allergic bronchopulmonary aspergillosis
