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FY1 > Clinical Presentations II > Flashcards

Clinical Presentations II Flashcards

1
Q

How is an acute GI bleed managed

A

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.

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2
Q

What are the life threatening causes of upper GI bleeds

A

Peptic ulcer
Vascular malformations
Varices
Upper GI malignancy

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3
Q

What is the scoring system for upper GI bleeds

A

Rockall risk scoring system - need endoscopy to complete scoring.

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4
Q

Causes of lower GI bleeds

A

Upper GI bleeds
Diverticulitis
Colorectal cancer
Angiodysplasia
haemorrhoids
Bowel ischaemia
Anal fissure
IBD

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5
Q

How to manage chronic GI bleeding

A

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

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6
Q

How to manage haemorrhoids

A

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.

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7
Q

How to manage anal fissures

A

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

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8
Q

How to manage angiodysplasia

A

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

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9
Q

How to manage nausea and vomiting

A

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

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10
Q

How to manage diarrhoea

A

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

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11
Q

Drugs that cause diarrhoea

A

Abx
Laxatives
Colchicine
NSAIDs
Digoxin
Iron
Ranitidine
Thiazide diuretics
Propranolol
PPIs

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12
Q

Causes of N+V

A

DKA
Stomach bug
Raised ICP
Acute abdomen
Ileus
Bowel obstruction
Gastroenteritis
Labyrinthitis
Migraine
Hyperemesis gravidarum
Drug induced

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13
Q

How is infective gastroenteritis managed

A

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

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14
Q

How is pseudomembranous ulcerative colitis managed

A

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

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15
Q

How is IBS managed

A

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

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16
Q

How is coeliac disease managed

A

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

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17
Q

How is IBD managed

A

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

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18
Q

Differences between crohns and UC

A

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

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19
Q

How is UC managed

A

Mild - oral +/- rectal mesalazine
Moderate/severe - prednisalone

Recovery - mesalazine
Surgery - toxic megacolon or failure to respond to max medical therapy after 5-7 days.

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20
Q

How is Crohns managed

A

Mild - pred
Moderate/severe - hydrocortisone IV

Recovery - pred/azathioprine
Surgery if strictures or abscesses but never curative

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21
Q

How is constipation managed

A

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.

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22
Q

Medications that induce constipation

A

Opioids, iron tablets, CCBs, psychotropic drugs, anticholingergics, chronic laxatives

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23
Q

How is acute liver failure managed

A

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

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24
Q

Causes of acute liver failure

A

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

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25
Q

Signs of acute liver failure

A

Flapping tremor, IV drug abuse, jaundiced sclera, ascities, hepatomegaly, abdo pain, ankle swelling, gyaenacomastia, loss of hair, spider naevi, caput medusa, muscle wasting.

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26
Q

What blood test is used for monitoring how severe liver disease is

A

PT - clotting

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27
Q

How is alcoholic hepatitis managed

A

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)

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28
Q

What is Budd-chiari

A

Hepatic vein obstruction - use doppler USS

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29
Q

How is glandular fever managed

A

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)

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30
Q

How is acute viral hepatitis managed

A

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

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31
Q

Three main features of decompensated chronic liver failure

A

Decreased synthetic function - hypoalbuminaemia and clotting issues
Decreased detoxification - encephalopathy
Portal hypertension - variceal bleeding

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32
Q

How is decompensated chronic liver disease managed

A

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

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33
Q

How is spontaneous bacterial peritonitis managed

A

S - abdo pain, ascites, fever, tenderness and peritonitis,
Ix - FBC, CRP, ascitic tap
Rx - abx (tazocin)

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34
Q

How is autoimmune liver disease managed

A

S - Fever, anorexia, ascites, flu-like symptoms, vomiting, hepatomegaly
Ix - FBC, CRP, antibody screen, USS, liver biopsy
Rx - pred and azathioprine

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35
Q

How is haemochromatosis managed

A

S - lethargy, hepatomegaly, hyperpigmentation, DM, erectile dysfunction
Ix - transferrin, FBC (ALT), glucose, ECG, liver USS and biopsy, FBC
Rx - weekly venesection until normal ferritin

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36
Q

How is NAFLD managed

A

S - obesity, hypertension, diabetes, liver failure
Ix - FBC, U+E, LFT, HbA1c, USS and elastography, biopsy
Rx - weight control

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37
Q

How is anti-trypsin deficiency managed

A

S - SOB, liver failure, FH
Ix - antitrypsin levels, FBC, LFT, genetic testing, CXR, liver biopsy
Rx - stop smoking, transplant, manage COPD

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38
Q

How is Wilson’s disease managed

A

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

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39
Q

How is Weil’s disease (leptospirosis) managed

A

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

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40
Q

How to investigate jaundice

A

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

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41
Q

How is choledocholithiasis managed

A

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.

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42
Q

How is cholangitis managed

A

S - charcots triad (fever, jaundice, RUQ pain), murphy positive
Ix - FBC, LFT, CRP, USS abdo,
Rx - abx, ERCP

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43
Q

How is PBC managed

A

S - fatigue, pruritus, cirrhosis, cholestatic jaundice
Ix - USS and liver biopsy
Rx - ursodeoxycholic acid, colestyramine, steroids, fat vitamin replacement

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44
Q

Causes of hypoglycaemia

A

Medication
Insulin overdose
Starvation
Excess alcohol
Acute liver failure
Sepsis
Renal failure
Insulinoma

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45
Q

How is PSC managed

A

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

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46
Q

Cholangiocarcinoma management

A

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

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47
Q

How to manage a hypoglycaemia emergency

A

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

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48
Q

How is DKA managed acutely

A

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.

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49
Q

How is Hyperosmolar hyperglycaemic state managed acutely

A

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.

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50
Q

Causes of DKA/HSS

A

Sepsis
Surgery
MI and other acute illnesses
Poor medication compliance
Alcohol

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51
Q

How to manage general hyperglycaemia

A

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

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52
Q

How do insulin sliding scales work

A

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

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53
Q

What do you do if sliding scales is not lowering blood glucose levels

A

Check equipment
1.5-2 the insulin dose as before.

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54
Q

What to do if the sliding scale is lowering blood glucose levels too much

A

Stop the sliding scale and restart at half the dose of original scale once BG >6mmol/L

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55
Q

What to give when stopping a sliding scale

A

SC insulin at normal dose for that patient.

56
Q

How is type 1 diabetes managed

A

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.

57
Q

How is type 2 diabetes managed

A

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.

58
Q

Other areas of diabetic management

A

BP - ACEI/ARB
Nephropathy - albumin: creatinine ratio, tighten Bp control
Neuropathy - duloxetine
Retinopathy - annual retinal screening, anti-VEGF if required.
Footcare
Flu vaccines

59
Q

How is hypopituitarism managed

A

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

60
Q

How is diabetes insipidus managed

A

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

61
Q

How is acromegaly managed

A

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

62
Q

How is cushings disease managed

A

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

63
Q

How is adrenal insufficiency managed

A

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

64
Q

How is an Addisonian crisis managed

A

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

65
Q

How is hyperaldosteronism managed

A

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

66
Q

How is a phaeochromocytoma managed

A

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

67
Q

How is hypothyroidism managed

A

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

68
Q

How is hyperthyroidism managed

A

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

69
Q

How is a thyrotoxic storm managed

A

S - tachycardia, AF, fever, agitation, confusion,
Ix - TFTs, ECG
Rx - propanolol, uracil, hydrocortisone

70
Q

How is a coma/reduced GCS managed acutely

A

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

71
Q

What drugs can cause sedation

A

Benzos - flumenazil
Opioids - naloxone
Antihistamines
TCA
Baclofen
Alcohol - parbinex

72
Q

What is the features of the GCS scoring system

A

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

73
Q

How are adult seizures managed acutely

A

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

74
Q

How to manage paediatric seizures acutely

A

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

75
Q

How to manage paediatric seizures acutely

A

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

76
Q

Give some life threatening causes of seizures

A

Hypoxia
Hypoglycaemia
Metabolic
Trauma
Meningitis, encephalitis, malaria
Raised ICP
Stroke
Drug overdose (tricyclics, phenothazines, amphetamines)
Eclampsia
Alcohol withdrawal

77
Q

Important questions to ask about seizures

A

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.

78
Q

How is epilepsy managed

A

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

79
Q

Drugs that lower seizure threshold

A

Gluoroquinolones, cephlasporins, penicillins, tricyclics, clozapine

80
Q

How is parkinson’s disease managed

A

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)

81
Q

How is MND managed

A

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

82
Q

How is a stroke managed acutely

A

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.

83
Q

How are strokes managed long-term

A

2 weeks of aspirin
Lifelong clopidogrel
SALT assessment
BP monitoring

84
Q

How is a TIA managed

A

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.

85
Q

How to locate a lesion

A

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.

86
Q

How to cerebellar lesions present

A

DANISH
Dysdiokinesis
Ataxia
Nystagmus and pass pointing
Intention tremor
Slurred speech
Hypotonia/heel shin test

87
Q

How does radiculopathy present

A

Nerve root pain - sharp and shooting pain along nerve root

88
Q

How is a space occupying lesion managed

A

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

89
Q

How is myasthenia gravis managed

A

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

90
Q

How is bells palsy managed

A

S - rapid mononeuropathy of facial nerve with forehead included
Ix - clinical
Rx - prednisalone, eye care (tape and drops) +/- aciclovir

91
Q

How is GBM syndrome managed

A

S - glove and stocking loss of sensation, weakness
I - LP with raised protein
Rx - immunoglobulins and plasmaphoresis and FVC monitoring

92
Q

How is MS managed

A

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

93
Q

Causes of polyneuropathies

A

B1 deficiency
GBM
Drugs - isoniazid, metronidazole
Diabetes
Hypothyroidism
Charcot-marrie tooth disease

94
Q

How is back pain generally managed

A

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

95
Q

How is mechanical back pain (+/- prolapsed disc managed)

A

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)

96
Q

What are the 6 types of mechanical back pain

A

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

97
Q

How is cord compression managed

A

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

98
Q

How is cauda equina syndrome managed

A

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

99
Q

How is a vertebral collapse fracture managed

A

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

100
Q

How is a headache managed and think of possible causes

A

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

101
Q

How to differentate trigeminal neuralgia and cluster headaches

A

TGN - Frequent unilateral stabbing pains in CN V distribution

Cluster - Frequent unilateral stabbing pains with rhinorrhoea, lacrimation and sweating

102
Q

How is a subarachnoid haemorrhage managed

A

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

103
Q

How is meningitis managed

A

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

104
Q

How is encephalitis managed

A

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

105
Q

How is raised ICP managed

A

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

106
Q

How is temporal arteritis managed

A

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

107
Q

How is a migraine managed

A

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)

108
Q

How is sinusitis managed

A

S - facial pain, voice changes, headache, cold symptoms, nasal discharge, amnosia
Ix - clinical
Rx - beclometasone nasal spray, saline nebulisers, amoxacillin if severe

109
Q

How are cluster headaches managed

A

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)

110
Q

How is a post-dural puncture headache managed

A

S - 4-5 days post LP or epidural
Ix - clinical
Rx - lie flat, analgesia, increase fluids, espcially caffeinated drinks, contact anaesthesia

111
Q

How is dizziness managed and its common causes

A

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

112
Q

How is vertigo managed

A

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

113
Q

How is imbalance/ataxia managed and what causes it

A

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)

114
Q

Causes of nystagmus

A

MS
Stroke
Space occupying lesions
Labyrnthitis
Vestibualr neuronitis
BPV
LSD, alcohol, ketamine
Lithium, SSRI, phenytoin
Wernickes encephalopathy

115
Q

How is aggressive behaviour acutely managed

A

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)

116
Q

Common causes of aggressive patients

A

Delirium
Intoxication
Psychosis
Pain
Hypoxia
Hypoglycaemia

117
Q

How is alcohol withdrawal managed

A

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

118
Q

How is delirium managed

A

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

119
Q

How is dementia managed

A

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.

120
Q

Give some reversible causes of dementia

A

Subdural haematoma
NPH
Korsakoff syndrome
B12 deficiency (replace before folate)
Folate deficiency
Hypothyroidism
Hypocalcaemia

121
Q

How to manage psychosis

A

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

122
Q

Give some organic causes of psychosis

A

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

123
Q

How is bipolar disorder managed

A

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

124
Q

How is depression managed

A

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.

125
Q

How is schizophrenia managed

A

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)

126
Q

What are the 4 first rank symptoms of schizophrenia

A

Delusions
Hallucinations
Passivity
Though flow and possession (withdrawal and insertion and broadcasting)

127
Q

How are anxiety disorders managed

A

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

128
Q

What are the three groups of personality disorders

A

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

129
Q

What are the three groups of personality disorders

A

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

130
Q

How is insomnia managed

A

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

131
Q

How is pregnancy diagnosed and managed

A

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

132
Q

What are the 5 types of miscarriage

A

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

133
Q

How does a miscarriage present

A

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.

134
Q

When are miscarriages investigated

A

When they become recurrent >=3

Do karyotyping on productions of conception
Maternal antiphospholipd antibodies
Thrombophilia screen
Pelvic USS

135
Q

What are the medical and surgical options for abortions

A

Medical (<9w) - mifepristone followed by misoprostol

Surgical - dilatation and evacuation or vacuumunder GA or spinal

FY1 (6 decks)

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