Clinical Presentations IV Flashcards
How is trauma managed
S - ask about mechanims, activities prior, ability to move, pain, associated symptoms AMPLE (allergies, medication, PMH, last meal, events leading up to trauma), car trauma - speed, seatbelts, otehr people, what stopped the car?, full primary and secondary survey
Rx - analgesia prior to exam, treat injuries
How are soft tissue injuries managed (sprain and strains)
S - ask about mechanims, activities prior, ability to move, pain, associated symptoms AMPLE (allergies, medication, PMH, last meal, events leading up to trauma)
Ix - x-ray
Rx - POLICE
Protection
Optimal Loading - rest then weight bear once pain controlled
Ice to reduce swelling
Compression
Elevation to reduce pain and swelling
How are dislocations managed
S - ask about mechanims, activities prior, ability to move, pain, associated symptoms AMPLE (allergies, medication, PMH, last meal, events leading up to trauma)
Ix - x-ray
Rx -analgesia, document NV status, x-ray before and after reduction, recheck NV status, immobilize with strap, discharge with follow up and sling, may need physio
How are fractures managed
S - ask about mechanims, activities prior, ability to move, pain, associated symptoms AMPLE (allergies, medication, PMH, last meal, events leading up to trauma)
Ix - x-ray
Rx - analgesia only if rib or coccyx, ortho referral (imobilisation with backslab or sling with analgesia for most. If open, unstable or NV status compromised then ORIF)
How are open fractures managed
ABCDE
Senior help
Morphine
Take pictures before
Cover wound with iodeine or saline swabs
Start IV abx as per local guidelines
Review tetanus status
X-ray
Ortho referral urgent
How are wounds managed
S - mechanism of injury, bites, foriegn bodies, contamination, tetanus status, measure, check for distal NV compromise, CRT, movement
Ix - imaging make be required for foreign objects (x-ray)
Rx - clean would with 0.9% saline, if deeper wound may need syringe for higher pressure, closure - glue if small or on face, steri-strips can also be sed, if larger then LA intradermally and simple interupted stitches of non-absorbalbe sture can be often used, if deeper then may require absorbable sutures underneath to close other layers so get senior help if so.
When would a tetanus shot be given for wounds
Document tetanus status for all wounds
Ensure wound irrigation
>50yrs old and migrants may not have tetanus shots
Rx -
Full 5 injections <10yrs ago - no prophylaxis
Partial course <=10yrs ago - tetanus booster
Not immunised or unknown - start tetanus course
When are antibiotics given for wounds
Bites - co-amoxiclav or doxycycline if penicillin allergic
How is osteoporosis managed
S - bone pain, fragility fractures, arching back
Ix - DEXA scan and FRAX tool
Rx - Smoking cessation, regular weight breaing exercises, calcium and vitamin D, bisphosphonates
Bisphosphonates if fragility fracture or >75
How are head injuries managed
S - mechanism of injury, time of injury, memory loss, loss of conciousness, whitnesses, seizures, visual changes, AMPLE, fluid from vose or ears, vomiting, weakness or tingling in limbs, PMH clotting issues D+A anticouagulants SH baseline and occupation, Battles sign , haemotympanum, panda eyes, focal neurology, cause of fall? (syncope, hypoglycaemia)
Ix - CT head, routine bloods
Rx - admit if imaging abnormalities, GCS<15, worrying signs (vomiting, severe headache etc), intoxication
How are subdural haematomas managed
S - headache, decreased GCS and raised ICP, can be fluxuating if chronic, may have fall history, patients usually older, alcoholics and on anticoagulation
Ix - CT head
Rx - burrhole or crainotomy
How are patients with no concerning features post-head injury managed
Can be discharged home with support of a responsible adult for first 24hrs with head injury advice leaflet to explain the signs of deterioration and thus return to ED if they occur.
How are patients with extradural haematomas managed
S - headache, decreased GCS 4-8hrs post-fall and raised ICP, patients usually have trauma to head
Ix - CT head
Rx - craniotomy or burr hole
How are patients with post-concussion syndrome managed
S - headache, dizziness, tired, memory issues
Ix - CT head if meets criteria
Rx - no treatment
What are the criteria for a 1hr head CT
GCS <13 on initial assessment
GCS<15 2 hours post injury
Any sign of basal skull facture
Seizure
Focal neurology
>1 vomiting episode
What are the criteria for an 8hr head CT
> =65years old
Clotting disorder or blood thinners
Dangerous mechanism
Retrograde amnesia before the head injury
How are neck injuries managed
S - mechanism of injury, walking since accident, pain and SOCRATES, comfortable sitting, head injury, limb symptoms, AMPLE, previous beck problems or surgery, tetanus status, occupation, spine immobilisation is key, ON EXAMINATION - midline and paravertebral cervical spine tenderness, deformity, limb weakness
Ix - examine cervical spine with palpation and movement if patients have GCS of 15, sober and no focal neurology or distracting injuries and no neck pain, CT cervical spine or C-spine x-ray
Rx - if abnormal scans then leave neck immobilised and refer urgently, carry out neuro obs, normal scans require senior review.
What risk factors qualify a CT cervical spine within 1hr
GCS<13
Intubation
Before surgery if definetly getting surgery
High risk injury
How is whiplash managed
S - gradual onset of a painful and stiff neck, few hours/days after injury, tender over neck paravetrebral and midline area
Ix - clinical, X-ray if unsure
Rx - paracetamol and regular NSAIDs, rest for 48hrs then return to normal activities
Give some causes of falls
MI
Postural hypotension
AS
Ataxia
PD
Alcohol excess
Delirium
Trip
Peripheral neuropathy
dysrhytmias
Shock
Sepsis
Stroke/TIA
Seizure
Hypoglycaemia
PE
Hpoxia
How are falls managed
Highly depends on cause.
S - ask about what they were doing before, during and after fall, any witness accounts, chest pain, palpiations, dizziness, confusion, tongue bitting, urination, fever, PMH diabetes, epilepsy, PD, CV disease, D+A sedatives, hypoglycaemic drugs
Ix - routine bloods, drugs chart review, possible CT head (1hr or 8hrs), x-ray of any sore joints
Rx - treat cause and any injuries
What are the features of a falls review
Before visiting - ask nurse to do a full set of obs, postural BP and blood glucose, ECG, get collateral to see if its been witnessed.
S - events leading up to fall, dizziness, palpitations, weakness, aura, during - do they remember everything, did they lose conciousness, after - do they remember getting up, pain anywhere, how long were they on the floor, PMH previous falls, heart issues, DM, PD,D+A - anticoagulants, antihypertensives, antiepileptics, hypoglycaemics, diuretics, nitrates, SH - alcohol, mobility, eat and drinking, ON EXAMINATION - brief CV and neuro exam, look over head for signs of injury, feel c-spine, check for reduced arm and shoulder and leg movement - especially for a fractured NOF, ensure patient is back to full mobility for themselves
Ix - ECG, observations, lying standing BP, 4AT, routine bloods if required, CT head if required, X-ray if fracture.
Rx - treat cause, document findings and inform senior, ask nurses to fill out an incident form.
Review patient in 4hrs if suspected neuro. ask nurses to do hourly neuro observations.
Give some causes of situational syncope
Micturition - vagal tone causes collapse, get them to sit down to urinate
Carotid sensitivity - can be brought on by shaving
Cough - brought on by coughing fits
How is an acutely painful limb managed
Hx - SOCRATES, any associating symptoms, PMH of CV disease, recent surgery that could mean compartment syndrome, painful joint? septic arthritis, skin changes? necrotizing fascitis, sickle cell crisis? drugs and allergies
A - patency
B - RR, sats, listen to chest, percuss, O2 if needed
C - ECG (exclude MI if arm pain), BP, listen to hear, IV access with bloods (FBC, U+E, D-dimer, troponin, LFT, CRP), HR, ABG (acidosis),
D - glucose, Eyes, GCS, quick neuro exam
E - expose patient and examine, check abdo and legs - pulses, temperature, parasthesia, tenderness, doppler, ABPI, CRT, parasthesia and motor
Call senior
Reassess
Acute ischaemic limb - analgesia and vascular surgeons, analgesia
Compartment syndrome - remove plaster and orthopaedics, analgesia
Septic arthritis - joint aspiration and IV abx with orthopaedics, analgesia
Nectrotizing fasciitis - IV abx and surgeon input, analgesia
Gangrene - IV abx, analgesia and surgical input
How is superficial thrombophelbitis managed
S - gradual onset of tenderness over the vein, red and hard palpable vein, DVT RFs present
Ix - wells score, s-simer and doppler
Rx - elevate, exercise, compression, analgesia, LMWH if DVT suspected
How is muscle pain managed and some possible causes
A - trauma, fibromyalgia, infection, rhabdomyloosis, drugs (statins, ACEI, steroids), polymyalgia rhemuatic, dermatomyositis, SLE, metabolic (low potassium calcium or sodium) thyroid disease, cushings disase, referred joint pain
Ix - routine bloods, CK, ESR, X-ray
Rx - trat cause and consider physio
How is osteomyelitis managed
S - hot, swollen deep seated painful bone, fever, malaise, tender bone
Ix - routine bloods, ESR, x-ray (poor sensitivity in first 10 days), MRI required (GS), bone biopsy/ USS-guided aspiration may be required for abx sensitivity
Rx - high dose antibiotics (6wks), surgical debridement and drainage if abscess
What is dry gangrene and how is it managed
Necrosis without infection
S - well-defiend, painless, shrivelled black/brown area
Ix - clinical
Rx - debridement or amputation, may even wait for it to fall off itself
How is acute limb ischaemia managed
S - unilaterally painful, pulseless, cold limb, parasthesia, paralysis, slow CRT, COMPARE LIMBS
Ix - FBC, ECG (AF is RF), CRP, LFTs, U+Es, doppler will show reduced or absent pulse (may be slushy pulse), ABPI
Rx - call vascular - embolectomy, intra-arterial thrombolysis, bypass or amputation, IV morphine and fluids
How is wet (gas) gangrene managed
S - unwell, painful extremities or wound, fever, systemic shock, bilstering around necrotic site, crepitus (from gas in the tissue)
Ix - routine bloods, CK, blood cultures, clotting, ABG (acidosis), gram stain of wound swab, x-ray (gas patches in soft tissue)
Rx - call senior surgeon for debridement, oxygen, fluids, broad spectrum antibiotics
How is compartment syndrome managed
S - excessive pain post fracture/injury, distal tingling, numbness, weakness, cool peripheries, pain at rest, worse on passive stretching of the muscle, reduced sensation, redness, swelling, slow CRT
Ix - clinical, compartment presssure using a manometer, may need updated bloods including CK
Rx - oxygen, elevate limb with patient lying flat, morphine, IV fluids if dehydrated, remove plaster cast, call orthopods for urgent fasciotomy.
How is peripheral aterial disease managed
S - claudication, hairloss, leg pain at night which is eased by hanging foot out of the bed, cold leg
Ix - FBC, lipid profile, CRP, U+Es, ESR, ABPI with doppler, ECG
Rx - treat vascualr RFs (exercise, better diet, stop smoking), statins, avoid beta bockers, surgical referral for bypass or angioplasty may be needed.
What do the ABPI values suggest
> 1.3 - may be calcified or not PVD
0.8-1.3 - normal
0.5-0.8 - Moderate PVD
<0.5 - critical limb ischaemia
How is lumbar spinal stenosis managed
S - cramp in thigh or legs on walking, worse when walking downhill or standing, associated back pain, pain on straight leg raise or back extension, usually no neuro symptoms
Ix - lumbar spine x-ray, MRI spine
Rx - exercise, NSAIDs, steroid injections, spinal decompression
How is carpal tunnel syndrome managed
S - aching of wrist and forearm, tingling of thumb, index, middle and ring finger, weaker grip
Ix - clinical
Rx - splints, steroid injections, surgical decompression
How is limb swelling managed
S - location, SOCRATES, associated symptoms (fever, reduced ROM, skin changes, weight loss, nausea, vomiting), PMH recent surgery, rheumatoid diseases, DH (CCBs, HRT/COCP and allergies), SH (travel, alcohol and smoking)
Ix - Look, feel, move, x-ray, doppler, routine bloods, CK, lactate, look for ascities or fluid overload elsewhere, CXR + ECHO if cardiac, abdo USS if liver, renal USS if kidney disease
Rx - treat cause
How is lymphoedema managed
S - limb swelling, reduced mobility, infections, pitting or woody if chronic
Ix - USS of lymph nodes
Rx - elevation, compression bandages, massage proximally, abx if infection, diuretics not shown to work
How is a DVT managed
S - unilateral swollen hot limb, painful, reddening of skin, PMH (cancer), D+A (COCP, HRT), SH (recent long haul flight)
Ix - routien bloods, Well’s score, D-dimer, ECG, ABG may be needed if resp symptoms.
Rx - fluids, analgesia, if d-dimer positive or delayed <4hrs then start enoxaparin
How is chronic venous insufficiency managed
S - thrombbing leg pain, relieved by elevating legs, worse on standing, previous DVT or thrombophlebitis, red discoloration, hyperpigmentation of skin
Ix - USS doppler, d-dimer, ABPI
Rx - compression mandages, varicose vein surgery - sclerotherapy or thermotherapy
What antibiotics do you give for a cannula site infection
Co-amoxiclav
What is an important differential for DVTs and why
Baker cyst - found in popliteal fossa but pain and swelling often radiates to calf so need a USS doppler to differentiate them
How is angioedema managed
S - colicky abdo pain, SOB, Dysphagia, watery dirrhoea, itch, well-demarcated swelling, urticaria
Ix - clinical
Rx - ABCDE, senior help IM adrenaline, salbutamol, chlorphenamine, hydrocortisone 200mg, identify cause and stop in future (ACEi), immunology referral
How is joint pain managed
S - SOCRATES, ROM, skin changes, associated symptoms (diarrhoea, STI symptoms, weight loss, trauma, fever, night sweats, SOB, dry eyes and mouth), deformity, crepitus, lymphadenopathy, hepatosplenomegaly
Ix - routine bloods, CK, ESR, Rh factor and ANA, urine dipstick, x-ray, joint aspiration
Treat cause
Give some causes of joint pain
OA
RA
Septic arthiritis
Fracture or ligament injury
Transient synovitis
Osteomyelitis
Enteropathic arthritis
Gout and pseudogout
Polymyalgia rheumatica
Ankylosing spondylitis
Leukaemia
Sickle cell
Haemophilia
How is rheumatoid arthritis managed
S - morning stiffness, malaise, fatigue, mild fever, weight loss, swelling, deformity and redness or small joints
Ix - FBC (anaemia), ESR, Rh F and anti-CCP, x-ray (erosions, cysts, osteopenia, narrow joint space, deformity)
Rx - analgesia, NSAIDs, exercise, physio, IM methyl pred (exacerbation), DMARDs
How is osteoarthritis managed
S - pain worse with activity, stiffness on resting, effusion or joint deformity, reduced range of motion and crepitius
Ix - routine bloods (normal or mildy raised CRP), X-ray (loss of joint space, osteophytes, subacondral cysts and subcondral sclerosis
How is polymyalgia rheumatica managed
S - biateral morning stiffness and pain in proximal muscles lasting >1hr, weight loss, fatigue, malaise, depression, mild fever, normal power but muscle tenderness, ask about STA arteritis symptoms
Ix - raised ESR, CRP, LFTs, CK, STA biopsy if required
Rx - prednisalone, gradually reduced over a number of months
How is septic arthritis managed
S - acute onset painful swollen erytematous joint, essentially no ROM due to pain, fever, hot and tender
Ix - FBC, CRP, ESR, positive blood culture, x-ray, joint aspiration (positive for organsms on culture)
Rx - analgesia, urgent ortho referral and high dose IV abx for 6 weeks, aspiration and wash out likel required.
How is gout managed
S - acute painful joint, possible fever, decreased range of movement, swollen, tender, alcohol and red meat, thiazide diuretics
Ix - routine bloods, x-ray, joint aspiration (negative birefringent needle shaped crystals)
Rx - acute - rest, fluids, reduced thiazide duiretics alcohol and red meat, diclofenac or colchicine, chronic - allopurinol, do not start in acute attacks
How is pseudo-gout managed
S - acute painful joint, possible fever, decreased range of movement, swollen, tender, usually less severe than gout and usually affects small joints compared to gout which affects the knee most commonly
Ix -routine bloods, x-ray, joint aspiration (positive birefringement crystals)
Rx - Rest, NSAIDs (diclofenac), no prophylactic treatment
How is ankylosing spondylitis managed
S - back pain worse at night, morning stiffness>1hr, heel pain, resitricted chest expansion, achilies enthesitis, aortic regurgitation,
Ix - clinical, sacroiliac disease on x-ray pelvis
Rx - exercise, NSAIDs, sulfasalazine, infliximab
How is reactive arthritis managed
S - pain in larger joints, recent diarrhoea or genitourinary infection, dysuria, urethral discharge, acute asymmetrical oligoarthritis with malaise, fatigue and fever, gritty eyes, bilateral conjuctivitis, joint inflammation and urethritis
Ix - FBC, CRP, U+E, x-ray (normal), throat or genital swabs
Rx - treat infection (little effect on reactive arthritis), NSAIDs, chloramphenicol eye drops
How is psoriatic arthritis managed
S - skin changes (psoriatic), varying pattern of joint inflammation, check scalp, nail changes, swollen fingers
Ix - ESR, CRP, FBC, serology negative, X-ray (pencil tip appearance but mild arthritis seen)
Rx - rest , splinting, treat psoriasis, NSAIDs, steroids and biologics if severe
How is SLE managed
S - malaise, fever, weight loss, joint pain, photosensitive malar or discoid rash, oral ulcers, oedema, haematuria, seizures, psychosis, chest pain, abdo pain, diahrrhoea, pallor, recurrent miscarriages, swollen joints, drug induced (isoniazid, methyldopa, hydralazine, diltiazem)
Ix - routine bloods (anaemia, low WCC and platelets), C3 and C4 compliment low, raised ESR ANA positive dsDNA positive, anti-sm, rhf, urinalysis (blood and protein), x-ray pleural effusions and arthritis
Rx - nsaids, hydrocychloroquine, oral steroids for flares, DMARDs, biological therapies
How are neck lumps managed
S - SOCRATES, associated symptoms (heat intolerance, weight gain or loss, dyspahgia dysphasia, night sweats, itch, bad breath, diarrhoea or constipation, voice changes), facial nerve palsys, tongue movement
Ix - routine bloods, ESR, LFTs, CXR, US-guided FNAC and biopsy.
Rx - treat cause and refer to ENT if required
Give some causes of neck lumps in the midline
Goitre
Thyroglossal cyst
Dermoid cyst
Give some causes of neck lumps in the anterior triangle
Lymph node
Thyroid mass
Salivary gland
Branchial cyst
Carotid artery aneurysm
Give some causes of neck lumps in the posterior triangle
Lymph node
Pharyngeal pouch
Cervical rib
How is a thyroid goitre managed
S - moves with swallowing but not tongue protrusion, hypo or hyperthyroid symptoms
Ix - routine bloods, TFTs, US guided-FNAC, ENT referral
Rx - treat thyroid disease
How is a salivary gland lump managed
S - pain and swelling when eating, may feel hard due to impacted stone
Ix - routine bloods, US-guided-FNAC ENT referral
Rx - supportive management
How are thyroglossal cysts managed
S - young patient, protrude on tongue protrusion, single lump on the hyoid, may be inflammed
Ix - routine bloods, US-guided-FNAC, ENT referral, TFTs
Rx - removal via ENT referral
How are dermoid cysts managed
S - single subcutaneous lump in the midline or next to eye, usually <20
Ix - routine bloods, US-guided-FNAC, ENT referral
Rx - removal from ENT
How are branchial cysts managed
S - slowly ennlarging smooth mass, second or third decade, anterior border of SCM, may be tender afer URTI
Ix - routine bloods, US-guided-FNAC, ENT referral
Rx - ENT for excision
How is a pherngeal pouch managed
S - elderly patients, recurrent aspiration pneumonia, regurgitation of undigested food, halitosis
Ix - routine bloods, USS, ENT referral, contrast swallow
Rx - surgical myotomy, nutritional support
How is a cervical rib managed
S - hard mass in the posterior triangle, usually unilateral, raynauds (compression of subclavian artery), distal muscle weakness and pain
Ix - routine bloods, USS, CXR, ENT referral
Rx- physiotherapy and surgical excision
How is epistaxis managed
S - trauma, SOCRATES, joint deformities in nose, look up nose for septal defect, back of throat for post-nasal drip D+A (aspirin, warfarin, DOACs, clopidogrel)
Ix - clinical but if persistent then FBC, U+Es, clotting, LFTs
Rx - resuscitate if needed, tilt head forewards and apply pressure on soft fleshy part of the nose for 15 minutes –> silver nitrate if visible bleeding points after topical LA, nasal packing and remove after 24hrs, speak to ENT if persistent, correct excessive INR and stop pro-bleeding drugs
How are sore throats managed
S - trauma, infectious symptoms, dysphagia, dysphasia, tonsilar exudate, peritonsilar abscess, night sweats
Ix - clinical, throat swab, routine bloods
Rx - urgent ENT review for drainage and IV abx if abscess formed, otherwise soluble aspirin/paracetamol gargled with mouthwash and antibiotics (phenoxymethlpenicillin if CENTOR crteria high). Refer if persistent >2 weeks to ENT as maybe malignant
How is earache/deafness managed
S - SOCRATES, discharge, itching, hearling loss, dizziness, tinnitus, cold symptoms, malaise, facial weakness, fever, look in ears for fluid, mastoid swellling (ear protrusion), inside mouth at tonsils
Rx - depends on cause
How is acute otitis media managed
S - SOCRATES, red, bulging drum and possible efusion
Ix -clinical
Rx - antibiotics if infant, temp >39, severe pain
How is otitis externa managed
S - SOCRATES, itching, tender dischrage and pus
Ix -clinical
Rx - clean canal , keep dry, topicl antibiotic and steroid combo
How is ear wax managed
S - deafness
Ix -clinical
Rx - olive oil drops and microsuction
How is glue ear managed
S - persistent middle ear effusion with deafness, consider ax, if complicated
Ix -clinical
Rx - grommets if symptomatic with hearling loss 3-6months later
How is cholesteatoma managed
S - discharge from middle ear that is offensive, recurrent OM, painless dicharge, unilateral deafness
Ix -clinical
Rx - ENT referral
How are acoustic neuromas managed
S - deafness and or persisitent vertigo
Ix -clinical, CT and MRI head
Rx - ENT referral
How is sudden sensorineural hearling loss managed
S - sudden or rapid hearing loss in 1 ear only
Ix - ENT emergency needs prompt audiology and senior review
Rx oral steroids and or steroind injection intratympanically, hearing rehab might be needed
How are groin lumps managed
S - SOCRATES, change in shape, skin changes, change in bowels or bladder movements, nausea, vomiting, weight loss, previous lumps, last menstraul period and pregnancy history, sex history from last 3 months and use of protection
Ix - clinical, routine bloods, lactate, CT abdo if strangulated hernia, USS if unsure of contents
Rx - treat cause
How is testicular torsion managed
S - lower abdo pain, swollen and painful testicles, nausea, vomiting, tachycardia, Prehn’s sign - elevating testicles does not relieve pain, absent cremasteric reflex
Ix - clinical
Rx - urgent explorative surgery, NBM, analgesia, anti-emetics, fluids
How are inguinal hernias managed
S - often asymptomatic, reducible, cough impulse, indirect extends into scotum
Ix - clinical
Rx - lose weight, high fibre diet, stop smoking, treat lung disease, day surgery - laproscopic mesh
How are femoral hernias managed
S - irreducible, painful lump near hernial orifice (inguinal or femoral), nausea, vomiting, constipation, abdo pain, erythematous skin changes, peritonism possibly
Ix - routine bloods, amylase, AXR (to exclude bowel obstruction) CXR to exclude perforation, lactate
Rx - gen surgeon review, NBM, analgesia, cyclizine, IV access and fluids
How to see if a hernia is reducible
Lie patient flat and ask them to relax abdo muscles
Try gently pushing hernia to contralateral shoulder
How are hydroceles managed
Enlarged transluminable testicle, non-tender, smooth, well defined
Ix - USS, Human chorionic gonadotropin test, AFP
Rx - conservative if asymptomatic or surgical suturing of tunica vaginalis if symptomatic
How is a spermatoclele (epididymal cyst) managed
S - soft, small and well-defined translissuminable lump that is superior and seperate to testes, painless
Ix - USS
Rx - transscrotal excision if symptomatic otherwise nothing
How is epididymitis/orchitis managed
S - acute testicular swelling, pain and enlarged testis, urethral dicharge, fever
Ix - USS
Rx - excluse torsion, urethral swabs for STI, MSSU for UTI, abx (doxycycline)
How is testicular cancer managed
S - painless craggy mass within testicle, hard, non-transillumniable, irregular surface of testicle, hydrocele possible
Ix - routine bloods, alpha fetoprotein, beta-HCG, LDH, scrotal USS, CT for staging, USS testicular biopsy
Rx - surical removal (orchodectomy) with radiotherapy and or chemo
How is a urogenital prolapse managed
S - dragging sensation, urinary urgency and frequency, constipation, coital pain
Ix - clinical (bear down on exam)
Rx - weight loss, stop smoking, trat constipation, hysterectom, pelvic floor repair
How is gonorrhoea managed
S - 1-14 days after exposure, green and yellow discharge with dysuria
Ix - vaginal or urethral swab with PCR and gram staining
Rx - cephlasporins (cefuroxime)
How is chlamydia managed
S - 1-3 weeks after exposure, watery white dicharge with dysuria
Ix - Vaginal or urethra swab, first catch urine specimen
Rx - doxycycline or azithromycin
How is lymphogranuloma venerum managed
S - linked to gay men, painless ulcer on penis 3-12 days later
Ix - serology or PCR
Rx - doxycycline
How is syphilis managed
S - can take up to 3 months to appear, painless red genital ulcer, flu like symptoms and rash
Ix - serological scrrening tets and treponemal specific test
Rx - penicillin
How are burns managed
Hx - SOCRATES, any associating symptoms, type of burn, ask about smoke, when it happened, any trauma or breathing difficulties, drugs and allergies
A - patency, stridor is common in face and neck burns due to sweling therefore intubation needed
B - RR, sats, listen to chest, percuss, O2
C - ECG, BP, listen to heart, IV access with bloods (FBC, U+E, D-dimer, troponin, LFT, CRP), HR, ABG and carobxohaemoglobin levels, IF fluids 0.9% saline 1L STAT, catheterize
D - glucose, Eyes, GCS, quick neuro exam
E - expose patient and examine, check abdo and legs, cover burns with cling film, keep patient war
Call senior
Morphine and cyclizine
Needs specialised plastics input
Specific fluid plan for burns
Reassess
What is the rule of 9s for burns
Head -9%
Arm - 9%
Leg - 18%
Trunk - 18%
Back - 18%
Perineum - 1%
What are the features of a superficial burn
Red
Blanching
Sensation present
Bleeding
What are the features of a partial dermal burn
Pink
Blisters
Blanching
Sensation present
Bleeding
What are the features of a deep dermal burn
Bright red, mottled
Doesnt blanch
Sensation present
Slow bleeding
What are the features of a full thickness burn
White, brown, black and leathery
No blanching
No sensation
No pain
How is an inhilation injury managed
S - breathlessness, hoarse voice, dysphagia, confusion, singed facial hair, soot around the nostrils or palate, stridor, drooling, swelling near the airways
Ix - decreased PERF, COHb up, ABG, ECG, CXR (ARDS)
Rx - intubation, high flow O2, salbutamol
How is carbon monoxide poisoning managed
S - headache, vomiting, malaise, red cherry lips
Ix - COHb (smokers will naturally have a higher level), ABG (Met acid), ECG to exclude arrythmias
Rx - high flow oxygen and mannitol
What three tests are important in chemical burns
ECG
Urine dip (might be blood - myoglobinuria)
Creatinine kinase
How is anaphylaxis managed
Hx - SOCRATES, any associating symptoms (wheezing, SOB, iching swelling, abdo pain, tachycardia, tongue swelling, cyanosis) ask what happened, check drug chart for allergies
A - patency
B - RR, sats, listen to chest, percuss, O2, IM adrenaline (1:1000 0.5ml), 5mg neb salbutamol
C - ECG, BP, listen to heart, IV access with bloods if time (FBC, U+E, mast cell tryptase), HR, ABG, IV fluids 1L 0.9% saline STAT
D - glucose, Eyes, GCS, quick neuro exam
E - expose patient and examine, check abdo and legs
Call senior
Give IV hydrocortisone and chlrophenamine IV
IMPORTANT - can get biphasic reactions where anaphylaxis crops up again a few hours later.
How is hypotension managed
S - SOCRATES, any associating symptoms (palpitations, fall, light headedness, vomiting, diarrhoea, rashes or utricaria, fever), PMH (AAA, gastroduodenal ulcers), check drug chart for allergies and hypotensive medication and steroids (withdrawal), assess volume status, feel AAA and for guarding, look for focal signs in chest, abdo, legs
Ix - serial BPs, ECG, routine bloods, glucose, cross-match, D-dimer, CXR, CT chest and or bedside echo may be needed.
Rx - treat cause and early senior help, 500ml fluid bolus if <90mmhg
How is orthostatic hypotension managed
S - dizziness, fall, palpitations, usually normal HR due to absense of autonomic cause
Ix - lying and standing BP is diagnostic, assess fluid status
Rx - medication review, patient education to get up slowly, increase fluids, resistant - fludrocortisone
How is a leaking AA managed
S - severe constant or colicky abdo pain radiating to back, collapse, feeling faint, expansile abdo pass (pushing hands apart - not just pulsating), shock, cold extremities
Ix - none if unstable
Rx - oxygen, IV access bilaterally with two wide-bore cannulas, IV fluids STAT, interventional radiology suite
How is hypotension managed acutely
Hx - SOCRATES, any associating symptoms (palpitations, fall, light headedness, vomiting, diarrhoea, rashes or utricaria, fever), PMH (AAA, gastroduodenal ulcers), check drug chart for allergies and hypotensive medication and steroids (withdrawal)
A - patency
B - RR, sats, listen to chest, percuss, O2, HR
C - IV access and bloods (routien, cardiac markers, D-dimer, blood cultures), ABG, IV fluids 500ml 0.9% saline or 250ml if elderly or congestive heart failure)
D - glucose, Eyes, GCS, quick neuro exam
E - expose patient and examine, check abdo and legs
Call senior
Key features of major haemorrhage protocol
Call 2222 for switchboard emergency line and innitiate major haemorrhage protocol
Patients name and your name
Location of patient
Blood pack - 4 units of O negative RBCs, 2 units of platlets, 2 units of FFP
What are the 6 post-transfusion bloods needed
X-match
FBC
CLotting studies
Fibrinogen
U+Es
Calcium
What are the 5 types of shock
Hypovolaemic - reduced circulating volume
Septic shock - loss of vascular tone due to pathogenic toxins and inflammator mediators
Cardiogenic shock - pump failure
Anaphylactic shock - loss of vascular tone due to excessive histamine release
Spinal shock - loss of vascular tone due to trauma of the cord following spinal anasthesia
What are the 5 types of shock
Hypovolaemic - reduced circulating volume
Septic shock - loss of vascular tone due to pathogenic toxins and inflammator mediators
Cardiogenic shock - pump failure
Anaphylactic shock - loss of vascular tone due to excessive histamine release
Spinal shock - loss of vascular tone due to trauma of the cord following spinal anasthesia
What are the causes of hypovolaemic shock and how is it managed
A - haemorrhage, ruptured AAA, GI bleed, diarrhoea, vomiting, burns, polyuria, acute 3rd splace loss (pancreatitis, ascities)
S - <90mmHg, tachycardia, oliguria, mottled skin, dizziness, chest pain, SOB, cool peripheries, low JVP, cause symptoms (abdo pain, malena, haematemisis)
Ix - routine bloods, VBG, Cross-match, ABG, CXR, ECG, FAST scan
Rx - ABCDE, lay flat, raise legs, IV access 500ml fluid bolus, bolus will give time to find cause, treat cause, ABCDE, catheter to monitor urine output and reassess starting with ABCDE
What are the causes of cardiogenic shock and how is it managed
A - pump failure (LV dysfunction, aortic dissection, arrhythmia) or inadequate filling (PE, pneumothorax, cariac tamponade)
S - dizziness on standing, SOB, chest pain, palpitations, shock, weak pulse, RAISED JVP, GCS low, mottled skin if severe
Ix - immediate ECG, CXR, routine bloods, VBG, cross-match, glucose, ECHO
Rx - ABCDE, 500ml fluid bolus, treat cause
What are the causes of neurogenic shock and how is it managed
A - epidural, trauma of spinal cord
S - usually motor or sensory dysfunction below level of lesion, bladder and bowel dysfunction, warm peripheries, low BP, may or may not have tachycardia, up going plantars
Ix - MRI and X-ray spine
Rx - lay flat and elevate legs if no spinal injury, oxygen, 500ml 0.9% salien bolus, ortho and spinal surgeon referral, stop epidural if present
What are the causes of septic shock and how is it managed
A - pnemonia, cellulitis, perforation, biliary tract, UT/Pyelonephritis, wound infection/bowel leak, endocarditis
S - low BP, tachycardia, reduced GCS, low urine output, sweats, shivers, nausea, vomiting, SOB, headache, confusion, fever, tachycardia, reduced JVP, reduced GCS, signs of underlying source of infection
Ix - sepsis 6 (oxygen, blood cultures (TWO SETS if possible), lactate, IV abx, IV fluids, catheterisation), routine bloods, find source of infection (CXR, skin swabs, urinalysis, ECHO/TOE, CT abdo)
Rx - ABCDE, lie flat and legs up, 500ml fluid bolus, IV abx, oxygen, IV fluids, analegsia, antiemetics, senior review, monitor over the next few days for signs and bloods for DIC (clotting screen).
What is the SOFA criteria
Mortality risk of sepsis -
Hypotension <=100
Altered mental status GCS<15
Tachypnoea >=21
Give some causes of pyrexia
septic shock/infection
transfusion reaction
infected line
drug reaction
neuroleptic malignant syndrome
PE
DVT
malignancy
How is pyrexia managed
S - fever, signs of infection source (cough, dysuria, SOB, chest pain, abdo pain, darrhoea, photophobia erythema), pain SOCRATES, myalgia, malaise, D+A (immunosuppresion, new medication allergies, transfusions), SH (recent close contact with infected, IVDU, ecstasy), look for infection source and listen to chest, heart and abdo
Ix - septic screen, routine bloods, urine dip, blood film, blood cultures, sputum culture, skin swabs, ABG, CXR, ECHO/TOE, LP if meningitis suspected
Rx - low threshold for sepsis 6, paracetamol and ibuprogen, analgesia, anti-emetics
What are the key components of a septic screen
Hx - fever, signs of infection source (cough, dysuria, SOB, chest pain, abdo pain, darrhoea, photophobia erythema), pain SOCRATES, myalgia, malaise, D+A (immunosuppresion, new medication allergies, transfusions), SH (recent close contact with infected, IVDU, ecstasy)
Ex - look for infection source and listen to chest, heart and abdo, look at all joints, look for bed sores, look at all IV/Central lines for source of infection.
Ix - routine bloods, BASED OFF SYMPTOMS (urine culture, sputum culture, blood cultures, wound/skin swabs, CXR, ECHO, blood film for parasites, LP)
Rx - treat source of infection and SEPSIS 6
How is pyrexia of unknown origin managed and its possible causes
A - infection, malignancy, drug induced (abx, atropine, hydralazine, GA, antipsychotics (NMS), aspirin, opioid withdrawal), post-op
S - fever of no obvious cause found for greater than 3 weeks or 1 week as an inpatient
Ix - investigate cause
Rx - treat cause
How is a UTI managed
S - urinary frequency, dysuria, offensive urine, cloudy urine, fever, suprapubic pain, haematuria
Ix - urinalysis, MSSU, routine bloods, blood cultures, blood glucose
Rx - paracetamol and abx, fluids
How is pylonephritis managed
S - urinary frequency, dysuria, offensive urine, cloudy urine, fever, loin pain, rigors, vomiting, haematuria
Ix - urinalysis, MSSU, routine bloods, blood cultures, blood glucose
Rx - IV abx, paracetamol, fluids
Ways to avoid UTIs
Drink >2 Litres a day
Good diabetic control
voiding regualrly
Voidinga fter sex and before bed
Wipe front to back
How is infective endocarditis managed
S - fatiuge, anorexia, weight loss, fever, night sweats, dyspnoea, new murmur, splinter haemorrhages, janeway lesions, olser nodes, roth spots, conjunctival haemorrhage
Ix - Routine bloods, blood cultures, TOE, CXR, ESR, ECG, assess using Duke criteria
Rx - early referral for microbiology and cardiology, analgesia, long-term abx, oxygen and fluids. May need valve replacement at later date.
How is febrile neutropenia managed
S - prexia, neutropenia, rigors, source of infection symptoms
Ix - routine bloods, clotting glucose, blood cultures, urine dip, sputum culture, stool culture, CXR
Rx - sepsis 6, tecnoplanin and pipercilin, consider antivirals and antifungals at 72hrs if no improvement
Give some common notifiable diseases
Tell PH within 3 days of knowing.
Infectious diarrhoea
Enephalitis
Food poisoning
HUS
Strep A
Malaria
Meningitis
Mumps
Rabies
Rubella
TB
Typhoid
Whooping cough
Yellow fever
Viral hepatitis
HIV IS NOT A NOTIFIABLE DISEASE
What are some important questions you should ask in child Hx taking
HPC - how is the child different, change in resp rate or nature, wet nappies, oral intake of fluids and food, any one with similar symptoms (infectious), any rashes? vomiting (colour)? blood in stool?
PMH - normal birth? reaching milestones?
D+A - any medication? up to date with vaccines?
FH - any similar presentations
SH - managing at nursery/school?
How is malaria managed
S - cyclic fevers, jaundice, presents 2-3 weeks after infection, headache, vomiting, fatigue, arthalgia, recent travel abroad
Ix - routine bloods, malaria blood film
Rx - discuss with ID, Chloroquine, doxycyline, proguanil, dont use the same drug that is used for prophylaxis
Give some examples of oportunistic infections
Candidiasis
CMV retinitits - ganciclovir
Cryptococcus neoformans
HSV
Pneuocystitis jiroveci
TB
Tinea corporis
Varicella zoster virus
How is pneumocystitis jirovecii managed
S - most common opportunistic HIV infection, fever, dry cough, desaturation on walking
Ix - CXR (diffuse bilateral infiltrates), sputum culture
Rx - co-trimoxazole, fluids and analgesia, O2
How is HIV managed
S - asymptomatic, kaposi sarcoma, rash, malaise, pneumocystitis jiroveci, candidiasis, IVDU or sex worker, gay men
Ix - HIV test, CD4 count, routine bloods, investigate for opportunistic infection,
R - HAART drugs (highly active anti-retroviral therapy) by GUM or ID expert, PEP if needed for healthcare workers, counselling
How is TB managed
S - dry cough, haemotypsis, night sweats, lymphadenopathy, breathless, weight loss, meningeal (reduced GCS fever, headache), renal (dysuria, haematuria and loin pain), bone (back pain and stiffness and abscess)
Ix - zeil-neeson stain for acid fast bacilli, routine bloods, CXR, mantoux test, drug sensitivity testing
Rx - isolate if suspiscion in negative pressure room, 2 months of (rifampicin, isoniazid, pyrazinamide, ethambutol), a further 4 months of (rifampicin and isoniazid)
What does the BCG vaccine protect against and who is it given to
At birth if a high risk group for TB
What are the important features of prematurity management
Two doses of maternal dexamethasone IM
Tocolytics - slows and or stops uterine contractions
Hospital transfer with neonatology
What are the features of foetal monitoring
Doppler probe
CTG
Foetal blood sampling - acidosis for hypoxia
How is a post-partum haemorrhage managed and what are the causes
A - failure of uterine contraction, tears, retained placenta, clotting disorders
S - shock, severe bleeding
Rx - ABCDE, elevate legs, oxygen, two large bore cannulae, bloods and clotting, 1L o.9% aline stat, urgent blood, compress bladder bilaterally, IV oxytocin, carboprost, repair tears if present under anaesthetic or emergency hysterectomy
How is post-natal pyrexia managed and what are the possible causes
A - endometritis, wound infection, mastitis, UTI, URTI, DVT
S - mode of delivery, prolonged rupture of membranes, cough/SOB, bleeding or disrcahge, dfficult birth, breast pain, abdo or breast tenderness, uterine tenderness, check legs
Ix - D-dimer and wells score, vaginal sputum, wound and blood culture
Rx - antibiotics, fluids, analgesia, continue breast feeding
Explain the parts of the cervical screening programme
NHS cervical screening programme is used for 25-64-year olds every 3-5 years. Over 50s every 5 years. Checks for cervical intraepithelial neoplasia (NOT CANCER)
3-5 year check up smear.
Smear checks for dyskariosis - Disorganised growth and development of the transformational zone (high grade dyskaryosis)
Dyskariosis present - get HPV test (reflex cytology)
Dyskariosis absent - go back to routine screening
Reflex cytology -
negative for HPV - 3-5yrs
positive for HPV - colposcopy –> Rx – long loop excision of transformation zone (LLETZ), check up 2 years later
Causes of a relative afferent pupillary defect (RAPD)
Retinal vein occlusion
Retinal artery occlusion
Open angle glucoma
Retinal detachment
Optic neuritis
