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FY1 > Clinical Presentations III > Flashcards

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
Q

How is hyponatraemia managed

A

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

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26
Q

How is hypernatraemia managed

A

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

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27
Q

How is SIADH managed

A

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

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28
Q

Why is checking the corrected calcium important

A

Hypoalbuminaemia can give falsely low recordigns of calcium

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29
Q

How is hypocalaemia managed

A

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).

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30
Q

How is hypercalaemia managed

A

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.

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31
Q

How is anaemia managed in general

A

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

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32
Q

What causes low MCV

A

Iron deficiency
Thalassaemia

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33
Q

What causes normal MCV

A

Pregnancy (dilution)
Haemorrhage
haemolysis
renal failure
malignancy
Anaemia of chronic disease
Bone marrow failure

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34
Q

What causes high MCV

A

Vitamin b12/folate deficency
alcohol
liver disease
throid disease
myelodisplasia
anti-folate drugs - methotrexate

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35
Q

Whats the difference between anaemia of chronic disease and anaemia of haemolysis and anaemia or iron deficiencies on iron studies

A

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

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36
Q

How is anaemia secondary to blood loss managed

A

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.

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37
Q

How is anaemia of chronic disease managed

A

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

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38
Q

How is haemolytic anaemia managed

A

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)

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39
Q

How is iron deficiency anaemia managed

A

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)

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40
Q

How is folate deficiency managed

A

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

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41
Q

How is folate deficiency managed

A

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

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42
Q

What are the types of leukaemia and how is it managed

A

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)

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43
Q

What are the types of lymphoma and how is it managed

A

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

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44
Q

How is myeloma managed

A

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

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45
Q

How is pancytopenia managed

A

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

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46
Q

How are blood transfusion products ordered and checked

A

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

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47
Q

When are irradiated blood products used

A

Prevents G VS H disease by killing of any lymphocytes, used in immunocompromised patients

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48
Q

How are red cell transfusions justified and prescribed

A

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

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49
Q

How are platelet transfusions justified and prescribed

A

<50X10(9)
Symptomatic thrombocytopenia (bleeding usually)

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50
Q

When is FFP indicated

A

Replacing coag factors
DIC

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51
Q

When is cryopercipitate indicated

A

Contains fibrinogen so for VW factor and VII and IX factors

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52
Q

How are haemolytic infusion reactions managed

A

S - pyrexia, abdo/chest pain, shock, flushing
Rx - stop transfusion, oxygen, 1L stat, hydrocortosine, chlorphenamine

Recheck bloods

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53
Q

How are non-haemolytic infusion reactions managed

A

S - pyrexia
Rx - slow transfusion and give paracetamol, monitor

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54
Q

How is TACO managed

A

S - SOB, cough, chest pain, oedema, raised JVP
Slow transfusion, 15L O2, sit up and furosemide 40mg and catheterize

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55
Q

How is a transfusion allergic reaction managed

A

S - urticaria, pyrexia and itch
Rx - slow transfusion, inform senior, hydrocortisone, chlorphenamine

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56
Q

How long does transfusion bloods take to be picked up on a FBC

A

6-12hrs
Anaemia in acute blood loss takes time to show as plasma is lost in equal proportions so doesnt look dilute.

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57
Q

sHow to manage a bleeding emergency

A

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
Q

How is haemophilia A and B managed

A

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
Q

How is Von Willebrand disease managed

A

S - mucosal bleeding and menorrhagia
Ix - clotting screen, FBC, VW factor levels
Rx - none usually

60
Q

How is DIC managed

A

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
Q

What is heparin-induced thrombocytopenia

A

Development of procoagulant antibodies in those receiving heparin and may lead to thrombocytopenia with thrombosis.

62
Q

When to consider DVT prophylaxis

A

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
Q

What is important to counsell patients about regarding warfarin

A

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
Q

How do you manage a rash emergency

A

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
Q

What rashes would present with shock

A

Meningococcal septicaemia
Anaphylaxis
Necrotizing fasciitis
Toxic epidermal necrolysis

66
Q

How is impetigo managed

A

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
Q

How is erysipelas/cellulitis managed

A

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
Q

How is necrotizing fasciitis managed

A

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
Q

How is meningococcal septicaemia managed

A

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
Q

How is chicken pox managed and its importance in pregnancy

A

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
Q

How is shingles managed

A

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
Q

How is measles managed

A

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
Q

How is rubella managed

A

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
Q

How is viral exanthema managed and what is it

A

S - rash, prodromal symptoms (fever, headache, myalgia), widespread maculopapular rash and features of infection (usually throat)
Ix - clinical
Rx - reassure and analgesia

75
Q

How is slapped cheek managed

A

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
Q

How is herpes managed

A

S - small painful vesicles, neuropathic pain, malaise
Ix - viral PCR
Rx - aciclovir, paracetamol and lidocaine

77
Q

How is molluscum contagiosum managed

A

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
Q

What are dermatophytes and how are they managed

A

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
Q

How is candida albicans managed

A

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
Q

How is scabies managed

A

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
Q

How is lice managed

A

S - itchy head or body, nits found
Ix - clinical
Rx - permethrin/malathion

82
Q

How is dermatitis managed

A

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
Q

How is psoriasis managed

A

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
Q

How is utricaria managed

A

S - itcy papules, mild erythema
Ix - clinical
Rx - antihistamines and find cause and avoid

85
Q

How is erythema nodosum managed

A

S - tender erythematous nodles on shins
Ix - investigate for cause (TB, EBV, sarcoidosis, IDB, pregnancy, drugs - COCP)
Rx - treat cause

86
Q

How is erythema multiforme managed

A

S - target lesions
Ix - investigate cause (adenovirus, HSV, mcoplasma pneumonia, NSAIDs penicillins)
Rx - treat cause

87
Q

How is SJS or TEN managed

A

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
Q

How is pemphigus and pemphgoid managed

A

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
Q

How is pyoderma gangrenosum managed

A

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
Q

How is henoch-scholein purpura managed

A

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
Q

How to investigate skin lumps

A

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
Q

How are lipomas managed

A

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
Q

How are epidermoid cysts managed

A

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
Q

How are ganglion cysts managed

A

S - single and non-painful, usually at wrsit, subcutaneous and smooth, transilluminable
Rx - conservative

95
Q

How are fibromas managed

A

S - slow growing and no overlying skin changes
Rx - excision

96
Q

How are sarcomas managed

A

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
Q

How are abscesses managed

A

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
Q

How are warts managed

A

S - painless, smooth lesions, genital (HPV 16 and 18)
Ix - clinical
Rx - salicylic acid or cryotherapy if single one

99
Q

What are actinic keratosis

A

Scaly lesions on sun exposed skin, can develop into SCC

100
Q

How are basal cell carcinomas managed

A

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
Q

How are squamous cell carcinomas managed

A

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
Q

How are milignant melanoma managed

A

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
Q

How are breast lumps investigated

A

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
Q

Give four common benign causes of breast lumps

A

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
Q

How are breast cancers managed

A

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
Q

How are venous leg ulcers investigated

A

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
Q

How are arterial leg ulcers investigated

A

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
Q

How are neuropathic leg ulcers investigated

A

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
Q

How are infective leg ulcers investigated

A

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
Q

How is keratitis managed

A

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
Q

How is episcleritis and scleritis managed

A

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
Q

How is anterior uveitis managed

A

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
Q

How is acute angle closure glaucoma managed

A

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
Q

Give 5 causes of an acute eye emergency

A

Keratitis
Acute closed angle glucoma
Episcelritis
Scleritis
Acute anterior uveitis

ALL REQUIRE URGENT OPHTHAMOLOGY REFFERALS

115
Q

How are corneal abrasions managed

A

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
Q

How is conjunctivitis managed

A

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
Q

How is subconjunctival haemorrhages managed

A

S - usually asymptomatic, burst vessel under conjunctiva
Ix - check BP, check FBC and clotting
Rx - self-limiting

118
Q

How is giant cell temporal arteritis managed

A

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
Q

Give 4 causes of sudden visual loss

A

giant cell temporal artieritis
retinal artery occlusion
retinal vein occlusion
vitreous haemorrhage

120
Q

How is retinal artery occlusion managed

A

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
Q

How is retinal vein occlusion managed

A

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
Q

How is vitreous haemorrhage managed

A

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
Q

How is optic neuritis managed

A

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
Q

How is cataracts managed

A

S - gradually blurred vision and poor distance judgement, catarcts visibile in lens
Rx - cataracts surgery if interfearing with reading or driving

125
Q

How is age-related macular degeneration managed

A

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
Q

How is chronic open angle glaucoma managed

A

S - gradual tunnel vision, cupping and atrophy of optic disc
Rx - timolol, carbonic anydrase inhibitors, prostaglandin drops, traneculectomy

127
Q

Give 3 causes of gradual visual loss

A

cataracts
open angle glaucoma
age-related macular degeneration

128
Q

Give 8 causes of photophobia

A

meningitis
SAH
migraine
encephalitis
glaucoma
scleritis
Corneal injury

129
Q

Give 5 causes of diplopia

A

Extra-ocular muscle palsy
CN palsy
myasthenia gravis
orbital fracture
MI

130
Q

Give 5 causes of tunnel vision

A

Glaucoma
Severe cataracts
Alcohol consumption
retinitis pigmentosa
migraine

131
Q

Give 2 causes of haloes around lights

A

Glaucoma
Cataracts

132
Q

Give 3 causes of floaters and flashing lights

A

Migraine
Retinal detachment
Vitreous haemorrhage
Idiopathic

133
Q

How is hypertension managed in pregnancy

A

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
Q

How is elampsia managed

A

S - headache, hyperreflexia, clonus, oedema, seizures
Ix - clinical, CTG
Rx - ABCDE, IV labetalol or hydralazine, urgent delivery, routine bloods and strict fluid balance

135
Q

How is HELLP (haemolysis, elevated LFTs, low platelets managed)

A

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
Q

How is gestational diabetes managed

A

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
Q

How is an antenatal haemorrhage caused and how is it managed

A

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
Q

What week is anaemia checked in pregnancy and whats the treatment

A

Week 28
Ferrous sulfate

139
Q

What is preformed for breech

A

External cephalic version at week 36

140
Q

What are the options to induce pregnancy

A

Vaginal sweep and amniotomy to rupture membranes
Vaginal prostaglandin to ripen the cervix
Oxytocin infusion

FY1 (6 decks)

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