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Clinical Presentations III Flashcards

1
Q

How is an AKI managed

A

S - dehydrated, abdo pain, malaise, vomiting, tender suprapubic region, rashes (GN), odema, raised JVP
Ix - investigate cause - fluid status, urinalysis, routine bloods, osmolality, ABG (acidosis), renal USS, bladder scan, medication review for nephrotoxic drugs, CT KUB, renal biopsy and immunological serology tests if intrinsic cause, PR exam
Rx - Insert catheter, fluids, treat the cause, may need furosemide if overloaded, treat hyperkalaemia, stop nephrotoxic drugs

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2
Q

How is CKD managed

A

S - late stage presentation, raised urea and creatinine, tiredness, weight loss and nausea, PMH (DM, HT, GN, polycystic kidney disease)
Ix - urinalysis, routine bloods, renal USS, albumin:creatinine ratio, calcium (hypocalcaemia)
Rx - treat risk factors - ACEI, DM medication, stop smoking, avoid nephrotoxic drugs, assess CVD health (statin and antiplatelet), erythropoietin injections, calcium and vitamin D, transplantation is late stage.

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3
Q

Name some nephrotoxic drugs (DAMN BOP)

A

Diuretics/digoxin
ACEI/ARB
Metformin
NSAIDs

Benzodiazepines
Opioids
Penicillins

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4
Q

What suggests a peritoneal dialysis infection

A

Turbid dialysate - send for cell count, gram stain and culture

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5
Q

How is haematuria managed

A

S - shock, suprapubic pain, inability to urinate (clot retention), volume and colour of urine, rashes, bruises, size of the prostate, travel, smoker, occupation, any SOB
Ix - urinalysis, urine microscopy, bladder scan, routine bloods, flexible cystoscopy and biopsy, G+S, Creatinine kinase if suspect rhabdomylosis
Rx - resuscitate if in shock, a three-way catheter for irrigation if needed, discuss with urology, treat cause (cells/nitrates - UTI, no protein - cancer, protein - glomerular).

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6
Q

How is proteinuria managed

A

S - recent exercise, pregnancy chance, blood or change in smell or pain when urinating, rashes, oedema, SOB, recent infections, medications, fluid overload signs - crackles, peripheral oedema
Ix - urinalysis, MC+S, routine bloods, pregnancy test, renal USS and biopsy, albumin:creatinine ratio, auto-antibodies (anti-GBM, ANCA, ANA)
Rx - reassure if (caused by exercise or orthostatic), UTI (abx and fluids, pre-eclampsia (labetalol, take to theatre etc), CKD (tight control of BP and diabetes), GN (refer for assessment, advanced aut-antibody bloods and steroids

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7
Q

How is rhabdomylosis managed

A

S - AKI-like presentation with muscle pain after long lie, intense exercise or crush injury
Ix - routine bloods, urinalysis, creatinine kinase, troponins (normal)
Rx - fluids, analgesia, stop nephrotoxic drugs, treat hyperkalaemia

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8
Q

How is tumour lysis syndrome managed

A

S - muscle cramps, chemo 3-4 days beforehand, weakness, seizures
Ix - routine bloods (high potassium, high phosphate, low calcium, high urate, high creatinine and high urea)
Ix - IV flids and allopurinol and monitor electrolytes, bicarbonate, refer to renal

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9
Q

How is glomerularnephritis managed

A

S - Nephritic (HOOP) haematuria, oliguria, oedema, proteinuria/ nephrotic (SHOP) - serum hypoalbuminaemia, hypercholesterolaemia, oedema, proteinuria, nausea, abdo pain, fatigue, rashes, recent infections
Ix - routine bloods, urinalysis, renal USS and biopsy,
Rx - treat cause (minimal change -nephrotic steroid responsive and seen in kids post-infection), (membranous - nephrotic and give immunosuppresion), (focal segmental glomerulosclerosis - nephrotic sndrome and respnds to steroids)

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10
Q

How is acute urinary retention managed

A

S - abdo pain, sweating, shock, suprapubic pain, percussable bladder, mixed neurology in lower limbs
Ix - PR, PSA, urinalysis and cluture, lower limb neuro exam, bladder scan
Rx - catheterisation, review medications, pre and post bladder scan, laxatives if constipated, abx if UTI, post-obstructive diuresis (check fluid balace and electrolytes), TWOC at a later date.

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11
Q

How is chronic urinary retention managed

A

S - palpable distended bladder with high residual and non-tender, enlarged prostate, poor flow usually
Ix - PSA, PR, routine bloods, pre and post bladder scan
Rx - only cathererise if pain or nauric, refer to urology for (TURP intermittent self-cetheterisation, finasteride or tamsulosin

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12
Q

How is urinary incontinence managed

A

S - can be urge/stress or overflow so ask to find out, happens abruptly, happens when laughing or coughing and can happen with urgency and poor voiding symptoms, dysuria, fever, haematuria, caffeine intake, number of children and birth types, any parasthesia or loss of sensation.
Ix - PSA, PR, routine bloods, look for prolapse and pelvic masses, MSSU, glucose, urinary diary
Rx - lose weight, pelvic floor exercises, less caffeine, clear fluids, stop smoking, transvaginal tape if required, bladder retraining therapy

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13
Q

How is a low urine output managed

A

A - hypovolaemia, septic, AKI, CKD, retention
S - low urine output, shock, abdominal pain, poor stream, poor fluid intake, high stoma output, look for sings of bleeding, SOB, fever as may be septic
Ix - routine bloods, bladder, scan, fluid status assessment, PR, urinalysis, MSSU, septic screen, CK
Rx - urinary catheter, hourly fluid balance, catheter irrigation, fluid bolus, treat cuase if identified.

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14
Q

How is hypovolaemia managed

A

S - low urine output, shock, abdominal pain, poor stream, poor fluid intake, high stoma output, look for sings of bleeding, SOB, fever as may be septic
Ix - fluid status assessment, routine bloods and septic screen if required
Rx - fluid challenge of 500ml then 0.9% saline 1L/4h and review in 1-2hrs

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15
Q

How is fluid overload managed

A

S - SOB, oedematous legs, pink frothy sputum, raised JVP, CHF history,
Ix - routine bloods, ECHO, CXR, stop fluids, hourly obs
Rx - sit up, oxygen, stop fluids, furosemide 40mg IV, catheter and daily weights

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16
Q

How is fluid status assessed

A

Go from arms up to face adn chest then down to leg -

CRT, pulse, skin turgor, BP, eyes sunken, mucus membranes, JVP, listen to chest and heart, look for bladder distention then view catheter bag and look at fluid chart.

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17
Q

How are resus fluids used

A

500ml of plasmalyte/0.9% saline IV over 15mins in normal people
250ml of plasmalyte/0.9% saline IV over 15mins in frail or heart problems
10ml/kg of plasmalyte/0.9% saline IV over 15mins if child

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18
Q

How are maintenance fluids used and whats important

A

Important to check fluid balance, why they need fluids, how much they can manage orally and U+Es

1 salty and 2 sweet if frail over 12hrs if unfrail then over 8hrs

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19
Q

What are the normal daily requirements

A

25-30ml of water/kg (this covers insensible losses)
1mmol/kg/day of sodium, potassium and chloride
50-100g of glucose

If significant insensible losses expected than 0.5-1.5l extra in 24hrs

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20
Q

What are the special cases for giving fluids and why

A

Post-op - may need more for third space losses (hartmanns 0.9% saline if GI surgery)
Heart problems - daily weights and 1.5l/day
CKD - avoid potassium unless hypokalaemic, keep an eye on U+Es
AKI - restrict sodium so give 5% glucose 1.5l/24hrs
CKD - reduced rate 1.5l/day

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21
Q

How is hypokalaemia managed

A

Hx - SOCRATES, any associating symptoms, chest fluttering, PMH, drugs and allergies
A - patency
B - RR, sats, listen to chest, percuss, O2 if needed
C - ECG (prolonger PR interval, ST depression, inverted T waves and U waves after T wave), BP, listen to hear, IV access with bloods (FBC, U+E (<2.5 or <3 with ECG changes), D-dimer, troponin, LFT, CRP), HR, CRP, 40mmol/L KCl in 1L saline IV at quickest rate of 4hrs, ABG (severe alkalosis)
D - glucose, Eyes, GCS, quick neuro exam
E - expose patient and examine, check abdo and legs, temp

Call senior
Reassess
Assess cause - V+D, diuretics, steroidsm cushings and dehydration and conns

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22
Q

How is hyperkalaemia managed

A

Hx - SOCRATES, any associating symptoms, chest fluttering, PMH, drugs and allergies
A - patency
B - RR, sats, listen to chest, percuss, O2 if needed
C - ECG (tall T waves, broad QRS and flat P waves), BP, listen to hear, IV access with bloods (FBC, U+E (>7 or >5.3 with ECG changes), D-dimer, troponin, LFT, CRP), HR, CRP, ABG (severe acidosis), 10ml of 10% calcium gluconate IV over 2 minutes every 15 minutes up to 5 times until potassium is normal again, 10 unites actarapid in 50ml of 50% glucose over 10 mins, salbutamol 5mg nebulizer
D - glucose, Eyes, GCS, quick neuro exam
E - expose patient and examine, check abdo and legs, temp

Call senior
Reassess
Assess cause - haemolysed blood, AKI, CKD, Potassium sparing duiretics, ACEI, trauma, burns, transfusions, addisions

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23
Q

How is tumour lysis syndrome managed

A

S - muscle cramps, chemo 3-4 days beforehand, weakness, seizures
Ix - routine bloods (high potassium, high phosphate, low calcium, high urate, high creatinine and high urea)
Rx - IV fluids and allopurinol and monitor electrolytes, bicarbonate, refer to renal

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24
Q

How to prescribe fluids properly

A

Decide 24hr requirement for fluids and electrolytes
Convert into 1 litre/500ml bags
If deficit to patient run at faster rate initially aka 1hr/2hr/4hr
Review fluids for later if required

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25
How is hyponatraemia managed
S - diarrhoea, abdo pain, urianry frequency, thirst, cough, chest or head pain, PMH organ failure, D+A diuretics and opioids. Ix - assess fluid balance - important to indicate for cause and thus treatment, U+E, urine and serum osmolality, CRP, FBC, Rx - Hypovolaemic and <20mmol urine Na - hypovolaemia (replace with 0.9% saline and stop diretics) Hypovolaemic and >20mmol urine Na - renal disease or diuretics (replace with 0.9% saline and stop diretics) Euvolaemic - SIADH (replace with 0.9% saline very slowly 8-10hrs per 1L and stop diretics) Hypervolaemic - heart, renal or liver failure (treat cause) CORRECT SLOWLY <10mmoll/day due to CENTRAL PONTINE DEMYLINATION
26
How is hypernatraemia managed
S - anorexia, nausea, weakness, hypovoalemia, confusion, reduced GCS, burns, neuro defects Ix - plasma and urine osmolality, CT head if neuro symptoms, U+Es Rx - depends of fluid status - Hypovolaemic - 0.9% saline 1L/6h until euvolaemic Normovolaemic - oral fluids or 5% glucose 1L/6hrs and monitor fluid balance with U+Es and catheter CORRECT SLOWLY <10mmol/day due to CEREBRAL OEDEMA
27
How is SIADH managed
S - Serum osmolality low, normal thyroid and adrenal, concentrated urine, usually asymptomatic, euvolaemic Ix - U+Es, urine and serum osmolality, TFTs, short synthacten test, A:C ratio, medication review (SSRI, antipsychotics, tricyclics, CXR (small cell ca), CT head (raised ICP) Rx - treat cause and 0.9% saline slowly 8-10hr/1L
28
Why is checking the corrected calcium important
Hypoalbuminaemia can give falsely low recordigns of calcium
29
How is hypocalaemia managed
S - hands spasms, twitching of muscles, depression, hyperflexia, bradycardia, arrhythmias Ix - U+Es, calcium, mg, vitamin D, bone profile PTH, ECG (prolonged QT and ST abnormalities), LFTs (raised ALP) Rx - 10ml 10% calcium gluconate IV over 10 minutes, correct low mg if present. If mild then calcichew with vitamin D if low, treat cause (hypoarathyroidsm - vit D and calcium), (osteomalacia/rickets - same).
30
How is hypercalaemia managed
S - bone pain, renal stones, depression, abdo pain, constipation, vomting, thirst and weight loss, arrhythmias, hypertension, dehydration Ix - FBC, U+Es, bone profile, Mg, ECG (shortened QT), CXR, serum and urine electrophoersis (myeloma), PTH, LFTs and ESR for myeloma Rx - IV fluids for rehydration then further IV fluids with furosemide to clush out calcium, catherisation to monitor fluid balance, daily bone profile bloods, U+Es and Mg, IV bisphosphonates, treat cause - malignancy (breast, lung, thyroid, kidney and prostate), hyperparathyroidism - partial parathyroidectomy, sarcoidosis - steroids. Pagets disease - calcium normal but ALP high, give bisphosphonates and analgesia and surgery if fractures.
31
How is anaemia managed in general
S - dizziness, sore head, SOB, hypotension, chronic disease, pregnancy, angular stomatitis, pale conjunctivi, pale palmer creases, jaundice Ix - PR exam, FBC, CRP, U+e, LFT, blood film, reticulocyte count, iron studies, B12 and folate, ECG, bence jones protein. Rx - identify cause (exclude malignancy if >40), assess diet and give oral supplements if needed, RBC transfusion if symptomatic or Hb <80g/l
32
What causes low MCV
Iron deficiency Thalassaemia
33
What causes normal MCV
Pregnancy (dilution) Haemorrhage haemolysis renal failure malignancy Anaemia of chronic disease Bone marrow failure
34
What causes high MCV
Vitamin b12/folate deficency alcohol liver disease throid disease myelodisplasia anti-folate drugs - methotrexate
35
Whats the difference between anaemia of chronic disease and anaemia of haemolysis and anaemia or iron deficiencies on iron studies
Chronic disease - low iron low TIBC high ferritin and normal MCV Iron deficiency - low iron high TIBC low ferritin and low MCV Haemolysis - high iron low TIBC high ferritin and normal MCV
36
How is anaemia secondary to blood loss managed
S - chest pain, palpitations, recent surgery, haematemesis, malaena, menorrhagia, shock signs, high RR, reduced GCS, Ix - PR (malena) Rx - lay flat and elevate legs, give oxygen, IV access, take bloods and give fluid challenge, apply pressure at bleeding site if present, contact senior.
37
How is anaemia of chronic disease managed
S - fatigue, SOB, dizziness, palour, headaches, chronic disease (infection - TB/IE, RA, malignancy, IBD) Ix - FBC, iron studies (low TIBC an diron, normal MCV and normal or high ferritin) Rx - treat chronic disease and consider EPO
38
How is haemolytic anaemia managed
S - mild jaundice, murmurs, hepatosplenomegaly (G6PD), metalic click on chest ausculatation Ix - LFTs raised bilirubin (unconjugated), RBC, reticulocyte count (Raised) Rx - steroids, immunosuppresion and splenectomy (if autoimmune)
39
How is iron deficiency anaemia managed
S - fatigue, SOB, dizziness, palour, headaches, abdo pain, malena, haematemesis, pallor, haemoptysis, koilonychia, glossitis, angular stomatitis Ix - FBC, LFTs, U+Es, reticulocyte count, blood film, iron studies (low iron low feritin and high TIBC), Stool FIT test, PR, OGD and colonoscopy Rx - treat cause, ferrous sulphate (can raise by 10g/l a week)
40
How is folate deficiency managed
S - fatigue, SOB, dizziness, palour, headaches, poor diet, alcohol history, coeliac disease history, crohns disease history Ix - FBC, LFTs, U+Es, vitamin B12, folate Rx - treat cause, treat B12 deficiency first, folic acid 5mg PO for 4 months
41
How is folate deficiency managed
S - fatigue, SOB, dizziness, palour, headaches, poor diet, alcohol history, coeliac disease history, crohns disease history, dyspepsia (autoimmune gastritis), crohns disease, neurological deficit (peripheral neuropathy), linked autoimmune conidtions (addisons disease and vitiligo), glossitis, depression and dementia Ix - FBC, U+E, vit b12, folate, intrinsic factor antibodies Rx - hydroxocobalamin IM every 3 months
42
What are the types of leukaemia and how is it managed
T - ALL (kids), CLL (40s male), AML (old and usually after chemo),CML (middle aged and best prognosis) S - recurrent infections, bruising, bleeding, night sweats, weight loss, hepatosplenomegaly, lymphadenopathy Ix - FBC (anaemia and raised WCC), routien bloods, blood film, bone marrow biopsy Rx - depends on type but acute (abx, blood transfusions) and long term (chemo and bone marrow transplant)
43
What are the types of lymphoma and how is it managed
T - hodgkins (usually young adults) and non-hodgkins (usually elderly but any age can be affected) S - lymphadenopathy, night sweats, itching, fever, weight loss, infections, fatigue, pain with alcohol, hepatosplenomegaly Ix - FBC, blood film, U+Es, LFTs, calcium, CXR, lymph node biopsy (reed sternberg cell - hodgkins), CT chest, abdo pelvis Rx - chemo, radiotherapy, steroids, bone marrow transplant
44
How is myeloma managed
S - CRAB (hypercalcaemia, renal failure, anaemia, bone pain), SOB, weight loss, fatige, lytic skull legions Ix - FBC, blood film, U+Es, LFTs, calcium, bence jones protein, bone marrow biopsy Rx - chemo, radiotherapy, allogenic stem cell transplant, bone work to fix fractures and steroids
45
How is pancytopenia managed
S - recurrent infections, bruising, bleeding, malignancy, infection Ix - FBC, blood film, vitamin B12 and folate, bone marrow biopsy Rx - treat cause and RBC and platelet transfusions
46
How are blood transfusion products ordered and checked
Take two samples at different times and label AT THE BEDSIDE G+S - analysed for group, lasts 72hrs Crossmatch - mixed with donor blood for antibody reactions O negative is the universal donor
47
When are irradiated blood products used
Prevents G VS H disease by killing of any lymphocytes, used in immunocompromised patients
48
How are red cell transfusions justified and prescribed
When Hb <70g/l or 80g/l in those with CVS or undergoing cardiac or ortho surgery Prescribe on the fluid chart and usually a seperate sheet Give over 3/4hrs usually
49
How are platelet transfusions justified and prescribed
<50X10(9) Symptomatic thrombocytopenia (bleeding usually)
50
When is FFP indicated
Replacing coag factors DIC
51
When is cryopercipitate indicated
Contains fibrinogen so for VW factor and VII and IX factors
52
How are haemolytic infusion reactions managed
S - pyrexia, abdo/chest pain, shock, flushing Rx - stop transfusion, oxygen, 1L stat, hydrocortosine, chlorphenamine Recheck bloods
53
How are non-haemolytic infusion reactions managed
S - pyrexia Rx - slow transfusion and give paracetamol, monitor
54
How is TACO managed
S - SOB, cough, chest pain, oedema, raised JVP Slow transfusion, 15L O2, sit up and furosemide 40mg and catheterize
55
How is a transfusion allergic reaction managed
S - urticaria, pyrexia and itch Rx - slow transfusion, inform senior, hydrocortisone, chlorphenamine
56
How long does transfusion bloods take to be picked up on a FBC
6-12hrs Anaemia in acute blood loss takes time to show as plasma is lost in equal proportions so doesnt look dilute.
57
sHow to manage a bleeding emergency
Hx - SOCRATES, any associating symptoms, PMH, drugs and allergies (blood thinners) A - patency B - RR, sats, listen to chest, percuss, O2 if needed C - BP, listen to hear, IV access with bloods (FBC, U+E , D-dimer, troponin, LFT, CRP), HR, CRP, IV vitamin K 5mg STAT D - glucose, Eyes, GCS, quick neuro exam E - expose patient and examine, check abdo and legs, temp Call senior Reassess Identify cause
58
How is haemophilia A and B managed
S - bleeding in childhood, usually haemarthrosis Ix - clotting screen, factor 8 and 9 levels, FBC, U+E, CRP Rx - avoid NSAIDs and IM injections, clotting factor replacement
59
How is Von Willebrand disease managed
S - mucosal bleeding and menorrhagia Ix - clotting screen, FBC, VW factor levels Rx - none usually
60
How is DIC managed
S - bleeding, petechiae, clots (cold limbs, DVTs etc) Ix - clotting screen, fibrinogen, D-dimer (up) Rx - Urgent help and ICU referral, treat cause (sepsis most commonly), supportive measures and correct coagulopathy as advised.
61
What is heparin-induced thrombocytopenia
Development of procoagulant antibodies in those receiving heparin and may lead to thrombocytopenia with thrombosis.
62
When to consider DVT prophylaxis
Medical patients - imobility >2 days, >60yrs, cancer, dehydrated, obese, DVT in past, HRT/COCP Surgical patients - above + surgery Remember to assess bleeding risk too. Give LMWH mostly (enoxaparin), can give stockings if meds are contraindicated due to bleeding risk but avoid in PAD
63
What is important to counsell patients about regarding warfarin
Check INR and how to adapt Reason for meds That warfarin is a dirty drug so tell doctors when going on it Loading doses - LMWH 7 days Life long for most conditions
64
How do you manage a rash emergency
Hx - SOCRATES, any associating symptoms, PMH, drugs and allergies A - patency - think anaphylaxis B - RR, sats, listen to chest, percuss, O2 if needed C - ECG, BP, listen to hear, IV access with bloods (FBC, U+E , D-dimer, troponin, LFT, CRP, blood cultures), HR, D - glucose, Eyes, GCS, quick neuro exam E - expose patient and examine, check abdo and legs, temp Call senior Reassess Identify cause
65
What rashes would present with shock
Meningococcal septicaemia Anaphylaxis Necrotizing fasciitis Toxic epidermal necrolysis
66
How is impetigo managed
S - honeycomb lesions on face and chin, serous discharge with occasional blisters and tenderness Ix - skin swabs Rx - fusidic acid, if extensive - flucloxacillin or phenoxymethylpenicillin, avoid sharing towels and good hand hygiene
67
How is erysipelas/cellulitis managed
S - well demarkated erythema (erysipelas), cellultitis (diffuse erythema), tenderness, fever, diarrhoea vomiting Ix - FBC, CRP, blood cultures if pyrexial, Wells score to assess if need for D-dimer/USS doppler Rx - flucloxacillin, fluids and analgesia If cannula site - remove cannula, swab it, put a dressing on and give flucloxacillin
68
How is necrotizing fasciitis managed
S - rapidly spreading painful blanching erythema that is disproportionate to the rash, fever, shock, reduced GCS, bilsters, oedema, lymphadenopathy Ix - FBC, CRP, lactate, blood cultures and skin swabs, x-ray (gas in subcutaneous of infected tissues) Rx - surgical emergency, senior input with surgical debridement needed in theatre, give
69
How is meningococcal septicaemia managed
S - fever, neck stiffness, photophobia, non-blanching pupuric rash, joint and muscle ache, shock Ix - CRP, FBC, meningococcal PCR, deranged clotting, blood cultures Rx - ABCDE, ceftriaxone IV, inform public health
70
How is chicken pox managed and its importance in pregnancy
S - fever, flu like symptoms, macules, papules, vesicles and scabbing, start on trunk Ix - usually clinical but can send viral PCR Rx - paracetamol and topical antihistamines to stop itch, if >16yrs then aciclovir Pregnancy - primary infection during first 20W of pregnancy - 1-2% risk of foetal anomolies and miscarriage. If no clear chicken pox hx - IgG titres then given vaccine if negative. Give immunoglobulin if infected.
71
How is shingles managed
S - focal pain and burning along dermatome with a blistering vesicular rash, malaise Ix - clinical but can give viral PCR if unsure Rx - valaciclovir if <72hrs, paracetamol, NSAIDs, amitriptyline If affects CNV1 then give aciclovir eye drops and ophthamology opinion Ramsay Hunt syndrome - facial pain, vesicles in EAM, facial nerve palsy
72
How is measles managed
S - fever, cough, cold, rash from necka nd face to trunk and limbs, koplik spots (grey/white on buccal mucosa) Ix - none usually but can have viral specific IgM Rx - supportive care and look out for complications (pneumonia, encephalitis)
73
How is rubella managed
S - fever, cough, cold, rash from necka nd face to trunk and limbs, arthalgia, tender lymphadenopathy Ix - none usually but can have viral specific IgM Rx - supportive care, foetal abnormalities if pregnancy (deafness and cataracts)
74
How is viral exanthema managed and what is it
S - rash, prodromal symptoms (fever, headache, myalgia), widespread maculopapular rash and features of infection (usually throat) Ix - clinical Rx - reassure and analgesia
75
How is slapped cheek managed
S - non-itchy rash on cheeks that later spreads to trunk and limbs, headache, well, children Ix - clinical (parovirus B19) Rx - 7-10d rash and supportive care
76
How is herpes managed
S - small painful vesicles, neuropathic pain, malaise Ix - viral PCR Rx - aciclovir, paracetamol and lidocaine
77
How is molluscum contagiosum managed
S - small non-itchy spots on trunk and limbs, usualy children, very contagious, papules with central depression Ix - clinical Rx - self limiting or potassium hydroxide 5%
78
What are dermatophytes and how are they managed
Pathological fungi - Tinea corporis - ringworm which causes a mildy itchy rash with asymmetrical spread, scaly edge with clear centre Tinea faciei - infection of the face Tinea cruris - ringworm of the groin with a well demarked border Tinea pedis - athletes foot, found in webspaces of toes with fissures and pustules can occur. Rx - topical antifungals or oral antifungals
79
How is candida albicans managed
S - erythematous with ragged peeling edge and small pustules. White plaques or discharge common Ix - clinical Rx - remove RFs (moist skin), topical clotrimazole or nyastatin for mouth
80
How is scabies managed
S - burrowing papular rash at interdigiral webspaces of hands, feet ankles and wrists Ix - skin scraping to look for mites Rx - permethrin on whole body, treat close contacts
81
How is lice managed
S - itchy head or body, nits found Ix - clinical Rx - permethrin/malathion
82
How is dermatitis managed
S - itchy, dry skin, erythema with wheeping skin usually in flexures, hyperpigmentation and linchenification if chronic Ix - clinical Rx - avoid irritants, topical steroids, topical emolients, if severer can use high dose topical steroids, calcineurin inhibitors and UV therapy
83
How is psoriasis managed
S - itchy dry patches of skin that bleed when scratched, pink scaly plaques on extensor surfaces, nail pitting, guttate psoriasis on trunk after viral infection Ix - clinical Rx - emolients, tar, topical steroids, vitamin D analogues, UVB light, methotrexate
84
How is utricaria managed
S - itcy papules, mild erythema Ix - clinical Rx - antihistamines and find cause and avoid
85
How is erythema nodosum managed
S - tender erythematous nodles on shins Ix - investigate for cause (TB, EBV, sarcoidosis, IDB, pregnancy, drugs - COCP) Rx - treat cause
86
How is erythema multiforme managed
S - target lesions Ix - investigate cause (adenovirus, HSV, mcoplasma pneumonia, NSAIDs penicillins) Rx - treat cause
87
How is SJS or TEN managed
S - widespread skin shedding, erythematous macules, mucosal erosions, <10% is SJS or >30% TEN Ix - usually medication (antibitoics, antiepleptics) Rx - fluids, analgesia, skin care, abx to prevent superimposed infection, remove causitive drug
88
How is pemphigus and pemphgoid managed
S - phemphigus (superficial blisters, younger, mucosal involvement)/phemphigoid (hard deep blisters, older and no mucosal involvment) Ix - skin swab testing and microscopy for antibody tests Rx - Derm input, steroids
89
How is pyoderma gangrenosum managed
S - painful nodules or pustules that ulcerate with a ragid purlpe edge Ix - skin swab, investigate for cause (IBD, RA, primary biliary cirrhosis) Rx - treat cause
90
How is henoch-scholein purpura managed
S - purpuric rash from legs to buttocks, haematuria, oliguria, proteinuria, abdo pain, arthalgia and oedema, recent flu Ix - U+Es, urinalysis, Rx - treat any GN
91
How to investigate skin lumps
Hx - size, change in shape, bleeding from site, pain, systemic symptoms, trauma, infections, PMH cancer,FH skin cancers, SH recent travel and sun exposure, lymphadenopathy, night sweats, weight loss Ix - FBC, U+E, CRP, LFTs, punch biopsy, excision biopsy, FNA cytology Rx - treat cause
92
How are lipomas managed
S - non-painful, found on neck or trunk, smooth and well-defined, soft subcutaneous and mobile with no skin changes Ix - clinical Rx - surgical excision
93
How are epidermoid cysts managed
S - painful if infected, firm and well defined, intradermal and mobile, can contain white discharge like cheese Ix - clinical Rx - flucloxacillin if inflammed, may need incision and drainage or surgical excision once not infected
94
How are ganglion cysts managed
S - single and non-painful, usually at wrsit, subcutaneous and smooth, transilluminable Rx - conservative
95
How are fibromas managed
S - slow growing and no overlying skin changes Rx - excision
96
How are sarcomas managed
S - singe, painful, progressive enlargment, firm and craggy and tethered to skin, lymphadenopahty regionally, weight loss Ix - X-ray and MRI Rx - surgery, radiotherapy and chemotherapy
97
How are abscesses managed
S - painful, erythematous, fever, onset over days, well defines, under the skin, neck, axilla, groin and perineum are common Ix - clinical Rx - incision and drainage, flucloxacillin
98
How are warts managed
S - painless, smooth lesions, genital (HPV 16 and 18) Ix - clinical Rx - salicylic acid or cryotherapy if single one
99
What are actinic keratosis
Scaly lesions on sun exposed skin, can develop into SCC
100
How are basal cell carcinomas managed
S - slow growing lesion on sun exposed skin, pink pearly edges with central ulceration, Drugs (imunosuppresion in the past), SH (sun exposure), CHECK FOR LYMPHADENOPATHY Ix - punch biopsy Rx - , surgical excision, may need topical chemo and radiotherapy, rarely metastasizes but can cause local tissue destruction
101
How are squamous cell carcinomas managed
S - fleshy plaque with scab, leeding and scaling or ulceration, crumbling texture, D+A (immunosuppresion) SH (arsenic or tar exposure, UV light exposure, CHECK FOR LYMPHADENOPATHY Ix - punch biopsy Rx - surgical excision, topical chemotherapy, photodynamic therapy, immunomodulators
102
How are milignant melanoma managed
S - assymmetry, border, colour, diameter or evolution over time of a brown naevi,CHECK FOR LYMPHADENOPATHY Ix - punch biopssy Rx - surgical excision with lymph node removal and chemo If moles originally, refer to specialist if changes in ABCDE
103
How are breast lumps investigated
S - onset, pain, size, change in shape, weight loss, lymphadenopathy, nipple discharge, skin changes, PMH (previous breast cancer or breast lumps), D+A (COCOP, HRT), FH (breast cancer) Ix - triple assessment (examination, biopsy with FNAC and imaging - mammogram if older and USS if younger Rx - depending on cause
104
Give four common benign causes of breast lumps
Fibroadenomas - young women, highly mobile lumps which are non-tender and well-defined. Refer to rule out cancer but usually just reassure. Fibroadenosis/fibrocystic change - middle aged with painfule and tender lumps which vary with menstrual cycle. Refer to surgeon, might be excised. Abscess - usually breastfeeding women or diabetics. Single, red and hot tender lump with possible pus from nipple and fever. Needs excision and drainage by the breast surgeon with antibiotics Breast seromas - fluid collections post breast surgery. Needs percutaneous drainage.
105
How are breast cancers managed
S - onset, pain, size, change in shape, weight loss, lymphadenopathy, nipple discharge and blood, skin changes, nipple inversion, skin dimpling, PMH (previous breast cancer or breast lumps, early menarhe and late menopause), D+A (COCOP, HRT), FH (breast cancer) Ix - triple assessment (examination, biopsy with FNAC and imaging - mammogram if older and USS if younger, USS axilla and liver with CT and bone scan if found lymphadenopathy Rx - depends on stage, surgery and chemo usually used either mastectomy or wide local excision
106
How are venous leg ulcers investigated
S - onset, pain, duration, trauma, hot swollen legs, sensation, oedema, feel for peripheral pulses, CRT, peripheral oedema, hair loss, temp, sensation, neuro exam, infection signs, size, depth and colour of ulcer (purple large and shallow on malleoli usually with chronic hyperpigmentation of legs and hot swollen legs, can be painful) Ix - FBC, CRP, HbA1C, ABPI, USS doppler, wound swab, x-ray and maybe MRI if osteomyeltitis suspected Rx - compression bandaging wit absorbable dressings, emolients and steroid creams as required, debridement and grafting.
107
How are arterial leg ulcers investigated
S - onset, pain, duration, trauma, claudication, hot swollen legs, sensation, oedema, feel for peripheral pulses, CRT, peripheral oedema, hair loss, temp, sensation, neuro exam, infection signs, size, depth and colour of ulcer (deep, bright red, usually on toes or lateral malleolus with pale cold skin and claudication, has CV risk factors, painful) Ix - FBC, CRP, HbA1C, ABPI, USS doppler, wound swab, x-ray and maybe MRI if osteomyeltitis suspected Rx - avoid compression bandages, address vascular RF and refer to vascular surgeon for bypass or angioplasty if required
108
How are neuropathic leg ulcers investigated
S - onset, pain, duration, trauma, claudication, hot swollen legs, sensation, oedema, feel for peripheral pulses, CRT, peripheral oedema, hair loss, temp, sensation, neuro exam, infection signs, size, depth and colour of ulcer (usually painless, on pressre points such as heal, can be very deep, callus around it, joint destruction, diabetes history) Ix - FBC, CRP, HbA1C, ABPI, USS doppler, wound swab, x-ray and maybe MRI if osteomyeltitis suspected Rx - careful footcare and surfgical debridement with abx can be needed.
109
How are infective leg ulcers investigated
S - onset, pain, duration, trauma, claudication, hot swollen legs, sensation, oedema, feel for peripheral pulses, CRT, peripheral oedema, hair loss, temp, sensation, neuro exam, infection signs, size, depth and colour of ulcer (red, hot, painful and inflammed and swollen) Ix - FBC, CRP, HbA1C, ABPI, USS doppler, wound swab, x-ray and maybe MRI if osteomyeltitis suspected Rx - give antibiotics and analgesia
110
How is keratitis managed
S - pain, photophobia, reduced vision, foreign body sensation over time, dry eyes, red conjunctivi, epithelial defect, corneal haze, hypopyon (pus in anterior chamber) Ix - corneal swabs Rx - antibiotic eye drops and ophthamology referral
111
How is episcleritis and scleritis managed
S - pain and tenderness (more severe in scleritis), photophobia, reduced vision, cant move injected vessels in scleritis as deep and too painful Rx - urgent ophthamology referral to rule out scleritis, topical NSAIDs for episcelritis and oral immunosuppressants for scleritis
112
How is anterior uveitis managed
S - blurred vision, photophobia and pain,red eye, decreased visual acuity, irregular and small pupil, hypopyon (puss in anterior chamber) Rx - urgent ophthamology referral with topical steroids and dilating agents
113
How is acute angle closure glaucoma managed
S - aching eye pain usually unilateral, headache, vomiting, photophobia, tunnel vision, semi-dilated pupil, opaque pupil, blurred vision, haloes around lights, pupil may be unreactive, tender to touch, red eye Rx - anti-emetics, IV opioids, emergency ophthamology referral, pilocarpine drops, acetazolamide (reduces AH), mannitol IV, iridectomy
114
Give 5 causes of an acute eye emergency
Keratitis Acute closed angle glucoma Episcelritis Scleritis Acute anterior uveitis ALL REQUIRE URGENT OPHTHAMOLOGY REFFERALS
115
How are corneal abrasions managed
S - sudden onset discomfort, lacrimation, trauma history, contact lens wearer, red watering eye, possibly visible foreign body, reduced visual acuity Ix - fluorescein stain Rx - anaesthetic to eye, pick out FB with cotton bud and irrigate with saline, tape eye until LA worn off, give chloramphenical eye drops afterwards, call on-call ophthamologist if cant remove
116
How is conjunctivitis managed
S - Eye discharge, itchy , hayfever, normal visual acuity, bacterial (pussy and sticky with no other symptoms), viral (watery and cold symptoms), allergic (itchy and watery with hay fever symptoms) Rx - seperate towels, bacterial (topical chlorampehnicol abx), allergic topical antihistamine, viral is slef limiting
117
How is subconjunctival haemorrhages managed
S - usually asymptomatic, burst vessel under conjunctiva Ix - check BP, check FBC and clotting Rx - self-limiting
118
How is giant cell temporal arteritis managed
S - pain, visual acuity, no RAPD, neurlogical signs, scalp tenderness, pain when chewing, floaters in vision Ix - ECG for AF, FBC, slit lamp, ESR, biopsy Rx - long term steroids
119
Give 4 causes of sudden visual loss
giant cell temporal artieritis retinal artery occlusion retinal vein occlusion vitreous haemorrhage
120
How is retinal artery occlusion managed
S - pain, visual acuity, RAPD, neurlogical signs, no (scalp tenderness, pain when chewing, floaters in vision,) CVD risk factors Ix - ECG for AF, FBC, slit lamp (cherry red spot of macula on slit lamp), ESR, lipid profile Rx - press on eye to dislodge if <1hr, secondary prevention
121
How is retinal vein occlusion managed
S - pain, visual acuity, no RAPD , neurlogical signs, no (scalp tenderness, pain when chewing, floaters in vision) Ix - ECG for AF, FBC, slit lamp, ESR, Rx - laser photocoagulation, intravitreal steroids, anti-VEGF
122
How is vitreous haemorrhage managed
S - sudden painloss loss of vision with floaters, RAPD, unable to see retina Ix - slit lamp, FBC, lipid profile Rx - should resolve spontaneously, prevent further episodes by laster photocoagulation
123
How is optic neuritis managed
S - subacute unilateral loss of vision and aching pain on movements, loss of colour vision, RAPD, normal optic nerve Ix - MRI head to assess for MS Rx - supportive and resolution over a few weeks
124
How is cataracts managed
S - gradually blurred vision and poor distance judgement, catarcts visibile in lens Rx - cataracts surgery if interfearing with reading or driving
125
How is age-related macular degeneration managed
S - deteroriation of central vision, reduced visual acuity, normal disc and visual feilds, smoker and older Rx - wet -VEGF/ dry is to stop smoking
126
How is chronic open angle glaucoma managed
S - gradual tunnel vision, cupping and atrophy of optic disc Rx - timolol, carbonic anydrase inhibitors, prostaglandin drops, traneculectomy
127
Give 3 causes of gradual visual loss
cataracts open angle glaucoma age-related macular degeneration
128
Give 8 causes of photophobia
meningitis SAH migraine encephalitis glaucoma scleritis Corneal injury
129
Give 5 causes of diplopia
Extra-ocular muscle palsy CN palsy myasthenia gravis orbital fracture MI
130
Give 5 causes of tunnel vision
Glaucoma Severe cataracts Alcohol consumption retinitis pigmentosa migraine
131
Give 2 causes of haloes around lights
Glaucoma Cataracts
132
Give 3 causes of floaters and flashing lights
Migraine Retinal detachment Vitreous haemorrhage Idiopathic
133
How is hypertension managed in pregnancy
Important to differentiate between hypertension and pre-eclampsia (>20W and need proteinuria) S - epigastric pain, headache, visual disturbances, vomiting, RUQ tenderness, oedema, papilloedema, hyperreflexia, clonus Ix - urinalysis, MSSU, urine PCR, routine bloods, clottig, G+S, USS, CTG Rx - stop any existing treatment with ARB or ACEI, refer to antenatal clinic, labetalol/CCB, if pre-eclapmsia admit and escalate treatment acocording to local protocl until BP controlled (labetalol and magnesium sulphate)
134
How is elampsia managed
S - headache, hyperreflexia, clonus, oedema, seizures Ix - clinical, CTG Rx - ABCDE, IV labetalol or hydralazine, urgent delivery, routine bloods and strict fluid balance
135
How is HELLP (haemolysis, elevated LFTs, low platelets managed)
S - upper abdo pain, malaise, vomiting, RUQ tenderness, oedema, hypertension Ix - FBC (anaemia), LFTs (raised bilirubin, raised ALT, low platelets) urinalysis (proteinuria) Rx - resus and stabilise BP, consider FFP, platlet or blood transfusion and urgent delivery
136
How is gestational diabetes managed
S - S - often asymptomatic and picked up at screening as OGTT, glucose on urine dip, large for dates, polyhydramnios Ix - OGTT, plasma glucose, regulat USS for foetal growth Rx - diabetic antenatal clinic review, dietary changes, exercise, start insulin or oral hypoglycaemics, repeat OGTT at 6 weeks
137
How is an antenatal haemorrhage caused and how is it managed
A - placenta praevia, placental abruption Ix - clinical Rx - ABCDE and treat for shock, speculum to look if cervical Oriffice is closed or open, CTG, urgent delivery considered
138
What week is anaemia checked in pregnancy and whats the treatment
Week 28 Ferrous sulfate
139
What is preformed for breech
External cephalic version at week 36
140
What are the options to induce pregnancy
Vaginal sweep and amniotomy to rupture membranes Vaginal prostaglandin to ripen the cervix Oxytocin infusion

FY1 (6 decks)

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