general Flashcards
starting antihypertensives
ABPM/HBPM >= 135/85 mmHg (i.e. stage 1 hypertension)
treat if < 80 years of age AND any of the following apply; target organ damage, established cardiovascular disease, renal disease, diabetes or a 10-year cardiovascular risk equivalent to 10% or greater
ABPM/HBPM >= 150/95 mmHg (i.e. stage 2 hypertension)
offer drug treatment regardless of age
PR prolongation
more than 3-5 small squares (120ms to 200ms)
what indicates in infective endocarditis that a left sided valve is affected?
septic emboli - Janeway lesions, Roth spots
digoxin therapy finding on ECG
scooped ST depression
There are four main categories of etiologies of ST depression associated with a normal QRS complex: ischaemia, hypokalemia, digoxin, normal variant. When the QT interval is very short and ‘scooped’ as in this case, think digoxin
Causes of inverted T waves
- myocardial ischaemia
- digoxin toxicity
- subarachnoid haemorrhage
- arrhythmogenic right ventricular cardiomyopathy
- pulmonary embolism (‘S1Q3T3’)
- Brugada syndrome
hypothermia ECG changes
bradycardia
‘J’ wave (Osborne waves) - small hump at the end of the QRS complex
first degree heart block
long QT interval
atrial and ventricular arrhythmias
features of hypercalcaemia on ECG
shortened QT interval
features of hypokalaemia on ECG
- prolonged PR
- prolonged QT
- small/inverted/absent T waves
- ST depression
What is Wellen’s syndrome?
Wellen’s syndrome is an ECG pattern that is typically caused by high-grade stenosis in the left anterior descending coronary artery.
The patient’s pain may have resolved at the time of presentation and cardiac enzymes may be normal/minimally elevated.
ECG features
- biphasic or deep T wave
- inversion in V2-3
- minimal ST elevation
- no Q waves
Secondary prevention of stable cardiovascular disease with an indication for an anticoagulant
- normally in this situation, all patients are recommended to be prescribed an antiplatelet
- if an indication for anticoagulant exists (for example atrial fibrillation) it is indicated that anticoagulant monotherapy is given without the addition of antiplatelets
ECG indications for PCI/thrombolysis
- new LBBB
- ST elevation >1mm in 2+ inferior leads
- ST elevation >2mm in 2+ anterior leads
Warfarin before emergency surgery
If surgery can wait for 6-8 hours - give 5 mg vitamin K IV
If surgery can’t wait - 25-50 units/kg four-factor prothrombin complex
STEMI ECG criteria
2.5 mm (i.e ≥ 2.5 small squares) ST elevation in leads V2-3 in men < 40 years, or ≥ 2.0 mm ST elevation in leads V2-3 in men > 40 years
1.5 mm ST elevation in V2-3 in women
1 mm ST elevation in other leads
new LBBB
What is bifascicular block?
- the combination of RBBB with left anterior or posterior hemiblock
anterior hemiblock -> left axis deviation
posterior hemiblock -> right axis deviation
What is trifascicular block?
features of bifascicular block as above + 1st-degree heart block
treatment of choice for facial hirsutism
eflornithine - contraindicated in pregnancy!
counselling for patient after pneumonia
+ CXR after 6 weeks!
chest draining swinging?
water rises on inspiration, falls on expiration
what type of lung cancer are cavitating lesions most commonly seen with?
squamous
TRALI and ARDS?
TRALI = ARDS within 6 hours of transfusion
pulmonary capillary wedge pressure?
measurement of pressure in pulmonary capillary, used to estimate pressure in left atrium (due to backlog)
high pressure indicates high backlog of blood from LA to pulmonary capillaries:
- mitral stenosis
- severe left ventricular dysfunction
Over rapid aspiration/drainage of pneumothorax can result in…?
Re-expansion pulmonary oedema
what causes hypotension in pneumothorax?
cardiac outflow obstruction -> obstructive shock
positioning helpful in patients with ARDS and on ventilation?
prone
pancoast tumour
- hoarseness of voice due to pressing on recurrent laryngeal nerve
- ## apex
pleural fluid drainage
All patients with a pleural effusion in association with sepsis or a pneumonic illness require diagnostic pleural fluid sampling
- if the fluid is purulent or turbid/cloudy a chest tube should be placed to allow drainage
- if the fluid is clear but the pH is less than 7.2 in patients with suspected pleural infection a chest tube should be placed
consequences of obstructive sleep apnoea
daytime somnolence
compensated respiratory acidosis
hypertension
Causes of true mediastinal widening
vascular problems: thoracic aortic aneurysm
lymphoma
retrosternal goitre
teratoma
tumours of the thymus
common sites for aspiration pneumonia
right lower and middle lobes
___ can mimic pneumothorax
large bullae in COPD
emphysema picture on pulmonary function tests
obstructive
BRCA2 mutation associated with breast cancer and…
prostate cancer
adverse effect of isoniazid can be prevented by prescribing…?
pyridoxine
Mycoplasma pneumoniae patient with anaemia, raised LDH, raised unconjugated bilirubin
autoimmune haemolytic anaemia
calcified nodule is visible in the lateral area of the right lung, mid zone
Ghon complex - latent TB
what is used to assess drug sensitivities in TB?
sputum culture
treating latent TB
3 months of isoniazid (with pyridoxine) and rifampicin
or
6 months of isoniazid (with pyridoxine)
legionella treatment
macrolides
most commonly affected site in ischaemic colitis - supplied by what vessels? imaging finding?
splenic flexure - supplied by superior and inferior mesenteric arteries. thumbprinting on CXR
preventing vasospasm in SAH
nimodipine
epilepsy management depending on seizure type and sex
Generalised tonic-clonic seizures
* males: sodium valproate
* females: lamotrigine or levetiracetam
* girls aged under 10 years and who are unlikely to need treatment when they are old enough to have children or women who are unable to have children may be offered sodium valproate first-line
Focal seizures
* first line: lamotrigine or levetiracetam
* second line: carbamazepine, oxcarbazepine or zonisamide
Absence seizures (Petit mal)
* first line: ethosuximide
* second line:
○ male: sodium valproate
○ female: lamotrigine or levetiracetam
* carbamazepine may exacerbate absence seizures
Myoclonic seizures
* males: sodium valproate
* females: levetiracetam
Tonic or atonic seizures
* males: sodium valproate
* females: lamotrigine
presentation of amaurosis fugax but on an anticoagulant
If a patient is on warfarin/a DOAC/ or has a bleeding disorder and they are suspected of having a TIA, they should be admitted immediately for imaging to exclude a haemorrhage
mid-shaft humeral fracture - which nerve damaged? how to test?
radial nerve
extend wrist
causes of SAH
- Head injury is top cause - traumatic SAH
- In the absence of trauma: ‘spontaneous SAH’
- Intracranial aneuyrsm e.g. saccular ‘berry aneurysms’
○ Associated conditions with berry aneurysms:
§ Polycystic kidney disease
§ Hypertension
§ Ehlers-Danlos syndrome
Coarctation of the aorta
*Atriovenous malformation
*Pituitary apoplexy
*Mycotic (infective) aneurysms
- Intracranial aneuyrsm e.g. saccular ‘berry aneurysms’
pontine haemorrhage
Pontine haemorrhage commonly presents with reduced GCS, paralysis and bilateral pin point pupils
resting tremor vs benign essential tremor
combination drugs in Parkinson’s
- Co-beneldopa (levodopa + benserazide) - Madopa
Co-careldopa (levodopa + carbidopa) - Sinemet
when is carotid endarterectomy the preferred intervention in TIA?
if stenosis > 70% in internal carotid artery
who should receive dexamethasone in bacterial meningitis?
everyone except:
- meningococcal septicaemia
- shock
- immunocompromised
- recently out of surgery
man with BPH has diabetic neuropathy pain. has trialled duloxetine. what to try next?
pregabalin
usually amitryptiline but to be avoided to prevent urinary retention
neck of femur fracture management options
- Cannulated screw fixation
○ Non-displaced intracapsular fractures
○ Insertion of screws across fracture line to stabilise- Dynamic hip screw
○ Stable, extracapsular
○ Insertion of single large screw into femoral head, combined with a side plate fixed to femoral shaft
§ If unstable, intermedullary nail generally preferred - Hemiarthroplasty
○ Replacing femoral head and neck with a prosthesis
○ Displaced intracapsular fractures in older patients with lower activity levels, as these fractures have a high risk of non-union and avascular necrosis - Total hip arthroplasty
○ Replacement of femoral head and acetabulum with prosthetic components
○ Typically for displaced intracapsular fractures in younger, more active patients or older patients with pre-existing osteoarthritis
- Dynamic hip screw
known complication of THR
posterior dislocation
changes in vision, confusion, and seizures & severe hypertension
Posterior Reversible Encephalopathy Syndrome (PRES) is a constellation of symptoms that results in oedema of the posterior occipital and parietal lobes. Manifestations include headache, changes in vision, confusion and seizures. It can be caused by severe hypertension, and it should resolve once the blood pressure is under control.
treating anaemia in ACS
The chest pain in ACS is caused by reduced blood flow to the myocardium resulting from a narrowing of the coronary arteries. Superimposed anaemia will worsen the ischaemia by compromising the ability of the blood to deliver oxygen through the already narrowed coronary arteries. For most indications, the haemoglobin threshold for blood transfusion is 70 g/L, however, in ACS, the threshold rises to 80 g/L.
treating respiratory failure with NIV
type 1 - CPAP
type 2 - BiPAP
C diff treatment
1st line: oral vancomycin for 10 days
If ineffective, oral fidaxomicin
Last line: faecal transplant
if patient can’t take Parkinson’s medicines orally?
They can be administered via a nasogastric tube or a rotigotine patch could be used.
components of a delirium screen
urine dipstick, urine MC&S, FBC, U&E, Calcium, LFTs, TFTs, Coagulation Screen, Glucose, Vitamin B12 and Folate
NICE criteria for total hip arthroplasty
able to mobilise outside with no more than the use of a stick
not cognitively impaired
medically fit for anaesthesia and the procedure.
scan for pyrexia of unknown origin?
PET-CT
most common source of Gram -ve sepsis
biliary and urinary systems
presence of a new-onset left sided varicocele in an older man (over the age of 40 years)
should prompt further investigation. It could be the presenting symptom of an underlying renal cell carcinoma that is compressing the venous drainage of the left testicle into the left renal vein
eligibility of patients with recurrent tonsillar infections for a tonsillectomy
Paradise Criteria
● ≥7 episodes of tonsillitis in the past 12 months
● ≥5 episodes of tonsillitis per year for 2 years
● ≥3 episodes of tonsillitis per year for 3 years
● ≥2 peritonsillar abscesses at any point in the patient’s life (≥1 in children)
child with non-tender small round bump in neck that moves with swallowing and protrusion of tongue
A thyroglossal cyst is an embryological remnant of the thyroglossal duct which has incompletely closed in utero. Thyroglossal cysts are benign but may cause difficulty in speaking and swallowing or may become infected. They typically present in children up to adolescence.
Thyroglossal cysts are managed by surgical excision, typically with a Sistrunk procedure, which involves complete removal of the cyst and part of the hyoid bone. Any underlying infection of the cyst must be treated with antibiotics prior to surgery.
Severe exacerbation of COPD. Currently undergoing NIV. O2 improved but still metabolic acidosis with high CO2.
Generally what needs to be done with IPAP and EPAP pressures? What are they normally?
Non-invasive ventilation is an umbrella term that encompasses CPAP and BiPAP.
There are two main measures that are used when describing NIV. Inspiratory positive airways pressure (IPAP) which is the pressure applied during the inspiratory phase of the respiratory cycle, and expiratory positive airway pressure (EPAP) which is the pressure during the expiratory phase. In CPAP, the pressure remains constant throughout inspiration and expiration (IPAP = EPAP). In BiPAP, the pressure during the inspiratory phase is higher than the pressure during the expiratory phase.
The EPAP is responsible for splinting open otherwise collapsed airways, thereby increasing alveolar recruitment and, hence, oxygenation of the blood. In other words, an increase in EPAP should bring about an increase in oxygenation. The difference between IPAP and EPAP creates a gradient which facilitates the expiration of carbon dioxide-rich air from the lungs. Therefore, increasing the gap between the IPAP and EPAP will lead to an increase in carbon dioxide excretion.
In this scenario, the patient’s pO2 has improved, however, their pCO2 has remained roughly the same. Therefore, an increase in the gap between the IPAP and EPAP would be recommended as it would increase carbon dioxide excretion. Given that the patient is on 60% FiO2 and their oxygenation has only slightly improved, it would not be appropriate to reduce their EPAP at this point in time.
SOB, afebrile, O2 92%, D-dimer not elevated after elective cholecystecomy?
Atelectasis refers to loss of lung volume due to collapse or inadequate ventilation. This may be caused by an obstruction (e.g. mucus plug) which the trapping of air within the airways distal to the obstruction. Over time, this trapped air will be absorbed into the circulation and the airway will collapse. It can also result from inadequate ventilation and is a common post-operative complication.
The reduced respiratory effort during anaesthesia and shallow-breathing due to post-operative pain are thought to contribute to the development of atelectasis. It can be prevented by encouraging patients to take regular deep breaths during the post-operative period, and using devices such as incentive spirometers.
Patient feels dizzy and unwell after stoma - 2400ml from stoma
A high output stoma is generally defined as having a stoma output of 1.5-2 L or greater and results from the inability of the small bowel to reabsorb fluid and electrolytes efficiently. It usually resolves over time, but it is relatively common for new stomas to develop this complication.
It can lead to dehydration and electrolyte imbalance. The management involves administering IV fluids and using loperamide or codeine to increase bowel transit time. In some cases, PPIs and histamine antagonists may also be used.
Oral fluids can further increase stoma output in patients with high-output stoma by reducing the osmolarity of the bowel contents and, hence, drawing more fluid into the bowel lumen.
Oral fluids should be heavily restricted (500 ml/day) and replaced with IV fluids. Sometimes an electrolyte-rich oral rehydration solution may be used.
Urobilinogen levels in acute cholangitis
low
One of the most infective complications in post-operative patients generally?
Pneumonia is one of the most common complications in post-operative patients. When a patient spikes a temperature in the post-operative period, it is important to try and identify the cause. The time the fever develops after surgery can indicate the likely underlying cause:
1-2 days post op: respiratory or part of physiological inflammatory response to surgery 3-5 days post-op: respiratory or urinary tract 5-7 days: surgical site infection, venous thromboembolism, anastomotic leak
It is important to manage pain well in patients who have had major abdominal or thoracic surgery. The pain can limit their ability to breathe deeply and, hence, adequately ventilate their lungs. This can result in atelectasis and the development of hospital-acquired pneumonia.
borders of inguinal canal
Anterior Wall: aponeurosis of the external oblique, reinforced laterally by the internal oblique muscle
Posterior Wall: transversalis fascia
Superior Wall (roof): transversalis fascia, internal oblique and transversus abdominis
Inferior Wall (floor): inguinal ligament thickened medially by the lacunar ligament
trigger finger vs duputryen’s contracture
Duputryen’s - digital contracture, ring finger most commonly affected - associated with ALCOHOL
Trigger finger - flexion of PIP - associated with DIABETES
TOTAL occlusion in the left common iliac artery - management?
Femoral-femoral crossover
When is aortobifemoral bypass indicated?
occlusion of both iliac vessels
When is axillofemoral bypass indicated?
if aorta and right common iliac artery are not patent
Treatment of Extended spectrum beta lactamases (ESBLs)
meropenem
bleeding post tonsillectomy
Primary haemorrhage occurs within the first 8 hours of the operation and requires immediate return to theatre.
Secondary haemorrhage usually occurs as a result of infection and tends to occur 5-10 days after the operation. In some cases, it may require a return to theatre.
All cases of post-tonsillectomy haemorrhage require review by ENT.
Hesselbach triangle
Hesselbach’s triangle is an anatomical landmark that demarcates the potential areas of weakness in the anterior abdominal wall through which herniation can occur.
It has three borders:
Medial: lateral border of the rectus abdominis Lateral: inferior epigastric vessels Inferior: inguinal ligament
pneumonia with hyponatraemia
Legionella pneumophila is one cause of atypical pneumonia, and it tends to be associated with hyponatraemia and confusion. The organism spreads via aerosolised water and common reservoirs for the bacteria include air conditioning units and water tanks. Legionella antigens can be detected in the urine, so a urinary antigens test should be requested in any patient with possible atypical pneumonia.
monitoring heparin
APTT
anti-thrombin III and enhancing its activity. It will result in a dramatic increase in the ability of anti-thrombin III to bind to and inhibit Factors II, IX, X and XI. As these factors are primarily involved in the intrinsic pathway of the clotting cascade, the effect of heparin is monitored using activated partial thromboplastin time
Right hemicolectomy anastomosis
ileo-colic
femoral canal borders
The femoral canal has four borders:
Medial: lacunar ligament Lateral: femoral vein Anterior: inguinal ligament Posterior: pectineal ligament, superior ramus of pubic bone and pectineus muscle
mobilising after primary elective knee replacement
NICE guidelines state that “a physiotherapist or occupational therapist should offer rehabilitation, on the day of surgery if possible and no more than 24 hours after surgery” for those who have had a primary elective knee replacement. This rehabilitation should include:
· advice on managing activities of daily living
· and home exercise programmes
· and mobilisation for people who have had knee or hip replacement
acute limb ischaemia but features which suggest you cannot intervene. what treatment is needed
Paraesthesia and Paralysis - amputation
supporting blood pressure in critically unwell patients after fluid boluses
Metaraminol is an alpha-1 agonist that is commonly used to support blood pressure in critically unwell patients. It tends to be the vasopressor of choice for patients who only have peripheral intravenous access (i.e. no central line).
severity of PAD based off symptoms
Fontaine I Asymptomatic patients
Fontaine II = Intermittent claudication
- IIa- walk over 200m before experiencing Sx
- IIb Intermittent claudication - walk <200m before experiencing Sx
iii - rest/nocturnal pain
iv - Most severe form of chronic limb ischaemia - tissue loss e.g. ulcers, gangrene
what is implied by leakage of CSF from epidural catheter?
A “high spinal” occurs when the local anaesthetic block extends above the desired level (in this case, above T4). This will block a greater proportion of the sympathetic output from the sympathetic chain (including the cardiac accelerator fibres to the heart) leading to dangerous bradycardia and life-threatening hypotension.
If the local anaesthetic progresses to the intracranial space, total spinal anaesthesia occurs. This can lead rapidly to loss of consciousness, respiratory arrest and cardiac arrest from sudden loss of sympathetic outflow.
TYPES OF MI
Type 1: Caused by ischaemia due to a sudden coronary artery occlusion (e.g. thrombus)
Type 2: Caused by ischaemia due to increased oxygen demand or decreased supply without any acute coronary event.
Type 3: Referred to cases of sudden death in patients with preceding features suggestive of a myocardial infarction but without available biomarkers.
Type 4: Associated with percutaneous coronary intervention or stent thrombosis.
Type 5: Associated with cardiac surgery (e.g. CABG).
treating atrial fibrillation in patients who are NBM
The first-line management choice for rate control in patients with atrial fibrillation is bisoprolol, however, in patients who are nil by mouth, other alternatives must be considered as bisoprolol does not have an intravenous preparation. IV metoprolol or IV atenolol are good alternatives that are cardioselective and able to rapidly achieve rate control. Labetalol is also available in an IV preparation, however, it is non-cardioselective and, so, tends to mainly be used to manage high blood pressure as opposed to high heart rate.
Zollinger-Ellison syndrome - what is it? investigations?
Zollinger-Ellison syndrome is a disease in which patients develop extensive mucosal ulceration across their oesophagus, stomach and duodenum. It is caused by excessive release of gastrin from a tumour of the enteroendocrine G cells. Gastrin is a hormone that stimulates gastric acid production and gastric motility. The excessive acid production in Zollinger-Ellison syndrome results in mucosal damage and ulceration.
This is usually followed by a secretin stimulation test in which secretin is administered and the change in serum gastrin is observed. Normally, secretin will reduce gastrin production, however, in Zollinger-Ellison syndrome it causes a paradoxical increase in gastrin secretion.
What is the strongest prognostic factor for the development of Graves’ eye disease?
smoking
impaired fasting glucose
A fasting glucose greater than or equal to 6.1 but less than 7.0 mmol/l implies impaired fasting glucose (IFG)
impaired glucose tolerance
fasting plasma glucose less than 7.0 mmol/l and OGTT 2-hour value greater than or equal to 7.8 mmol/l but less than 11.1 mmol/l
A 55-year-old man is brought to the emergency department by his colleagues due to confusion, unsteadiness, and slurred speech. On examination, he is disoriented, with a noticeable smell of alcohol on his breath. His vital signs include a blood pressure of 130/80 mmHg and a heart rate of 88 bpm. His colleagues are unsure about any of his past medical history.
Which option is the best next immediate step?
capillary glucose
diabetes sick day rules - T1DM
Patients with type 1 diabetes
if a patient is on insulin, they must not stop it due to the risk of diabetic ketoacidosis
check blood glucose more frequently, for example, every 1-2 hours including through the night
consider checking blood or urine ketone levels regularly
maintain normal meal pattern if possible
if appetite is reduced meals could be replaced with carbohydrate-containing drinks (such as milk, milkshakes, fruit juices, and sugary drinks)
aim to drink at least 3 L of fluid (5 pints) a day to prevent dehydration
diabetes sick day rules - T2DM
advise the patient to temporarily stop some oral hypoglycaemics during an acute illness
medication may be restarted once the person is feeling better and eating and drinking for 24-48 hours
metformin: stop treatment if there is a risk of dehydration, to reduce the risk of lactic acidosis.
sulfonylureas: may increase the risk of hypoglycaemia
SGLT-2 inhibitors: check for ketones and stop treatment if acutely unwell and/or at risk of dehydration, due to the risk of euglycaemic DKA
GLP-1 receptor agonists: stop treatment if there is a risk of dehydration, to reduce the risk of AKI
if on insulin therapy, do not stop treatment, as above
monitor blood glucose more frequently as necessary
A 53-year-old man with type 2 diabetes mellitus (T2DM) managed on metformin presents to his GP for a routine diabetes review. His recent HbA1c level is 56 mmol/mol. With Ramadan approaching, he inquires about the possibility of discontinuing metformin during the fasting period.
What should this patient be advised?
1/3 before sunrise
2/3 after sunrise
calcium and cataracts
hypocalcaemia associated with cataracts
primary hyperaldosteronism
Types of multiple endocrine neoplasia + features
Segond fracture?
avulsion fracture of the proximal lateral tibia and is pathognomonic of an anterior cruciate ligament tear. Therefore, the most appropriate management option is an anterior cruciate ligament repair.
AKI staging?
BPH that has caused complications?
referral to urology for surgery
hydrocele in baby - management?
Hydroceles occur when the tunica vaginalis becomes distended and filled with serous fluid. They are common in newborn boys, especially if preterm. The majority resolve on their own within the first year of life.
If the hydrocele has not resolved on its own by the time the baby is one year old, referral to a paediatric surgeon should be considered.
Persistent hydroceles may require surgery (usually laparoscopic) at 12-24 months of age.
markers of deranged hepatic synthetic function - most sensitive?
albumin & clotting times
international normalised ratio (INR) which is calculated by dividing the patient’s prothrombin time by a fixed reference prothrombin time, is most sensitive as it is affected by the levels of factor VII. Factor VII has the shortest half-life (4-6 hours) of all the clotting factors and, hence, would be first to be deranged in liver failure.
types of hypercalcaemia of malignancy and causes
severe CAP (CURB65>3) management
Admit &
5 day course of IV Co-Amoxiclav 1.2 g TDS and Clarithromycin 500 mg BD
investigation to do before treating bell’s palsy when seeing patient with facial droop + non forehead sparing
otoscopy should be performed to check for the presence of a vesicular rash in the outer ear that would be suggestive of Ramsay-Hunt syndrome
myasthenia gravis vs lambert eaton
myasthenia: anti-achr on postsynaptic membrane
- movements worse with exertion
- first line: pyridostigmine
lambert eaton: anti-voltage gated calcium channels on presynaptic membrane
- movements better with exertion as acetylcholine overpowers
- first line: amifampridine
CREST aka?
limited scleroderma
X-ray of the affected knee which reveals subchondral cysts, joint degeneration and calcification of the medial meniscus - likely diagnosis?
pseudogout
transitional cell carcinoma - most likely lymph node spread?
para-aortic
types of graft rejection
Hyperacute
● Within seconds of clamp release
● Mediated by preformed antibodies
● Results in immediate loss of graft
Accelerate Acute
● First few days
● Cellular and antibody mediators
Acute
● Days to weeks
● Cell mediated – usually lymphocytes
Chronic
● Most common
● Graft atrophy and atherosclerosis
Fibrosis is a very late event
triad of anaesthesia
analgesia, hypnosis and relaxation
muscle relaxant meds in anaesthesia
Muscle relaxants are also known as neuromuscular blocking agents (NMBAs)
NMBAs are divided into depolarising and non-depolarising blockers.
Depolarising blockers, such as suxamethonium, are agonists of the acetylcholine receptor (AChR), creating a long-lasting depolarisation which eventually causes desensitisation and thus paralysis.
Non-depolarising agents, such as rocuronium, are competitive antagonists of the AChR, preventing ACh from binding to its receptor and causing muscle contraction.
Benign Early Repolarisation
benign ECG pattern that appears as widespread concave ST elevation that is usually seen in leads V2-5.
It may be associated with a notched J point and the T waves are usually prominent, such that the ST elevation: T wave ratio is < 0.25. It is usually seen in young people under the age of 50 years.
raised ICP and MI?
Raised intracranial pressure (e.g. due to an intracranial bleed) can give rise to a number of ECG changes that could mimic myocardial ischaemia (such as ST elevation or depression and T wave inversion).
In patients who are drowsy and have marked ECG changes, an urgent CT head scan should be conducted to check for any intracranial pathology.
Given that these changes could be caused by an intracranial bleed (such as a subdural haemorrhage in this patient subset), it is important to conduct a CT head scan prior to starting antiplatelet or anticoagulant therapy that would dramatically worsen any bleed.
constrictive vs restrictive cardiomyopathy
Constrictive pericarditis is a condition in which inflammation results in thickening and scarring of the pericardium.
This can result in reduced ventricular filling as the heart cannot relax fully as it is constrained by the stiff pericardium.
It may present with features of heart failure such as peripheral and pulmonary oedema. As it causes diastolic failure, an echocardiogram is likely to reveal preserved ejection fraction
Constrictive pericarditis usually arises following diseases that inflict damage to the pericardium such as viral and non-viral pericarditis
Restrictive cardiomyopathy may present similarly, however, it is a disease of the myocardium as opposed to the pericardium. It may be genetic, or caused by infiltrative diseases such as sarcoidosis and amyloidosis.
acute UC flare with heavy bleeding - anticoagulate or no?
As this patient is actively bleeding, it is often assumed that they should not be given venous thromboembolism prophylaxis upon admission as it may worsen their bleeding.
Inflammatory bowel disease, however, is a systemic inflammatory condition which creates a very pro-thrombotic state. This, coupled with the dehydration due to diarrhoea and immobility due to hospital admission, puts the patient at a very high risk of developing a venous thromboembolism.
Therefore, patients with suspected inflammatory bowel disease should be given VTE prophylaxis during a hospital admission (e.g. tinzaparin 4500 units SC OD).
hiatus hernia - elevated gastric bubble
acute mesenteric ischaemia
Acute mesenteric ischaemia refers to ischaemia of the bowel resulting from an occlusion of the superior mesenteric artery. It classically manifests with a triad of abdominal pain, shock and normal abdominal examination findings.
Risk factors include hypercoagulable states (e.g. multiple myeloma which may have developed from this patient’s previous MGUS). It may be treated interventionally with embolectomy and bypass surgery.
causes of dysphagia
most likely cause of an irregular broad complex tachycardia in a stable patient
AF with bundle branch block
carcinoid syndrome
usually occurs when metastases are present in the liver and release serotonin into the systemic circulation
may also occur with lung carcinoid as mediators are not ‘cleared’ by the liver
Features
flushing (often the earliest symptom) diarrhoea bronchospasm hypotension right heart valvular stenosis (left heart can be affected in bronchial carcinoid) other molecules such as ACTH and GHRH may also be secreted resulting in, for example, Cushing's syndrome pellagra can rarely develop as dietary tryptophan is diverted to serotonin by the tumour
Investigation
urinary 5-HIAA plasma chromogranin A y
Management
somatostatin analogues e.g. octreotide diarrhoea: cyproheptadine may help
what is S1? when is it soft? when is it loud?
S1
closure of mitral and tricuspid valves soft if long PR or mitral regurgitation loud in mitral stenosis
what is S2? when is it soft? what does splitting indicated?
closure of aortic and pulmonary valves
soft in aortic stenosis
splitting during inspiration is normal
what is S3? when is it heard?
caused by diastolic filling of the ventricle
considered normal if < 30 years old (may persist in women up to 50 years old)
heard in left ventricular failure (e.g. dilated cardiomyopathy), constrictive pericarditis (called a pericardial knock) and mitral regurgitation
associated with rapid ventricular filling
what is S4? when is it heard?
may be heard in aortic stenosis, HOCM, hypertension
caused by atrial contraction against a stiff ventricle
therefore coincides with the P wave on ECG
in HOCM a double apical impulse may be felt as a result of a palpable S4
A 64-year-old-man is admitted to the cardiology ward for routine catheter ablation to treat his atrial fibrillation. His wife asks whether he needs to continue his longterm apixaban.
What is the correct advice to give her and the patient?
risk of stroke same, need to remain on apixaban
metabolic consequences of refeeding syndrome
hypophosphataemia
this is the hallmark symptom of refeeding syndrome
may result in significant muscle weakness, including myocardial muscle (→ cardiac failure) and the diaphragm (→ respiratory failure)
hypokalaemia
hypomagnesaemia: may predispose to torsades de pointes
abnormal fluid balance
thyroid storm management
beta blockers, propylthiouracil and hydrocortisone
thyroid storm features
fever > 38.5ºC
tachycardia
confusion and agitation
nausea and vomiting
hypertension
heart failure
abnormal liver function test - jaundice may be seen clinically
when should amiodarone be avoided?
- severe conduction disturbances (unless pacemaker fitted)
- sinus node disease (unless pacemaker fitted)
- iodine sensitivity
- sino-atrial heart block (except in cardiac arrest)
- sinus bradycardia (except in cardiac arrest)
- thyroid dysfunction
Women who suffer regular urinary tract infection following sexual intercourse
offered PRN nitrofurantoin as post-coital prophylaxis
hyperglycaemia in HHS
> 30mmol/L
reactive arthritis
- conjunctivitis (cant see)
- urethrtis (cant pee)
- arthritis (cant climb a tree)
- cant ski (keraoderma blenorrhagicum)
- can’t get jizzy (Circinate balanitis -Serpiginous ring-shaped dermatitis on glans penis)
lucid interval with head injury
extradural
initially loses, briefly regains and then loses again consciousness after a low-impact head injury.
The brief regain in consciousness is termed the ‘lucid interval’ and is lost eventually due to the expanding haematoma and brain herniation.
As the haematoma expands the uncus of the temporal lobe herniates around the tentorium cerebelli and the patient develops a fixed and dilated pupil due to the compression of the parasympathetic fibers of the third cranial nerve.
salter harris
paediatric fractures involving growth plate (ie physis)
I: S - straight across (ie only physis)
II: A - above (physis and metaphysis)
III: L - lower (physis and epiphysis to include joint)
IV: T - through (physis, metaphysis, and epiphysis)
V: ER - erasure of growth plate (crush injury)
sickle cell crises
Thrombotic crises
* also known as painful crises or vaso-occlusive crises
* precipitated by infection, dehydration, deoxygenation (e.g. high altitude)
* painful vaso-occlusive crises should be diagnosed clinically - there isn’t one test that can confirm them although tests may be done to exclude other complications
* infarcts occur in various organs including the bones (e.g. avascular necrosis of hip, hand-foot syndrome in children, lungs, spleen and brain
Acute chest syndrome
* vaso-occlusion within the pulmonary microvasculature → infarction in the lung parenchyma
* dyspnoea, chest pain, pulmonary infiltrates on chest x-ray, low pO2
* management
○ pain relief
○ respiratory support e.g. oxygen therapy
○ antibiotics: infection may precipitate acute chest syndrome and the clinical findings (respiratory symptoms with pulmonary infiltrates) can be difficult to distinguish from pneumonia
○ transfusion: improves oxygenation
* the most common cause of death after childhood
Aplastic crises
* caused by infection with parvovirus
* sudden fall in haemoglobin
* bone marrow suppression causes a reduced reticulocyte count
Sequestration crises
* sickling within organs such as the spleen or lungs causes pooling of blood with worsening of the anaemia
associated with an increased reticulocyte count
threshhold for stopping metformin in AKI
eGFR < 45
stopping drugs in AKI
drugs to avoid prescribing with methotrexate
avoid prescribing trimethoprim or co-trimoxazole concurrently - increases risk of marrow aplasia
beta thalassaemia major
Overview
absence of beta globulin chains chromosome 11
Features
presents in the first year of life with failure to thrive and hepatosplenomegaly microcytic anaemia HbA2 & HbF raised HbA absent
Management
repeated transfusion
this leads to iron overload → organ failure
iron chelation therapy is therefore important (e.g. desferrioxamine)
papiloedema
- venous engorgement
- loss of venous pulsation
- blurring of optic disc margin
- elevation of optic disc
- loss of optic cup
- Paton’s lines: concentric/radial retinal lines cascading from optic cup
suspected Achilles tendon rupture investigation
ultrasound
myocarditis
inflammation of the myocardium in the absence of ischaemia. Patients are usually under 50 and have a history of recent viral illness, as in this presentation. Common symptoms are chest pain and features of pulmonary oedema. Typically, inflammatory markers and troponin will be raised, and ECG will show non-specific ST segment and T wave changes. Focal ST elevation is a possible finding, as in this patient. Myocarditis can manifest as new-onset congestive heart failure (due to inflammation reducing the contractile strength of the heart), as evidenced by the presence of orthopnea and pulmonary oedema on chest x-ray.
Chlamydia trachomatis management
non-pregnant: doxycycline
pregnant: azithromycin, erythromycin or amoxicillin
herpes simplex keratitis presentation & management
presents with dendritic corneal ulcer: painful red eye + tearing
branching linear lesion with terminal bulbs seen on fluorescein staining
- immediate referral to ophthal
- topical aciclovir
testing before initiating rituximab
hep b serology
cystic fibrosis social groups
Patients with cystic fibrosis should minimise contact with each other due to the risk of cross-infection
neovascularisation on fundoscopy
diabetes
salter harris I
- most distal part of radius has moved back on lateral view ie gone through growth plate, making it salter harris I
breast cancer: looking for axillary lymphadenopathy
- no palpable axillary lymphadenopathy -> ultrasound
if ultrasound -ve, sentinel node biopsy to assess nodal burden
- breast cancer with clinically palpable lymphadenopathy -> axillary node clearance (may lead to arm lymphoedema and functional arm impairment)
breast cancer: types of surgery and indications
mastectomy:
- multifocal tumour
- central tumour
- large lesion in small breast
- DCIS > 4
wide local excision
- solitary lesion
- peripheral tumour
- small lesion in large breast
- DCIS < 4
everyone offered breast reconstruction
breast cancer: radiotherapy
offered after WLE
for mastectomy: offered for T3-T4 tumours OR 4+ positive axillary nodes
breast cancer: hormonal therapy
adjuvant if tumours positive for hormonal receptors
pre and peri menopausal: tamoxifen
post-menopausal: anastrazole
tamoxifen side effects
-increased risk of endometrial cancer
- VTE
- menopausal sx
breast cancer: biological therapy. contraindication?
HER2 positive tumours - trastuzumab (Herceptin)
NOT in patients with history of heart disorders though
breast cancer: chemotherapy
neoadjuvant to downstage primary lesion
OR
adjuvant depending on stage e.g. if axillary node disease, FEC-D used
adnrealine doses for anaphylaxis
management for patients who have varicose veins and an active or healed venous leg ulcer
refer to secondary care
suspected aortic dissection investigation of choice
CT angiography
TOE if unstable
anastrazole mechanism of action
reducing peripheral synthesis of oestrogen
inducers and inhibitors of P450, interacting with warfarin
inducers will decrease INR, inhibitor will increase INR
serotonin syndrome vs neuroleptic malignant syndrome
common side effects of diabetic drugs
caecal volvulus: foetal sign
sigmoid volvulus: coffee bean sign
chondrocalcinosis -> pseudogout
types of aphasia
difference between neurofibromatosis and tuberous sclerosis
IV hydrocortisone - Addisonian crisis
WHO pain ladder
pre-op anaemia
discharge post-anaphylaxis
mesenteric ischaemia vs ischaemic colitis
otitis externa
legionella vs mycoplasma
confirming cardiac arrest
- patient unresponsive
- not strongly palpable carotid pulse
- take <10s for assessment: feel pulse, feeling for breath sounds, looking for chest wall movements, listening for breath sounds
- call for help early!
classification of non-proliferative diabetic retinopathy
palliative treatment for breathlessness
we want a short acting benzo so lorazepam and go sublingual
types of laxative? how do they work? examples?
main antiemetics in palliative care
indications and contraindications?
morphine conversions
common symptoms in last hours to days of life
treatment?
subcut ‘anticipatory’ drugs
anticipatory medications
