FINALS Flashcards

Question

HF acute + chronic Mx (criteria for third line)

Answer 1

Acute Mx: IV furosemide 40mg, oxygen if required (CPAP in resp failure), nitrates if BP >90; hypotension: dobutamine in LV dysfunction + shock +/- norepinephrine Chronic Mx - treat cause + lifestyle, ABAL: ace / arb, beta blocker, aldosterone antagonist, loop diuretic. New evidence shows SGLT-2 improves outcomes even without diabetes. Third line: ivabradine, sacubitril-valsartan, digoxin, hydralazine + nitrate, cardiac resynchronisation TL criteria: ivabradine - HR > 75, LVEF < 35%; S-V LVEF < 35%; digoxin - coexistent AF; H+N - afro-caribbean; cardiac resynchronisation therapy - wide QRS (LBBB)

Answer 2

Lethargy, confusion, n+v, abdo pain, weakness; severe: hypotension, severe hypoglycaemia (sweating, confusion, shaking) Hyperkalaemia, hyponatraemia, hypoglycaemia, metabolic acidosis, low cortisol, raised ACTH (low in secondary) In emergency setting treat before waiting for results (Not crisis: 9am cortisol + ACTH, short synacthen test GS, renin + renin:aldosterone, DHEA, U+Es, BMs, antibodies) Mx: 100mg hydrocortisone IV stat (then 50mg QDS), fluids, glucose if hypoglycaemic, monitor electrolytes Treatment will lower potassium but treat for hyperkalaemia if ECG changes

Answer 3

Vague presentation, weakness, fatigue, palpitations, paraesthesia, cramps, n+v Concerns due to ECG changes: peaked / tall T waves, PR prolongation / loss of P, QRS widening; sine wave pattern; ventricular fibrillation / asystole ECG all patients with K > 6 Mx (ECG changes): IV calcium gluconate (stabilises myocardium), insulin + dextrose (salbutamol); remove from body: calcium resonium (enema > oral), loop diuretics, dialysis (AKI) Non urgent: loop diuretics, polystyrene sulfonate resin (prevents absorption) + laxatives

Answer 4

FeverPAIN (strep pharyngitis / whether to give Abx): fever, purulent tonsils, attends rapidly (Sx < 3d), inflamed tonsils, no cough / coryza 1 point for each criteria 0-1 no Abx, 2-3 delayed Abx, 4-5 immediate Abx

Answer 5

C(U)RB-65 (severity / mortality of pneumonia): confusion (AMTS <=8/10), urea > 7, RR > 30, BP < 90/90, age > 65 CRB-65: home care for score 0-1, 2+ hospital admission Also CRP: < 20 no Abx, 20-100 delayed Abx, > 100 immediate Abx CURB-65: 0-1 home based care, 2 admission, 3+ consider intensive care

Answer 6

Well’s (PE): clinical signs of DVT 3, PE most likely diagnosis 3, HR > 100 1.5, immobilised for 3d / surgery last 4w 1.5, previous DVT / PE 1.5, haemoptysis 1, active cancer 1 4+ PE likely: CTPA, if delayed interim LMWH. CTPA negative - proximal leg US if DVT suspected <4 PE unlikely: D-dimer; +ve CTPA; -ve consider alternative diagnosis PE rule out criteria (used when suspicion low before testing): age > 50, HR > 100, sats < 94%, previous DVT / PE, recent surgery / trauma in 4w, haemoptysis, unilateral leg swelling, oestrogen meds If all are absent probability of PE is < 2%

Answer 7

Well’s (DVT) - all 1: calf > 3cm larger than asymptomatic, localised tenderness along DV system, entire leg swollen, pitting oedema only on affected, collateral superficial (non varicose) veins, previous DVT, cancer in last 6m, paralysis / paresis of leg, immobile for 3d / surgery in last 3m Alternative as likely = -2 2+ DVT likely: proximal US within 4h (delayed interim LMWH); -ve D-dimer Scan negative but D-dimer +ve : stop anticoagulation, repeat US in 1w <2 DVT unlikely: D-dimer within 4h, +ve proximal US within 4h; D-dimer -ve consider alt diagnosis

Answer 8

CHA2DS2-VASc: chronic HF, hypertension, 75+ 2, diabetes, stroke / TIA 2, vascular disease, 65+, sex female 1+ men / 2+ females consider long term anticoagulation, 0 anticoagulation for 2m ORBIT (bleeding in AF) 1 each: older 75+, reduced haemoglobin (< 130 M, < 120 F), bleeding history, insufficient kidney function (eGDR < 60), treatment with antiplatelets / NSAIDs 0-2 low risk, 3 intermediate (monitor), 4+ high risk (consider low dose / not anticoagulating)

Answer 9

Glasgow-blatchford (GI bleeding before endoscope): HR > 100, systolic BP, haemoglobin, urea, melaena, recent syncope, liver disease, cardiac failure 0 discharge, 1 hospital admission, > 6 urgent endoscopy and intervention Rockall (post endoscopy): age, shock, comorbidities, diagnosis on scope, major stigmata (blood in tract, adherent clot, spurting vessel) < 3 discharge, 3+ admit for monitoring, 6+ high risk repeat endoscopy and intervention

Answer 10

Glasgow-Imrie (pancreatitis severity) - (PANCREAS): PaO2 <8 kPa, Age >55, Neutrophils (WCC) >15*109, Calcium <2, Renal (urea) >16, Enzymes LDH >600 AST >200, Albumin <32, Sugar >10 0-2 supportive, 3-4 aggressive IV fluids consider escalating, 5+ ICU

Answer 11

4AT (delirium): Alertness: clearly abnormal 4 AMT4: age, date of birth, place, current year. 1 mistake - 1, 2+ or untestable - 2 Attention (lists months backwards): 7+ correct 0, <7m or refuses 1, untestable 2 Acute / fluctuating in last 2w: yes 4 <4 delirium unlikely, 4+ delirium likely

Answer 12

APGAR: 7-10 normal, 4-6 monitoring, 0-3 resus Bishop: > 8 favourable, < 5 unfavourable. > 6 amniotomy + oxytocin, =< 6 vaginal prostaglandin / misoprostol Order of intervention: membrane sweep, vaginal prostaglandin E2, misoprostol, oxytocin, amniotomy (artificial rupture), cervical ripening balloon

Answer 13

Pulmonary oedema: hypotension = TRALI, hypertension = TACO Systemically unwell + hypotension: fever + pain = acute haemolytic, wheeze + angioedema = anaphylaxis, septic = bacterial colonisation Non haemolytic febrile: fever, chills, systemically well; slow / stop transfusion, paracetamol, monitor Antibodies reacting with white cell fragments and cytokines that have leaked from cells Acute haemolytic (ABO incompatibility): fever, abdo / chest pain, hypotension, agitation, starts minutes after transfusion; stop transfusion, confirm diagnosis (check ID + product, direct coombs test, repeat typing + cross matching), fluid resuscitation ABO incompatible blood (usually human error). Complications; DIC, renal failure Minor allergic reaction: pruritus, urticaria; temporarily stop transfusion, antihistamine, oxygen, fluids Foreign plasma proteins Anaphylaxis: hypotension, dyspnoea, wheeze, angioedema; stop transfusion, IM adrenaline, oxygen, fluids Typically IgA deficiency with anti-IgA antibodies Transfusion associated circulatory overload: pulmonary oedema, hypertension, no fever; slow / stop transfusion, IV furosemide, oxygen Excessive rate of transfusion +/- pre existing heart failure Transfusion related acute lung injury: pulmonary oedema + hypoxia, fever, hypotension; stop transfusion, oxygen + supportive care Non cardiogenic pulmonary oedema, secondary to increased vascular permeability due to immune response

Answer 14

HBsAG (surface antigen) = active infection (acute or chronic) Anti-HBs (surface antibody) = immunity (vaccination of past infection) Anti-HBc (core antibody) = infection (past or current) IgM present for 6m, IgG persists HbeAG (breakdown of core antigen) = marker of infectivity + replication Vaccination = only anti-HBs Resolved infection = anti-HBs + anti-HBc (HBsAG negative) Acute infection = HBsAg + igM anti-HBc Chronic infection = HBsAg > 6m, anti-HBc +/- HBeAg Hep C (no vaccination!): HCV RNA (PCR) = active, anti-HCV = past or current Active = both positive, resolved = only anti-HCV

Answer 15

Right hemicolectomy: removes caecum, ascending colon and part of transverse colon Right sided colon cancer, Crohn’s, ischaemia Usually no stoma, ileo-colic anastomosis Left hemicolectomy: removes descending colon, part of transverse Left sided colon cancer, diverticular disease, ischaemia Usually no stoma, colo-colon anastomosis Sigmoid colectomy: removes sigmoid Diverticular disease (with perforation / abscess), sigmoid cancer, volvulus If anastomosis high risk - temporary loop ileostomy Hartman’s: emergency for perforation (risk of anastomosis much higher), sigmoid removed + end colostomy, can be reversed Diverticular with perforation, obstructing rectosigmoid cancer End colostomy that can be reversed Anterior resection: removes rectum and sigmoid, colo-rectal anastomosis Sigmoid colon - high anterior resection Upper rectum - anterior resection Low rectum (< 8cm from anus) - low anterior resection +/- defunctioning loop ileostomy Abdomino-perineal resection: removes entire rectum and anus (no sphincter) anal verge cancer, low rectal (< 4cm from anus) Permanent end colostomy

Answer 16

Loop ileostomy (R, temporary): defunctioning for low rectal cancer / protecting anastomosis End ileostomy (R, temporary / permanent): total colectomy, anastomosis not possible Loop colostomy (L temporary): diverting stool from obstruction or in palliative End colostomy (R / L, temporary): Hartman’s procedure (anastomosis not possible)