Gen Med, ICU and Misc Flashcards
1
Q
Over what timeframe will most chronic wounds heal with correct diagnosis and mangement?
A
12 weeks
2
Q
What are clinical features of venous leg ulcers?
A
- champagne bottle appearance of lipodermatosclerosis
- haemosiderosis of surrounding skin
- irregular border, shallow, above malleoli but below knee
- Oedema
- Atrophie blanche: small white areas caused by skin ischaemia
3
Q
How are venous leg ulcers treated?
A
- rarely with antibiotics
- Debridement: sharp or blunt, mechanical or with dressing
- protect peri ulcer skin
- Dressing: primary, absorbent layer, compression
- Address factors for wound healing: nutrition, smoking, exercise, venous ablation
4
Q
What are features of lymphoedema ulcer?
A
- cobble stone cracks
- Stemmer sign: attempt to pinch and lift skin fold at base of second toe, positive = unable to pinch
5
Q
How is lymphoedema treated?
A
- compression
- massage
- weight loss
6
Q
What are features of arterial ulcers?
A
- sharp, punched out (deep) ulcers
- distal to ankle
- poor perfusion: poor capillary return, shiny hairless skin
- ABPI < 0.7
7
Q
When is compression safe for mixed arterial/venous ulcers?
A
ABPI >0.7
8
Q
What are the treatments for arterial ulcers?
A
- antibioitcs
- debridement
- dressings
- compression if ABPI > 0.7
- analgesia
- revascularisation
9
Q
What are clinical features of diabetic foot ulcers?
A
- usually distal or planatar foot/toes, or distal ankle where footwear rubs
- charcots foot
- prone to infection
- callus
10
Q
How are diabetic neuroischaemic ulcers treated?
A
- debridement except for dry gangrenous
- dressings
- offload
- podiatry
- BSL control
- Agressive treatment of infection and high suspicion for osteomyelitis
11
Q
How are skin tears prevented and managed?
A
- prevention: moisturisation, avoid trauma, minimise steroid
- treatment: oppose edges, non-adhesive dressing, remove dressings from base of flap
12
Q
What are features of zoster rash?
A
- Vesicular rash clustered on erythematous base
- unilateral in sensory dermatome distribution, most common thoracic, also cervical and ophthalmic
- vesicles crust over 7-10 days, full healing over 1 month
13
Q
How are Zoster rashes treated?
A
- antivrial
- treat secondary infection
- hydrogel, non adhesive dressing
- vaccination for prevention
14
Q
What are features of vasculitic ulcers?
A
- associated with underlying autoimmune condition
- associated rash (palpable purpurae)
- red edge
- non diagnostic biopsy
15
Q
How are vasculitic ulcers treated?
A
- immunosuppresion: steroids incl. topical, tacrolimus, anti-TNF mAbs (adalimumab, infliximab)
16
Q
What are common features of pyoderma gangrenosum?
A
- peripheral necrotic tissue
- purplish edge
- no rash
- occur anywhere on body
- biopsy non diagnostic
- DO NOT GRAFT: get pathergy = new disease at site of graft
17
Q
What are treatments of calciphylaxis ulcers?
A
- sodium thiosulfate to treat nephrocalcinosis
- 10 g IV 3x/week for 12 weeks
- can also be given topically
18
Q
How are pressure injuries managed?
A
- prevention through frequent turning, if bed bound at least every 2 hours
- if chair bound reposition every hour
- padding with pillows or foam wedges
- cleaning (no soap, reduce friction)
- moisturisers
- lifting devices to lift
- pressure relieving devices
- treat at first sign of redness
- nutrition (some evidence for 4.5 -9g arginine per day)
19
Q
What clinical features suggest a diagnosis of secondary hypertension?
A
Age < 30
On 3 or more agents
Acute worsening control
20
Q
What are indicators of a renovascular cause for secondary hypertension?
A
- increase in serum Cr >50% occurring in 1/52 of initiating ACEi/ARB
- severe hypertension with unilateral smaller kidney or size discrepancy > 1.5 cm
- recurrent flash pulmonary oedema
21
Q
What is the triad of hyperaldosteronism?
A
Hypertension, unexplained hypokalaemia, metabolic alkalosis
(note 50-70% patients have normal potassium)
22
Q
What is the definition of hypertensive urgency and what is recommended management?
A
SBP >180 or DBP > 110, with symptoms such as headache, moderate non acute end organ damage
Managed with oral medications (small doses of short acting medications, or usual if missed dosed)
23
Q
What is the definition of a hypertensive emergency and how is it managed?
A
SBP > 220 or DBP > 140, severe end organ damage such as APO, encephalopathy, neurological symptoms, AKI, aortic dissection, eclampsia
Lower MAP by 20-25% within first 2 hours with rapid acting meds (may need to be faster in haemorrhagic stroke or aortic dissection)
24
Q
When is pharmacological management indicated for elevated BP?
A
- if high absolute risk (>15%)
- High BP >160/100
- CKD, TIA/CVA, diabetes, MI, CCF, PAD, elderly
24
What are lifestyle modifications that can help to manage elevated BP?
- weight
- physical activity
- salt reduction
- diet
- alcohol intake
- smoking cessation
24
What are recommended first line anti-hypertensives?
ACEi or ARB, CCBs or thiazides
24
From the REASON study, what factors and complications were associated with increased mortality?
FACTORS:
- increasing age
- higher ASA status
- pre op albumin < 30
- unplanned surgery
COMPLICATIONS:
- renal impairment
- unplanned ICU admissions
- systemic inflammation
25
What cardiac conditions are high risk and pose as contraindications to non-cardiac surgery?
- ACS
- Acute decompensated HF
- Unstable arrhythmias
- symptomatic severe AS
26
When is perioperative stress testing indicated?
For patients at elevated risk for non cardiac surgery with poor functional capacity (<4 METs) if the results of stress testing will change management
Stress testing performed as dobutamine stress echo
27
What are the guidelines for antiplatelets following cardiac stent for non cardiac surgery?
- DAPT for minimum 1/12 after BMS (bare metal stent)
- minimum 3-6 months after DES
- minimum 12 months after ACS
28
What are the risk factors for post operative respiratory complications?
- increased age
- smoking
- pre existing lung disease
- OSA
- pulmonary hypertension
- heart failure
- duration of anaesthesia
- anaesthetic technique
- neuromuscular blockade type
(not obesity)
29
What is the role of preoperative pulmonary function tests and CXR?
PFTs indicated for:
- cardiac surgery or lung resection
- investigation of undiagnosed SOB
- assess airways disease control
CXR indicated for undiagnosed dyspnoea, > 50 undergoing high risk surgery and known cardiopulmonary disease
30
What are key considerations with methadone prescription?
Causes QTc prolongation
Metabolised by CYP450:
- inducers cause decreased drug levels (anticonvulsants, rifampicin)
- inhibitors cause increased drug levels (azoles, fluoxetine)
31
What is malignant SVCO syndrome and what cancers is it commonly associated with?
Direct invasion or external compression of the SVC by a tumour that leads to thrombosis within the SVC
50% seen in NSCLC
30% SCLC
15% Non-hodgkins lymphoma
60% SVCO are in patients prior to cancer diagnosis, 10% SCLC present with SVCO
32
What are clinical features of SVCO and the grades?
Face, neck or arm swelling
Chest pain
Dyspnoea, stridor, cough or hoarse voice
Cerebral oedema - headache
Grade I: incidental
Grade II: symptomatic
Grade III: severe symptoms
Grade IV: life threatening
Grade V: death
33
How should SVCO be managed?
Diagnosed on CT with contrast
Glucocorticoids (dex) to reduce swelling
Recanalisation and stenting
Radiation therapy (risk of complete SVC obstruction due to swelling, needs dex cover)
Chemotherapy for underlying malignancy
34
What are common cause of malignant spinal cord compression?
Prostate cancer
Breast cancer
Lung cancer
Multiple myeloma
35
What are key features of malignant spinal cord compression?
- New progressive severe back pain esp thoracic, worse on coughing, straining or lying flat
- New motor deficit
- Bowel or bladder disturbance (late sign)
36
How should malignant spinal cord compression be managed?
MRI whole spine, CT myelography if patient unable to under go MRI
High dose dexamethasone (16 mg OD) started when suspected
Pain control
IDC
Laxatives
Surgical decompression and spine stabilisation or external beam radiotherapy
37
What cancers are the most common cause of catastrophic bleeding? What are other high risk cancers?
Head and neck advanced cancer (5% of cases)
Central lung cancers
Cancers with thrombocytopenia
Cancers with liver disease
38
How are catastrophic bleeds managed?
- reassurance for patient and family
- positioning of patient for comfort
- midazolam 10 mg for sedation (may need to be higher if already on benzos)
- consider opioid
39
What cancers are associated with major airway obstruction?
- lung cancers
- laryngeal and nasopharyngeal carcinoma
- oesophageal carcinoma
- mediastinal tumours
40
How should major airway obstruction be managed?
CT chest once stabilised
Bronchoscopy and stenting if appropriate
External beam radiation as appropriate
Dexamethasone
Opioids and benzodiazepines for comfort
41
What are common causes of malignant hypercalcaemia?
-80% caused by PTHrP (many cancers)
- Osteolysis (breast, MM, lymphoma, leukaemia)
-1,25DihydroxyVitD: lymphoma, ovarian germinomas
- Ectopic PTH: ovarian, lung, NET, thyroid papillary, pancreatic)
42
How should malignant hypercalcaemia be managed?
Serial measurements of CCa
PTH, PTHrP, Vit D levels
Bisphosphonate IV
Normal saline +/- IV frusemide
Denosumab in patients who cannot have bisphosphonate esp renal impairment
43
What is the most dangerous glomerulonephritis in pregnancy?
SLE
44
What is the significance of maternal SSA/SSB (Ro/La) in pregnancy?
Fetal heart block (need to be on hydroxychloroquine)
45
When is the best time to plan a pregnancy in CKD?
Stable kidney function
BP well-controlled
On pregnancy safe medications
Underlying disease (SLE) well-controlled
46
Is RAAS blockade contraindicated in pregnancy?
Yes - is teratogenic
47
What is the target BP in pregnancy and what medications are safe for hypertension?
Target BP < 140/90 and continue unless BP < 110/70
Nifedipine, methyldopa, labetalol, hydralazine
48
When should aspirin be given in pregnancy?
For prevention of pre-eclampsia in women who are high risk
100-150 mg OD from 10-14/40 until 10 days before delivery
49
How is proteinuria in pregnancy defined and what is its significance?
>300 mg protein in 24 hour urine
OR
Urine Protien:Cr ratio >30
OR
Urine albumin:CR ratio >8
Before 20 weeks = underlying renal disease
After 20 weeks and hypertensive = at risk of pre-eclampsia
After 20 weeks and normotensive = new onset renal disease including autoimmune disease
50
How should hypothyroidism be managed in pregnancy?
- iodine supplement 150 micrograms OD
- TSH > 10 with decreased T4 should receive replacement
- there is no role in treating or screening for anti-TPO antibodies in pregnancy
51
How should Graves disease be managed in pregnancy?
PTU = 1st line
The can continue throughout or switch to carbimazole at 16/40 noting PU risk of maternal hepatotoxicity and carbimazole risk of maternal and foetal hypothyroidism
