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fy1 > Clinical Presentations I > Flashcards

Clinical Presentations I Flashcards

1
Q

When to call arrest team in a peri-arrest

A

If concerned about A B or C

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2
Q

When to call the anaesthetist on D

A

When GCS <=8

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3
Q

What to do for ABCDE for basic life support

A

Airway - speak to patient, check in mouth, suction if required, triple airway manouvure
Breathing - listen, look and feel, listen to chest and look for equal expansion, resp rate, non-rebreathe 15 litres, saturations
Circulation - HR, ECG, two wide bore cannulas with IV access and bloods taken off the back, listen to chest
Disability - glucose, eyes, quick neuro exam and GCS
Exposure - remove all clothing, check temp, look for rash

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4
Q

Who usually makes up an arrest team

A

Leader - registrar, F1 - access/defib and BLS, anaesthetist (airway), nurses - BLS and drugs, timepoints and ECG

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5
Q

What blood test should always try to be achieved in an arrest

A

VBG

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6
Q

What are the three common ALS drugs

A

Adrenaline (1mg/10ml -1/10,000), atropine, amiodarone 300mg in 10ml

ALWAYS give with large flush (20ml) to encourage it to go centrally. 99% of things will be found on the trolley

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7
Q

What to do if a shockable rhythm is present

A

VT/VF –> deliver a shock –> CPR cont. 2 mins –> adrenaline every 3-5 mins –> shock then CPR –> shock then CPR –> amiodarone after 3 shocks.

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8
Q

What should be done by the leader during an arrest

A

Building picture of patients PMH and ruling out the four Ts and four Hs.

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9
Q

What are the 8 reversible causes (4T’s and 4H’s)

A

Thrombosis, tamponade, toxins, tension pneumothorax

Hypoglycaemia, hypoxia, hyper/hypo-kalaemia, Hypovolaemia

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10
Q

Things to do if spare in an arrest

A

Scribe, steady hand for IV access, find patient history

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11
Q

What are the stages of maintaining the airway in ALS

A

Triple airway manoeuvre
Nasopharyngeal airway (6-7mm) - horizontal with lubrication and safety pin. Don’t use if significant head injury
Oropharyngeal airway - angle of mouth to mandible. Insert upside down and rotate.
Suction - clear if required.
Intubation - anaesthetics.

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12
Q

What are the stages of maintaining breathing in ALS

A

Usually go for 15litre non-rebreathe with pulse oximeter and resp rates

Simple to advanced -

Nasal cannula (1-4L/min)
Simple face mask (Hudson mask) (5-10 L/min)
Venturi mask (can give exact % - used in COPD with type 2 resp failure)
15 litre non-rebreathe/reservoir

May require salbutamol nebuliser

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13
Q

What are the stages of maintaining circulation in ALS

A

Defibrillator (monitor mode), IV access large bore both sides with bloods, BP, HR

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14
Q

What are the stages of maintaining disability in ALS

A

Finger prick glucose
Eyes - RAPD or PEARL
GCS
Neuro exam if possible

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15
Q

What are the stages of maintaining exposure in ALS

A

Temp
Top to toe inspection and secondary survey for internal bleeding and rashes

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16
Q

What are the parts of the secondary survey

A

Exposure for injuries - has my critical care assessed patient priorities or next management decision (acronym)
AMPLE - allergies, medications, PMH, last meal, events leading up to presentation

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17
Q

What is the has my critical care assessed patient priorities or next management decision acronym for secondary survey

A

Has - head/skull
My - maxillofacial
Critical - cervical spine
Care - chest
Assessed - abdomen
Patient’s - pelvis
Priorities - perineum
Or - orifices (PR/PV)
Next - neurological
Management - msk
Decision - diagnostic tests and definitive care

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18
Q

Name 5 places to check for catastrophic bleeding

A

On the floor and four more -

Floor, long bones, cranium, chest, abdomen

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19
Q

Pulses to check in infant CPR

A

Brachial

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20
Q

Chest compression ration in any child or infant

A

15:2

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21
Q

Stages of a neonatal arrest

A

Dry baby –> assess tone, RR and HR, –> gasping or not breathing then 5 rescue breaths –> 5 rescue breaths –> HR<60 or undetectable CPR

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22
Q

What are the two major differences in an obstetric arrest

A

Left lateral position 15 degrees
Emergency surgery within 5 minutes if no success as improves chest compression and venous return for the mother. Mother takes priority over baby.

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23
Q

How would you approach a patient with acute chest pain and think about scans or test to do

A

Hx - SOCRATES, any associating symptoms, pain on eating, postural pain, pain on moving, pain on breathing, cold symptoms, PMH, drugs and allergies
A - patency
B - RR, sats, listen to chest, percuss and feel trachea, O2 if needed
C - ECG, BP, listen to hear, IV access with bloods (FBC, U+E, D-dimer, troponin, LFT, CRP), HR, CRP, fluids if needed
D - glucose, Eyes, GCS, quick neuro exam
E - expose patient and examine, check abdo and legs, temp

Scans - CXR, ECG, bloods, ECHO (wall motion abnormalities)
Call for senior help
Reassess from ABCDE
Medication to give - morphine, cyclizine, treatment for diagnosis

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24
Q

Possible diagnoses for acute chest pain

A

ACS, pneumothorax, pneumonia, pericarditis, PE, pulmonary oedema, anxiety, costochondritis, peptic ulcer disease, reflux, myocarditis, cardiac tamponade, sickle cell crisis

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25
Q

How to tell the difference between the 3 ACS’s

A

STEMI - raised ST on ecg and raised troponin
NSTEMI - T wave inversion, q waves, raised troponin
Unstable angina - ST depression, T wave inversion and no elevated troponin

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26
Q

Features that point towards pericarditis/myocarditis on examination

A

Pericardial rub, fever, recent flu/cold

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27
Q

What to check on examination if suspected aortic dissection

A

Tearing between scapulas so check if dirrences in both radial pulses.
CXR - widened mediastinum

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28
Q

What is heard in pneumonia on the chest

A

Basal crepitations
fine - alveoli
coarse - wider airways

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29
Q

When is troponin sensitive for MI

A

3-12 hours after myocardial necrosis

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30
Q

Other causes of raised troponin

A

sepsis
hypovolemia
atrial fibrillation
congestive heart failure
pulmonary embolism
myocarditis
myocardial contusion
renal failure

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31
Q

What is the acute treatment for a STEMI

A

Remember and see if it rests as you investigate and before giving treatment - could be stable angina

MOANAA - Morphine, oxygen, aspirin, nitrites (GTN), atenolol (beta-blocker)
Anti-emetic

PCI <2hrs or thrombolysis
Continuous ECG monitoring thereafter with DVT prophylaxis

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32
Q

What is the secondary prevention for a STEMI

A

5 As - Aspirin, anti-platelet (clopidogrel), atenolol (BB), atorvastatin, ACEi

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33
Q

What is the acute treatment for a NSTEMI

A

BATMAN -
Beta blockers, aspirin, ticagrelor, morphine, anticoagulant (LMWH - fondaparinux), nitrates - GTN
Anti-emetic
GRACE score for PCI

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34
Q

What is the difference between unstable angina and NSTEMI

A

NSTEMI - positive troponin and chest symptoms and ECG signs
UA - negative troponin but chest symptoms and possibly ECG signs

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35
Q

What is the acute treatment for unstable angina

A

BATMAN -
Beta blockers, aspirin, ticagrelor, morphine, anticoagulant (LMWH - fondaparinux), nitrates - GTN
Anti-emetic
GRACE score for PCI

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36
Q

What is the treatment for stable angina

A

Investigate as NSTEMI
GTN and morphine

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37
Q

What is the secondary prevention for stable angina

A

5A’s - atenolol, ACEi, aspirin, anticoagulants (clopidogrel), atorvastatin,

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38
Q

How is an aortic dissection investigated

A

Radial-radial delay and tearing chest and back pain with hypertension usually.
FBC, troponin, U+Es, CRP, ECG, CXR (widened mediastinum), TOE

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39
Q

How is an aortic dissection acutely managed

A

Senior help ASAP
If hypotensive - treat as shock, two large bore cannula with bloods and fluid bolus (speak to senior first)
If hypertensive - ACEi or CCB (speak to senior first)

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40
Q

How is an aortic dissection managed long-term

A

Type A (ascending aorta) - surgery
Type B - (descending aorta) - conservative management

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41
Q

How to manage MSK chest pain

A

Usually sorer on palpation and movement with negative cardiac investigations
Reassure with simple analgesia

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42
Q

How to manage pericarditis

A

Pleuritic chest pain worse on lying flat and deep inspiration with recent viral illness and pericardial rub
Reassurance and NSAIDs/paracetamol, settles in 2-4 weeks

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43
Q

How to investigate a tachyarrhythmia emergency

A

Brief history - pain, associated symptoms, PMH, D+A,
Airway
Breathing - O2, sats, RR
Circulation - listen to heart, CRT, HR, BP, IV access, bloods (FBC, U+E, LFT, TFTs, troponin, CRP, VBG,), ECG
Disability - glucose, eyes, GCS, neuro exam
Exposure - Temp

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44
Q

How to treat tachyarrhytmia’s

A

If shock or syncope - 3 DC shocks –> Amiodarone 300mg IV –> shock –> amiodarone 300mg IV over 24 hrs

Narrow and regular (SVT) - vasovagal –> 6mg –> 12mg –>12mg
Narrow and irregular (AF) - Beta blocker (if HF then amiodarone/digoxin)

Broad and regular (VT) - ALWAYS CHECK FOR CAROTID PULSE (no pulse then CPR) if pulse - Amiodarone 300mg IV over 20-60mins then 900mg over 24 hrs
Broad and irregular - amiodarone

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45
Q

How is AF managed acutely

A

If shock or syncope - 3 DC shocks –> Amiodarone 300mg IV –> shock –> amiodarone 300mg IV over 24 hrs

If no shock/syncope - Beta blocker/CCB
Unless HF then flecainide/amiodarone or DC cardiovert

Investigate cause
Can do HASBLED and CHADVASC score if time

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46
Q

How is atrial flutter managed

A

IV access and bloods
Monitor rhythm
Vagal manouvures –> DC cardioversion

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47
Q

What drugs to avoid in WPW syndrome and how to treat

A

Verapamil and digoxin
Need electrophysiology studies before ablation of the accessory pathway.

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48
Q

What is the acute treatment for VT

A

If pulseless - call arrest team and start BLS

If pulse - IV access, bloods, amiodarone or DC cardioversion

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49
Q

Causes of prolonged QT

A

Amiodarone, fluoxetine, haloperidol, loratadine, fluconazole, erythromycin and clarithromycin.

Low magnesium, low potassium and low calcium

Sinus brady and complete heart block

SAH

Myocarditis

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50
Q

How to treat torsades de pointes

A

2g IV over 15 mins of magnesium sulphate

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51
Q

How is a bradyarrhythmia acutely managed

A

Brief history - pain, associated symptoms, PMH, D+A,
Airway
Breathing - O2, sats, RR
Circulation - listen to heart, CRT, HR, BP, IV access, bloods (FBC, U+E, LFT, TFTs, troponin, CRP, VBG,), ECG, ATROPINE
Disability - glucose, eyes, GCS, neuro exam
Exposure - Temp

If shock or syncope risk - atropine 500 micrograms IV - can repeat up to 6 times –> transvenous pacing
If no adverse features - observe

Work out cause

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52
Q

Causes of bradyarrhythmias

A

Inferior MI (RCA infarction)
Drugs - digoxin, BB, calcium antagonists, amiodarone, ivabradine
Cushings reflex
Thyroid disease
Anorexia
Hypothermia
Type 3 HB

Treat the same way acutely

53
Q

What is the long-term management of symptomatic bradycardia

A

Pacemaker

54
Q

How to treat a hypertensive emergency acutely

A

Brief history - pain, associated symptoms, PMH, D+A,
Airway
Breathing - O2, sats, RR
Circulation - listen to heart, CRT, HR, BP, IV access, blood (FBC, U+E, LFT, TFTs, troponin, CRP, VBG,), ECG, GET SENIOR HELP
Disability - glucose, eyes, GCS, neuro exam
Exposure - Temp

Usually give -
No LVF- labetalol IV
LVF - Furosemide and hydralazine

55
Q

Give 6 causes of a hypertensive emergency

A

Pre-eclampsia
Malignant hypertension
Hypertensensive encephalopathy
Phaemochromocytoma
Thyrotoxic storm
Cushing’s reflex

56
Q

End-organ damage signs of a hypertensive emergency (>200/120)

A

CNS - reduced GCS, vomiting and headache, confusion
Eyes - visual disturbance, papilloedema
Heart - chest pain, orthopnoea
Aorta - shearing back pain and collapse
Kidney - haematuria and lethargy

57
Q

How to deal with acute heart failure

A

Brief history - pain, associated symptoms, PMH, D+A,
Airway
Breathing - O2, sats, RR, CXR, sit up
Circulation - listen to heart, CRT, HR, BP, IV access, blood (FBC, U+E, LFT, TFTs, troponin, CRP, VBG,BNP), ECG, IV furosemide, stop fluids
Disability - glucose, eyes, GCS, neuro exam
Exposure - Temp

Treat like pulmonary oedema in acute compensation - Sit up, O2, furosemide

58
Q

How is chronic heart failure managed

A

Beta blockers and ACEI –> Increase doses –> spironolactone and ARB –> ivabradine or cardiac resync therapy

59
Q

What is the chronic management for hypertension

A

<55/diabetic – ARBs/ACEI  thiazide like diuretic/CCB  + thiazide-like diuretic/CCB

> 55/ afrocaribbean – CCB  ARB/ACEi or thiazide like diuretic  ARB/ACEi or thiazide like diuretic

Next is based of K levels –
<=4.5  spironolactone
>=4.5  BB or alpha blocker

60
Q

How to manage a breathlessness and low SATS emergency

A

Brief history - pain, associated symptoms (colds, sputum, heart pain, syncope, fever, recent travel, wheeze), PMH, D+A,
Airway
Breathing - O2, sats, RR, CXR, sit up, salbutamol nebuliser
Circulation - listen to heart, CRT, HR, BP, IV access, blood (FBC, U+E, LFT, TFTs, troponin, CRP, VBG, D-dimer), ABG, ECG
Disability - glucose, eyes, GCS, neuro exam
Exposure - Temp, check legs!

Treat appropriately, usually can give salbutamol nebs to help

61
Q

Life-threatening causes of SOB

A

PE
AECOPD
Asthma
Pneumonia
Pneumothorax
Pulmonary oedema
MI
Anaphylaxis

62
Q

Signs of upper airway obstruction and management

A

Stridor and call anaesthetist

63
Q

Signs of a lower airway obstruction and management

A

Wheeze - salbutamol nebs, hydrocortisone, impatropium nebs

64
Q

Signs of a tension pneumothorax and management

A

Tracheal deviation and shock
2nd intercostal space wide bore cannula

65
Q

Signs of pneumonia and management

A

Asymmetrical coarse crackles, bronchial breathing and reduced air entry
Oxygen, fluids and abx

66
Q

Signs of LVF and management

A

Reduced air entry, raised JVP, symmetrical fine crackles

67
Q

Sputum colour for pulmonary oedema

A

Pink and frothy

68
Q

Features of ARDS

A

Hypoxia, fever, amjor insult (sepsis, surgery, pancreatitis)
New bilateral infiltrates on CXR

69
Q

How is acute asthma managed

A

Brief history - pain, associated symptoms (colds, sputum, heart pain, syncope, fever, recent travel, wheeze), PMH, D+A,
Airway
Breathing - O2, sats, RR, CXR, sit up, hyperinflated chest with wheeze, salbutamol nebuliser (every 10-15mins and reassess), ipatropium nebuliser, prednisalone/hydrocortisone, (senior - theophylline, magnesium sulphate, escalate)
Circulation - listen to heart, CRT, HR, BP, IV access, blood (FBC, U+E, LFT, TFTs, troponin, CRP, VBG, D-dimer), ABG, ECG
Disability - glucose, eyes, GCS, neuro exam
Exposure - Temp, check legs!

O SHIT ME - oxygen, salbutamol, hydrocortisone, ipatropium, theophylline, magnesium sulphate, escalate

70
Q

When to call ICU in acute asthma attack

A

Normal or rising CO2
Poor RR
Exhaustion
Cyanosis
Reduced GCS
Silent chest
Sats <92%

71
Q

What is the chronic treatment for asthma

A

SABA +ICS –> SABA,ICS,LABA –> medium ICS, SABA, LABA –> specialist

72
Q

How would you treat an acute exacerbation of COPD

A

Brief history - pain, associated symptoms (colds, sputum, heart pain, syncope, fever, recent travel, wheeze), PMH, D+A,
Airway
Breathing - O2, sats, RR, CXR, sit up, hyperinflated chest with wheeze, salbutamol nebuliser (every 10-15mins and reassess), ipatropium nebuliser, prednisalone/hydrocortisone, antibiotics (amox/clarithromycin), theophylline, NIV
Circulation - listen to heart, CRT, HR, BP, IV access, blood (FBC, U+E, LFT, TFTs, troponin, CRP, VBG, D-dimer, blood cultures), ABG, ECG
Disability - glucose, eyes, GCS, neuro exam
Exposure - Temp, check legs!

ABG every 30 minutes at least. Consider ICU referral

73
Q

What is the chronic management for COPD

A

SABA
ICS if atopy, high esinophils or reversible nature
LABA and LAMA if none of above

SABA, ICS LABA and LAMA 3rd line –? consider long-term O2 therapy
Flu and pneumococcal vaccines.

74
Q

How is pneumonia acutely managed

A

Brief history - pain, associated symptoms (colds, sputum, heart pain, syncope, fever, recent travel, wheeze), PMH, D+A
Airway
Breathing - O2, sats, RR, CXR, sit up, crepatations in base with purelent sputum and consolidation and bronchial breathing.
Circulation - listen to heart, CRT, HR, BP, IV access, blood (FBC, U+E, LFT, TFTs, troponin, CRP, VBG, D-dimer, blood cultures), ABG, ECG
Disability - glucose, eyes, GCS, neuro exam
Exposure - Temp, check legs, urine dip for pneumoccocal and legionella antigen

CURB65 score to determine if admission is required. Give antibiotics per local guidelines, IV fluids, anti-emetics, pain relief.

75
Q

CURB65 score features

A

new onset confusion; urea >7 mmol/L; respiratory rate ≥30/minute, systolic blood pressure <90 mmHg and/or diastolic blood pressure ≤60 mmHg; and age ≥65 years.

0-1: Treat as an outpatient
2: Consider a short stay in hospital or watch very closely as an outpatient
3-5: Requires hospitalization with consideration as to whether they need to be in the intensive care unit

76
Q

Risk factors for aspiration pneumonia

A

Reduced GCS
Oesophageal pathology
Dementia
PD
MS

Involve SALT and chest physio

77
Q

How are pulmonary embolisms managed acutely

A

Brief history - pain, associated symptoms (colds, sputum, heart pain, syncope, fever, recent travel, wheeze), PMH, D+A
Airway
Breathing - O2, sats, RR, CXR, sit up, usually normal
Circulation - listen to heart, CRT, HR (tachy), BP, IV access, blood (FBC, U+E, LFT, TFTs, troponin, CRP, VBG, D-dimer), ABG, ECG (sinus tachy or S1Q3T3)
Disability - glucose, eyes, GCS, neuro exam
Exposure - Temp, check legs

Get a wells score for PE, fluids, CTPA, based off BP give enoxaparin or thrombolysis (alectaplase) if systolic <90mmhg.

78
Q

How is a spontaneous pneumothorax managed

A

Brief history - pain, associated symptoms (colds, sputum, heart pain, syncope, fever, recent travel, wheeze), PMH, D+A
Airway
Breathing - O2, sats, RR, CXR, sit up, hyperresonant on one side with reduced breath sounds, check for tracheal deviation.
Circulation - listen to heart, CRT, HR, BP, IV access, blood (FBC, U+E, LFT, TFTs, troponin, CRP, VBG, D-dimer), ABG, ECG
Disability - glucose, eyes, GCS, neuro exam
Exposure - Temp, check legs

Definitive management depends on primary or secondary and size

Tension – 2nd intercostal midclavicular line rapid cannula insertion then chest drain.
Primary –
<2cm and asymptomatic – go home and review in clinic (2-4 weeks)
>2cm and/or symptomatic – stay in and aspirate and if unsuccessful then chest drain.
Secondary –
 <1cm – monitor
 1-2cm - aspirate
>2cm or SOB – chest drain

79
Q

How are pleural effusions managed acutely

A

Brief history - pain, associated symptoms (colds, sputum, heart pain, syncope, fever, recent travel, wheeze), PMH, D+A
Airway
Breathing - O2, sats, listen to chest, RR, CXR (loss of costophrenic angle and meniscus line), sit up, stony dull on one side with reduced breath sounds, and unilateral reduced chest expansion check for tracheal deviation.
Circulation - listen to heart, CRT, HR, BP, IV access, blood (FBC, U+E, LFT, TFTs, troponin, CRP, VBG, D-dimer, blood cultures), ABG, ECG
Disability - glucose, eyes, GCS, neuro exam
Exposure - Temp, check legs

Chest aspiration to aid diagnosis done by senior. Treat cause

80
Q

What are the two types of pleural effusions

A

Lights criteria -

transudates <25g/l - pulomary oedema, nephrotic syndrome and hypothyrodism

Exudates >35g/l - malignancy, infection, RA,

Acidic - empyema (infection)

81
Q

What is the acute management of pulmonary oedema

A

Brief history - pain, associated symptoms (colds, sputum, heart pain, syncope, fever, recent travel, wheeze), PMH, D+A
Airway
Breathing - O2, sats, listen to chest, RR, CXR (blunting of costophrenic angles, cariomegaly, alveolar oedema, kerly b lines), sit up, crackles bilaterally
Circulation - listen to heart, CRT, HR, BP, raised JVP, IV access, blood (FBC, U+E, LFT, TFTs, troponin, CRP, VBG, BNP, D-dimer), ABG, ECG
Disability - glucose, eyes, GCS, neuro exam
Exposure - Temp, check legs, catheter

Give furosemide (40mg, can give up to 120mg) and diamorphine IV. Then guided by blood pressure -

<100 systolic - probs cardiogenic shock so get senior for inotropes
>100 systolic - GTN and IV nitrates
Wheezing - treat like COPD

Once stabilised the patient needs a fluid restriction and daily weights and an ECHO.

82
Q

How is SVC syndrome managed acutely

A

Brief history - pain, associated symptoms (colds, sputum, heart pain, syncope, fever, recent travel, wheeze), PMH, D+A
Airway (distended facial veins), stridor (senior help immediately including anaesthetist)
Breathing - O2, sats, RR, CXR, sit up,
Circulation - listen to heart, CRT, HR, BP, raised JVP, IV access, blood (FBC, U+E, LFT, TFTs, troponin, CRP, VBG, BNP, D-dimer), ABG, ECG
Disability - glucose, eyes, GCS, neuro exam
Exposure - Temp, check legs

Rx - dexamethasone IV and diuretics with quick senior input.

83
Q

How is stridor managed acutely

A

Do NOT take history - medical emergency but try to find out if theyre choking
Airway, stridor (senior help immediately including anaesthetist and ENT), dont examine neck,
Breathing - O2, sats, listen to chest, RR, CXR, sit in any position comfortable, give nebulised adrenaline
Circulation - listen to heart, CRT, HR, BP, raised JVP, IV access, blood (FBC, U+E, LFT, TFTs, troponin, CRP, VBG, BNP, D-dimer), ABG, ECG
Disability - glucose, eyes, GCS, neuro exam
Exposure - Temp, check legs, rashes? anaphylaxis

84
Q

Give some life threatening causes of stridor

A

Infection
Tumour
Trauma
Foreign body
Post-op
Anaphylaxis

85
Q

How is massive haemoptysis managed

A

Brief history - pain, associated symptoms (colds, sputum, heart pain, syncope, fever, recent travel, wheeze), PMH, D+A
Airway
Breathing - O2, sats, RR, listen to chest, CXR, sit up,
Circulation - listen to heart, CRT, HR, BP, raised JVP, IV access, blood (FBC, U+E, LFT, TFTs, CRP, VBG, BNP, D-dimer, blood cultures), ABG, ECG, fluids if in shock
Disability - glucose, eyes, GCS, neuro exam
Exposure - Temp, check legs

Refer to resp team for CT throax and bronchoscopy

86
Q

How is bronchiectasis managed acutely

A

Brief history - pain, associated symptoms (colds, sputum, heart pain, syncope, fever, recent travel, wheeze), PMH, D+A
Airway
Breathing - O2, sats, RR, listen to chest, CXR, sit up, salbutamol nebs and corticosteroids, antibiotics, BIPAP
Circulation - listen to heart, CRT, HR, BP, ECG, raised JVP, IV access, blood (FBC, U+E, LFT, TFTs, CRP, VBG, BNP, D-dimer, blood cultures), ABG, ECG
Disability - glucose, eyes, GCS, neuro exam
Exposure - Temp, check legs, chest physio

87
Q

How to manage abdominal pain acutely

A

Brief history - pain, associated symptoms (bowel movements, vomiting, dysphagia, haematemsis, malena, last menstrual period, bleeding pattern), PMH, D+A
Airway
Breathing - O2, sats, RR, listen to chest, erect CXR (perforation), sit up
Circulation - listen to heart, ECG, CRT, HR, BP, raised JVP, IV access, blood (FBC, amylase, cross match 4 units, blood cultures, U+E, LFT, TFTs, CRP, VBG, BNP, D-dimer), ABG, ECG, fluid bolus if shock
Disability - glucose, eyes, GCS, neuro exam
Exposure - Temp, check legs, examine abdo - palpation, rebound tenderness, suprapubic tenderness, hernia check, bruits and bowel sounds, PR, urine dip and PREGNANCY TEST

Pain relief, anti-emetics, AXR/CT KUB non-contrast, PR exam and NBM, abx if peritonitic or abdominal sepsis, AAA -USS at bedside, urgent senior review

88
Q

Give some life-threatening causes of abdo pain

A

AAA rupture
AAA dissection
Ectopic rupture
Bowel obstruction
Ulcer perforation
Strangulated hernia
Testicular/ovarian torsion
Acute pancreatitis
Acute cholangitis
Appendicitis
MI

89
Q

How is bowel perforation managed acutely

A

Brief history - pain, associated symptoms (bowel movements, vomiting, dysphagia, haematemsis, malena, last menstrual period, bleeding pattern), PMH, D+A
Airway
Breathing - O2, sats, RR, listen to chest, erect CXR (perforation), sit up
Circulation - listen to heart, CRT, HR, BP, raised JVP, IV access, blood (FBC, amylase, cross match 4 units, blood cultures, U+E, LFT, TFTs, CRP, VBG, BNP, D-dimer), ABG, ECG, fluid bolus if shock
Disability - glucose, eyes, GCS, neuro exam
Exposure - Temp, check legs, examine abdo - palpation, rebound tenderness, suprapubic tenderness, hernia check, PR, bruits and bowel sounds, urine dip and PREGNANCY TEST

Abx (co-amoxiclav), fluids, anti-emetics (cyclizine), analgesia, NBM, NG tube and catheter with urgent senior review - gen surgery (likely ask for CT abdo and ready for surgery)

90
Q

How to manage bowel obstruction acutely

A

Brief history - pain, associated symptoms (bowel movements, vomiting, dysphagia, haematemsis, malena, last menstrual period, bleeding pattern), PMH, D+A
Airway
Breathing - O2, sats, RR, ECG, listen to chest, erect CXR (perforation), sit up
Circulation - listen to heart, CRT, HR, BP, IV access, blood (FBC, amylase, cross match 4 units, blood cultures, U+E, LFT, TFTs, CRP, VBG, BNP, D-dimer), ABG, ECG, fluid bolus if shock
Disability - glucose, eyes, GCS, neuro exam
Exposure - Temp, check legs, examine abdo - palpation, rebound tenderness, suprapubic tenderness, hernia check, PR, bruits and bowel sounds, urine dip and PREGNANCY TEST

Small bowel - Drip and suck - fluids (remember K replacement) and reverse NG tube to decompress the stomach. Give anaelgesia too. If doesnt work after 2/3 days then surgery. Refer early. Likely ask for a CT abdo.

Large bowel - drip and suck and will likely need surgery so refer. Likely ask for CT abdo.

Paralytic ileus - drip and suck with med review and electrolyte review to rule out causes. Usually not painful unlike true small and large bowel obstruction.

91
Q

How is bowel ischaemia/infarction managed

A

Brief history - pain, associated symptoms (bowel movements, vomiting, dysphagia, haematemsis, malena, last menstrual period, bleeding pattern), PMH, D+A
Airway
Breathing - O2, sats, RR, listen to chest, erect CXR (perforation), sit up
Circulation - listen to heart, ECG, CRT, HR, BP, IV access, blood (FBC, amylase, cross match 4 units, blood cultures, U+E, LFT, TFTs, CRP, VBG, BNP, D-dimer), ABG (acidosis), ECG, fluid bolus if shock
Disability - glucose, eyes, GCS, neuro exam
Exposure - Temp, check legs, examine abdo - palpation, rebound tenderness, suprapubic tenderness, hernia check, PR, bruits and bowel sounds, urine dip and PREGNANCY TEST

NBM, antibiotics, heparin, IV fluids and analgesia, might need surgery.

92
Q

How is appendicitis managed

A

Brief history - pain, associated symptoms (bowel movements, vomiting, dysphagia, haematemsis, malena, last menstrual period, bleeding pattern), PMH, D+A
Airway
Breathing - O2, sats, RR, listen to chest, erect CXR (perforation), sit up
Circulation - listen to heart, ECG,CRT, HR, BP, IV access, blood (FBC, amylase, cross match 4 units, blood cultures, U+E, LFT, CRP, VBG), ABG (acidosis), ECG, fluid bolus if shock
Disability - glucose, eyes, GCS, neuro exam
Exposure - Temp, check legs, examine abdo - palpation, rebound tenderness, suprapubic tenderness, hernia check, PR, Rosving positive, bruits and bowel sounds, urine dip and PREGNANCY TEST

Inform senior - NBM, IV fluids, analgesia, IV abx, immediate surgery only if peritonitic.

93
Q

How is dyspepsia managed

A

Hx - ask about pain, acid reflux, nausea, vomiting, back passage
Ex - abdo exam - epigastric pain, peritonitis, PR
Ix - ALARM or 55 and above then urgent endoscopy, urea breath test (No PPI for 2 weeks beforehand), bloods
Rx - treat triple therapy (amox, clarithromycin and lansoprazole), weight loss and stop smoking, antacids

94
Q

How is diverticular disease managed

A

Hx - pain (LIF), bowel habit, fever, diet, blood, bloating
Ex - RIF pain, PR, fever, peritonitis
Ix - Bloods, colonoscopy (only to exclude other causes)
Rx - high fibre diet, abx and fluids if infection, laxatives and buscapan

95
Q

How is renal colic managed

A

Hx - flank to groin pain, haematuria, fever, dysuria, vomiting
Ex - flank tenderness, positive urine dip
Ix - urine dip, Bloods, CT-KUB, pregnancy test if female
Rx - depends on size of stone, IM diclofenac, opiods, fluids, abx (if infection signs), urology opinion for stones >5mm and/or hydronephrosis (nephrostomy)

96
Q

How is biliary colic managed

A

Hx - colicky abdo pain in RUQ, no jaundice, vomiting, nausea
Ix - USS abdo, bloods
Rx - elective cholecystectomy and analgesia

97
Q

How is acute cholecystitis managed

A

Hx - RUQ pain, unwell and vomiting, Murphys sign positive
Ix - USS abdo, LFTs, FBC, CRP
Rx - NBM, analgesia, abx, ERCP

98
Q

How is acute pancreatitis managed

A

A - idiopathic, gall stones, alcohol, steroids, mumps, SV, ERCP
S - severe epigastric pain radiating to back, vomiting, anorexia, shock, epigastric tenderness, turners sign.
Ix - FBC, Lipase, amylase, glucose (up), low calcium, deranged clotting, LFTs, USS for gallstones, CT abdo if doubt, glasgow-eimre score
Rx - IV fluids, oxygen analgesia, NBM and NG tube, ERCP, close monitoring.

99
Q

How is chronic pancreatitis managed

A

S - weight loss, steatohrrea, anorexia, DM, bloaing, epigastric tenderness
Ix - gkucose, stool elastase, USS, CT/MCRP
Rx - avoid alcohol, fat soluble vitamins, high protein diet, pancreatic enzymes (creon), coeliac plexus block, pancreatectomy

100
Q

How is an overdose managed

A

Brief history - pain, associated symptoms, what the took, when they took it, how much they took, how they were found, any alcohol consumed too, MSE, PMH (previous overdoses), D+A, SH (who they live with and relationships with friends and family
Airway - beware of vomiting
Breathing - O2, sats, RR, listen to chest, sit up
Circulation - listen to heart, ECG,CRT, HR, BP, IV access, blood (FBC, U+E, LFT, CRP, VBG), ABG, ECG, fluid bolus if shock
Disability - glucose, eyes, GCS, neuro exam
Exposure - Temp, check legs, examine abdo - palpation

Inform senior, gastric lavage if within an hour, look on toxbase for treatment and antedote, get in touch with liaison psych, MHA needed?

101
Q

How is a salicylate/aspirin overdose managed

A

S - vomiting, increased RR, tinnitus, vertigo, sweating
Ix - resp alkalosis then metabolic acidosis, deranged glucose, high salicylate levels, routine bloods, ECG
Rx - activated charcoal if <1hr, sodium bicarbonate and haemodilaysis if severe

102
Q

How is a trycyclic antidepressant overdose managed

A

S - dilated pupils, blurred vision, reduced GCS, seizures, tachycardia, dysrhythmia
Ix - ABG (acidosis), ECG (prolonged PR and QRS), routine bloods
Rx - activated charcoal if <1hr, sodium bicarbonate

103
Q

How is a digoxin overdose managed

A

S - nausea, confusion, yellow haloes around lights
Ix - routine bloods (hypokalaemia), ECG (reverse tick/upsloping ST segment)
Rx - digibind/dogoxin specific antibody

104
Q

How is an opioid overdose managed

A

S - low RR, low GCS, pinpoint pupils, constipation
Ix - ABG (resp acidosis), routine bloods, opioids on urine drug screen
Rx - naloxone, can be repeated or given as a continuous infusion and fluids given to flush out opioids

105
Q

How is a benzodiazepine overdose managed

A

S - low GCS, low bp, low tone, hypoflexia
Ix - ABG (resp acidosis), blood and urine toxicology
Rx - activated charcoal if <1hr, flumenazil

106
Q

How is a ecstasy/cocaine overdose managed

A

S - thirst, confusion, agitation, tremor, dilated pupils, high HR, BP and temp
Ix - urine toxicology, ECG arrhythmias
Rx - lorazepam/diazepam

107
Q

What is the criteria used to assess the risk after a suicide attempt

A

SAD PERSONS criteria

108
Q

How is a paracetamol overdose managed

A

Brief history - pain, associated symptoms, what the took, when they took it, how much they took, how they were found, any alcohol consumed too, MSE, PMH (previous overdoses), D+A, SH (who they live with and relationships with friends and family
Airway - beware of vomiting
Breathing - O2, sats, RR, listen to chest, sit up
Circulation - listen to heart, ECG,CRT, HR, BP, IV access, blood (FBC, U+E, LFT (raised ALT), CRP, VBG), ABG, ECG, fluid bolus if shock
Disability - glucose, eyes, GCS, neuro exam
Exposure - Temp, check legs, examine abdo - palpation

Inform senior, charcoal if within an hour, get in touch with liaison psych, MHA needed?, start NAC if staggered dose or above the treatment level.

109
Q

How is vaginal bleeding managed

A

S - pain SOCRATES, associated symptoms (amount of blood, clots, LMP, chances of pregnancy, difference in discharge, any lumps trauma, weight loss, effect on lifestyle, anaemia symptoms - SOB, dizziness, fatigue, headache), PMH (previous epsisodes, pregancies, miscarriges, last smear, D+A (COCP, HRT, tamoxifen, anticoagulants), feel for pelvic masses, speculum exam, prolapse, rashes
Ix - BhCG, FBC, CRP, clotting, U+Es, LFT, USS (transvaginal), genital swabs if infection
Rx - treat shock if present, if positive pregnacy test assume ectopic until proven otherwise (two large bore cannulas, Cross-match 4 units, laproscopy), if post-menopasal then refer to PMB clinic

110
Q

Give some possible causes of vaginal bleeding

A

Ectopic
Miscarriage
Dysfunctional uterine bleeding
Fibroids
Endometrial cancer
PID
Ectropion/erosion
Polyps
Cervical cancer
Ovarian cancer
Clotting abnormality

111
Q

How is cervicitis/vaginitis managed

A

S - itching, vaginal discharge, dysuria, abnormal odour, small amounts of bleeding, vaginal/cervial erythema
Ix - genital swabs
Rx - treat cause with abx/antifungals or oestrogens (atrophic vaginitis)

112
Q

How is an ectopic pregnancy managed

A

S - pain in shoulder and back, SOCRATES, associated symptoms (PV bleeding, recent amenorrhoea, dizziness, shock, amount of blood, clots, LMP, chances of pregnancy, difference in discharge, any lumps trauma, weight loss, effect on lifestyle, anaemia symptoms - SOB, dizziness, fatigue, headache), PMH (previous epsisodes, pregancies, miscarriges, last smear, D+A (COCP, HRT, tamoxifen, anticoagulants), feel for pelvic masses, speculum exam, guarding, cervical excitation
Ix - BhCG (serum and uterine), routine bloods, G+S and crossmatch, clotting, transvaginal USS (Sac and free fluid)
Rx - surgical - (2 large bore cannula, IV fluids, urgent gynae referral for laproscopic salpingectomy)/ medical (methotrexate if <3.5cm and no pain)

113
Q

How is dysfunctional uterine bleeding managed

A

S - heavy bleeding during periods only, interfering with daily activities, otherwise well, normal systemic and gynae exam
Ix - routine bloods (iron deficiency anaemia possibly)
Rx - tranexamic acid/ COCP/Mirena coil

114
Q

How is cervical ectropion managed

A

S - postcoital bleeding, intermenstrual bleeding, menorrhagia, red flare or ring around external cervical orofice on speculum exam
Ix - clinical and smear test
Rx - change of contraception, usually none though

115
Q

How is cervical/endometrial polyps managed

A

S - menorrhagia, intermenstrual, postcoital or postmenopausal bleeding, visible on speculum exam
Ix - hysteroscopy and polypectomy
Rx - surgical removal with silver nitrate

116
Q

How are fibroids managed

A

S - may be asymptomatic, menorrhagia, dragging feeling, prolonged periods, urinary incontinence or increased frequency, INFERTILITY, palpable mass on abdo or vaginal exam
Ix - routine bloods (may have anaemia), pelvic USS
Rx - GnRH agonists, embolization, myomectomy or hysterectomy

117
Q

How is endometrial cancer managed

A

S - post-menopausal or intermenstrual bleeding, menorrhagia, watery vaginal discharge, lower abdo pain, dyspareunia, weight loss, usually no signs on examination
Ix - transvaginal USS (endometrial thickness), pipelle biopsy, hysteroscopy for further biopsies
Rx - hysterectomy and bilateral salpingo-oophrectomy, radiotherapy and palliative treatment with radiotherapy may be an option

118
Q

How is cervical cancer managed

A

S - young women usually but can be middle aged too, asymptomatic is common as comes up on smear, postcoital bleeding and pain, ulceration, mass on examination, post-menoapusal bleeding or intramenstrual bleeding
Ix - cervical smear, colposcopy, biopsy, CT/MRI for staging
Rx - low stage is surgery and radiotherapy and high grade is chemo and radiotherapy

119
Q

How is ovarian cancer managed

A

S - lower abdo pain, weight reduction, bloating, irregular periods, postmenopausal bleeding, urinary infrequency, adnexal mass, abdo mass, ascities, pleural effusions, DVT
Ix - CA125, alpha fetoprotein, BHCG, USS pelvis and CT thorax, abdo, pelvis for staging
Rx - surgery +/- chemo

120
Q

How is PID managed

A

S - lower abdo pain, vaginal discharge, intermenstraul/postcoital bleeding, pyrexia, dysuria, dysparenuia, nausea, vomiting, infertility, general malaise, abdo tenderness, adnexal tenderness, cervical excitation
Ix - MSSU, genital swabs for MC+S, routine bloods, USS (excludes ovarian cyst)
Rx - IV fluids, analgesia, remove IUCD, IV abx, refer to GUM

121
Q

How is ovarian cyst/torsion managed

A

S - severe, sudden lower abdo pain, radiating to flank and causing nausea and vomiting, fever, abdo tenderness, may have signs of shock
Ix - serum BhCG, routine bloods, urine dipstick and MSSU, pelvic USS
Rx - immediate gynae referral, IV fluids and analgesia, urgent laproscopy

122
Q

How is endometriosis managed

A

S - painful periods, pelvic pain before and durign periods, deep dysparenuia, infertility, rectal pain, generalised abdo pain
Ix - laproscopy
Rx - medical (COCP or GnRH agonists)/ surgery (laproscopic diathermy or excusion, bilateral salpingooopherectomy and hysterectomy)

123
Q

What are the 5 options for contraception

A

Barriers - condoms, femidoms
IUCD - mirena coil (progesterone only) or copper IUD (both can cause bleeding, ectopics and perforations)
Oral - COCP or POP
Hormones - implants (3 years) and injections (3 months)
Sterilization - more effective in males

124
Q

Give some side effects and cautions for oral contraceptive pills

A

S/E - acne, altered menstrual pattern, breast tenderness, bloating, weight gain, mood changes, nausea, DVT/PE, hypertension, migraines

Cautions - smokers, DM, hypertension,>35years old, BMI>30

125
Q

COCP advice for missed pills

A

1 missed pill - take immediately then no extra precautions needed

> 2 - take next pill at normal time and other contraception for 7 days. Start another pack without a break if due to finish pack within 7 days. Emergency contraception if in last 7 days

126
Q

POP advice for missed pills

A

If >12hrs take missed immediately and continue as normal contraception if within 48hr

127
Q

What is the advice for oral contraception if patient has diarrhoea or vomiting

A

Barrier contraceptions until 7 days after resolution of symptoms

128
Q

What is the risks of taking HRT

A

PE/DVT
Stroke
Breast cancer
Ovarian cancer
Endometrial cancer

129
Q

What is the treatment options for emergency contraception

A

Levonorgesterel - 3 days
Copper IUD - 5 days
Ulipristal - 5 days

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