Clinical Presentations II Flashcards
How is an acute GI bleed managed
Hx - pain, associated symptoms, run up to the bleed, PMH (alcohol and reflux), D+A
Airway - speak to patient, check in mouth, suction if required, triple airway manouvure, lay in recovery position if vomiting
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 (including G+S and cross match and clotting) taken off the back, listen to chest, fluid challenge if shock, ABG
Disability - glucose, eyes, quick neuro exam and GCS
Exposure - remove all clothing, check temp, look for rash, abdo exam quickly (peritonitis, bowel sounds, PR exam)
Urgent call for senior and endoscopist. Might need terlipressin IV then ligation in endoscopy. Might need an IV PPI. Propranolol prophylactic. Stop NSAIDs and blood thinners. Might need colonoscopy if from lower end. Will have upper scope if large lower GI bleed as can be from upper GI.
What are the life threatening causes of upper GI bleeds
Peptic ulcer
Vascular malformations
Varices
Upper GI malignancy
What is the scoring system for upper GI bleeds
Rockall risk scoring system - need endoscopy to complete scoring.
Causes of lower GI bleeds
Upper GI bleeds
Diverticulitis
Colorectal cancer
Angiodysplasia
haemorrhoids
Bowel ischaemia
Anal fissure
IBD
How to manage chronic GI bleeding
Hx - when it started, pain, associated symptoms, abdo tenderness, cachexic, pale, PR exam, weight loss
Ix - FIT test, bloods, colonoscopy and endoscopy, stool sample, (small bowel - video capsule endoscopy)
Rx - treat anaemia (ferrous sulphate) and investigate cause
How to manage haemorrhoids
Hx - bowel habits, pain, associated symptoms, abdo tenderness, PR exam
Ix - clinical
Rx - high fibre diet, anusol, laxatives, band ligation if resistant, haemarrhoidectomy if needed
Strangulated - cant sit down and very painful consider haemorrhoidectomy and conservative management in the meantime.
How to manage anal fissures
Hx - bowel habits pain, associated symptoms (fever for abscess), abdo exam, inspection (cannot manage PR exam, may have discharge),
Rx - high fibre diet, lidocaine, laxatives, GTN
How to manage angiodysplasia
Hx - blood in stools and PR but no abdo pain
Ix - positive FIT, colonoscopy may be negative, capsule endoscopy
Rx - angiographic emblisation or argon plasma coagulation
How to manage nausea and vomiting
Hx - ask about fever, pain, headache, dizziness (labyrinthitis), bowel obstruction, alcohol/drugs, visual issues, haematemesis or malena, full set of obs, D+A and PMH
Ix- fluid status, abdo exam for hernias and bowel movement, AXR, ECG, routine bloods, ABG (if acute), CT head if brain trauma
Rx - treat cause, antiemetics and fluids
How to manage diarrhoea
Hx - ask about pain, fever, blood in stools, length of time, diet, recent travel, stress, immunosuppression, PMH, D+A
Ix - fluid status, obs, abdo exam, PR, stool sample (C diff and MCS), routine bloods, AXR if obstructed picture
Rx - increase fluids, analgesia, review meds, stool chart, isolate if C.diff, find cause
Drugs that cause diarrhoea
Abx
Laxatives
Colchicine
NSAIDs
Digoxin
Iron
Ranitidine
Thiazide diuretics
Propranolol
PPIs
Causes of N+V
DKA
Stomach bug
Raised ICP
Acute abdomen
Ileus
Bowel obstruction
Gastroenteritis
Labyrinthitis
Migraine
Hyperemesis gravidarum
Drug induced
How is infective gastroenteritis managed
Hx - pain, recent food, diarrhoea, vomiting, fever, family members, PMH, D+A, recent travel
Ix - obs, fluid balance, stool sample (MCS and C.diff), routine bloods
Rx - usually supportive but may be given oral rehydration therapy with abx in hospital
How is pseudomembranous ulcerative colitis managed
Hx - pain, fever, dysentery, vomiting, fluid intake, PMH,D+A (especially C antibiotics), usually greeny watery stools
Ix - Obs, fluid balance, routine bloods, stool culture (MCS and C.diff)
Rx - fluids, analgesia, patient isolation!, metronidazole IV and vancomycin oral. Fidazomicin if that doesnt work
How is IBS managed
Hx - pain, diarrhoea, constipation, stress, oral intake, pattern, normal exam
Ix - routine bloods plus calcium and magnesium, faecal calprotectin, TGAA antibodies, TFTs
Rx - diagnosis of exclusion. Reassure, FODMAP, buscopan, and loperamide, SSRI/amitriptyline are second line
How is coeliac disease managed
Hx - abdo pain, bloating, dermatitis herpetoformis, diarrhoea, steatthorea, weight loss, mouth ulcers, sore tongue (B12 deficiency)
Ix - TGAA, duodenal biopsy, folate, b12, RBC, Iron
Rx - gluten avoidance
How is IBD managed
Hx - abdo pain, diarrhoea, bloody stools, fever, weight loss, mouth ulcers, sore joints, pyoderma gangrenosum, abdo obstruction, erythema nodosum, clubbing
Ix - routine bloods, stool culture, faecal calprotectin, b12 (terminal ileal disease), AXR (obstruction), colonoscopy
Rx - depends if UC or crohns, rehydrate, pain relief and correct electrolyte imbalances
Differences between crohns and UC
Crohns - no blood or mucus, entire length of gut, skip lesions, thickness (full), smoking is RF
UC - Continuous inflammation, limited to colon, only superficial, smoking is protective, continuous blood or mucus, use aminosalicylates, PSC
How is UC managed
Mild - oral +/- rectal mesalazine
Moderate/severe - prednisalone
Recovery - mesalazine
Surgery - toxic megacolon or failure to respond to max medical therapy after 5-7 days.
How is Crohns managed
Mild - pred
Moderate/severe - hydrocortisone IV
Recovery - pred/azathioprine
Surgery if strictures or abscesses but never curative
How is constipation managed
Hx - not passing stool, bloating, loss of appetite, pain, hard stool on PR, can ask about hypercalaemia (headaches, stones) and hyperthyroidism (depression, weight gain, heat intolerance), ensure no obstruction (passing wind, no vomiting, abdo pain, shock), if over 40 think MALIGNANCY (weight loss, blood etc)
Ix - fluid balance, drugs review, PR, U+Es, FBC, calcium and magnesium, TFTs if refractory
Rx - Laxatives, increase fluids, ensure eating, fix electrolyte imbalances, reduce opioids, get up and moving. Laxatives- bulk-forming laxative and then add in osmotic then if still difficult to pass add in stimulant. Phosphate enemas are last line. Use osmotic or stimulant if opioid induced.
Medications that induce constipation
Opioids, iron tablets, CCBs, psychotropic drugs, anticholingergics, chronic laxatives
How is acute liver failure managed
Hx - pain, associated symptoms, jaundice, BBV exposure, PMH, alcohol and drugs
Airway - speak to patient, check in mouth, suction if required, triple airway manouvure, lay in recovery position if vomiting
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 (including G+S and cross match and clotting, paracetamol levels, viral serology) taken off the back, listen to chest, fluid challenge if shock, ABG
Disability - glucose, eyes, quick neuro exam and GCS
Exposure - remove all clothing, check temp, look for rash, abdo exam quickly (peritonitis, bowel sounds, PR exam)
Call for senior help and reassess ABCDE, investigate with fibroscan, the above blood results and an USS abdo and ascitic tap
Long-term - abx, daily bloods, steroids, lactulose, HDU/ICU
Causes of acute liver failure
Acute - paracetamol overdose, alcoholic hepatitis, Hep B, Hep C, autoimmune hep, ischaemic hepatitis (HF and shock)
Decompensated liver disease - alcohol excess, malginancy, GI bleeds, portal vein thrombosis, infection
Signs of acute liver failure
Flapping tremor, IV drug abuse, jaundiced sclera, ascities, hepatomegaly, abdo pain, ankle swelling, gyaenacomastia, loss of hair, spider naevi, caput medusa, muscle wasting.
What blood test is used for monitoring how severe liver disease is
PT - clotting
How is alcoholic hepatitis managed
S - jaundice, fever, RUQ, anorexia
Ix - raised WCC, ALT, bilirubin and prothrombin, ascitic tap for SBP
Rx - treat as acute liver (abx, daily bloods, steroids, lactulose, HDU)
What is Budd-chiari
Hepatic vein obstruction - use doppler USS
How is glandular fever managed
S - tonsilitis, lymphadenopathy, splenomegaly, rash (with amox), jaundice
Ix - raised lymphocytes , raised ALT, positive monospot
Rx - HNO, oral steroids, safety netting - no sports or alcohol for 6 weeks (hepatotoxicity and splenic rupture respectively)
How is acute viral hepatitis managed
A - Hep A,B,C,E, EBV, CMV
S - fever, anorexia, ascites, flu-like symptoms, vomiting, hepatomegaly, splenomegaly
Ix - Viral serology screen, FBC (raised WCC), LFT (raised ALT, PT and bilirubin)
Rx - avoid alcohol, supportive treatment, interferon alpha
Three main features of decompensated chronic liver failure
Decreased synthetic function - hypoalbuminaemia and clotting issues
Decreased detoxification - encephalopathy
Portal hypertension - variceal bleeding
How is decompensated chronic liver disease managed
S - like acute liver failure but with chronic changes - gynaecomastia, spider naevi, varices, enceophalopathy
Ix - FBC, LFTs, USS, liver biopsy, clotting profile, ascitic tap, OGD endoscopy
Rx - steroids, stop alcohol, low sodium diet, daily weights, spironolactone, ascitic cultures and abx if positive, lactulose
How is spontaneous bacterial peritonitis managed
S - abdo pain, ascites, fever, tenderness and peritonitis,
Ix - FBC, CRP, ascitic tap
Rx - abx (tazocin)
How is autoimmune liver disease managed
S - Fever, anorexia, ascites, flu-like symptoms, vomiting, hepatomegaly
Ix - FBC, CRP, antibody screen, USS, liver biopsy
Rx - pred and azathioprine
How is haemochromatosis managed
S - lethargy, hepatomegaly, hyperpigmentation, DM, erectile dysfunction
Ix - transferrin, FBC (ALT), glucose, ECG, liver USS and biopsy, FBC
Rx - weekly venesection until normal ferritin
How is NAFLD managed
S - obesity, hypertension, diabetes, liver failure
Ix - FBC, U+E, LFT, HbA1c, USS and elastography, biopsy
Rx - weight control
How is anti-trypsin deficiency managed
S - SOB, liver failure, FH
Ix - antitrypsin levels, FBC, LFT, genetic testing, CXR, liver biopsy
Rx - stop smoking, transplant, manage COPD
How is Wilson’s disease managed
S - tremor, slurred speech, depression, psychosis, liver failure, kaiser fleischer rings
Ix - caeruloplasmin, total copper, free copper, genetic testing, 24hr urianry copper excretion, liver biopsy
Rx - penicillamine and transplant
How is Weil’s disease (leptospirosis) managed
A - rat urine through cut
S - fatigue, bleeding, jaundice, nausea, vomiting, photophobia, RUQ tenderness, myocarditis
Ix - urine dip, cultures, FBC (anaemia), U+E, LFT (raised bilirubin and ALT), serology
Rx - doxycycline
How to investigate jaundice
A - think of pre-hepatic, hepatic and post-hepatic, pre - haemolysis and malaria/ hepatic - paracetamol overdose, alcohol, NAFLD/ Post-hepatic - ascending cholangitis, pancreatic cancer, cholangiocarcinoma
S - weight loss, anorexia, jaundice, bleeding, vomiting,
Hx - alcohol, gallstones, paracetamol, BBV
Ix - Routine bloods, reticulocytes, amylase, lipase, liver serology, blood cultures, CT abdo
How is choledocholithiasis managed
P - gallstone in common bile duct
S - mild RUQ tenderness, dark urine, little pain, pale stools
Ix - LFT (raised ALP and bilirubin), USS (dilated bile ducts)
Rx - Abx, ERCP, fluids, cholecystectomy once jaundice has resolved.
How is cholangitis managed
S - charcots triad (fever, jaundice, RUQ pain), murphy positive
Ix - FBC, LFT, CRP, USS abdo,
Rx - abx, ERCP
How is PBC managed
S - fatigue, pruritus, cirrhosis, cholestatic jaundice
Ix - USS and liver biopsy
Rx - ursodeoxycholic acid, colestyramine, steroids, fat vitamin replacement
Causes of hypoglycaemia
Medication
Insulin overdose
Starvation
Excess alcohol
Acute liver failure
Sepsis
Renal failure
Insulinoma
How is PSC managed
S - leads to cirrhosis and linked to UC, fatigue, pruritus, cirrhosis, cholestatic jaundice
Ix - USS, ERCP and biopsy, routine bloods, antibody testing
Rx - ursodeoxycholic acid, colestyramine, fat vitamin replacement, transplatation
Cholangiocarcinoma management
S - jaundice, pruritus, weight loss, RUQ pain, gallstones
Ix - routine bloods, CA19-9, USS, MRCP, ERCP and biopsy
Rx - surgery, chemo and ERCP for stenting
How to manage a hypoglycaemia emergency
Hx - sweating, hunger, confused, dizzy, pale, seizures, PMH, alcohol and drugs
Airway - speak to patient, check in mouth, suction if required, triple airway manouvure, lay in recovery position if vomiting
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, fluid challenge if shock, ABG, IV glucose (100ml of 20%)
Disability - glucose, eyes, quick neuro exam and GCS (returns in <15mins)
Exposure - remove all clothing, check temp, look for rash, abdo exam quickly (peritonitis, bowel sounds, PR exam)
Call for senior help and reassess ABCDE, start 1L 10% glucose 4-8hrly IV and monitor fingerprick every 30 mins, find the cause of hypoglycemia, inform seniors.
Can also manage with 200ml orange juice then toast. If stays low after 600ml orange juice then start IV as above, recheck BG every hr
How is DKA managed acutely
Brief history - pain, associated symptoms (breathing, fatigue, urinating, confusion, infection symptoms, weight loss), PMH (DM), D+A
Airway
Breathing - O2, sats, RR, listen to chest, CXR, sit up
Circulation - listen to heart, CRT, HR, BP, IV access, blood (FBC, amylase, cross match 4 units, blood cultures, U+E, LFT, glucose, CRP, VBG, osmolality), ABG (acidosis), ECG, NO fluid bolus if shock
Disability - glucose and ketones, eyes, GCS, neuro exam
Exposure - Temp, check legs, examine abdo - palpation, urinalysis for ketones and osmolality
Inform senior and critical care team, FIG PICK - fluids (1l 0.9% first hr), insulin (0.1unit/kg/h IV), glucose, potassium, infection screen, chart fluids, ketones, takes DAYS to develop.
How is Hyperosmolar hyperglycaemic state managed acutely
Brief history - pain, associated symptoms (breathing, fatigue, urinating, confusion, infection symptoms, weight loss), PMH (DM), D+A
Airway
Breathing - O2, sats, RR, listen to chest, CXR, sit up
Circulation - listen to heart, CRT, HR, BP, IV access, blood (FBC, amylase, cross match 4 units, blood cultures, U+E, LFT, glucose, CRP, VBG, osmolality), ABG, ECG, fluid bolus if shock
Disability - glucose and ketones, eyes, GCS, neuro exam
Exposure - Temp, check legs, examine abdo - palpation, urinalysis for ketones and osmolality
Inform senior, fluids (1l 0.9% first hr), insulin if ketones are raised, infection screen, takes WEEKS to develop.
Causes of DKA/HSS
Sepsis
Surgery
MI and other acute illnesses
Poor medication compliance
Alcohol
How to manage general hyperglycaemia
S - urinary symptoms and infection screen
Ix - glucose, ketones, U+Es, ABG
Rx - if mild treat with a 20% in insulin doses and close monitoring and increase fluids if type 1/ if type 2 - fluids and increase hypoglycaemic medication and increase monitoring
How do insulin sliding scales work
Strict control and monitoring of BG levels in insulin-dependent patients where their oral intake is significantly disrupted (NBM, coma, and severe vomiting).
Insulin sliding scales prescribe insulin AND fluids simultaneously.
5% glucose if < 11mmol/l glucose
0.9% NaCl if >11mmol/l glucose
What do you do if sliding scales is not lowering blood glucose levels
Check equipment
1.5-2 the insulin dose as before.
What to do if the sliding scale is lowering blood glucose levels too much
Stop the sliding scale and restart at half the dose of original scale once BG >6mmol/L
What to give when stopping a sliding scale
SC insulin at normal dose for that patient.
How is type 1 diabetes managed
S - weight loss, fatigue, deep and labored breathing, weight loss, infections increase, urinating more, thirst, vomiting
Ix - (HbA1c, fasting glucose, OGTT, random blood glucose) - 2 and no symptoms or 1 with symptoms, ABG, infection screen, ketones
Rx - treat any DKA, insulin regime (usually long acting morning and night with short acting before meals), and patient education - never stop insulin, use sugary drinks if ill, check insulin and ketones more regularly, stop metformin if dehydrated.
How is type 2 diabetes managed
S - weight loss, fatigue, deep and labored breathing, weight loss, infections increase, urinating more, thirst, vomiting
Ix - (HbA1c, fasting glucose, OGTT, random blood glucose) - 2 and no symptoms or 1 with symptoms, ABG, infection screen, ketones
Rx - treat any HHS, lifestyle changes –> metformin –> sulfonlyurea/ SLGT2 inhibitor/DPP4 inhibitor/Thiazolidinediones. If doesnt work with double therapy consider insulin switch if high BMI or third drug. Patient education - never stop insulin, use sugary drinks if ill, check insulin and ketones more regularly, stop metformin if dehydrated.
Other areas of diabetic management
BP - ACEI/ARB
Nephropathy - albumin: creatinine ratio, tighten Bp control
Neuropathy - duloxetine
Retinopathy - annual retinal screening, anti-VEGF if required.
Footcare
Flu vaccines
How is hypopituitarism managed
A - infection, radiotherapy, amyloidosis
S - mix bag depending in lost hormone
I - test LH, FSH, TSH, TFTs, cortisol, IGF-1, short synthacten test,
Rx - treat with hormone replacement
How is diabetes insipidus managed
S - polydipsia, polyuria, dilute urine, dehydrated
Ix - urine and serum osmolality, desmopressin test (failed to concentrate - renal cause)
Rx - neurogenic (desmopressin)/ nephrogenic - NSAIDs and bendroflumethiazide
How is acromegaly managed
S - enlarged and coarse facial features, increased hand and feet size, sleep apnoea, diabetes, enlarged tongue, bitemporal hemiopia, headache, hypertension
Ix - IGF-1, OGTT, pituitary MRI
Rx - transsphenoidal resection of pituitary tumour, somatostatin analgoues
How is cushings disease managed
S - fat pad on back, abdominal striae, thinning skin, increased infection risk, hypertension, depression, red moon face, weight gain, fatigue, hirutism, peripheral muscle waisting.
Ix - morning cortisol test, glucose, 24hr urinary cortisol, dexamethasone suppression test, adrenal CT (adenoma/ hyperplasia), possible CXR
Rx - surgical excision, bisphosphonates, vitamin D
How is adrenal insufficiency managed
S - tiredness, reduced GCS, weight loss, weakness, dizziness, depression, abdo pain, diarrhoea, vomiting, hyperpigmentation
Ix - short syntahcten test, routine bloods (low NA and high K), adrenal CT
Rx - hydrocortisone and fludricortisone
How is an Addisonian crisis managed
S - long term steroid use, addisons disease, shock, reduced GCS, hypoglycaemia
Ix - cortisol levels
Rx - 200mg IV hydrocortisone then 100mg IV/8hrs, abx, endocrine advice
How is hyperaldosteronism managed
S - thirst, polyuria, weakness, headaches
Ix - renin:aldosterone ratio (low), U+E (low potassium high sodium), CT abdo
Rx - spironolactone and surgical removal once BP and electrolytes controlled
secondary hyperaldosteronism (R:A ratio is high) treat with spironolactone
How is a phaeochromocytoma managed
S - anxiety, sweating, hypertension, tachycardia, flushing, chest tightness, tremor, breathlessness, abdo pain
I - plasma and urine 24hr metanephrines, adrenal CT
Rx - alpha-blockers then beta blockers then surgical resection
How is hypothyroidism managed
S - bradycardia, weight gain, cold intolerance, course hair, hypoflexia, depression, confusion, dementia, infertility, menorrhagia, goitre
Ix - TSH, ECG, thyroid autoantibodies (TSH receptor antibodies, TPO antibodies)
Rx - levothyroxine
How is hyperthyroidism managed
S - anxiety and irritation, weight loss diarrhoea, heat intolerance, sweating, goitre oligomenorrhoea, tachycardia, AF, eye signs, pretibial myxodema
Ix - TSH, ECG, antibodies (TSH receptor antibodies, TPO antibodies)
Rx - propanolol, carbimazole/uracil, radioactive iodine, excision of lesions
How is a thyrotoxic storm managed
S - tachycardia, AF, fever, agitation, confusion,
Ix - TFTs, ECG
Rx - propanolol, uracil, hydrocortisone
How is a coma/reduced GCS managed acutely
Brief history - pain, associated symptoms (headache, vomiting, seizures, LADY, fever), PMH, D+A
Airway and maintain C spine if injury risk, look in mouth and suction if needed
Breathing - O2, sats, RR, listen to chest, CXR, sit up
Circulation - listen to heart, CRT, HR, BP, IV access, blood (FBC, amylase, cross match 4 units, blood cultures, U+E, LFT, glucose, CRP, VBG, osmolality, toxicology screen), ABG (acidosis), ECG, fluid bolus if shock, abx if meningitis suspected
Disability - glucose and ketones, eyes, GCS, neuro exam, check for sedatives on drug chart
Exposure - Temp, check legs, examine abdo - palpation, urinalysis for ketones and osmolality, rashes
Call seniors and anaesthetist, request CT head urgent, may need mannitol to reduced ICP, normalise PaCO2, LP if CT is normal
What drugs can cause sedation
Benzos - flumenazil
Opioids - naloxone
Antihistamines
TCA
Baclofen
Alcohol - parbinex
What is the features of the GCS scoring system
Best eye response (4)
1 No eye opening
2 Eye opening to pain
3 Eye opening to sound
4 Eyes open spontaneously
Best verbal response (5)
1 No verbal response
2 Incomprehensible sounds
3 Inappropriate words
4 Confused
5 Orientated
Best motor response (6)
1 No motor response.
2 Abnormal extension to pain
3 Abnormal flexion to pain
4 Withdrawal from pain
5 Localizing pain
6 Obeys commands
How are adult seizures managed acutely
Airway - look in mouth and suction if needed, recovery position
Breathing - O2 in ALL patients, sats, RR, listen to chest
Circulation - listen to heart, CRT, HR, BP, IV access, blood (FBC, amylase, cross match 4 units, blood cultures, U+E, LFT, glucose, CRP, VBG, osmolality, toxicology screen), ABG (acidosis), ECG, fluid bolus if shock, abx if meningitis suspected
Disability - glucose and ketones, eyes, GCS, neuro exam, check drugs chart
Exposure - temp, rashes
CALL SENIORS and anaesthetist
IV access - lorazepam –> again at 10 mins if need be –> phenytoin at another 10 mins
No IV access - diazepam PR or buccal midazolam every 10 mins (3 runs).
Alcoholic - parbinex IV
If >40mins then anaesthetist will intubatie with propofol and send to ICU
How to manage paediatric seizures acutely
Airway - look in mouth and suction if needed, recovery position
Breathing - O2 in ALL patients, sats, RR, listen to chest
Circulation - listen to heart, CRT, HR, BP, IV access, blood (FBC, amylase, cross match 4 units, blood cultures, U+E, LFT, glucose, CRP, VBG, osmolality, toxicology screen), ABG (acidosis), ECG, fluid bolus if shock, abx if meningitis suspected
Disability - glucose and ketones, eyes, GCS, neuro exam, check drugs chart
Exposure - temp, rashes
CALL SENIORS and anaesthetist
START TREATING SEIZURE WITH MEDICATION AFTER A 5 MINUTE WAIT FROM WHEN SEIZURE STARTS -
IV access - lorazepam –> again at 10 mins if need be –> phenytoin at another 10 mins
No IV access - diazepam PR every 10 mins (3 runs).
If >40mins then anaesthetist will intubatie with propofol and send to ICU
Will need head CT and toxicology screen once stable
How to manage paediatric seizures acutely
Airway - look in mouth and suction if needed, recovery position
Breathing - O2 in ALL patients, sats, RR, listen to chest
Circulation - listen to heart, CRT, HR, BP, IV access, blood (FBC, amylase, cross match 4 units, blood cultures, U+E, LFT, glucose, CRP, VBG, osmolality, toxicology screen), ABG (acidosis), ECG, fluid bolus if shock, abx if meningitis suspected
Disability - glucose and ketones, eyes, GCS, neuro exam, check drugs chart
Exposure - temp, rashes
CALL SENIORS and anaesthetist
START TREATING SEIZURE WITH MEDICATION AFTER A 5 MINUTE WAIT FROM WHEN SEIZURE STARTS -
IV access - lorazepam –> again at 10 mins if need be –> phenytoin at another 10 mins
No IV access - diazepam PR every 10 mins (3 runs).
If >40mins then anaesthetist will intubatie with propofol and send to ICU
Give some life threatening causes of seizures
Hypoxia
Hypoglycaemia
Metabolic
Trauma
Meningitis, encephalitis, malaria
Raised ICP
Stroke
Drug overdose (tricyclics, phenothazines, amphetamines)
Eclampsia
Alcohol withdrawal
Important questions to ask about seizures
S - headache, trauma, palpitations, chest pain, collateral, PMH - epilepsy, DM, SH - alcohol, drugs, occupation, recent travel
Collateral - what happened before, how they looked during it and awareness, post - weakness, sleepy and tongue trauma.
How is epilepsy managed
S - aware (focal), unaware (generalised), reduced GCS, tongue trauma, weakness, incontinence, Todd’s paraesis (transient weakness post-seizure like a TIA), post-ictal state
Ix - CT head, MRI, EEG, glucose, routine bloods
Rx - anti-epileptic medications, patient education
Drugs that lower seizure threshold
Gluoroquinolones, cephlasporins, penicillins, tricyclics, clozapine
How is parkinson’s disease managed
S - cogwheel rigidity, small lip movements, weak voice, bradykinesia, shuffling gait, resting tremor, dyspagia
Ix - CT and med review (haloperidol)
Rx - neuro PD MDT referral, levodopa, carbidopa, selegiline (MOA-B inhibitor) and Tolcapone (COMT inhibitor), domperidone (anti-emetic)
Have parkinson plus syndromes - multiple systems atrophy (cerebellar and autonomic dysfunction), progressive supranuclear palsy (impaired upwards gaze)
How is MND managed
S - UMNL and LMNL signs, purely motor, dysphagia, dysphasia, weakness, no sensation affected.
Ix - diagnosis of exclusion but EMG can help.
Rx - supportive, SALT, OT, PT, MND team, baclofen for gramps, riluzole
If similar with behaviour change and possibly younger think huntingtons disease
How is a stroke managed acutely
Brief history - pain, associated symptoms (headache, vomiting, seizures, LADY, fever), weakness, facial droop, PMH, D+A
Airway - look in mouth and suction if needed
Breathing - O2, sats, RR, listen to chest, CXR, sit up
Circulation - listen to heart, CRT, HR, BP, IV access, blood (FBC, amylase, cross match 4 units, blood cultures, U+E, LFT, glucose, CRP, VBG, osmolality, toxicology screen), ABG (acidosis), ECG (AF), slow fluids (100ml an hour).
Disability - glucose and ketones, eyes, GCS, neuro exam, check drug chart
Exposure - Temp, check legs, examine abdo - palpation, urinalysis for ketones, rashes
Inform senior, urgent CT head, management plan after head CT
Ischaemic -
<4.5hrs - thrombolysis with t-PA and thrombectomy
>4.5hrs - thrombectomy
Haemorrhagic -
Neurosurgery referral and clipped.
Carotid doppler and ECG are key for secondary prevention checks.
How are strokes managed long-term
2 weeks of aspirin
Lifelong clopidogrel
SALT assessment
BP monitoring
How is a TIA managed
S - same as stroke but likely resolve in around 24hrs as ischaemic not infarction
Ix - CT head, blood glucose, routine bloods
Rx - <3hrs then treat as stroke, if not then ABCD2 risk scoring (7-d stroke risk) then decide based off that for admission and start aspiring 300mg a day for 2 weeks and clopidogrel. Look for AF and carotid narrowing and lifestyle advice.
How to locate a lesion
UMNL - weakness, hyperflexia, hypertonia, no muscle waisting, up going plantars,
LMNL - weakness, hypoflexia, hypotonia, muscle waisting and fasciculations, down going plantars
Sensory - use dermatomes, glove and stocking - peripheral neuropathy.
How to cerebellar lesions present
DANISH
Dysdiokinesis
Ataxia
Nystagmus and pass pointing
Intention tremor
Slurred speech
Hypotonia/heel shin test
How does radiculopathy present
Nerve root pain - sharp and shooting pain along nerve root
How is a space occupying lesion managed
S - morning headaches, worse when coughing, vomiting, focal signs, behavioural change
Ix - CT head, MRI brain, LP if no raised ICP
Rx - treat cause (tumour, aneurysm, abscess, haematoma
How is myasthenia gravis managed
S - weakness, fatigue and ptosis as it gets later into day, diplopia, upward gaze is heard, normoflexia
Ix - EMG test, anticholinesterase antibodies, CT chest
Rx - anticholinesterase (pyridostigmine), immunosuppresion, thymectomy
Myasthenic crisis - caused by illness, surgery or medication (gent). Presents as severe fatigue, assess spirometry. Immunosuppresio and plasmapheresis
How is bells palsy managed
S - rapid mononeuropathy of facial nerve with forehead included
Ix - clinical
Rx - prednisalone, eye care (tape and drops) +/- aciclovir
How is GBM syndrome managed
S - glove and stocking loss of sensation, weakness
I - LP with raised protein
Rx - immunoglobulins and plasmaphoresis and FVC monitoring
How is MS managed
S - variable but can be motor and or sensory, optic neuritis is commonest presentation, LMNL and UMNL, incontinence
Ix - MRI and LP (oligocolonal bands)
Rx - lifestyle advice, biologics, methylpred for acute flares, catheter, MDT input, Physio and OT, baclofen for spasticity
Causes of polyneuropathies
B1 deficiency
GBM
Drugs - isoniazid, metronidazole
Diabetes
Hypothyroidism
Charcot-marrie tooth disease
How is back pain generally managed
S - trauma, pain (SOCRATES), change or loss of sensation, bladder and bowel function, weakness in limbs, weight loss, fever, PMH (previous episodse of back pain, osteoporosis), straight leg raise and skeletal tenderness and deformity.
Ix - FBC, CRP, U+E, PR exam (anal tone?), PSA, X-ray, MRI
Rx - depends on cause
How is mechanical back pain (+/- prolapsed disc managed)
S - trauma, pain (SOCRATES), change or loss of sensation, bladder and bowel function, weakness in limbs, weight loss, fever, PMH (previous episodse of back pain, osteoporosis), straight leg raise and skeletal tenderness and deformity, worse on coughing, radicular pain, normal PR
Ix - PR, FBC, CRP, X-ray spine, MRI if progressive neurology or features of cord compression.
Rx - reassurance, patient education, early mobilsation, avoid lifting and pain control (NSAID short term and dihydrocodeine)
What are the 6 types of mechanical back pain
Sprain - muscular spasm or pain without neurology
Prolapse - unilateral radiculopathy (sciatica)
Spondylosis - degenerative changes of spine (OA)
Spondylolysis - recirrent stress fracture leading to defect (L5 usually)
Spondylolisthesis - anterior displacement of vertebra, usually younger
Limbar spinal stenosis - narrowing of spinal canal due to OA, leg aching and heavy walking
How is cord compression managed
S - weakness, numbness, shooting pains, urinary or faecal retention/inncontinence, LMNL signs at the level of the lesion and UMNL signs below the lesion, normal above
Ix - routine bloods and urgent MRI
Rx - catheterise and refer immediately to ortho/neurosurgery
How is cauda equina syndrome managed
S - urinary/faecal incontinence/retention, painful or painless, bilateral leg weakness, reduced power and sensation LMNL signs, reduced perianal sensation, reduced anal tone and bilateral absent ankle reflexes.
Ix - urgent MRI spine
RX - catheterise and refer immediately to ortho/neurosurgery
How is a vertebral collapse fracture managed
S - sudden onset of back pain due to trauma, central verterbral tenderness, reduced mobility
Ix - spinal x-ray, routine bloods (anaemia if myeloma, raised ALP if cancer mets)
Rx - analgesia, find cause, treat osteoporosis
How is a headache managed and think of possible causes
A - tension headache, meningitis, raised ICP, encephalitis, temporal arteritis, migraine, cluster, sinusitis, trigeminal neuralgia, exertional, acute glucoma, drug-induced
S - pain and socrates, change with lying down of coughing, fever, vomiting, visual changes, jaw pain, scalp tenderness, seizures, trauma, rashes, eye pain or tunnel vision (glucoma), focal neurology, PMH (Migraines), Drugs (nitrates, analgesics, CCB), neck stiffness, fundoscopy for papillodema, sinus tednderness, STA tenderness
Ix - FBC, U+E, CRP, LFTs, glucose, head CT, LP, EEG, TPA biopsy, slit lamp.
Rx - treat cause, fluids analgesia, abx if infection, senior input, surgical referral if bleed, ophthamology referral if acute glucoma suspected
How to differentate trigeminal neuralgia and cluster headaches
TGN - Frequent unilateral stabbing pains in CN V distribution
Cluster - Frequent unilateral stabbing pains with rhinorrhoea, lacrimation and sweating
How is a subarachnoid haemorrhage managed
S - rapid onset thunderclap headache, loss of conciousness, neck stiffness, drowsy, vomiting, seizures, photophobia
Ix - urgent head CT, LP 12 hours later for blood in CSF
Rx - oxyen, morphine, metoclopramide, surgical referral for coiling or clipping, ICU referral, lie flat, neuro obs, nimodipine
How is meningitis managed
S - fever, malaise, neck stiffness, photophobia, headache, seizures, shock, rash
Ix - Head CT, FBC, U+E, CRP, LP
Rx - ceftriaxone, fluids, analgesia, dexamethasone, contact public health and contact tracing, anti-emetic
How is encephalitis managed
S - abnormal behaviours, seizures, drowsy, headache, altered personality, reduced GCS, fever, headache
Ix - Head CT (temporal lobe changes), FBC, U+E, CRP, LP and viral PCR
Rx - aciclovir, dexamethasone, fluids analgesia, public health contact, anti-emetics, abx if required
How is raised ICP managed
S - Headache in mornings and when coughing, tiredness, visual problems, seizures, reduced GCS, cushings reflex, papillodema
Ix - urgent head CT,
Rx - elevate bed, correct hypotension with 0.9% saline, discuss with senior for dexamethasone and mannitol to reduced ICP, neurologist and neurosurgery input
How is temporal arteritis managed
S - headache, jaw pain, scalp tenderness, pulseless/nodular STA, STA tenderness, visual problems, pain when eating
Ix - raised ESR, CRP, clotting (raised platelets), TPA biopsies in multiple sites
Rx - high dose prednisalone and strong analgesia, ENT and ophthamolgy review., doppler USS of atery can be helpful
How is a migraine managed
S - throbbing unilateral headache with nausea and vomiting and possibly aura, photophobia
Ix - normal bloods, CT and LP
Rx - acute (simple analgesia + anti-emetic + triptans), prevention (BB or topiramate)
How is sinusitis managed
S - facial pain, voice changes, headache, cold symptoms, nasal discharge, amnosia
Ix - clinical
Rx - beclometasone nasal spray, saline nebulisers, amoxacillin if severe
How are cluster headaches managed
S - short lasting unilateral sharp pain around the eye with nasal and eye discharge and sweating
Ix - clinical
Rx - sumitriptan and 100% oxygen, Prevention (verapamil)
How is a post-dural puncture headache managed
S - 4-5 days post LP or epidural
Ix - clinical
Rx - lie flat, analgesia, increase fluids, espcially caffeinated drinks, contact anaesthesia
How is dizziness managed and its common causes
A - labyrinthitis, vestibular neuritis, anaemia, hypoglycaemia, alcohol, CVA, ototoxic dtugs, hypotension
S - is it dizziness (light headed), or vertigo (being on ship), ask about loss of conciousness
Ix - romberg test, DANISH, examine ear, neuro exam, CT head and audiometry.
Rx - treat cause
How is vertigo managed
A - BPV (vertigo on moving), labyrinthitis (vertigo with hearing loss or tinnitus), vestibular neuritis (just vertigo no hearing issues), menieres (waves of attacks and hearing loss - progressive)
S - fever, recent colds, hearing issues
Ix - dix halpike test, clinical
Rx - cyclizine and betahistamine
How is imbalance/ataxia managed and what causes it
A - TIA/Stroke, cerebellar tumour, alcohol toxicity, wernickes encephalopathy, vitamin b12 decifiency, NPH, Trauma
S - Dysdiokinseia, ataxia, nystagmus, intention tremor, slurred speech, hypotonia/heel test, romberg positive
Ix - MRI
Rx - treat cause, wernickes (thiamine)
Causes of nystagmus
MS
Stroke
Space occupying lesions
Labyrnthitis
Vestibualr neuronitis
BPV
LSD, alcohol, ketamine
Lithium, SSRI, phenytoin
Wernickes encephalopathy
How is aggressive behaviour acutely managed
Stay close to exit, get extra help if needed, phone police if needed
Invite the patient to sit down with you to discuss the problem
Listen to the patient
Assess for psychosis
Ask about pain or worry
Consider sedation - 1mg lorazepam IV or haloperidol 5-10mg (2mg elderly)
Common causes of aggressive patients
Delirium
Intoxication
Psychosis
Pain
Hypoxia
Hypoglycaemia
How is alcohol withdrawal managed
S - 12-36hrs post alcohol, anxiety, shaking, sweating, vomiting, tonic-clonic seizures, hallucinations (delirium tremens), confusion, delusions
Ix - bone profile (all low), U+E, LFTs, investigate for chronic liver disease
Rx - chlordiazepoxie, parbinex, monitor BP and blood glucose, treat seizures if >5mins
How is delirium managed
S - fluctuating mood, change in consciousness, hallucinations, poor speech, aggressive, sleepy, do infection screen and full examination
Ix - routine bloods, bone profile, 4AT scoring, bladder scan, CXR, assess medications, PR exam, check pupils, urine dip, ECG
Rx - nurse in side room, close observations, consider cause (PINCH ME - Pain, infection, nutrition, constipation, hydration, medication and environment), sedation IF patients or staff at risk - haloperidol IM (No if parkinsons or alcohol Hx), give lorazepam
How is dementia managed
S - loss of memory, change in behaviour, step-wise worsening, worsening of cognition, language issues (FT dementia), gait issues (Lewy body), incontinence, worsening of independence, PMH (seizures, TIAs), D+A (sedatives), ADL struggles
Ix - MMSE, confusion screen (TFTs, FBC, U+Es, vitamin B12, folate, EST, calcium), neuro examination, CT possibly, ECG
Rx - refer to neurologist or psychogeneriatrician for specialise MST approach.
Give some reversible causes of dementia
Subdural haematoma
NPH
Korsakoff syndrome
B12 deficiency (replace before folate)
Folate deficiency
Hypothyroidism
Hypocalcaemia
How to manage psychosis
S - hallucinations, delusions, mood changes, change in interest in things, substance abuse or withdrawal, eating disorder, concentration, recent stresses, SUCIDAL IDEATION
Ix - full medical examination including neuro, MSE, for organic causes (FBC, U+E, LFTs, calcium, TFTs, ESR, B12, folate, cortisol)
Rx - urgent psych referral if manic, psychotic or suicidal, treat organic cause
Give some organic causes of psychosis
Endocrine - hyper/hypothyroidism, cushings, addisons
Neuro - Stroke, dementia, MS
ID - EBV, syphilis
Inflammatory - rheumatoid, SLE
Autoimmune - encephalitis
Electrolytes - Na, Calcium
Metabolic - wilsons disease
Medication - steroids
How is bipolar disorder managed
S - DIGFAST (distractable, indiscrete, grandiose, flight of ideas, activity increase, sleep decrease, talkative), periods of depression in Hx
Ix - review medications (steroids), infection screen, urinalysis, CT head.
Rx - urgent psych referral, antipsychotics (olanzapine), benzodiazepines, long term - lithium, valproate or lamotrigine
How is depression managed
S - apathy, low confidence, suicidal, sleep disturbance, anhedonia, appetite changes, loss of concentration, lack of eye contact, psychosis, poorly kempt, slowed speech
Ix- often none but risk assess, consider organic cause like thyroid or calcium levels
Rx - CBT, SSRI, ECT
Inform patient that antidepressants take time to work.
How is schizophrenia managed
S - positive (delusions, hallucinations often auditory), negative (blunted affect, apathy, loss of drive, social withdrawal, poverty of speech, cognitive impairment, neglect)
Ix - check medication
Rx - urgent psych referral, atypical antipsychotics (olanzapine or clozapine)
What are the 4 first rank symptoms of schizophrenia
Delusions
Hallucinations
Passivity
Though flow and possession (withdrawal and insertion and broadcasting)
How are anxiety disorders managed
S - worry, irratibility, fear, checking for reassurance, somatic (muscle tension, hyperventilation, tight chest, SOB, palpitations, tingling in fingers, aches and pains.
Ix - FBC, U+Es, LFTs, Calcium, troponin, ECG, TFTs
Rx - patient education on disorder and relaxing techniques, CBT, SSRIs, investigate cause
Causes - specific phobia, social phobia, panic attack, GAD, OCD
What are the three groups of personality disorders
Group A - odd, eccentric and paranoid
Group B - dramatic, emotional, antisocial and borderline
Group C - anxious, fearful and includes dependent
Treat with dialectial behavioural therapy
What are the three groups of personality disorders
Group A - odd, eccentric and paranoid
Group B - dramatic, emotional, antisocial and borderline
Group C - anxious, fearful and includes dependent
Treat with dialectical behavioural therapy
How is insomnia managed
S - struggle to sleep
Rx -
Short term (<4W) - ear plugs, sleep hygiene (no phone, better sleeping times, no caffeine, evening exercise), eye masks, 2 weeks of zopiclone if daytime impairment present
Long term (>4W) - CBT, specialist sleep clinic, melatonin
How is pregnancy diagnosed and managed
S - missed periods, urinary frequency, nausea, vomiting, malaise, breast enlargement, enlarged uterus, nipple tingling
Ix - BhCG, transvaginal USS
Rx - break news, folic acid (5mg dose if anticonvulsants, DM, BMI>30, previous children, neural tube defects), health promotion, no smoking or alcohol, avoid unpasteurized cheese, shellfish, education on DM, pre-eclampsia, rhesus disease and miscarriage signs
What are the 5 types of miscarriage
Threatened - bleeding with closed OS, heart beat
Inevitable - bleeding with an open OS, heart beat
Missed - none/bleeding, no heart beat
Incomplete - bleeding, open OS, retained products, could turn septic
Complete - bleeding settled and empty uterus
How does a miscarriage present
S - vaginal bleeding, crampy lower abdo pain, nausea, vomiting, shock, abdo tenderness, vaginal exam, speculum exam (clots/cervical orrifce open or closed)
Ix - routine bloods, G+S, BhCG, transvaginal USS
Rx - exclude ectopic, fluid resus if shock, ergometrine IM for severe bleeding, analgesia, may need surgical evacuation of retained tissues.
When are miscarriages investigated
When they become recurrent >=3
Do karyotyping on productions of conception
Maternal antiphospholipd antibodies
Thrombophilia screen
Pelvic USS
What are the medical and surgical options for abortions
Medical (<9w) - mifepristone followed by misoprostol
Surgical - dilatation and evacuation or vacuumunder GA or spinal
