General Bits Flashcards
COPD key things increasing survival
stopping smoking most important!!
salbutamol
tiotropium also
mortality predictor PE
PESI score
anticipatory medications palliative
anti secretions drugs
morphine
midazolam
antiemetic
significant ST elevation
1mm in 2 consecutive non chest leads
2mm in 2 chest leads
inflammatory / septic bloods
raised platelets
low albumin
raised CRP
raised ferritin
and the usual
obstructive jaundice
ALP up and BR too
usually a stone
can be tumour etc
do USS then if not clear do MRCP
anaphylaxis treatmnet
remove cause 1 in 1000 0.5ml IM adrenaline 200mg IV hydrocortisone 500ml-1000ml saline 10mg chlorphenamine
can repeat adrenaline every 5 mins
hypoglycaemia, DKA, HHS
HHS - they are very very dehydrated with much higher sugars
DVT examination
colour changes swelling signs of venous insufficiency temp tenderness pitting oedema measure circumference 10cm below tibial top palpate pulses
when to do D dimer
if Well’s score <2
signs of venous insuffiency
venous eczema
haemosiderin deposits
lipodermatosclerosis (inverted champagne bottle leg)
venous ulcers
describe # xray
Describing a fracture: PAID • Radiographs must be orthogonal: request AP and lat. films. • Need images of joint above and joint below #. • Demographics § Pt. details § Date radiograph taken § Orientation and content of image • Pattern • Transverse • Oblique • Spiral • Multifragmentary • Crush • Greenstick • Avulsion • Anatomical Location • Intra- / extra-articular • Dislocation or subluxation • Deformity (distal relative to proximal) § Translation § Angulation or tilt § Rotation § Impaction (→shortening) • Soft Tissues § Open or closed § Neurovascular status § Compartment syndrome • ? Specific # classification/type § Salter-Harris § Garden § Colles’, Smith’s, Galeazzi, Monteggia
hyperthyroid o/e
– hyper -> hot, sweaty, palmar erythema, tachy, anxious, flushed hypo, fine tremor, oncholysis, fast reflexes +/- (pretib myx, thyroid acropachy, exopth, proptosis, lid lag, H test pain) thyroid swelling, AF
hypothyroid o/e
cold, muscle wasting, dry hair/waxy skin, lateral third of eyebrows gone, myxoedema, slow reflexes, +/- thyroid swelling,
extra thyroid exam bits
thyroglossal cyst moves on swallowing, proximal myopathy in hypo+hyper
diabetic foot exam
Charcot joints, clawed toes, dystrophic nails, hairless+pallor (vasc insuff), LPS, eczema HS deposits-> complete with ABPI, Doppler, blood gluc, HbA1c
venous ulcer
gaiter region, superficial, sloping edge, pink, some pain, diabetic skin changes
arterial ulcer
pressure areas, deep, punched out, sloughy, pale, painful, no pulses
neuropathc ulcer
pressure areas, depp, punched out, bloody, painless, neuropathy
Cushing’s syndrome o/e
NB ‘examine endocrine status’ can be hypoT, Cush or acromegaly. Central adiposity, intrascapular fat pad, hirsutism, osteoporosis, pigmented (Disease), thin skin, bruising, poor healing, moon face, acne, thrush, hoarse voice, striae, prox myopathy, signs of cause (complete with BP, urine dip, visual fields, hx, 24 hr cortisol, dex suppression test)
acromegaly o/e
large hands, osteoarthritis, boggy soft tissue, carpal tunnel scar, coarse features, enlarged nose/ears, macrognathia, bitemp hemianopia, frontal bossing, splayed teeth, macroglossia, goitre, +/- cardiomyopathy and rolling gait + prox myopathy
acromegay hx Qs
headaches vision pins and needles back ache muscle weakness change in shoe size change in appearnce what did you notice first?
Qs to differentiate Cushing’s and hypothyroid
taking any steroids?
changes in appearance?
mood?
heat/cold intolerance?
change in periods?
varicose veins
tortuous dilated superficial. Retrograde flow from deep to surface veins. May get pains, cramps, restless legs. Skin changes like diabetic ones. Colour flow duplex to assess.
Peripheral arterial disease – acute limb ischaemia (6Ps), critical ischaemia (rest pain at night,
PVD
Peripheral arterial disease – acute limb ischaemia (6Ps), critical ischaemia (rest pain at night, gangrene, 0.3), intermittent claudication (rest stops, 0.9), rest pain 0.6. ABPI. Manage as CVD +/- revascularisation or amputation. Bypasses incl fem-pop, aortofemoral, femoral – femoral.
pregnant skin changes
pregnant skin changes – linea nigra, striae gravidarum (purplish-current preg), striae albicans (prev pregnancy), excoriations (OC), distended veins, umbilicus eversion
uterus enlarged
Uterus enlarged o/e pregnant, fibroids, malignancy, endometrial fluid collection
cervical excitation
cervical excitation o/e – PID or ectopic
adnexal tenderness
adnexal tenderness o/e – salpingitis, ovarian torsion, ectopic
fundal height excesssive
fundal height bigger than expected – macrosomia, polyhydramnios, multiples, dates wrong, fibroids
fundal height small
fundal height small IUGR, oligohydramnios, small baby
presentation of baby
presentation of baby round hardish presenting part – cephalic, broader and softer = breech bottom
baby head engaged
baby head engaged >50% in pelvis
normal foetal HR
120-160
normal fundal height
should match weeks in cm approx
12 weeks - feel uterus
20-22 fundus near umbilicus
36 weeks fundus near xiphi
forceps trauma
cephalhaematoma
Down’s
dysmorphia, cleft lip, low set ears and epicanthic folds
fontanelles
bulging raised ICP sunken dehyrdated
red relfex baby
red reflex baby absent – congenital cataracts, white – retinoblastoma
scaphoid abdo
diaphragmatic baby hernia
kidney large kid
kidney mass kid Wilm’s tumour
coarctation baby exma
lack of femoral pulese
Barlow Ortolani hip tests
Barlow + Ortalani test Barlow dislocates, O replaces
talipes
is club foot
spina bifida o/e
spina bifida lipomas, tufts of hair on back
spine abnormal on palpatoon
baby exam reflexes
grasp Moro
sats uneqaul in baby arms
congen heart disease
examining kids - tips
keep talking and asking Qs and using their name!!
make it a game
if child upset, talk to their family calmly first
always invovle them to the max
use simple words
undress in small stages
keep rechecking they are okay
distract
reassure
newborn baby hx Qs
Newborn hx Qs – how long since born, problems in labour incl mum/ROM time, drugs in labour, mother – any temps, overall preg health/ complics, any hip dysplasia hx baby – pre/post term baby, weight, breast/bottle feeding, any urine within first 12 hours, meconium, breathing well?
unwell child assessment
ABCDE approach. A – stridor (croup, foreign body), grunting (bronchiolitis, pneumo, asthma) B – rate, recessions/flaring/trach tug, sats 97+ C – pallor / mottling / blue, brachial pulse, hydration signs (nappies, skin, central CRT, temp), ausc, palpate L D – alert/ reactive, inconsolable, fontanelle, GCS, pupils, rash, tone, glucose E – ENT exam, abdo
child red flags
stridor, resp distress RR 60+, grunting, chest indrawing, pale/mottled / ashen/blue, turgor reduced, no response to cues/can’t stay awake, non blanching rash, seizures, neuro signs, bulging fontanelles, fever < 3months
paeds normal obs
<1 year
1-2
5-12
older
Paeds obs <1 year (RR 30-40, HR 110-160), 1-2 years (RR 25-35, HR100-150), 5-12 years (RR 20-25, HR 80-120), 12+ normalises to adult obs
stridor in baby / child
never look in throat!!
croup
foreign body
grunting in baby / child
bronchioloitis pneumonia asthma
wheeze in baby/child
asthma/viral induced / bronch
sluggish baby/child pupils
post ictal or drug toxic
unequal sizes of pupils = SOL
paeds resp o/e signs
wheezing - bronchiolitis, astham, VIW
stridor - croup, FB
grunting - bronch, pneumo, asthama
cough - barking = croup, dry = URTI, cough with insp whooping = whooping cough
clubbing - CF or bronchiect
barrel chest - asthma
crackles - bronchioloitis, infection
paeds cardiac o/e
dysmorphic features - Down’s, Williams, DiGeorge
Turner - AS
Noonan - PS
continuous machinery like murmur = PDA
systolic murmur left interscarpular zone - coarctation
preductal/postductal sats
paeds abdo exam
PR never routine or really needed in a child!
liver may be 2cm below rib margin and be normal
key developmental milestones in a child
smiles 6 weeks,
head control / eye following / laughing 3 months,
rolling/ babbling/eating solids, sits/crawls/pincer grip 9 months,
stands/mama/socially responsive 12 months,
walks/words 18 months,
runs/phrases 2 years
o/e dev assess a child
- 4 areas (gross motor, fine motor and vision, hearing/lang, social). GM – look for rolling, head control, sitting, standing, walking, crawling FMV – transferring betweenhands, grips used, building towers, drawing, fixing and following HL – startles to sound, turns to name/noise, babbling/phrases/words, follows commands S – smiling, laughing, stranger
global developmental delay
Global dev delay – prenatal (chromosomal, alc/drugs/infection in pregnancy), perinatal (IVentricular bleed, hypoxia, hypoglyc), postnatal (meningitis, anoxic events, head injury)
isolated developmental delay
– motor (cerebral palsy, visual impairment, spotted 1st yr), language (hearing, cleft palate, neglect, 2nd yr), social (autism, hyperactivity, attention deficit, 3rd yr life)
categorise the skin lesion descriptors
skin lesions define <0.5cm flat = macule, raised = papule, vesicle (fluid), pustule (pus // >0.5cm flat = patch, plaque (palpable) raised = nodule, bulla (fluid)
central scotoma
can’t see red pin in middle of vision
large blind spot
papilloedema
lost adult red reflex
cataract, retinoblastoma, bleed
examine optic disc , abnormalities
check optic disc o/e - cup, colour, contours enlarged cup (>0.3 of total diameter) – glaucoma, colour grey = optic atrophy, swollen = papoed
hypertesnive retinopathy
silver wiring, AV nipping, cotton wool spots, papilloedema
check each quadrant following vessels from optic disc
diabetic retinopaty
dot/blot haemorrhages, cotton wool spots, neovasc, retinal fibrosis
drusen
macular degeneation
macula dark when they focus on the light (should be pink)
periperhal pigmentation of retina
retinitis pigmentosa
non CN3 eye muscles
superior oblique CN4 lateral rectus CN6
systemic sclerosis define and categorise incl key features
– AI condition due to excess collagen deposition by fibroblasts. Limited cutaneous – only skin signs below elbows vs diffuse cutaneous (organ involvement more likely). Features CREST – calcinosis, Raynaud’s, oEsophageal dysfunction, Sclerodactyly, Telengiectasia. i.e. thick, tight, itchy skin + calcium deposits + heartburn. Mask like face, microstomia, beaked nose.
systemic sclerosis inv and management
Organ involvement = lung fibrosis, arrhythmias, kidney injury, dysphagia, incontinence. Limited – anti centromere Abs, diffuse – anti Scl 70 Abs. assess organs on imaging and XR hands. Treat – CCBs for Raynaud’s, PPIs, cyclophosphamide Isupp.
Paget’s disease summarise features
Paget’s disease increasing and disorganised bone remodelling. White >55 yrs. Bony pain, kyphosis, OA, frontal bossing, nerve deafness/tinnitus enlarged maxilla, raised JVP, bowed femur, sabre tibia, path #.
Paget’s inv and treat
Inv – XR = cotton wool lesions, ALP raised with normal electrolytes. Bone radioscan. Treat – NSAIDs, alendronate, vitD/cal, physio.
key complicationsn = nerve compression, secondary osteosarcoma
summarise Marfan’s and complications
conn tissue disease. Auto dominant fibrillin mutation. Tall/thin, scoliosis, wide arm span, hyperextension, myopia, high arched palate, chest deformity, AR murmur, flat feet. Inv – genetic testing. Treat – no cure, MDT + annual echo, 5 yearly MR aorta, beta blockers, eye exams, screen family. Complic – ½ lens dislocates, AR/MR, aneurysms.
neurofibromatosis summary
Neurofibromatosis – auto dominant nerve tumour condition. Generalised brown circular nodules, SNT with button hole sign. Flat brown patches+café au lait spots. Axiallary, inguinal freckling, Lisch nodules. 2+ neurofibromas + 6+ CaL spots = NF. Inv BP, spine, eyes. type 1 NFomas type 2 schwannomas. MRI + monitoring
type 1 vs type 2 NF
type 1 - peripheral, neurofibromas, cafe au lait, axillary freckling, optic nerve gliomas (visual loss), Lisch nodules, spinal cord tumours
type 2 - central schwannomas, bilateral acoustic neuromas causing 20-30 yr old person hearing loss
also get gliomas, meningiomas, tinnitus SKIN signs uncommon
NF1 complications
malignant nerve sheath tumours, HTN, phaeo,rrneal artery stensosi, GI neurofibromas (bloat, dyspepsia, bleed , constipation)
psoriasis define and types
erythematous extensor plaques with scaling, nail pitting, oncholysis. +/- symmetrical polyarthropathy of DIPs. Guttate = raindrop lesions chronic plaque type = most common seborrheic = nose and ears pustular = palms/soles erythrodermic = 90%+ of all skin affected
treat psoriasis
emollients, vit D analogues/steroid cream, phototherapy, methotrexate/infliximab.
psoriasis complications
erythroderma
nail changes
p arthritis
atopic eczema
Atopic eczema flexor papules/vesicles with lichenification/scaling. Atopic hx Qs x3. Exacerb by allergens, infection, heat, sweat. Treat – emollients, topical steroids, tacrolimus, avoid trigger.
beware secondary infection or eczema herpeticum
basal cell carciomas
BCC – pearly rolled edge with surface telangiectasia. Sun exposed areas. Mohs surgery. Mets v rare.
seborrhoeic keratosis
Seb keratosis stuck on appearance, dark brown warty papule. Reassure, remove if uncertain dx
vitiligo
melanocyte AI destruction, patchy depigmentation. Assoc other AI. Avoid sun, use strong suncream. Screen thyroid/diabetes/pernicious a/addison’s. topical steroids, topical tacrolimus.
compare foot ulcer histories
arterial - tips of toes, pretibial zone, nocturnal pain, worse on elevating the leg
venous - gaiters, mild pain, worse standing, assoc varicose
neuro - pressure points (soles/heels), painless, loss of sensation too
INV - fasting glucose,ABPI, duplex US, x ray to exclude OM, swab and culture
diabetic retinopathy
no signs unless bleeds. Non prolif mild = microaneurysms mod – blot haemorrhages, venous beading, hard exudates, cotton wool spots prolif any neovascularisation! Optimise diabetes +/- photocoagulationfor neovasc.
CHECK PICS!
hypertensive retinopathy grading
Hypertensive retinopathy grade 1 – arteriolar narrowing 2 - + AV nipping, silver wiring 3 - + flame haemorrhages, hard exudates, cotton wool spots 4- ++ papilloedema. Treat HTN.
CHECK PICS
retinal artery / vein occlusion
both same hx - sudden painless loss of vision
central = all vision lost
branch occlusion = partial vsion loss
difference seen on opthalmoscopy
retinal artery occlusion on picture + treta
Retinal artery occlusion swollen pale macula with cherry red spot. Urgently reduce IOP
CHECK PIC
retinal vein occlusion on eye look
Retinal vein occ tortuous dilated vessels, stormy sunset, disc oedema
retinitis pigmentosa
Ret pigmentosa deteriorating night vision + getting tunnel vision. Bone spicule peripheral pigmentation, waxy disc. No cure, genetic.
wet vs dry macular degeneration
central vision loss dry mac degen = drusen, no treatment, don’t smoke. Wet mac degen = subret haems, localised retinal oedema. Intravit anti VEGF, laser photocoag
optic neuritis vs optic atrophy
reduced acuity, loss of red colour vision, central scotoma, afferent pupillary defect
Optic neuritis unilat swollen optic disc – give methylpred if MS. Optic atrophy pale setting sun disc, no treatment, treat cause.
optic neuritis vs optic atrophy
reduced acuity, loss of red colour vision, central scotoma, afferent pupillary defect
Optic neuritis unilat swollen optic disc – give methylpred if MS. Optic atrophy pale setting sun disc, no treatment, treat cause.
bilateral swollen optic discs with blurred margins
papilloedema
raisd ICP
treat cause
chronic open angle glaucoma
chronic open angle glaucoma asympto until sev impaired vision. Optic disc cupping + atrophy. BB eye drops, prostaglandin eye drops, c anhydrase eye drops, laser trabeculoplasty
acute closed angle glaucoma
Acute closed angle glaucoma eye pain, red eye, headache, halos, blurring. Ciliary flush, mid dilated irreg pupil. Optic cupping. IV/PO acetazolamide, alpha / beta blocker drops. Laser periph iridectomy
vitreous haemorrhage
sudden painful vision loss or haze. No red reflex, can’t visualise retina. Treat cause (detachment/diabetic R).
digital clubbing causes
digital clubbing resp = idio PF, lung ca, bronchiect, TB, CF, sarcoid CVS = cyanotic congenital, inf endocarditis abdo – IBD, liver cirrhosis others – preg, acro, thyroid
stages of labour
Stages of Labour 1 – ROM, bloody show, 3-4 contractions/10 mins. 15hrs prima/7.5 multiparous. Foetal head descends into pelvis. May be induced by prostaglandin pessary or given IV oxytocin. Left OA most common lie. 2 – 90 mins primp/45 mins multip. Expulsion of foetus in this stage. Descent, internal rotation until facing to mum’s spine, extension of head, restitution (rotates to face sideways, shoulders out A,P. 3 – delivery of placenta, 30-60mins. Give IM syndometrine to speed. Controlled cord traction
postpartum haemorrhage
Postpartum bleed – primary = within 24 hrs of birth (tone, tissue, trauma, thrombin). Secondary – retained placenta or clots
female pelvis diffs
Female pelvis – wider, round inlet, curved sacrum.
major LN areas
Major lymph node areas cervical, supraclavicular fossa (gastric mal), axillary, epitrochlear (elbow), inguinal, popliteal, palpate hep/spleen. Hard/tethered/irregular = mal, rubbery = lymphoma.
neck exam
Neck o/e – feel anterior LNs, feel thyroid lobes + stay there on swallow+sticking tongue out, feel posterior LNs, feel supraclav (esp Virchow Left), percuss sternum, ausc thyroid/carotid.
midline neck path
thyroid, thyroglossal cyst, dermoid cyst
ant triangle pathology
branchial cyst, laryngocoele, carotid body tumour (v rare
posterior triangle path
cystic hygroma (since childhood, lights up), pharyngeal pouch
breast exam
breast o/e chaperone, inspect relaxed, hands on hips/above head, spiral palpation, pt massages nipple d/c, axillary/sc LNs. 2WW triple assess exam/imaging/FNA if cystic, core biopsy if solid. If <35 do US, if older do mammogram.
mental state examintion
A+B, SMT, PCI
appearnce - appropriate, dress, clean
behaviour - eye contact, manner
speech - rate, volume, fluency
mood/affect - facial expressions and general vibe
thoughts - delusions, coherency, content
perceptions - hallucinations
cognition - concentration/attention, memory, MMST
insight - understanding of illness / need for treatment
RISK
finish with rest of psych hx
hydration status exam
Hydration status exam – general vibe, fluid in / out + chart, obs (temp, HR, BP), eyes, mucus membranes, JVP, carotid volume, central CRT, apex, ausc, ascites, oedema. Follow up – daily wt, catheter and monitor UO, UEs, ABG+lactate
refeeding bloods
refeeding bloods UE, cal, mag, phosphate
vitamin A def
night blindness, dry eyes
vit E def
haemolysis, neuro deficits, retinopathy
Wernicke’s encephalopathy
ophthalamoplegia ataxia confusion
Korsakoff syndrom
prolonged Wernicke’s b1 thiamine def
amnesia, confabulation, apathy
B3 niacin def
Pellagra (diarrhoea, dermatitis, dementia, death)
B6 pyridoxine def
dermatitis, glossitis, neuropathy, conjuncitvitsi
B12 def
macro anaemia, polyneuropathy, subacute combined degen of the cord, glossitis, pancytopaneia
vit C def
scurvy )listless bleeding gums, gingitivits, rough dry skin, anorexia brusiing
fat malabsoprtion vits
ADEK (liver stored)
512hz
cranial nerves
128hz
legs arms neuro
tender pinna
and mastoid = mastoiditis
examining ear
pull pinna up and back in adults, down and back in kids
hold otoscope in the same hand as eaer youre examining e..g right hand right ear
rest ulnar border of hand on cheek to stabilise
look at - canal, tympanum+light cone reflect, behind membrane
check hearing if necc
otitis externa
otitis externa inflamed swollen narrow canal with d/c + flaking. Acute – Sofradex (Abx/steroid) or antifungal if chronic e.g. swimmers. Be careful not perf- ototoxicity.
otitis media
Otitis media swollen red tympanum, bulging behind, oral abx
otitis media with effusion / glue ear
Ot media with effusion/glue ear fluid level seen behind tympanic memb, observe for 3 months, may resolve. If not tympanostomy/grommet.
choleastoma
slowly expanding thick white canal growth, can invade. Excise
perf and wax ear
Perf – most heal spontaneously. Wax never syringe, give olive oil and bicarb. Can use otoscope to look in nose
quinsy appearacne
obliterates posterior arch, uv dev
Scarred tympanum tympanosclerosis
DVLA guidelines
check 3 Ps provocation, prodrome, postural -> if present, okay to drive
solitary+unknown cause -6 month ban
solitary + treated cause - 1 month ban
recurrent seizures - must be seizure-free for 1 year
