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
later changes in ank spon on plain x-ray
sacroiliitis: subchondral erosions, sclerosis
squaring of lumbar vertebrae 'bamboo spine' (late & uncommon) syndesmophytes: due to ossification of outer fibers of annulus fibrosus chest x-ray: apical fibrosis
if patient deemed high risk on QFracture or FRAX
DEXA scan
when to take simvastatin
last thing in the evening
lyme disease features
Early features (within 30 days)
* erythema migrans
○ ‘bulls-eye’ rash is typically at the site of the tick bite
○ typically develops 1-4 weeks after the initial bite but may present sooner
○ usually painless, more than 5 cm in diameter and slowlly increases in size
○ present in around 80% of patients.
* systemic features
○ headache
○ lethargy
○ fever
○ arthralgia
Later features (after 30 days)
* cardiovascular
○ heart block
○ peri/myocarditis
* neurological
○ facial nerve palsy
○ radicular pain
meningitis
DVT: if D dimer positive but USS -ve
stop anticoag and repeat scan in a week
cervical screening during pregnancy
usually delayed until 3 months post-partum unless missed screening or previous abnormal smears
hormonal changes during pregnancy can lead to physiological alterations in cervical cells. For example, increased oestrogen initiates cervical cell proliferation, creating potentially misleading changes on a smear test.
TCA overdose, most important investigation
ECG -> can widen QRS complex and increase risk of seizures
within 1 hour paracetamol overdose
activated charcoal
how long is NAC infused over?
1 hour NOT 15 minutes
NAC reaction
commonly causes an anaphylactoid reaction (non-IgE mediated mast cell release). Anaphylactoid reactions to IV acetylcysteine are generally treated by stopping the infusion, then restarting at a slower rate.
When should NAC be given in paracetamol overdose?
the plasma paracetamol concentration is on or above a single treatment line joining points of 100 mg/L at 4 hours and 15 mg/L at 15 hours, regardless of risk factors of hepatotoxicity
there is a staggered overdose* or there is doubt over the time of paracetamol ingestion, regardless of the plasma paracetamol concentration; or
patients who present 8-24 hours after ingestion of an acute overdose of more than 150 mg/kg of paracetamol even if the plasma-paracetamol concentration is not yet available
patients who present > 24 hours if they are clearly jaundiced or have hepatic tenderness, their ALT is above the upper limit of normal
acetylcysteine should be continued if the paracetamol concentration or ALT remains elevated whilst seeking specialist advice
King’s College Hospital Criteria for liver transplant
Arterial pH < 7.3, 24 hours after ingestion
or all of the following:
prothrombin time > 100 seconds creatinine > 300 µmol/l grade III or IV encephalopathy
Knee locking and giving-way
meniscal tear
giving bisphosphonate - what to do beforehand?
correct vitamin D and calcium deficiency
malignant hyperpyrexia
caused by an inherited mutation in the ranitidine receptor which interferes with calcium regulation in skeletal muscle.
Anaesthetic agents known to trigger an episode of malignant hyperpyrexia include all potent inhaled general anaesthetic agents (e.g. halothane, thiopental) and all depolarising muscle relaxants (e.g. suxamethonium). As ketamine is not in either of these classes of drug, it will not cause malignant hyperpyrexia in this patient.
preceding influenza predisposes to what type of pneumonia
Staph aureus
diagnosing AKI in adults
↑ creatinine > 26µmol/L in 48 hours
↑ creatinine > 50% in 7 days ↓ urine output < 0.5ml/kg/hr for more than 6 hours
BPH: If mixture of storage and voiding symptoms after management with alpha blocker
anticholinergic e.g. tolterodine or darifenacin
proximal pole scaphoid fracture
surgical fixation due to risk of development of avascular necrosis
An 18-year-old man presents to the emergency department with a 2-hour history of dyspnoea and chest pain described as a heavy pressure, not specific to a certain area, and not worsened by anything specific. His past medical history includes sickle cell disease and previous hospitalisation for scarlet fever when he was 6. His oxygen saturation is measured at 90% breathing air but is responsive to oxygen, and breath sounds were normal. A chest X-ray shows pulmonary infiltrates. The patient is not on any regular medications.
Which diagnosis is most likely for this patient?
Acute chest syndrome - dyspnoea, chest pain, hypoxia + pulmonary infiltrates
not ARDS - same as above however no mention of sepsis, trauma, or pneumonia (causing trauma to lungs causing non-cardiogenic pulmonary oedema due to increase in capillary permeability) and when given O2, hypoxia does not usually respond in ARDS
Treatment of asymptomatic hyperuricaemia in an attempt to prevent gout
not recommended by NICE
indications for starting antibiotics in otitis media
antibiotics should be prescribed immediately if:
Symptoms lasting more than 4 days or not improving Systemically unwell but not requiring admission Immunocompromise or high risk of complications secondary to significant heart, lung, kidney, liver, or neuromuscular disease Younger than 2 years with bilateral otitis media Otitis media with perforation and/or discharge in the canal
Alport syndrome
genetic condition caused by the defective production of type IV collagen. Features include glomerulonephritis, end-stage kidney disease, and hearing loss, and it is managed using ACE inhibitors and haemodialysis.
amitryptiline + SSRIs
no established risk of serotonin syndrome!
interactions with SSRIs causing serotonin syndrome
tramadol and St John’s Wort
levothyroxine interactions
Iron / calcium carbonate tablets can reduce the absorption of levothyroxine - should be given 4 hours apart
Widened QRS or arrhythmia in tricyclic overdose
- give IV bicarbonate
medications that all patients with PAD should be on
clopidogrel & statin
inducers and inhibitors of P450, interacting with warfarin
inducers will decrease INR, inhibitor will increase INR
serotonin syndrome vs neuroleptic malignant syndrome
malignant otitis externa management
IV ciprofloxacin to cover pseudomonas aeruginosa
otitis externa in diabetics
ciprofloxacin to cover pseudomonas
wet vs dry age-related macular degeneration
Wet age-related macular degeneration is typified by rapid vision loss (over weeks), and choroidal neovascularisation, which in this case is indicated by subretinal fluid and haemorrhages in the macula. Dry age-related macular degeneration progresses more slowly (over months) and is associated with drusen;
anion gap
(Na+) - (bicarb + chloride)
the normal AG = 0.2 x [albumin] (g/L) + 1.5 x [phosphate] (mmol/L)
generally normal: 4-12
causes of normal anion gap or hyperchloraemic metabolic acidosis
gastrointestinal bicarbonate loss: diarrhoea, ureterosigmoidostomy, fistula
renal tubular acidosis
drugs: e.g. acetazolamide
ammonium chloride injection
Addison’s disease
causes of raised anion gap metabolic acidosis
lactate: shock, hypoxia
ketones: diabetic ketoacidosis, alcohol
urate: renal failure
acid poisoning: salicylates, methanol
5-oxoproline: chronic paracetamol use
CO, CN Alcoholic ketoacidosis and starvation ketoacidosis Toluene Metformin, Methanol Uremia DKA Pyroglutamic acidosis, paracetamol, phenformin, propylene glycol, paraladehyde Iron, Isoniazid Lactic acidosis Ethylene glycol Salicylates
investigations for epididymo-orchitis
sexually active younger adults: NAAT for STIs
older adults with a low-risk sexual history: MSSU
common side effects of diabetic drugs
acid base balance in cushing’s syndrome
hypokalaemic metabolic alkalosis
Cushing’s syndrome causes hypokalaemic metabolic alkalosis because when the levels of cortisol are high, the cortisol that is not inactivated by 11β-hydroxysteroid dehydrogenase is free to bind to mineralocorticoid receptors. This causes an increase in water and sodium retention, increased potassium excretion, and increased hydrogen ions excretion.
Lower levels of hydrogen ions cause alkalosis and less potassium causes hypokalemia.
drug that can cause gingival hyperplasia
amlodipine
Felty’s syndrome
condition characterized by splenomegaly and neutropenia in a patient with rheumatoid arthritis.
diagnostic test for Mycoplasma pneumoniae
serology
cancer associated with signet ring cells
gastric adenocarcinoma
renal stones >10mm in pregnancy
ureteroscopy
renal stone management
Renal stones
watchful waiting if < 5mm and asymptomatic
5-10mm shockwave lithotripsy
10-20 mm shockwave lithotripsy OR ureteroscopy
> 20 mm percutaneous nephrolithotomy
Uretic stones
shockwave lithotripsy +/- alpha blockers>< 10mm shockwave lithotripsy +/- alpha blockers
10-20 mm ureteroscopy
ank spon x-ray findings
subchondral erosions, sclerosis
and squaring of lumbar vertebrae
treating delirium in parkinson’s
atypical antipsychotics quetiapine and clozapine are preferred
confusion screen
B12/folate: macrocytic anaemias, B12/folate deficiency worsen confusion
TFTs: confusion is more commonly seen in hypothyroidism
Glucose: hypoglycaemia can commonly cause confusion
Bone Profile (Calcium): hypercalcaemia can cause confusion
acid-base imbalance with IV saline
hyperchloraemic metabolic acidosis
can arise as a complication of substantial intravenous administration of 0.9% sodium chloride. This disorder is typified by an increase in serum chloride and a concurrent decrease in bicarbonate levels, which reduces pH
myxoedemic
thyroxine and hydrocortisone
blood pressure target in patients who have both CKD and diabetes
130/80
sarcoidosis and DI
sarcoidoisis can cause cranial DI by depositing granulomas in the pituitary gland
treating subclinical hypothyroidism
for <65
if the TSH level is 5.5-10 mU/L on 2 separate occasions 3 months apart + symptomatic
if TSH > 10 on 2 separate occasions 3 months apart
for >65:
watch and wait
skull for multiple myeloma vs primary hyperparathyroidism
MM - raindrop
PTH - pepperpot
advice for PSA testing
should not be done within at least:
6 weeks of a prostate biopsy
4 weeks following a proven urinary infection
1 week of digital rectal examination
48 hours of vigorous exercise
48 hours of ejaculation
critical limb ischaemia vs acute
critical > 2 weeks
investigations for PAD
1) handheld arterial Doppler
2) if doppler signals present, ABPI
acute limb ischaemia management
Initial management
ABC approach analgesia: IV opioids are often used intravenous unfractionated heparin is usually given to prevent thrombus propagation, particularly if the patient is not suitable for immediate surgery vascular review
Definitive management:
intra-arterial thrombolysis surgical embolectomy angioplasty bypass surgery amputation: for patients with irreversible ischaemia
caecal volvulus: foetal sign
sigmoid volvulus: coffee bean sign
rush injury, limb swelling and inability to move digits
should raise suspicion of compartment syndrome
Addison’s patient with intercurrent illness
double the glucocorticoids, keep fluodrocortisone the same
pertussis management
oral macrolide if within 21 days
Visual loss, relative afferent pupillary defect, ‘red spot’ on the retina
central retinal artery occlusion
raised ESR & osteoporosis
multiple myeloma until proven otherwise
Measure _____ in suspected gout (i.e. in the acute setting)
a uric acid level ≥ 360 umol/L is seen as supporting a diagnosis
if uric acid level < 360 umol/L during a flare repeat the uric acid level measurement at least 2 weeks after the flare has settled
chronic subdural haematoma on CT
hypodense (dark), crescentic collection around the convexity of the brain
NICE guidance recommends that if patients suffer significant upper gastrointestinal side effects from the use of alendronate, then this should first be changed to
risedronate or etidronate
Disseminated gonococcal infection triad
tenosynovitis, migratory polyarthritis, dermatitis
bacteria associated with staghorn calculi
proteus mirabilis
simmonds triad - used for what?
Use Simmonds triad (palpation, examining the angle of declination at rest and the calf squeeze test) to assess for evidence of Achilles tendon rupture
HIV, neuro symptoms, single brain lesions with homogenous enhancement
CNS lymphoma
screening for diabetic nephropathy
Measure the urinary albumin/creatinine ratio (ACR) on a spot urine sample. If results abnormal, repeat with a first-pass morning urine specimen
chondrocalcinosis -> pseudogout
False positive VDRL/RPR
‘SomeTimes Mistakes Happen’ (SLE, TB, malaria, HIV)
functional tricuspid regurg
often occurs secondary to pulmonary hypertension as a result of chronic lung disease such as chronic obstructive pulmonary disease (COPD) producing a loud pulmonary component of the second heart sound, raised jugular venous pressure and a pansystolic murmur in the left lower sternal edge.
suppression of MRSA from a carrier once identified
Nasal mupirocin + chlorhexidine for the skin
reversal agent for dabigatran
idarucizumab
dabigatran is a DOAC and direct thrombin inhibitor
reversal agent for apixaban or rivaroxaban?
andexanet alfa
modified Xa protein
reversal agent for heparin
protamine sulphate
risk factors for idiopathic intracranial hypertension
obesity
female sex
pregnancy
drugs
combined oral contraceptive pill
steroids
tetracyclines
retinoids (isotretinoin, tretinoin) / vitamin A
lithium
On slit-lamp assessment, a hypopyon is present and there are focal white infiltrates on the cornea.
pseudomonas keratitis
commonly used anaesthesia for NoF fracture
iliofascial block
Most common cause of endocarditis:
Staphylococcus aureus
Staphylococcus epidermidis if < 2 months post valve surgery
AKI dehydration
urea that is proportionally higher than the rise in creatinine
management of volvulus
sigmoid volvulus: rigid sigmoidoscopy with rectal tube insertion
- In patients with sigmoid volvulus who have bowel obstruction with symptoms of peritonitis, skip the flexible sigmoidoscopy and treat with urgent midline laparotomy
caecal volvulus: management is usually operative. Right hemicolectomy is often needed
Compartment syndrome is most commonly associated with
supracondylar + tibial shaft
bitemporal heminaopia
lesion of optic chiasm
upper quadrant defect > lower quadrant defect = inferior chiasmal compression, commonly a pituitary tumour
lower quadrant defect > upper quadrant defect = superior chiasmal compression, commonly a craniopharyngioma
true seizure vs pseudo seizure
prolactin
- raised in true epileptiform seizures
Wernicke’s aphasia (receptive aphasia)
due to a lesion in superior temporal gyrus
typically supplied by inferior division of left MCA
‘forms’ the speech before sending it to Broca’s area
=> word salad
comprehension impaired
Broca’s aphasia
expressive aphasia
inferior frontal gyrus -> typically supplied by superior division of left MCA
- speech non-fluent, laboured, and halting
repetition impaired
- comprehension normal
Conduction aphasia
stroke affecting arcuate fasciculus
- connection between Wernicke’s and Broca’s area
Speech fluent but repetition poor - aware of errors they are making
Comprehension normal
Global aphasia
large lesion affecting receptive, expressive, and conductive aphasia -> may still be able to communicate using gestures
types of aphasia
pituitary apoplexy diagnostic investigation? management?
pituitary MRI
urgent steroid replacement due to loss of ACTH
careful fluid balance
surgery
3rd nerve palsy causes
diabetes mellitus
vasculitis e.g. temporal arteritis, SLE
false localizing sign* due to uncal herniation through tentorium if raised ICP
posterior communicating artery aneurysm
pupil dilated
often associated pain
cavernous sinus thrombosis
Weber’s syndrome: ipsilateral third nerve palsy with contralateral hemiplegia -caused by midbrain strokes
other possible causes: amyloid, multiple sclerosis
when can autonomic dysreflexia happen? features? management?
if lesion above t6
cause of a dysreflexia is an discontinuity between the nociceptors on the viscera and the brain stem autonomic centres due to the cord injury.
features:
the result is an unbalanced physiological response, characterised by extreme hypertension flushing and sweating above the level of the cord lesion agitation in untreated cases, severe consequences of extreme hypertension have been reported, e.g. haemorrhagic stroke.
All the pain receptors on smooth muscle on the abdominal and some pelvic viscera are carried by the sympathetics and the specific nerve which extends to the pelvis is the greater splanchnic nerve (which has its lowest innervation at T6 and so this is the lowest level at which autonomic dysreflexia can still occur).
management:
removal/control of the stimulus and treatment of any life-threatening hypertension and/or bradycardia.
rinne and weber’s in bilateral acoustic neuroma
normal!
Distal sensory loss, tingling + absent ankle jerks/extensor plantars + gait abnormalities/Romberg’s positive
subacute combined degeneration of the spinal cord
tuberous sclerosis - features
Cutaneous features
depigmented 'ash-leaf' spots which fluoresce under UV light roughened patches of skin over lumbar spine (Shagreen patches) adenoma sebaceum (angiofibromas): butterfly distribution over nose fibromata beneath nails (subungual fibromata) cafe-au-lait spots* may be seen
Neurological features
developmental delay epilepsy (infantile spasms or partial) intellectual impairment
Also
retinal hamartomas: dense white areas on retina (phakomata) rhabdomyomas of the heart gliomatous changes can occur in the brain lesions polycystic kidneys, renal angiomyolipomata lymphangioleiomyomatosis: multiple lung cysts
difference between neurofibromatosis and tuberous sclerosis
general features and management for intracranial venous thrombosis
Common features
headache (may be sudden onset) nausea & vomiting reduced consciousness
Investigation
MRI venography is the gold standard
CT venography is an alternative
non-contrast CT head is normal in around 70% of patients
D-dimer levels may be elevated
Management
anticoagulation
typically with low molecular weight heparin acutely
warfarin is still generally used for longer term anticoagulation
sagittal sinus thrombosis - signs
may present with seizures and hemiplegia
parasagittal biparietal or bifrontal haemorrhagic infarctions are sometimes seen
‘empty delta sign’ seen on venography
cavernous sinus thrombosis signs
other causes of cavernous sinus syndrome: local infection (e.g. sinusitis), neoplasia, trauma
periorbital erythema and oedema ophthalmoplegia: 6th nerve damage typically occurs before 3rd & 4th trigeminal nerve involvement may lead to hyperaesthesia of upper face and eye pain central retinal vein thrombosis
lateral sinus thrombosis
6th and 7th cranial nerve palsies
surgical vs non-surgical cause of CN III palsy signs
if pupillary reflexes affected, that’s due to pressing on parasympathetic fibres ie surgical cause
In trauma, to test if the fluid draining from the nose or ear is CSF?
glucose
remembering respective lesions for wernicke’s and brocha’s
W B
STIF
Wernicke’s - superior temporal
Brocha’s - inferior frontal
biochem in neuroleptic malignant syndrome
- raised CK
- AKI secondary to rhabdo
- leukocytosis
idiopathic pulmonary fibrosis meds for treatment
pirfenidone
nintendanib
diagnosis of diverticulitis
contrast CT abdo
Leriche syndrome
also known as aortoiliac occlusive disease, is a form of peripheral vascular disease caused by narrowing at the point at which the aorta branches to form the common iliac arteries. It manifests with erectile dysfunction, buttock claudication and weak femoral pulses.
main classes of commonly used drugs that are associated with peptic ulcer disease
SSRIs, NSAIDs, bisphosphonates
acute vs subacute endocarditis
Acute bacterial endocarditis is when previously normal heart valves become damaged by very virulent organisms such as Staphylococcus aureus.
Subacute bacterial endocarditis occurs in patients with pre-existing valvular damage (e.g. due to rheumatic heart disease). The abnormal valves provide ground on which less virulent bacteria, such as Streptococcus viridans, can form vegetations.
vessel occlusion in ischaemic colitis
inferior mesenteric artery
monitoring patients with NAFLD for features of advanced liver fibrosis
ELF - enhanced liver fibrosis
- blood test that measures 3 molecules that are involved in development of liver fibrosis
A rare but important risk factor to counsel patients about wrt carbimazole
agranulocytosis (cessation in the production of granulocytes) which can result in patients developing life-threatening infections. Patients should be advised that if they develop any features of an infection (e.g. sore throat, fever) they should seek urgent medical attention.
calculating total calcium conc from ionised serum conc
Blood gas machines only provide a value for the ionised serum calcium concentration. Calcium exists in the blood in two forms - around 50% is free ionised calcium and the remaining 50% is bound to proteins (e.g. albumin) or anions. The total serum calcium concentration, therefore, is roughly double the ionised serum calcium concentration.
Long-term oxygen therapy should be considered for patients with chronic respiratory conditions (e.g. COPD, pulmonary fibrosis) who have
a resting pO2 of less than 7.3 kPa.
It should also be considered for patients who have a resting pO2 of 7.3-8 kPa with one of secondary polycythaemia, peripheral oedema or pulmonary hypertension. It is important to ensure that the patient is no longer smoking before issuing long-term oxygen therapy.
when to do ankle x-ray
Malleolar pain
- Ankle X-ray only required if pain in the malleolar zone and any of:
- Bone tenderness at the posterior edge or tip of lateral malleolus
- Bone tenderness at the posterior edge or tip of medial malleolus
- Inability to bear weight both immediately and in front of clinician for 4 steps
Midfoot pain
- Foot X-ray only required if midfoot zone pain and any of the below:
- Bone tenderness at base of fifth metatarsal
- Bone tenderness at navicular bone
- Inability to bear weight both immediately and in front of clinician for 4 steps
To note
It is important also to use clinical judgement and appreciate this decision aid might not be accurate if:
* The patient is intoxicated or has reduced consciousness
* The patient has other distracting painful injuries
* The patient has evidence of reduced sensation in the lower limb
Bifid P waves
ECG feature suggestive of left atrial enlargement. Having been generated within the sinoatrial node in the wall of the right atrium, the wave of depolarisation will spread across the right atrium followed by the left atrium. In cases of left atrial enlargement, the second half of the P wave (as it goes across the left atrium) will be enlarged, giving it a bifid appearance. Left atrial enlargement may occur due to pressure overload (e.g. mitral stenosis) or volume overload (e.g. mitral regurgitation).
managing HF secondary to severe HTN
IV nitrates (e.g. sodium nitroprusside)
bariatric surgery indications
The indications for bariatric surgery on the NHS are a BMI of over 40 kg/m2 or a BMI between 35 and 40 kg/m2 and a significant comorbidity like hypertension or type 2 diabetes, when all other weight loss methods have failed (lifestyle and medical). To qualify for the surgery, patients need to be fit enough for general anaesthesia, agree to long-term follow-up and be prepared to make lifelong lifestyle changes. Bariatric surgery is also considered for patients with a BMI of less than 35 kg/m2 if they have recently been diagnosed with type 2 diabetes mellitus. It is the first-line management option for patients with a BMI of over 50 kg/m2 (so other weight loss methods do not need to be trialled first before offering surgery to these patients).
post-operative nausea - risks/contraindications?
1st line: 5HT3 receptor - ondansetron, risk of QT prolongation and constipation
2nd line: H1 receptor antagonist e.g. cyclizine, avoid in severe heart failure
3rd line: dopamine receptor antagonist e.g. prochlorperazine. risk of extrapyramidal SEs
if oral analgesics not tolerated post-op?
IV patient controlled analgesia
contraindicated airway adjunct in suspected basilar skull fracture?
nasopharyngeal airway
- can potentially enter the cranial vault through fractured cribiform plate, causing further injury
domperidone mechanism of action
D2 D3 antagonist
what reading is used to confirm intubation?
End-tidal CO2 - measures the partial pressure of CO2 at the end of expiration.
what is suxamethonium apnoea?
occurs when there’s prolonged paralysis and apnoea following administration of suxamethonium, typically due to a deficiency or abnormality of the enzyme pseudocholinesterase - enzyme is responsible for rapid metabolism of suxamethonium
key features of suxamethonium
- reduced effort to cough or breathe spontaneously at the end of a procedure
suxamethonium investigations and management
- plasma cholinesterase levels
management:
- intubate and ventilate
- avoid suxamethonium in the future
metoclopramide mechanism of action
- D2 receptor antagonist
contraindicated in Parkinson’s and phaeochromocytoma
malignant hyperthermia causes
suxamethonium and volatile anaesthetics eg. sevoflurane and isoflurane
malignant hyperthermia management
cooling and dantrolene which prevents calcium release from the sarcoplasmic reticulum
IV hydrocortisone - Addisonian crisis
COCP and surgery
stop 4 weeks prior to surgery and use barrier contraception
A-E manouvre you should never do in a trauma patient at risk of C-spine injury
head tilt chin lift - do jaw thrust instead
first line treatment for spasmodic pain in palliative care patients
diazepam
pre-op advice for patient on clopidogrel, aspirin, atorvastatin, rampiril, bisoprolol and with a drug-eluting stent?
discuss with cardiology before changing meds
usually aspirin and clopidogrel stopped 1 week before surgery due to increased bleeding tisk but may get stent stenosis
if risk of aspiration during induction is high…
rapid sequence induction
side effect of epidural anaesthesia
- hypotension due to local anaesthesia of sympathetic nerves
- epidural haemotoma
- low pressure headache
where should epidural be injected?
L3-L4 or L4-L5
urine in malignant hyperthermia
can be brown! damaged muscles -> myoglobinuria
Addison’s - pre-op
switch to increased dose of IV hydrocortisone peri-op and temporarily stop fludrocortisone
if any associated hypotension, fludrocortisone can be added
minor ops:
- oral pred can be restarted immediately post-op
major op:
- hydrocortisone for up to 72 hours post-op
propofol mechanism of action
GABA agonist - good for nausea!
WHO pain ladder
pre-op anaemia
metaclopramide and GI surgery
avoid! as it is a pro-kinetic
Unilateral glue ear in an adult
22WW ENT referral for evaluation for a posterior nasal space tumour
test that should be offered to all patients with suspected TB
HIV
discharge post-anaphylaxis
refractory anaphylaxis - what next?
not responsed to 2 IM injections of anaphylaxis
expert help for IV adrenaline
Patients with PCOS at highest risk of developing ___ cancer
endometrial - oligo/anovulation => uterus exposed to high levels of unopposed oestrogen
it is because of this that patients with PCOS recommended to have a withdrawal bleed at least every 3-4 months
pain that’s worse 2 hours after eating? gastric or duodenal ulcer
duodenal - food takes time to pass through duodenum
investigations of choice for Meckel’s diverticulum
1st line: CT abdo
2nd line: scintigraphy using technetium-99m pertechnetate due to presence of ectopic gastric mucosa
what is Meckel’s diverticulum
congenital gastrointestinal abnormality characterised by the presence of a remnant of the omphalomesenteric duct. It is usually found around the ileum
where are neuroendocrine tumours causing carcinoid syndrome usually found
small bowel
when do neuroendocrine tumours causing carcinoid syndrome tend to cause issues?
when they metastasise to the liver
amantadine drug class
used in the treatment of Parkinson’s disease as it has some agonist activity on central dopamine receptors. It also blocks the M2 proton channel of influenza A which prevents endosomal escape of the virus. It is, therefore, used to treat influenza A.
evidence of right heart strain on ECG
ECG changes associated with right heart strain include :
T wave inversion and ST depression in the leads corresponding to the right ventricle (V1-3, II, III and aVF) - v1-3 and inferior leads.
Other features include right bundle branch block, dominant R wave in V1 and dominant S wave in V5-6.
breast abscess investigations & management
a breast abscess requires incision and drainage of the pus, in addition to antibiotic therapy. Breast cancer should always be excluded in patients with a breast abscess. The most appropriate investigation in this patient is therefore ultrasound-guided fine needle aspiration as this can also simultaneously treat the abscess, alongside prescribing antibiotics.
clinical signs of a fracture
- pain
- swelling
- crepitus
- deformity
- adjacent structure injury: nerves/vessels/ligaments/tendons
marked interstitial oedema and interstitial infiltrate in the connective tissue between renal tubules
acute interstitial nephritis
sterile pyuria
white cell casts
acute interstitial nephritis
antibiotic class that increases risk of idiopathic intracranial hypertension
tetracyclines
diagnosis and diagnostic criteria for family members of someone with polycystic kidney disease?
abdominal ultrasound
diagnostic criteria:
- 2 cysts, unilateral or bilateral, if aged <30 years
- 2 cysts in both kidneys if 30-59
- 4 cysts in both kidneys if > 60
Heparin induced thrombocytopenia - prothrombotic or antithrombotic?
prothrombotic - occurs when molecules of the cytokine Platelet factor 4 (PF4) bind to heparin to form an antigen. This antigen is then recognised by antibodies which in turn activate platelets through their Fc receptors, and thereby initiate a pro-thrombotic cascade.
If low-lying placenta is found at the 20-week scan
rescan at 32 weeks to reassess
acute Addisonian crisis management
IV saline + hydrocortisone (don’t need fludocortisone as high cortisol exerts weak mineralocorticoid action)
Hodgkin’s worst prognosis
Lymphocyte depleted
most common subtype of Hodgkin’s in developed countries
nodular sclerosing
best prognosis in Hodgkin’s lymphoma
lymphocyte predominant
Pneumonia, peripheral blood smear showing red blood cell agglutination
Mycoplasma pneumoniae
Routine maintenance IV fluid rates for children and young people who do not need an accurate calculation of insensible losses should be calculated using…
the Holliday-Segar formula*
First 10 kg 100 ml/kg
Second 10 kg 50 ml/kg
Subsequent kg 20 ml/kg
When should patients with HIV receive prophylaxis for PCP?
When CD4 < 200
monitoring for patients with Henoch Schonlein purpura
urinalysis + BP
which patients are at an increased risk of developing hepatotoxicity?
patients taking liver enzyme-inducing drugs (rifampicin, phenytoin, carbamazepine, chronic alcohol excess, St John’s Wort)
malnourished patients (e.g. anorexia nervosa) or patients who have not eaten for a few days
Management of placental abruption when the fetus is alive, <36 weeks and not showing signs of distress
admit + administer steroids
Management of placental abruption when fetus alive and < 36 weeks & there is fetal distress
immediate caesarean
Management of placental abruption if foetus alive and > 36 weeks and there is foetal distress
immediate caesarean
management of placental abruption if foetus is alive and >36 weeks and there is no foetal distress
vaginal delivery
management of placental abruption if foetus is dead
induce vaginal delivery
ischaemic disease and aspirin
All patients with ischaemic heart disease should take aspirin if there is no contraindication
what should you not do to treat a patient with cardiogenic shock
give fluids as increases strain on heart by increasing preload
New B-symptoms in CLL
Richter’s transformation
diagnosis of acute epiglottitis
direct visualisation performed by senior, airway trained staff
how long to give Abx for with septic arthritis
4-6 weeks
Bilateral, mid-to-lower zone patchy consolidation in an older patient
Legionella pneumophila
constellation of symptoms including a dry cough, fever, hyponatraemia, relative bradycardia, abnormal liver function tests (LFTs), mid-to-lower zone patchy consolidation on chest X-ray, and pleural effusions
In children the most common site where osteomyelitis occurs in a long bone
metaphysis
mesenteric ischaemia vs ischaemic colitis
monitoring for methotrexate
FBC, U+E, LFTs every 3 months
methotrexate side effects
mucositis
myelosuppression
pneumonitis
the most common pulmonary manifestation similar disease pattern to hypersensitivity pneumonitis secondary to inhaled organic antigens typically develops within a year of starting treatment, either acutely or subacutely presents with non-productive cough, dyspnoea, malaise, fever
pulmonary fibrosis
otitis externa
osteoporosis in a man - you should check ___
testosterone
shortened EXTERNALLY rotated leg?
hip fracture
shortened INTERNALLY located leg?
dislocation
HIV management
prescription of two nucleoside reverse transcriptase inhibitors (NRTI) and either a protease inhibitor (PI) or a non-nucleoside reverse transcriptase inhibitor (NNRTI).
how to assess suxamethonium efficacy in patient
ooking for fasciculations in the patient. These fasciculations occur due to the depolarisation of the motor end plates of skeletal muscle. They are transient and are first seen supraorbitally, then progress downwards to the chest, then abdomen, and eventually down to the feet. After this, the patient goes into full paralysis.
intermittent claudication vs critical limb ischaemia
Critical limb ischaemia is a severe form of peripheral vascular disease which is characterised by the presence of tissue loss (e.g. arterial ulcers), gangrene and pain at rest. This is different from stable angina which is characterised by leg pain upon exertion that is relieved by rest.
what medication is contraindicated in severe aortic stenosis
nitrates
coronary ostia (proximal opening of the coronary arteries) arise from behind the aortic valve leaflets. Nitrates cause a sudden decrease in preload, and patients with severe aortic stenosis will not be able to compensate sufficiently by increasing their stroke volume. This may result in worsening myocardial ischaemia.
what is ejection fraction
Stroke Volume/End Diastolic Volume
WHO surgical safety checklist
The sign in involves checking patient details, the surgical site, procedure and consent. The anaesthetic machine and medication list must be checked, confirm any allergies, discuss any aspiration risks and anticipated blood loss.
Time out involves re-checking patient identity, procedure and site, discussing any anticipated critical events from the surgeon, the anaesthetist and the nurse/ODP. The surgical site infection bundle should be checked, check VTE prophylaxis and any essential imaging as appropriate.
The sign out involves the ODP confirming the procedure has been recorded, the instrument and swab check is correct, specimens are labelled, any equipment issues identified, and the surgeon, anaesthetist and ODP must discuss any concerns anticipated during recovery. All of these steps must occur while the patient is in theatre.
spinal stenosis - what is it? how does it usually present? investigation of choice?
a condition in which the central canal of the spine becomes narrowed due to tumour or disc prolapse. It usually presents with back and leg pain that is worse when standing or walking downhill.
MRI spine
what does a dietician’s plan for a patient with CKD usually focus on?
The kidneys of a patient with CKD have an impaired ability to carry out the regulatory involved in maintaining fluid and electrolyte homeostasis.
This usually manifests with potassium retention (hyperkalaemia), phosphate retention (hyperphosphataemia) and an impaired ability to excrete uraemic waste products (uraemia).
Therefore, a dietician’s plan for a patient with CKD usually focuses on potassium, phosphate and protein.
treating itch in PSC
cholestyramine
types of hepatorenal syndrome
Type 1 HRS is characterised by a rapid, progressive impairment in renal function whereas type 2 is more stable and less progressive impairment in renal function.
medical management for hepatorenal syndrome
administering human albumin solution and terlipressin. Human albumin solution (HAS) is a colloid that helps maintain the effective circulating volume in patients who are hypoalbuminemic due to liver disease. Terlipressin is a vasopressin analogue that specifically causes splanchnic vasoconstriction. It is thought, in cirrhosis, blood pools within the splanchnic circulation due to the increased resistance to blood flow within a cirrhotic liver and the inability of the liver to metabolise vasoactive substances. The combination of HAS and terlipressin is therefore able to shift more of the circulating volume into the systemic circulation, thereby improving renal perfusion.
main criteria for hepatorenal syndrome
(it is largely a diagnosis of exclusion).
● Cirrhosis with ascites
● Serum creatinine concentration > 133 µmol/L
● Absence of shock
● Absence of hypovolaemia
● No current or recent treatment with nephrotoxic drugs
Absence of parenchymal renal disease (defined by the absence of proteinuria, haematuria and structural urinary tract abnormalities)
treating hypocalcaemia in CKD
Vitamin D is activated in two steps by two different enzymes: 25-hydroxylase in the liver, then 1a-hydroxylase in the kidneys. In CKD, the ability of the kidneys to activate Vitamin D via the action of 1a-hydroxylase is compromised, therefore, resulting in vitamin D deficiency and hypocalcaemia.
The two most common forms of vitamin D that are used as supplements are vitamin D2 (ergocalciferol) and vitamin D3 (colecalciferol). These, however, require activation and, so, would not be effective in end stage renal failure.
These patients should, instead, be given alfacalcidol which is a form of vitamin D that has already undergone 1a-hydroxylation.
salicyclate poisoning management
Activated charcoal can be given within 1 hour of ingesting more than 125 mg/kg of aspirin. Fluid losses should be replaced and intravenous sodium bicarbonate may be given (ensuring plasma-potassium concentration is within the reference range) to enhance urinary salicylate excretion (optimum urinary pH 7.5–8.5).
Plasma-potassium concentration should be corrected before giving sodium bicarbonate as hypokalaemia may complicate alkalinisation of the urine.
Haemodialysis is the treatment of choice for severe salicylate poisoning and should be considered when the plasma-salicylate concentration exceeds 700 mg/litre (5.1 mmol/litre) or in the presence of severe metabolic acidosis.
legionella vs mycoplasma
CKD medical management
ACE inhibitors (or angiotensin II receptor blockers) are key in the management of proteinuria
they should be used first-line in patients with coexistent hypertension and CKD, if the ACR is > 30 mg/mmol if the ACR > 70 mg/mmol they are indicated regardless of the patient's blood pressure
SGLT-2 inhibitors
patients who have proteinuric CKD (with or without diabetes) may benefit from treatment with SGLT2 inhibitors
glucose requirements when prescribing fluids
the glucose requirement is 50-100 g/day irrespective of the patient’s weight
stopping PPI for how long before endoscopy for suspected gastric cancer
2 weeks
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!
how far to push chest in CPR
see what CO2 monitor is doing!
capnography will tell you if you are doing it properly
blood glucose targets in t1dm
5-7 mmol/l on waking and
4-7 mmol/l before meals at other times of the day
atrial fibrillation but patient on warfarin + CHADSVASC score indicates anticoagulation
if INR in range, keep warfarin at current dose
classification of non-proliferative diabetic retinopathy
palliative treatment for breathlessness
we want a short acting benzo so lorazepam and go sublingual
medications in people’s last hours to days of life?
don’t give oral as swallowing usually impaired
types of laxative? how do they work? examples?
laxative to avoid in palliative
bulking agents as often reduced bowel motility, especially if on opiates
laxative to avoid in bowel obstructino and colostomy
stimulant
ideal drug route for antiemetic in palliative
continuous subcut
best drugs for chemical cause of vomiting
- haloperidol
- cyclizine
- metoclopramide
main antiemetics in palliative care
indications and contraindications?
parkinson’s + chemical cause of N&V
cyclizine
step up pain relief
morphine conversions
common symptoms in last hours to days of life
treatment?
subcut ‘anticipatory’ drugs
anticipatory medications
what drug route is NEVER the correct route in palliative?
IM
An increase in serum creatinine up to __ from baseline is acceptable when initiating ACE inhibitor treatment
30%
ruptured AAA vs renal colic?
shock -> ruptured AAA
Finasteride treatment of BPH may take ___ before results are seen
6 months
infective endocarditis causing congestive cardiac failure
emergency valve replacement surgery
murmur/heart sounds with left sided heart failure
3rd heart sound
advice to give patients after discharging for hypercalcaemia of malignancy
Advice about maintaining good hydration (drinking 3-4 L of fluid per day), provided there are no contraindications (such as severe renal impairment or heart failure).
Reassure that a low calcium diet is not necessary, as intestinal absorption of calcium is usually reduced. Advise the person to avoid any drugs or vitamin supplements that could exacerbate the hypercalcaemia. Encourage mobilization where possible to avoid exacerbating the hypercalcaemia. Advise the person to report any symptoms of hypercalcaemia.
Indications for sending for MSU to look for atypical/resistant organisms causing lower UTI
Have symptoms that are persistent or do not resolve with antibiotic treatment.
Have recurrent UTI (2 episodes in 6 months or 3 in 12 months).
Have a urinary catheter in situ or have recently been catheterised.
Have risk factors for resistance or complicated UTI such as abnormalities of the genitourinary tract, renal impairment, residence in a long-term care facility, hospitalisation for more than 7 days in the last 6 months, recent travel to a country with increased resistance or previous resistant UTI.
Have atypical symptoms.
Have visible or non-visible (on urine dipstick) haematuria.
Pregnant
Age more than 65 years old.
most common cause of large bowel obstruction?
colon cancer
most common cause of small bowel obstruction?
adhesions from previous surgery
admitting to regional burns unit
Burns > 10 % TBSA in an Adult
Burns > 5 % TBSA in a Child
Full thickness burns > 5% TBSA
Burns of face, hands, feet, perineum, genitalia, and major joints
Circumferential burns
Chemical or electrical burns
Burns in the presence of major trauma or significant co-morbidity
Burns in the very young patient, or the elderly patient
Burns in a pregnant patient
Suspicion of Non-Accidental Injury
burns first aid
First aid for burns such as this would be to hold under cool running water for 20 minutes. Guidelines do not recommend the application of any creams or gels. Ice packs are not recommended as they can cause frostnip/old burns. Burns are painful due to air moving across exposed nerve endings. The burn should be layered in cling film – not wrapped around circumferentially to reduce the risk of vasoconstriction . Cling film stops the nerve endings being exposed the air.
is codeine recommended in children?
no
types of burns and thickness
Superficial burns are usually dry, sometimes with minor blistering and erythema. Painful. Often due to sunburn or minor scalds. Involve the epidermis.
Partial thickness burns are moist and red, usually with broken blisters and normal capillary refill. Involve the dermis. They are usually painful unless they are deep dermal. Deep dermal burns may also have sluggish capillary refill.
Full thickness burns are dry, charred and often white. They are painless and have absent capillary return. They have destroyed the epidermis and dermis and have begun to destroy the underlying subcutaneous tissue.
Leg compartments
Anterior - extensor muscles of the foot and lower limb are in the anterior compartment as is the deep peroneal nerve that innervates them
Lateral - Nerves - Superficial peroneal nerve, Muscles - Peroneal longus and brevis muscles,Damage here would cause paraesthesia of the dorsum of the foot (except the 1st interweb space) and inability to evert the foot.
Posterior - Nerves – Tibial Nerve (L4, L5, S1), Muscles – Flexor Digitorum Longus, Flexor Hallucis Longus, Tibialis Posterior, Popliteus, Vessels - Posterior tibial vein and artery, Damage here causes inability to plantarflex the ankle, flex the digits as well as sole of foot paraesthesia
Superficial posterior compartment - Muscles – Gastrocnemius, Plantaris, Soleus, Vessels – Peroneal artery and vein, Damage here also causes impaired ankle plantarflexion
pressure sore risk score system
Waterlow
further investigations for a young person with hypertension…
In general, it is recommended that patients under the age of 40 years who are diagnosed with hypertension should be referred for further investigations to identify a secondary cause. This is often due to some form of renal pathology (e.g. renal artery stenosis, polycystic kidney disease). An ultrasound scan of the urinary tract is useful in assessing the size of the kidneys. This can provide useful information about the possible causes of hypertension (e.g. in renal artery stenosis, one kidney will likely be bigger than the other, polycystic kidney appear large and bulky).
gold standard for endotracheal tube insertion
Capnography measures the concentration/partial pressure of inhaled and exhaled carbon dioxide (CO2). It is displayed as a waveform, showing how the exhaled CO2 changes between inspiration and expiration. The end-tidal CO2 is the peak measurement taken at the very end of expiration, which reflects the clearance of CO2 from the lungs. This measurement can therefore be used reliably to confirm that the ETT is correctly positioned within the trachea.
rocuronium reversal agent
Rocuronium is a non-depolarising muscle relaxant, which is able to be reversed through the use of agents such as sugammadex and neostigmine.
A 72-year-old woman is brought in by ambulance to the heart attack centre. The ECG performed in the ambulance reveals ST elevation in the anterior leads. In the Cath Lab she undergoes a primary PCI to the left anterior descending coronary artery. The procedure is carried out without any complications and she is stepped down to the coronary care unit.
6 hours after her procedure, the nurse alerts you that she has had a run of non-sustained VT. An ECG is performed which shows no acute changes. The patient is asymptomatic.
What is the most appropriate management option?
Non-sustained ventricular tachycardia (NSVT) is defined as an ectopic ventricular rhythm with all of the following features:
● Wide QRS complex
● Rate > 100 bpm
● Lasts for at least 3 beats
● Spontaneously resolves in 30 seconds
NSVT is very common in patients post-PCI. There are many causes of NSVT after an ACS such as:
· Ischaemia
· Reperfusion after PCI
· Electrolyte imbalances (e.g. hypomagnesemia or hypokalaemia)
· Underlying myocardial scar
· Increased automaticity (ability of heart cells to spontaneously depolarise) in the myocardium adjacent to the infarcted area
Hypomagnesemia can precipitate ventricular arrhythmias. Magnesium sulphate can be administered to stabilise the myocardial cell membrane. It works by inhibiting L-type Ca2+ channels and delayed rectifier channels, reducing Ca2+ and K+ concentrations, thereby reducing automaticity and subsequent possible arrhythmias.
what is Hy’s law
ALT or AST more than 3 times the upper limit of normal
Serum bilirubin more than 2 times the upper limit of normal
No other reason that could explain this abnormality (e.g. alcoholic or viral hepatitis)
SIADH management
The first line treatment for hyponatraemia caused by SIADH is fluid restriction (usually 1-1.5 L per day).
If this fails, demeclocycline can be used.
Demeclocycline is a tetracycline antibiotic that can be used in SIADH as it causes nephrogenic diabetes insipidus (thereby countering the effect of the excess ADH). Other agents that may be used include tolvaptan (vasopressin receptor antagonist), sodium chloride and furosemide.
Cause of TIA investigations
- carotid doppler
- ambulatory ECG
- echocardiogram
what should you do after removing chest drain?
ask patient to do valsalva manoeuvre
memantine mechanism of action
NMDA receptor antagonist
treating cerebral oedema in patients with brain tumours
dexamethasone
time between first puff and second puff of inhaler
30 seconds
TIA mimic that should be ruled out
hypoglycaemia
key diagnostic test in GBS
lumbar pincture - elevated protein with normal white cell count
drug to avoid with myasthenia gravis
beta blocker
most common cause of peritoneal dialysis secondary to peritonitis
coagulase negative staphylococcus epidermidis
suxamethonium mechanism
acetylcholine receptor agonist => persistent stimulation of acetylcholine receptor which eventually results in desensitisation
how to increase thyroxine dose
by 25mcg
what are Looser’s zones
transverse lucencies with sclerotic borders that traverse part of the way through a bone and is perpendicular to the cortex. The pubic rami are commonly affected and they are sometimes referred to as ‘pseudofractures’.
which vitamin is vitamin B1
thiamine
which vitamin is vitamin B6
pyridoxine
which vitamin is vitamin b2
riboflavin
which vitamin is b3
niacin
PERC vs PESI
PERC to determine whether PE should be investigated further
PESI: assess severity of PE and associated mortality
managing SBO secondary to adhesions
Adhesions form as part of the body’s healing process following surgery, so surgically accessing the abdomen to relieve an obstruction would increase the risk of further adhesions forming and, in turn, increasing the risk of future obstruction.
If there is any concern of bowel strangulation, the patient is likely to require an emergency laparotomy to break down the adhesions and relieve the obstruction.
If there is no concern about strangulation, patients should be treated with gastrografin. It is a contrast medium which has a very high osmolality, thereby causing a laxative effect and reducing intestinal oedema.
An abdominal X-ray should be taken around 6 hours after the patient is administered gastrografin to check for resolution of the obstruction.
indications for ICD
If medical treatment of the underlying cause of VT/VF fails (e.g. electrolyte imbalances)
Patients who have survived cardiac arrest due to VT/VF Idiopathic and prolonged VT/VF with either syncope, haemodynamic instability or a reduced ejection fraction < 35% Inherited conditions that increase risk of developing VT/VF such as long QT syndrome, hypertrophic cardiomyopathy and Brugada syndrome. Patients who have developed heart failure with a reduced ejection fraction < 35% secondary to myocardial infarction
indications for pacemaker
● Complete atrioventricular block or third degree heart block.
● Mortbitz type II atrioventricular block. There is a risk of progressing to third degree heart block, and therefore a pacemaker is needed.
● Persistent symptomatic bradycardia.
chronic mesenteric ischaemia vs ischaemic colitis
chronic: superior mesenteric artery
ischaemic: inferior mesenteric artery
what to check before compression bandaging?
ABPI - should not apply if there’s arterial insufficency (ABPI < 0.8)
