GP 22 Flashcards

1
Q

A to E approach

A

General Approach

How do they look?

“How do you feel?”

Look at obs eg overall trends, request ECG?

Airway

Speaking = patent

cyanosed/ accessory breathing muscles, see-saw breathing

check mouth : forceps to remove, not fingers

high flow oxygen and maintain airway;

headtilt/chinlift or jawthrust: consider adjuvent if breathing only clear in this position

Gurgling/Burbling?: turn head to side (gurgling/burbling) and suction

airway adjunct if compromised (try guardal first to see how unconscious, then nasopharyngeal, lubricate, 6 for female and 7 for male)

Give high flow 15l non -rebreath. If bag mask then hold right behind jaw, not under. 12/min or 1/5-6s)

anaphylaxis?

Breathing

Look/listen/feel for resp distress (sweat, accessory muscles, cyanosis)

RR (>25 may deteriate suddenly)- Count for 1m

assess depth and pattern, ueven expansion?

chest deformity? abdominal distension? raised jvp?

record sats and o2 levels (does not detect hypercapnea)

breath sounds (rattle (secretions not clearing), wheeze, stridor)

percussion

Auscultate (bronchiol breathing indicates consolidation)

position of trachea

chest wall crepitas

all critically ill get a non rebreath mask 15L/min

Can step down to Venturi 28% mask (4 L min-1) or a 24% Venturi mask (4 L min-1) initially in COPD and reassess

if depth of breathing inadequate use bag mask and call for specialist help

nebs can give 6 litres max but add 5l via nasal canula

Circulation

Temp

HR - count for 1 min (weak central= poor cardiac output, bounding = sepsis

BP

are they septic?

Quick cardio exam: temp, CRT, Pulse, heart sounds, oedema

Oliguria = sign of poor cardiac output

external/internal bleeding?

cannulate

IX; All get FBC, U&E, LFTs

Major harmorhage protocol = call blood bank or 2222 . . will need trained runner

then specific:

Sepsis: CRP, lactate, blood cultures

Haemorrhage or surgical emergency: Coagulation and cross-match

Acute coronary syndrome (ACS): Cardiac enzymes

Arrhythmia: Calcium, magnesium, phosphate, TFTs, coagulation

PE: D-dimer (depending on Well’s score)

Overdose: Toxicology screen

Electrolyte imbalance: Calcium, magnesium, phosphate

Ruptured ectopic: Coagulation, cross-match, ß-HCG levels

Anaphylaxis: Consider serial mast cell tryptase levels

ECG, Cathetarisation, bladder scan, pregnancy test, swabs/cultures?

3 lead ECG = red/right, lemon/left and green/spleen

Hyovolemic? - MC . . . IVF to all cool peripheries and tachicardic

Lay patient supine and raise legs if appropriate

Give 500ml bolus Hartmann’s solution/0.9% sodium chloride (warmed if available) over 15 mins

In heart failure: Give 250ml fluid as above; check the chest for crackles after each bolus as there is a risk of fluid overload and pulmonary oedema

Repeat up to 4 times (2000ml/1000ml), monitoring response

assess BP q5mins aiming for thir normal or >100

Stop and seek help if the patient has a negative response (e.g. increased chest crackles).

Seek senior help if the patient isn’t responding adequately to repeated boluses.

ACS : ECG,po aspirin 300mg, subliguial glyceryle trinitate spray/tablet, oxygen, morphine + antimimetic,

Disability

Consciousness;

repeart AVPU (alert, responds to voice, responds to pain, uresponsive)

assess pupils (pinpoint opioids, dilated = intracranial pathology of TCA overdose)

PEARL = pupils equal and reactive to light

Check for head injury while you are here

calculate GCS (<= 8 = anaethetist or crash team)

Movement: ‘squeeze my fingers

check drug chart (opioids, sedatives, anxiolytics and antihypertensives)

Causes of decreased consciousness:

Hypovolaemia

Hypoxia

Hypercapnia

Metabolic disturbance (hypoglycaemia)

Seizure

Raised intracranial pressure/other neurological insults

Drug overdose

Iatrogenic causes (e.g. administration of opiates for pain relief)

DIABETES Blood glucose (4.0-11.0 mmols/L)

check ketones if >15

<4 give 50ml 10% dextrose - give every minute till 250ml if no response

urine dipstic?

imaging?

Exposure

Any pain?

Bleeding? - rate/ amount .. . . ax for shock

rashes? coagulopathy/infection

calves - red swollen dvt?

Lines - any concerning?

Cathetar- puss or blood?

surgical wound?

drains- pus? blood? high/low output?

Reasses . . . who can help?

Full hx from pt or collateral

r/v notes - esp vital signs and meds

lap results?

What care? HDU? ICU?

Notes and SBAR handover

keep realtivesinformed

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2
Q

Antibiotic Ladder

A

Rules

  1. If sick go broad
  2. Escalate Rapidly
  3. Descalate slowly
  4. Target Cultures and Sensitivies
  5. Empiric treatment - use the lowest possible

Amnionpenicillins = g-ves etc but with b lactimase inhibitors has some +ve coverage

Cephalosporins

1st - cephalexin, cefadroxil, cephradine (strep and MSSA)

2nd-

3rd - Ceftriaxone (Strep and g +ves)

4th - cefeprime (pseudomonas coverage)

amoxicillin clavulanic acid = co-amoxicillin

Pip-Taz = Piperacillin/tazobactam aka tazocin

Tic-sulb = ticarcillin sulbactam

Aztreonam - would only jump to if severe beta lactam allergy

Daptomycin used in blood stream

Linozolid for lung infection

Fluroquinolones - need to go through each base? - used to be good for UTIs but now for pseudomonas coverage

levofloxacin ver specific infections

moxifloxacin - respiratory fluroquinolone but do not use.

IV gentamicin, amoxicillin & metronidazole: Also known as ‘triple therapy’, these antibiotics are often used together in severe intra-abdominal infections.

TMP/SMX = co-trimoxazol

Animal Bite = co amoxiclav

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3
Q

Pneumonia

A

Fever and cough = CXR and Sats for everyone

ABG if low sats

FBC - neutrophilia in bacterial

U&Es for dehydration and curb 65

CRP - raised in response to infection (<20 no abx, >100 abx, 20-100 consider delay)

Blood culture should do but only returns 10% of time and does not really alter tx

Sputum culture is low yield and we tx empiracally anyway

Nothing? - bronchitis aka atypical pneumonia (CAP lite)

-PO abx

Cavity lesion?

  • usually malodorous sputum

differentiate with CT chest

Tx 3rd gen + G+ve and anaerobic coverage (clindomycin)

Consolidation?

Pneumonia

Differentiate with Time relation to hospital building

Empiric tx depending on category

Low severity community = amoxicillin (macrolide/tetracyclin if pen allergy)

more severe = Amoxacilin + macrolide (7-10d)

  • consider co amoxiclav/ ceftriaxone / piperacillin with tazobactam and a macrolide

Admit?

-CURB 65 score

Confusion (AMT <=8)

Urea >7 mmol/L

RR>30/min

BP <90/60

>65yo

0 mx in community

1 - SATS and community CXR

2- MX in hospital

4 = 30% mortality by 30days

CRB65 in community - 2 = go to hospital

PCP

HIV+ve (immunosuppressed)

not solid consolidation but patchy diffue infiltrates

longer subacute presentation

ix silver sputum stain (not culture)

Tx with co trimoxazole

Give steroids if hypoxaemic

FLU

Myalgia giveaway

confirm with swab

prevent with vaccine

presdisposes to S.Aureus pneumonia

AND

Klebsiella ax with aspiration (MC righ lower lobe)

H.flu = COPD or smokers

3RD gen cephalosporin = ceftriaxone

Imaging

  1. Pneumonia
  2. PCP
  3. Abscess

Mycoplasma Pneumonia

Associated erythema multiforme

tx: doxycycline or a macrolide

Allergic Bronchopulmonary Aspergillosis

IX: po glucocorticoids + itraconazole

Legionella Pneumophilia

flu-like symptoms including fever (present in > 95% of patients)

dry cough

relative bradycardia

confusion

lymphopaenia

hyponatraemia

deranged liver function tests

pleural effusion: seen in around 30% of patients

Dx: Urinary Antigen

MX: erythromycin/clarithromycin

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4
Q

AKI full

A

Pre

PUMP = mi and chf

Leaky - also a bit CHF but think OSI

Hole : diuresis, dehydration, diarhoea and haemorhage

FMD (fibromuscular dysplasia) = young woman with secondary htn and renal failure

RAS (renal artery stenosis) = old man with atherosclerosis

Renal

RBC casts = glomerulonephritis - BUT r/o nephrotic syndrome (triad)

AIN - itis . .. look for infections. Look for WBC casts or eosiophils

but also some drugs (TMX-SMP, penicillins, cephalosporins)

ATN - muddy brown casts (not sensitive or specific)

Things in tubules coming into contact and damaging them

two main types (ischamia and toxins) prevent with IVF

Three main phases

Post

hydroureter/hydronephrosis

depends on level of obstruction (both kidneys = urethra. . only one dialted = ureter)

more causes the lower down you go

neurogenic = nerve damage or medications

foley kink

Approach

PRE

first rule this out

U:Cr >100 / Urins sodium <10 = pre-renal

give IVF if hypovolaemic

give diuresis if hypervolaemic

Post

Then rule out this

US or CT scan (CT better for stones)

then relieve obstruction

intra

hx/physical/UA usually enoght

eg DM with glucose and protein = diabetic nephropathy

Might need bx occosionally to prove dx

AEIOU = indications for dialysis

Staging

AKI is staged according to the serum creatinine changes, and/or the production of urine.

1 = Increase 1.5-1.9x baseline or < 0.5ml/kg/h for >6 consecutive hours

2 = Increase 2.0-2.9x baselinem or < 0.5ml/kg/h for >12 consecutive hours

3 = Increase > 3x baseline or >354 µmol/L or < 0.3ml/kg/h for > 24h or anuric for 12h

Extra

Stop NSAIDs in AKI as can worsen

Renal replacement therapy indications: (i) fluid overload that is refractory to diuresis, (ii) hyperkalaemia refractory to medical therapy, (iii) metabolic acidosis (pH <7.1) and (iv) complications arising from uraemia (e.g. encephalopathy, pericarditis).

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5
Q

Brain Inflammation

A

Fever + HA raise suspician (in real life maybe general innfection) - Photo/phono further raises this

Meningitis MC general bacterial unless specific clues

AMS for encephalitis (encephalitis leads to encephalopathy)

Encephalitis = 1000s and all just need supportive tx

  • except HSV which is common and can be tx

FAILS - do not do if any one of these (brain will herniate through foramen magnum and die)

Immunosuppressed = elderly neonate who is on monoclonal antibody chemotherapy for their HIV

Unsafe you give Abx THEN CT scan (better a bad diagnosis and alive pt than dead pt and good diagnosis)

1000s of WBCs and mostly polys = bacterial . .. if not then consider something else (can still be bacterial)

No corticosteroids in suspecting bacterial meningitis if <3 months

Mass

cannot LP

HIV/AIDS - Tx for toxoplasmosis

Lymphocytes

temporal lobe/ haemoragic tap = HSV on test but means nothing in life

Cryptosporogenes Tx with Amphotericin

Lymes = Tx with ceftriaxone

TB tx with RIPE

Contact prophylaxis

Meningococcal Meningitis ciprofloxacin or rifampicin

Neisseria meningitides MC children (5% develop neurolgical sequlae and 10% mortality)

Men B 60% of meningococcal disease

Men C for 40%

the rest from travel/ uni

Neontes: Gp B Strep, E Coli, Listeria, Pneumococcus, Staph aureus.

In babies over one month and children, causes include: Meningococcus, Pneumococcus and Haemophilus influenzae B

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6
Q

UTI

A

General

Typically ascending infectino from urethra to kidneys (higher = worse)

MC young woman with contraception (having sex) and men who penetrate the anus

Uncomlicated must be a non pregnant female

Comlicated = the Ps

E.coli 85% of the time

klebsiella and proteus = other enteric GNR

Cloudy offensive urine

U/A and urine culture = the go to tsts

(>10 WBC/ high powered field)

CT/ US to ix more serious

(>10 to the 5 colonies)

Urethritis

Not really UTI but STD

gonorrhea = chlamydia (ie if you find one then you tx the other)

test urine sample now (first void urine sample NAAT test)

Gonnorhoea = IM ceftriaxone (ciprofloxacin if its known to be sesnitive)

Chlamydia = 7d Doxycycline (azithromycin if not tolerated)

HIV screen

Asx Bacteriuria

should only really be for regant or prepp for urologic procedure ( no-one else should be tx)

Tx with nitrofurentoin (amoxacillin/cefalexin 2nd line) - 7days

repeat to see if tx (only one that you repeat test)

nitrofurentoin can cause neonatal haemolysis near to term so use amoxacillin instead

Cystitis

MC young women

U/F/D (urgency, frequency and dysuria) w/o systemic symptoms (in life you can of course get sepsis from this)

Can choose the abx (TMP-SMX if CKD) but decide how long for

complicated - 7day in uk

Men get abx straight away, woman have back up prescription if not improved in 48hrs

Pyelonephritis

U/F/D but with systemic sx

CVA = costrovertebral angle

WBC casts = give away

urine culture here as long course of abx

Can give PO ciprofloxacin if ambulatory (young and still getting around but still all the sx)

want to admit them to see if perinephritic abscess

Perinephric abscess

(walled off or in parenchyma itself)

suspect if don’t improve after 72hrs confirm with US/CT

Children

Maybe more generalised sx

<3months refer to paediatrician and admit if upper UTI

>3month then usual 3 day

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7
Q

Plasma cell dyscrasias

A

Monoclonal exansion of plasma cells in BM

Multiple Myeloma = Most important

  • -Raised ESR and osteoporosis represents multiple myeloma until proven otherwise*
  • -raised calcium and bone pain = myeloma until proven otherwise*

Incomplete IgG

BM becomes crowded and good plasma cells not made so prone to infections

Protein gap on LFTs

Spep = serum protein electrophoresis (M spike)

IgA, IgG

Immunoglobulins: The most common type of heavy chain produced in myeloma is IgG, followed by IgA and then IgD. IgM myelomas are rare, but when IgM is elevated in the blood, the patient more likely has a related disorder, known as Waldenstrom’s Macroglobulinemia.
As MM progresses you get more light chains than heavy (more light chains = more aggressive)

A Bence Jones protein is a monoclonal globulin protein - deposits in kidneys so use Upep (M spike)

Osteoclast stimulating factor leads to Lytic lesions and subsequent pathological fractures

-detect with seletal survey (not bone scan) . . . do with MRI body (CT if not possible)

CRABBI

Calcium

  • Hypercalcaemia occurs as a result of increased osteoclast activity within the bones*
  • This leads to constipation, nausea, anorexia and confusion*

Renal

  • Monoclonal production of immunoglobulins results in light chain deposition within the renal tubules*
  • This causes renal damage which presents as dehydration and increasing thirst*
  • Other causes of renal impairment in myeloma include amyloidosis, nephrocalcinosis, nephrolithiasis*

Anaemia

  • Bone marrow crowding suppresses erythropoiesis leading to anaemia*
  • This causes fatigue and pallor*

Bleeding

bone marrow crowding also results in thrombocytopenia which puts patients at increased risk of bleeding and bruising

Bones (middle/lower back, ribs and hips)

  • Bone marrow infiltration by plasma cells and cytokine-mediated osteoclast overactivity creates lytic bone lesions*
  • This may present as pain (especially in the back) and increases the risk of fragility fractures*

Infection

a reduction in the production of normal immunoglobulins results in increased susceptibility to infection

Chemotherapy often with melphalan and steroid (dexomethasone) and EITHER thalidomide (if no autologous stem cell transplant) or bortezomid (if being induced for autologous stem cell translant)

<70 possible stem cell transplant

also zolondric acid for fractures, VTE prophylaxis, vaccinations, ig replacement

Monoclonal Gammopathy of uncertain significance

monitor for conversion (2% a year)

usually die before this

key is <10%

Waldenstrom’s Macroglobulinaemia

IgM so can form petamers which lead to hyperviscosity

Key is >10% LYMPHOMA ie lymphoplasmosidic lymphoma

Constitutional sx = night sweats, fevers ,weight loss

tx rituximab based chemo

tx the hyperviscosity with plasmaphoresis

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8
Q

Approach To Anaemia

A

Symptoms represent severity not type of anaemia

Men: 135-180 g/l Women: 115-160 g/l

More 100 usually asymptomatic

HOHF = high output heart failure

<80 pallor of skin and anterior rim

Delivery of O2 = Cardiact output * Hb * SATS - depending on your reserve you exerience sx differently

It also depends on how quick the loss in hb happens

Micro and Macro = mostly production anaemias (low reticulocyte count)

Normocytic mostly destruction anaemias (increased retiulocyte count)

Megaloblastic (Impaired DNA synthesis) looking for hypersegmented neutrophils (5+ lobes)

If B12/Folate levels not clear can request methylmelonic acid to differentiate.

Normocytic

Haemolytic or haemorhage

Haemorhage = increase LDH, decreased haptoglobin, increased bili

Haemorhage you should see evidence so find and plug

MDS = myelodysplasic syndrome

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9
Q

Sodium

A

Moderate symptoms: nausea, confusion, headache

Severe symptoms: vomiting, cardiorespiratory distress, severe somnolence, seizures, coma (GCS = 8)

Acute (<48hrs)

Severe = <125 with severe symptoms = consultant management only in with close observation ICU, HDU, Resus or maybe AMU

Moderate = <129 with mooderate symptoms

aim is to stop further decrease (stop diuretics, acei and hypotonic fluids if possible)

if strong suspician of new onset symptoms consider IC hypertonic saline (consult a consultant) aim to increase by 5 every 24hrs but no more than 10 in 1st 24hrs or 8 thereafter, receck at 1, 6 and 12 hrs

non-symptomatic = <135 without severe or moderate sx (stop further decrease as above) further mx is dx specific as there is time.

Chronic (>48hrs)

USE HANDBOOK for dx
ix: if possible, stop diuretics/angiotensin-II antagonists/ACE-inhibitors for 48 hours and then measure serum and urine osmolality, and urinary sodium. Assess clinically for volume status.

Hypovolemic tx = stop relevent drugs, IV nacl, 100mg IV hydrocortison if clincial suspician of adrenal insufficiency

euvolemic tx= stop relevent drugs, water restric 1 L/day, oral sodium chloride (slow sodium) +/- low dose furesemide, consider demeclocycline

hypervolemic tx = tx underlying cause, sodium restrict, fluid restrict 1l/day

Monitoring: CNS observations and reassess every 6 hrs till stablised?

HYPERNATRAEMIA

causes: diarrhoea, vomitting, burns, nephrogenic/central diabetes insipidus, glucosuria eg dM, excessive iV sluids, lithium, phenytoin, demeclocycline and corticosteroids

Mild = <155 (drinking may be enough)

severe/hypovolemic = > 155 with salt and water loss

tx: initially hartmann’s until haemodynamics stabalised then correct with 0.45%

Severe hypernatraemia/dehydration (water loss >155mmol/l)

tx: slow infusion of sodium chloride 0.45% or glucose 5%

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10
Q

AKI Guidelines

A

Prevention

At risk = elderly, diabetic, hypotensive and septic pt

Keep well hydrated

Recognition

Cr = 1.5x baseline

1 = Increase 1.5-1.9x baseline or < 0.5ml/kg/h for >6 consecutive hours

2 = Increase 2.0-2.9x baselinem or < 0.5ml/kg/h for >12 consecutive hours

3 = Increase > 3x baseline or >354 µmol/L or < 0.3ml/kg/h for > 24h or anuric for 12h

clarify what type and reasoning

presence or absence of immune sx (rashe, new arthritis, nasal crusting/bleeding, haemoptysis, bew deafness, mouth ulcers, alopecia, iritis/episcleritis, mononeuritis or neuropathy)

Obstructive sx? FUD, poor stream, hesitancy,, nocturia, PV bleeding, stones

Examination and Observations

Fluid status exam (inc autoimmune)

Urine Dipstick (all AKI, non dialysis CKD, DVT &PE , oedematous pt and suspected UTI)

fluid input/output (cathetarise if this is hard)

send MSU if urinalysis abnormal

send urine protein creatinine ration if protein >2+

Investigations

daily U&Es, bone profile and bicarbonate until fxn improving

autoimmune screen if glommerulonephritis/vasculitis suspected

urine sodium if oliguric (<20 implies pre-renal)

Renal US:

  • urgent if >3x or > 400 or obstructions suspected
  • non-urgent if 1.5-3x or suspected GN
  • may not reed if recovering function or US in last 6 months

Management

Stop nephrotoxic drugs (NSAIDs, ACEi, ARB, pottassium sparing diuretics)

Diuretics should only be suspended if hypovolemic

Stop metformin if eGFR <30

optimise fluids

treat infection promptly

suspected vasculitis/ renal syndromes are a renal emergency (call nephrologist)

30% increase in Cr acceptable on starting RAAS inhibitor (ARBs/ACEi)

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11
Q

Calcium Aetiology and Mx

A

PT glands behind thyroid

PTH released by dishinibition of Ca receptors

PTH acts on gut indirectly via Vit D- 1,25 which tells gut to reabsorb Calciuma and phosphate (1 alpha hydroxylase)

kidney resabsorbs calcium and extrets phosphate

Clasts breakdown bony matrix releasing calcium and phosphate

Albumin

only 1% free (as ionised calcium)

every one change in albumin = a change in the opposite diection of calcium (from normal)

Hypocalcaemia Management

Check if symptoms

Trousseau = capal pedal spasm on cuff inflation

Chvostek = Tapping (no dulling of reflex)

Prolinged QT interval on ECG

Hypercalcaemia Mx

‘bones, stones, groans and psychic moans’

corneal calcification

shortened QT interval on ECG

hypertension

Increased risk of pseudogout

Moans = AMS

Groans = abdo pain

Sx then tx straight away with IVF (solution to polution is dilution) and Bisphosphonates

Calcitonin (calcium turn down) if severe

Can add loop directics (block calcium reabsorption) when volume resiscitated (or it could make it worse)

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12
Q

Hypercalcaemia Diagnosis

A

Hyperthyroidism MC

Primary - One hyperfunctioning

Tertiary = all Hyperfunctioning

Secondary = Appropriate response to relative hypocalcaemia in early kidney disese GIVE CINACELCET (calcium mimicker) to prevent tertiary

IX

Differentiate with Sestamibi Scan (technetium-MIBI subtraction scan)

Xray may show pepperpot skull

High calcium and as kidney is functioning it wins

brown tumours = unique to parathyroidism (not really malignancy by eat away at bone)

Tx with resection but watch out fo hypocalcaemia as remainiong PT glands atrophied as suppressed

calcimimmet compounds if unsuitable for surgery

Hypercalcaemia of cancer

Ca inhibits PT release therefore kidneys do not win

PT related protein acts on kidney so Kidney wins

differentiate with phosphate

Hypervitaminosis D

Can see with ingesting in practice

Granulomatous disease increase completed 1,25 vit D produciton so kidneys absorb more calcium an phosphate so

TB and Sarcoid presentation

Hypercalcaemia of immobility = rare, ASx ,old person, trauma, immobility with hypercalcaemia

Familial Hypecalcaemic hypocalcinuria = benign

First ones = big derangements and last = small derangements

Thiazide diuretics can cause hypercalcaemia

Bone Mets Cause

MC source: Prostate>breast>lung

MC site: Spine>Pelvis>Ribs>Skull>Long bones

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13
Q

Hypcalcaemai diagnosis

A

MC Thyroidectomy (oopsy) or appropriate repsonse to parathyroid resection

AI = very rare

tetany/perioral tingaling = post op day 1

phosphate irrelevent as no pth so no reabsorption or secretion

parathyroid should switch back on with time (or supplement with PTH in future)

Pseudoparathyroidism

end organ resistance to PT so as if its low

HIGH PHOSPHATE not low

Vit D deficiency

poor dairy intake or not going outside

Diagnose with 25 -vit D

Bisphosphonates if significantly osteopenic

Acute hypocalcaemia in pancreatitis is due to sequestration and is an ominous sign

CKD

early = impaired vitamine D formation

Cinacalcet to prevent tertiary

Late = Hyperphosphataemia

EXTRA

Prolonged QT interval on ECG

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14
Q

HF approach

A

Left HF - backs up to lungs

Right HF- backs up to body

often mixed

SX - RHF - peripheral oedema, hepatosplenomegally, raised JVP . . . dyspnoeea etc from hypoperfusion

  • liver = firm, smooth, tender and pulsatile liver edge

LHF - Dyspnea, orthopnea, paroxysmal nocturnal dyspnoea, crackles, S3

IX - BNP>TTECHO>Left heart cath (ischaemic or not)

1st line N-terminal pro-B-type natriuretic peptide (NT‑proBNP)

High = > 2000 pg/ml (236 pmol/litre) = TTE <2w and specialist assessment

Raised = 400-2000 pg/ml (47-236 pmol/litre) = TTE <6w and specialist assessment

Normal = < 400 pg/ml (47 pmol/litre)

BNP levels different (H= >400, R = 100=400 and N<100)

TX

Annual influenza vaccination

One off pneumococcal vaccine

check U and Es 2 weeks after ACEi or Spironolactomne started

1st line ACEi and Beta blockers (bisoprolol, carvedilol, and nebivolol)

If still symptomatic and LVEF <35%:

second line ARBs and aldosterone antagonist (spironolactone/eplerenone) - cause hyperkalaemia along with ACEi

If still symptomatic and LVEF <35%:

Third line ;

ivabradine, sacubitril-valsartan, hydralazine in combination with nitrate, digoxin and cardiac resynchronisation therapy

Diuretics for managing fluid overload but no change in mortality

Aspirin and statin if know ischaemic cause

Pacemaker if <35% but not stage class IV

Class IV- bridge to transplant

Acute bloods for anaemia, infection, electrolyte imbalance . . . . BNP >1mg/L supports diagnosis

NYHA classification

Stage I - No limitation on ordinary physical activity (incorrect)
Stage II - Normal at rest. Ordinary physical activity causes breathlessness (correct)
Stage III - Normal at rest. Less-than-ordinary activity causes breathlessness (incorrect)
Stage IV - Symptoms at rest. (incorrect)

Extra

Measure digoxin levels 6hrs post dose

XRAY:

A - alveolar oedema (bat wing opacities)

B - Kerley B lines.

C - cardiomegaly.

D - dilated upper lobe vessels.

E - pleural effusion.

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15
Q

CKD

A

Diagnose if eGFR is <60 on 2 consecutive prsentations. Do yearly U+Es and ACR

remember ACEi can decrease by 25%+. nsaids can affect too

consider referal 3b and down or if complications start

  1. Stage it (when to dialysis)
  2. Prevent Progression
  3. Mx Complications

US: bilateral enlarged in diabetic nephropathy, shrunken in other types

Staging

Assume stable Cr so eGFR not reliable in AKI

ESRD = essential anuric

stage 1 - evidence of CKD but normal eGFR

Stage II usually asx

stage III you see start of complication mx here

stage IV means ESRD inevitable so prepare with a AV fistual (matures over months . . . at least 8 weeks)

HD = 4 hours three times a week

PD = every night via peritoneal cathetar

Renal transplant final option

eGFR innacurate in extremes of muscle mass

Prevention

Prevent progression at every stage

Htn

want tighter targets with ACE-I

ACE-i reduce filtration pressure therefor decrease of eGFR by 25% or increase in Cr of 30% acceptable

Can also use furesomide

DM

same goals as everyone else

do not use metformin as causes lactic acidosis

target <48 mmol/mol (6.5%)

Proteinuria

covered by ACEi/ARB + low protein diet

measure via albumin:creatine ratio via a 1st pass urine spot sample

if > 3 significant and > 70 mg/mmol should be on ACEi regardless of htn

Hyperlipidaemia

atorvastatin 20mg offered to all CKD - increase dose if 40% reduction not achieved

  • <30ml/min should be mx by renal specialist

Complications

anaemia of CKD

due to EPO

dx by R/O other causes of normocytic anaemia and malnutrition (iron/folate/b12)

Tx with Fe (PO or IV)

EPO - ESAs (erythropoiesis-stimulating agents) such as erythropoietin and darbepoetin

may need transfusions

secondary hyperparathyroidism and mineral bone disease

phosphate stimulates PTH release in attempt to eliminate via kidney but kidneys unable to

Ca low as kidney cannot stimulat 1, 25 vitamine D so not absorbed

Phoshate binders =sevelamer

calcimimetics (cinecalcet) . . . act as calcium and reduce PTH

also replace Ca and vitamine D (alfacalcidol, calcitriol)

want to prevent osteopenia and pathological fractures

Volume overload

prevent with Loops (can add in thiazide later on)

not uncommon to see stage IV on furosemide and metalozone ot get the last out of kidneys

Metabolic acidosis. . . bicarb usually settles around 10-20 . . .. give po sodium bicarbonate to stop metabolic acidosis

Drugs to avoid in renal failure

antibiotics: tetracycline, nitrofurantoin

NSAIDs

lithium

metformin

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16
Q

Pottassium Disturbance

A

Hypokalaemia

symptoms = CAWP cramps, arrhythmias, muscle Weakness, Polyuria

Mild = 2.5-3.5, no symptoms tx: oral K+

Severe = <2.5 or symptomatic Tx: ECG, IV 40mmol 4-6 hrs

causes: thiazides, corticosteroids, salbutamol, theophyline, rTA, IVF, laxitive abuse, GI loss, alkalosios

Hyperkalaemia

symptoms: PHEW BPP palpitatios, hypotension, ecg changes, muscle Weakness, bradycardia, parasthesia, flacid paralysis

Mild/Moderate = 5.4 -6.4 no symptoms tx = calcium resonium 15d po t/qds

severe = >6.5 or ECG changes or severe symptoms

tx

  1. ecg
  2. 10mls 10%d calcium glucanate IV bolus over 3 minutes every 15 mins up to 50ml until ECG improves
  3. 10 units of actrapid with 25g glucose (250ml of 10% or 50ml of 50%) IV
  4. nebulised salbutamol 10mg
  5. if persists then renal/ critical care team
    causes: acei, arbs, nsaids, heparin, digoxin, pattassium sparing diuretics, renal failure, addisons, burns, metabolic acidosis
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17
Q

COPD MEDED

A

If they have Asthma too it should have already been diagnosed

Bronchitis - low o2 leads to hypertension and RHF

Emphysema - damaged aveoli and co2 retension - cachexic and prolonged forced expiration

Diagnose - Spirometry. .. . . the other stuff is for acute

Asthma: raised eosinophil count +/- diurnal variation +/- peak flow varition over time (at least 400ml)

FEV1/FVC = <0.7

FEV1 of predicted for severity

->80% =mild stage 1

50-79 = moderate stage 2

30-49 = stage 3 severe

<30% = stage 4 very severe

Simplified drugs

beclometasone, formoterol and glycopyrronium (Trimbow) - triple therapy in one for better compliance

Non asthmatic = SAMA + LABA + LAMA

Asthmatic = LABA + ICS (can add in LAMA if refractory

Mucolytics for productive cough

SABA = Albuterol (can also use SAMA first line in uk but need to switch to SABA for second line)

LAMA = ibatropium (2ND line ICS+LABA instead if asthmatic features)

LABA- ending in -alol

COPDER - long term management

O2 and smoking cessation = only things that prelong life (and colume reduction surgery in some patients

O2 - 88-92%

  • -long term - IX if FEV1 <30%/cyanosis/raised JVP*
    • 2 ABG 3w apart offer if <7.3 kPa or 7.2-8 and peripheral/pulmonart oedema or polycythamia*

Exacerbation

ECG, ABC, CXR important to see if anything else causing

Add ABX if sputum looks infected. Cycle between doxycycline (ruin teeth) and azithromycin (QT prolongation so check ECG first)

  • azithromycin used for prophylaxis in UK
  • amoxicillin, doxycycline or clarithromycin for acute in UK

Causative organisms

Haemophilus influenzae (most common cause)

Streptococcus pneumoniae

Moraxella catarrhalis

IX

The following investigations are recommended in patients with suspected COPD:

post-bronchodilator spirometry to demonstrate airflow obstruction: FEV1/FVC ratio less than 70%

chest x-ray: hyperinflation, bullae, flat hemidiaphragm. Also important to exclude lung cancer

full blood count: exclude secondary polycythaemia

body mass index (BMI) calculation

Ventilation

Non invasive ventilation benefits pts with pH 7.25-7.35

also indicated if respiratory acidosis persists despite maximal standard medical therapy for 1 hour or more

Invasive ventilation if pH <7.25

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18
Q

PE

A

Common, high mortality, extensive topic

Continuous with DVT

Need Vircow’s Triad to get DVT

1-

2- eg central lines or smoking

3- COCP, coagulopathy, malignacy

CALF SIGNS = NO DIAGNOSTIC VALUE

  • unilateral odema >2cm

Retinal haemorrhages and intra-arterial fat globules on fundoscopy can be assoicated with fat embolsim

2 Level DVT wells score

=>2 = DVT likely

<=1 do D-dimer to rule out

Post Thrombotic Syndrome

Complication following DVT

painful, heavy calves, pruritus, swelling, varicose veins, venous ulceration

tx with compression stockings

Wedge Infarct

can see on CXR

Ischaemia - pleuritic chest pain

  • Pulmonary hypertension from pushing against clot

Hypoxaemia from decreased perfusion

S1Q3T3 - indicates rs heart strain (also new RBBB associated with PE)

Haemodynamically unstable + Right Heart straign indicates massive PE (thrombolyse them)

Body’s response (why PE size not important)

  • platelet mediators spread over lungs leading to vasodilation and fluid to leak out
  • O2 diffusion limited so hypoxaemia develops
  • hypoxaemia leads to tachyC/P
  • co2 perfussion limited so decreases with rachypnoea

-hypocapnaeia/alkalaemia develop
therefore Blood gas = hypoxaemia with respiratory alkalosis

IX (NICE)

ABG, ECG, CXR

Blood: fbc, u+es, clotting screen and G+S

Use well’s criteria to

>4 CTPA (ie >=5)

-V/Q scan if renaly impared and CXR clear (needs to be able to visualose ventilation)

=<4 = D-dimer to rule out (>50yo you need to age adjust)

tPA - massive PE eg drop in BP (can give IVF also). if haemodynamically unstahble after fluid challenge can consider POC echocardiogram ix right ventricular strain or to visualise thrombus. tPA (eg alteplase) also considered for haemodynamically stable patients with severe right ventricular dysfunction, extensive clot burden and cardiopulmonary arrest due to PE

if cont. haemodynamically unstable after tPA can consider cathetar directed or surgical embelectomy.

Submassive PE = RHS (ix with trop, bnp and echo) but haremodynamically stable

Massive = RHS + Haemodynamically unstable

-sit up, give 15L o2

IVC filter (eg DVT likely to kill and GI bleed)

The warfarin bridge is 5d/ when INR 2-3 (whichever longest)

NICE - GIVE DOAC straight off if PE likely its not contraindicated as can just cont. after - apixaban, rivaroxaban

ROH Process

Gestalt assessment = unlikely then rule out with PERC assessment

if not then Wells score (d-dimer to rule out if negative (adjust if >50))
CTPA unless <35 or pregnant/breast feeding
if can do within 4 hours then wait for treatment, if not then tx straight away

provoked? main =surgery, major trauma, pregnant or puperium, Hormone treatment (pill or HRT), immobility (bedbound, unable to walk or proprtionate part of day in bed/chair)
all unprovoked should be offered cancer screening

DOAC for most unprovoked
LMWH in Ca, pregnancy, breast feeding, eGFR <15

Lifelong = warfarin

egfr <5 = unfractionated

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19
Q

GI bleed Approach

A

Can’t rely on sx as some variation

  • even upper can present as haematocetzia

Call GI when stabalised

  • minimal : FBC, U&Es, LFTs, clotting, obs, crossmatch

Give Terlippressin before OGD in varicies

OGD all suspected upper GI within 24hrs of admission (first gastrographin/ barium in borhaeves)

NICE says you don’t need to do IV PPI but conflicting evidence so many still do

Mallory weiss = weekend warrier. does not usually vommit

Boorhaeves = professional vomitter

Lower GI you want to find source of bleed. . .. based on rate of bleed (hypotension?). rapidly decreasing HB?

Mesenteric Ishcaemia = ‘gut attack’ POOP (pain out of proportion to examination) - pain after meals is like angina to the heart. colonoscopy looking for ischarmic tissue.
Colonic ischaemia = watershed areas in hypotensive patient. This would be a painful bleed after someone becomes hypotensive for another reason. colonoscopy

Haemorhoids - Internal = painless + blood (not mixed in)

external = painful - blood

glasgow-blatchford bleeding score

assess upper GI bleed severity

1-6 each graded on points

>8 ICU admission

Score is “0”only if all the following are present :

  1. Hemoglobin level > 12.9 g/dL (men) or > 11.9 g/dL (women)
  2. Systolic blood pressure > 109 mm Hg 3. Pulse < 100/minute
  3. Blood urea nitrogen level < 39 mg/dL
  4. No melena or syncope
  5. No past or present liver disease or heart failure.

ROH Approach

A to and oxygen

2 large bore cannulas : FBC, U+Es, LFRs, Clotting, VBG, crossmatch 6 units

arrange blood transfusion/ give crystalloid vs major haemorhage protocol

correct coagulopathy (plts \> 50, vit/ffp, reverse anti-coags)
Varicell bleed + 2mg IV terlipressin, 4.5g pip-tazo, metoclopromide 10mg

escalate to med reg or GI consultant

discontinue NSAIDs, aspirin and antiplatelets

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20
Q

Microcytic Anaemia

A

Go to iron studies

Silo metaphor

  • tap/ output release to blood
  • ferritin = iron stores

TIBC = room in the silo

Iron in from diet (mainenance is 1g . . . can take in max 3-4g)

Menometrorrhagia = prolonged or excessive uterine bleeding occurs irregularly and more frequently than normal.

IDA (iron deficiency anaemia)

1st line ix all IDA should be screened for coelic disease

slow bleed think:

  • old man colon cancer
  • young woman menometrorrhagia

BM biospy definitive but don’t do

silo slowly runs out

stool softeners to prevent constipation

If before surgery can give transfusion or IV iron (ferric carboxymaltose) 1g

ACID = anaemia of chronic inflammatory disease

our cells can survive longer w/o iron than bacteria therefore defence mechanism

silo tap turned off but continues to fill

Look for chronic inflammation eg RA/ Lupus

often no tx needed if asx - EPO if needed

Thalassaemias

Iron studies and silo normal

Do electrophoresis - As with something else = Beta thalasaemia

Normal = Alpha thalassaemia (beta does not bind with other)

4 copies of each gene - just one = won’t notice and all 4 = dead so have mild (don’t treat) and severe (transfusion)

tx the iron overload w deferoxamine (undo iron from me)

Beta Thalasaemia trait: disproportionatly low MCV and HbA2 raised (> 3.5%)

Sideroblastic

Increased Fe with everthing else normal l l loften show photo of BM biopsy showing ring sidoblasts (iron stuck in mitochondria)

Divide into reversible and non reversible

B6 - cannot tx with B6

MDS - Myelodysplasic syndrome

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21
Q

Arhythmias

A

Palpitations? - exclude arrhythmias with Holter Monitering (24hr potable 3 lead ecg)

fast = tachycadia?

Narrow = <3 boxes (0.12s) - wide is >

Adenosine = 6mg then 12 then 12 (IV adenosine needs to be infused via a large-calibre vein or central route)

Ventricular Fibrillation

MC cause of death following an MI

SVT

no p waves, HR>150, regular

if haemodynamically stable do vagal manouvres

if this fails give IV adenosine 6mg>12mg>12mg (veramapril if asthmatic)

AF

no p, irregularly irregular, <150

  • chaotic background and flutter sawtooth

Torsades de points = turning of points around heart therefore changing amplitude

V-tach - monomorphic, wide complex, fast rhythm

Diltiazem (CCB) can be used instead of beta blocker in asthmatics

AF MX

echo: to assess left ventricular function, atrial size and valve function

Paroxysmal AF: consider antithrombotic
infrequent and/or asymptomatic antiarrhythmics may not be required. Symptomatic start bisoprolol 2.5mg OD and titrate to 10mg if needed (second line or beta blocker contraindicated = flecainide or solatol) . CAD?: amiodarone or dronedarone. poor LVF? amiodarone or non pharma

Persistent AF (longer than 7 days or terminated by cardioversion)

Rate controlled: >65, CAD, w/o CHF, contraindications for antiarrhythmics, unsuitable for cardioversion

rhythm controlled: symptomatic, younger, first time lone af, af secondary to corrected precipitant, CHF

Cardioversion: part of rhythm control . . . should be anticoagulated 4 weeks prior with warfarin . pharmacological with flecainide 2mg/kg iv over 10-30mins with monitoring

Acutre onset and haemodynamically unstable
(chest pain, SOB, hypotension/underperfusion, pulmonary oedema, myocardial ischarmia)
DC cardioverioversion stat

  • if CHF then use digoxin in acute setting if already on beta blocker . . rate limiting CCB contraindicated in excerbation HF

stable and decide to cardiovert? (beneficial in young, non CAD, low risk)

<48hr - heparinise and give DC cardioversion (anticoag not needed after unless CHADVAS score) or amiodarone

>48hrs either anticoag 3 weeks before and 4 weeks after DC conversion or TOE to exclude left atrial appendage (LAA) thrombus then can heparanise and DC cardiovert immediatelly

if previous cadioversion failure should have 4w amiodarone before DC cardioversion

CHA2DV2ASC - determine anticoag strategy:

0- non aspirin no longer recommended

1- consider for males

2 - offer anticoag (NOAC or Warfarin)

HASBLED score if starting warfarin - high risk =>3

Slow

Narrow and wide not as important here

PACE if too slow or unstable

Atropine helps for the first two - maybe 3rd

Idioventricular rhythm has no p waves as only ventricles contracting

stability - American Heart Association, includes systolic blood pressure < 90 mm Hg, altered mental status, cardiac ischemia, or severely decompensated heart failure due to the underlying rhythm.

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22
Q

Thyroid

A

T4 = spark plug of the body

mentaion = brain moving

Hyperthyroidism

Hyperthyroid = thyrotoxicosis = too much T4

weight loss form diarhoea and metabolism

Oligomenorhoea leading to Amenorrhoea

Screen with TSH and confirm with free T4

Exception to decrease TSH is central where TSH drives the T4

Thyroid Storm

Hypertension

IV propanalol

antithyroid drugs ; methimazole or propylthiouracil

dexamethasone -stops T4 conversion to T3

RAIU scan = radioactive iodine uptake = nuclear scintigraphy

. . . goes wherever T4 being MADE

MNG = multinodular goitre

Graves

smoking is a risk factor

TSH receptor antibodies (also anti-TPO antibodies)

RAIU lights up

specific findings = bugg eyes and muddy shins, acropachy (clubbing)

surgery as radioactive iodine will make exo and PM worse

Anti-thyroid drug titration (40mg carbimazole then gradual reduce when euthyroid) 12-18 months

block and replace (40mg carbimazole then add thyroxine when euthyroid) 6-9 months

carbimazole can cause agranulocytosis

Thyroiditis

T4 leaks out there transient hyperthyroid state . . .will heal or die after

painfull = de querveins and painless = hashimotos

RAIU = cold

Riedel’s thyroiditis = rare, dense fibrosis, painless, usually mroe common in women

De qierveoms (subacute) -

reduced iodine uptake in scintography - usually self limiting - NSAIDs for pain

2-6w painful hyperthyroidism >1-3w euthyroid > weeks/months hypothyroidism > structure/fxn back to normal

MNG and toxic adenoma

RAIU will show nodes

factitious and stroma present stroma ovaria = both exogenous . . .. factitious = trying to lose weight

TX

can use same medications for ther conditions but go for surgery/ Radioactive iodine ablation as don’t want lifelong medication

Hypothyroidism

Menorrhagia but can lead to Amenorrhoea

Doesn’t matter how you get it, tx with levothyrxin

TSH up unless its a central problem (rare)

Iatrogenic = Graces Tx

non iatrogenic = MC hashimotos ( TPO abs to confirm)

Myxedemic coma = sever of hypo (give iv corticosteroids to tackle co-existing adrenal insufficiency)

so cold intolerant that becomes hypothermic which leads to hypotension

Tx with warm IVF and warm blankets

give IV T4 and more potent T3 if that does not work.

MX

Levothyroixine = 50-100mcg od (severe/cardiac disease/ elderly start 25mcg and titrate up)

target TSH value 0.5-2.5 mU/l

measure every 8-12 weeks

pregnancy icnrease by 50% as early as 4-6 weeks of pregnancy

REMEMBER in the vast majority of cases:

Low TSH = high T4 = hyperthroidism

High TSH = Low T4 = Hypothyroidism

EXTRA

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23
Q

Infective Endocarditis

A

Dukes Criteria technically not clinical criteria

Definite if:

Two Major (culture and echo)

one major + 3 minor

5 minor

Murmur

The most common valvular abnormality in infective endocarditis is tricuspid regurgitation. Combined with the fact that this man is showing sings of right sided heart failure (peripheral oedema)

Holosystolic Murmur louder on inspiration

RFs

h/o endocarditis (scares perfect place to set up shop)

vascular

Acute limb ischaemia

Splinter haemorages

janeways lesions (painless)

Rhematologic Sx

Roth spots (eyes)

Osler nodes (painful lesion on finger pulp)

Glomerulonephritis

Two main presentations in Practice

Acute

CHF presentation or Bacteraemia presentation

empiric tx and blood culture until nothing

not enough time for Rheum sx to present

Subacute

more insidious

keep doing cultures till you detect something (harder to grow)

no abx at first or won’t culture

TEE for IE (In practice you would probs do TTE first)

Empiric Tx

Depends on pt (what valve and how long), not organism

Vanc & Gent backbone

NICE TX

Native : amoxacillin

Prosphetic : Vanc + low dose gent + rifampicin

Pen al/MRSA/ SEVERE : vanc + low dose gentamicin (acts on biofilms well)

strep - benzylpenicillin

staph- flucloxacillin

Surgery

if risk of embolism or something the abx won’t tx

Prophylaxis (NICE actually recommonds against PPX)

If Bad Valve + mouth/Throat procedure

BV = h/o endo, prosthetic, congenital heart disease

MT - dental procedues/ biopsy of airway + GI tract + gynae obs procedures

AND

if you can’t us vanc then use dapto

If you culture S.Bovis do a colonoscopy (they have colon cancer)

Organisms

S.aureus MC

S.epididimus MC postoperative eg indwelling lines

Strep viridans (pseudotoxic term . . . MC ones are S.mitis and S. Sanguinis) (poor dental hyegine)

Strep bovis - colon cancer

Culture negative;

HACEK: Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella)

or used abx

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24
Q

Post Op Fever

A

Fever = inflamation, not neccessarily infection

Wound healing causes fever (closer to surgery the more likely wound healing)

temp >39 is what’s alarming (or sx)

>38 after 48hrs do the fever workup

5 Ws

used to be what infections (not true) now use for prevention framwork

so fever with some sx

atechelitis does not case fever but can lead to collapsed alveoli and pneumonia

incetative spirometry not enough evidence (big breaths should open up alveoli but waliking will open more naturally)

Get cathetar out early to prevent infection

Malignant hyperthermia

AD= autosomal dominant

(ca channels stay open leading to massive sustained contraction using lots of energy and generating lots of heat)

Wound is rest of slide

predicting infxn

different types of wound

clean = does not go near any mucosa

clean contaminated = mucosa but it was deliberate without spillage

contaminated (oopsy or ruptured prior to surgery)

Dirty = dirty source eg fecal contamination, foreign object wound

wash out as things can be hinding in crevices

Nec Fac

any organism but those are most associated.

black = evidence of necrotic tissue under skin

Grey dishwater as serum with lots of dead stuff in it

Bacteraemia
no skin changes to differentiate from Nec Fac

Superficial Skin Infection

usually infection of subcutaneous fat (cellulitis)

usually don’t see alone but with wound dishenence.

Deep Peritoneal Infection

2 kinds.

free fluid is normal after surgery but if not absorbed can develop to abscess

abscess is inflamed by definition as immune system has made it

If leak then spillage is ongoing . .. will be sicker

abscess = focussed peritonitis as its walled off

Always look for these if unresolving ileus.

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25
Q

Ortho Trauma

A

Comminuted = broken in several places

Angular/oblique = curved or at angle

AD - dislocates forward . . . maybe deltoid parastheisis (axilliary neve damage)

Montegia and Galleazzi

Humerus # AX w radial nerve damage (wrist drop)

Colles- fall on outstretched wrist - damage to median nerve leads to loss of thumb abduction

Scaphoid - all proximal scaphoid fractures req surgical fixation

Knee - not swollen? probs hip

Hip- Garden classification for neck of femur fractures

iliofascial nerve block is effective pain relief

MCL/CCL - VuLgar Stress = Lateral stress = MCL injury

  • vargus is the other

Tib/Fib - if tib breaks then probs fi also

Ankle - surgery as casting ankle weird and they don’t usually break well.

Compartment Syndrome - on repurfusion, after crush injury, very tense, check compartment pressure, tx - fasciotomy

Ottawa Rules

Xray if: pain in malleolar zone and one of

bony tenderness at the lateral malleolar zone (from the tip of the lateral malleolus to include the lower 6 cm of posterior border of the fibular)

bony tenderness at the medial malleolar zone (from the tip of the medial malleolus to the lower 6 cm of the posterior border of the tibia)

inability to walk four weight bearing steps immediately after the injury and in the emergency department

Subluxation of the radial head

Pulled Elbow

MC upper limb injury in >6

elbow pain with limited supination and extension of the elbow

MX: analgesia and passively supination of the elbow joint whilst the elbow is flexed to 90 degrees

Iliotibial band syndrome (not trauma)

a common cause of lateral knee pain in runners. Athletes commonly present with a sharp or burning pain around the lateral knee joint line.

Plantar Fasciitis (not trauma)

Plantar fasciitis is the most common cause of heel pain seen in adults. The pain is usually worse around the medial calcaneal tuberosity.

Management

rest the feet where possible

wear shoes with good arch support and cushioned heels

insoles and heel pads may be helpful

trochanteric bursitis (non trauma)

aka Greater trochanteric pain syndrom

MC women 50-70

from repeated movement of the fibroelastic iliotibial band

pain over the lateral side of hip/thigh

tenderness on palpation of the greater trochanter

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26
Q

ECG Rhythm

A

Key Approach

Relationship of p waves to QRS

Width of QRS

Sinus Arrhythmia

changes in rate associated with respiration normally seen in young

sUpraventricular rhytms have narrow QRSs and ventricular are wide (except supraventricular with bbb or WPW syndrome)

Escape Rhythms

normal sinus then SAN fails to discharge. you then get:

atrial escape (abnormal p wave followed by qrs then back to normal)

junctional escape (no p waves and normal qrs

ventricular escape (larger delay then abnormal qrs . . . t wave often inverted)

Extrasystoles

This is the same as escape rhythms but occur early rather than late)

again have atrial, junctional and ventricular.

extrasystoles rarely require mx

Supraventricular Tachicardias

Atrial Tachicardia (subtype)

atria depolorise faster than 150bpm

if >200 then av block occurs preventing higher rates in ventricles

Atrial Flutter (subtype)

atrial rate >250 (no flat baseline between p waves)

often associated with 2:1 block

a narrow complex tachicardia with a ventricular rate of 125-150 should always alert you to possibility of atrial flutter with 2:1 block

Junctional Tachicardia (subtype)

P waves v close or not seen at all with normal QRSs

Carotid Sinus Massage

Do in SVT to tx but also make nature of arrythmia more obvious

rub along one carotid artery at the point of maximal pulsation for 5-10s

do not attempt in pts with known carotid artery stenosis or in those with recent TIAs or strokes because of risk of dislodging emboli

Diagnostic use:

sinus tachicardia = temporary slowing of HR

atria or junctional tachicardia = may terminate or have no effect

atrial flutter = usually causes temporary increase in block

atrial fibrillation or ventricular tachicardia = no effect

Ventricular Tachicardia

= very tidy

wide abnormal QRSs

Atrial Fibrillation

No p waves, irregular baseline, irregular QRS, Normal QRS morphology

Ventricular Fibrillation

= very fuzzy (ecg totally disorganised)

pt will quickly lose conciousness

Bundle branch block complications

compare to sinus rhythm

if qrs> 4 squares its probs ventricular origin

in context of MI invariably ventricular tachicardia

LAD indicates ventricular origin

very irregular may have AF on top

Wolff-parkinson-white syndrome

short PR interval with slurred upstroke on QRS complex

What to do:

  1. For fast or slow sinus rhytm treat the underlying cause, not the rhythm itself
  2. extrasystoles rarely need treatment
  3. in patients with acute HF or low BP due to rachycardia, DC cardioversion should be considered early on
  4. Patients with any bradycardia that is affecting the circulation can be treated with atropin, but if this is innefective they will need temporaty or permanent pacing
  5. Consider Vagal manouvres such as CSM, valsalva or eyeball compression in abnormal narrow wave tachycardia
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27
Q

ECG Rhythm

A

Key Approach

Relationship of p waves to QRS

Width of QRS

Sinus Arrhythmia

changes in rate associated with respiration normally seen in young

sUpraventricular rhytms have narrow QRSs and ventricular are wide (except supraventricular with bbb or WPW syndrome)

Escape Rhythms

normal sinus then SAN fails to discharge. you then get:

atrial escape (abnormal p wave followed by qrs then back to normal)

junctional escape (no p waves and normal qrs

ventricular escape (larger delay then abnormal qrs . . . t wave often inverted)

Extrasystoles

This is the same as escape rhythms but occur early rather than late)

again have atrial, junctional and ventricular.

extrasystoles rarely require mx

Supraventricular Tachicardias

Atrial Tachicardia (subtype)

atria depolorise faster than 150bpm

if >200 then av block occurs preventing higher rates in ventricles

Atrial Flutter (subtype)

atrial rate >250 (no flat baseline between p waves)

often associated with 2:1 block

a narrow complex tachicardia with a ventricular rate of 125-150 should always alert you to possibility of atrial flutter with 2:1 block

Junctional Tachicardia (subtype)

P waves v close or not seen at all with normal QRSs

Carotid Sinus Massage

Do in SVT to tx but also make nature of arrythmia more obvious

rub along one carotid artery at the point of maximal pulsation for 5-10s

do not attempt in pts with known carotid artery stenosis or in those with recent TIAs or strokes because of risk of dislodging emboli

Diagnostic use:

sinus tachicardia = temporary slowing of HR

atria or junctional tachicardia = may terminate or have no effect

atrial flutter = usually causes temporary increase in block

atrial fibrillation or ventricular tachicardia = no effect

Ventricular Tachicardia

= very tidy

wide abnormal QRSs

Atrial Fibrillation

No p waves, irregular baseline, irregular QRS, Normal QRS morphology

Ventricular Fibrillation

= very fuzzy (ecg totally disorganised)

pt will quickly lose conciousness

Bundle branch block complications

compare to sinus rhythm

if qrs> 4 squares its probs ventricular origin

in context of MI invariably ventricular tachicardia

LAD indicates ventricular origin

very irregular may have AF on top

Wolff-parkinson-white syndrome

short PR interval with slurred upstroke on QRS complex

What to do:

  1. For fast or slow sinus rhytm treat the underlying cause, not the rhythm itself
  2. extrasystoles rarely need treatment
  3. in patients with acute HF or low BP due to rachycardia, DC cardioversion should be considered early on
  4. Patients with any bradycardia that is affecting the circulation can be treated with atropin, but if this is innefective they will need temporaty or permanent pacing
  5. Consider Vagal manouvres such as CSM, valsalva or eyeball compression in abnormal narrow wave tachycardia
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28
Q

Hip Fractures

A

CF: shortened, externally rotated flexed leg

IX: AP pelvis and lateral xray

MX :

Pre-operatively

Analgesia including a fascia iliaca block, stop anticoagulants/anti-platelets & early surgery.

Post operatively

Thromboprophylaxis, early mobilisation Beware of delirium!

Garden Classification ( for intracapsular fractures)

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29
Q

Principoles of fracture Mx

A

Resuscitate > Reduce > Hold > Rehabilitate

Reduce

Reduction in the taction of soft tissues (to reduce swelling) of transversing nerves ( to reduce neuropraxia) and reduction of pressures on blood vessels (restoring blood supply).

Some use an initial exaggeration of fraction to uncouple distal and proximal fragments

can be done open or closed

Requires analgesia e.g. local/regional blockade or conscious sedation

requires at least two people (one apply reduction force and another counter reduction . . . . often 3rd for casting)

Hold

immonilising fracture

consider need of traction where strong muscles pull across facture sites eg femur fractures

most commonly simple splints or casts

casts non circumferential in first 2 weeks due to risk of compartment syndrome

axial instability: casts need to cross both the joint above and below if # able to rotate along axis eg combined tibia/fibula metaphyseal # or radius/ula metaphyseal #

weight bear? always let pt know if they can

Thromboprophylaxis: common if immobilised and non-weight bearing

safety net pt on sx of compartment syndrome.

Rehabilitate

Intensive period of physiotherapy as pts stiff after immobilisation

encourage movement of non-immobilised unaffected joints from outset

Frailty a significant risk factor so therapists essential to making sure suitable adaptions implemented for their recovery

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30
Q

Orthopedic Radiology

A

Projection

  • -2 views generally AP and lateral
  • -if shaft of long bone image joint above and below
  • -Comment on skeletal maturity (fused epiphyses/growth plates)

Patient Details

-name, DOB, date taken

Technical Adequacy

  • -Penetrance? – make out bones and soft tissue
  • -rotation/?
  • Obvious Abnormalities?
  • -fractures, subluxations/dislocations

Systemic r/v of the xray

  • -look at disruption of smooth continuous cortex (fractures)
  • -then medulla for fracturs (trabecular disruption and sclerotic/lucent lines)
  • -soft tissue swelling and join effusion
  • -joint surfaces for subluxation or dislocation
    • assess joints for degenerative changes (loss of joint space, subchondral sclerosis, subchondral cysts and osteophytes)
  • -assess joints for inflammatory changes (periarticular osteoporosis, soft tissue swelling and bony erosions)
  • -r/v bone densitiy for lucent and sclerotic areas.

Summary

  • -State key findings (description or findings)
  • -differential diagnosis
    • further relevant imaging
    • appropriate initial mx

Fracture Description

  • What bone involved
  • What part of bone (proximal/middle/distal third, intraarticular)
  • Fracture pattern (simple/open, comminuted (>2 fragments), impacted (fragments driven into eacchother))
  • Type of fracture (Transverse(perpendicular), oblique(<90degrees), vertical (parallel), spiral, greenstick (break in once cortex but not other)
  • Subluxation (some contact between articular surfaces) vs dislocation (no contact)
  • Translational Displacement (relation of distal to proximal fragment . . . . anterior/posterior/medial/lateral displacement) . . . AP view displacement = medial/lateral and lateral view displament = anterior/posterior
  • Angulation (movement of distal fragment relative to proximal in degrees
  • Rotation (internal or external, measured along long axis – might be easier on examination)
  • Shortening
  • Joint space (smaller/larger, asymmetrical, fragments/foreign bodies)
  • Joint cartilage (symmetrical outline of cartilage?)
  • Bone texture
    • Mostly radiolucent with thin cortices = osteopenia
    • Radiolucent around joint = inflammation/infected joint
    • Focal lucent areas indicate lesion (tumour/infection)
    • Sclerotic lesions (rarer – paget’s, osteochondritis, sclerotic bone mets)
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31
Q

General Surgical Approach

A

End of bed o gram

look at patient

look at obs

speak to nurse

then . . . .

32
Q

Lower Limb Fracture

A

Ottowa rules

General mx

Closed reduction with propafol (try in A&E)

RICE = Rest, Ice, Compression, Elevation

Webber Classification

lateral malleolus classification

based on level of fracture of fubual compared to syndesmosis

Extra

Trimalleolar includes posterior malleolus

Lauge-Hansen classification used in orthopaedics. . . . depends on position at time of fracture

immobilised with below knee backslab

Any signs of NV compromise requires immediate surgical review (check pulses)

lightbulb sign on xray is aposterior shluder dislocation

33
Q

Back Pain

A
  1. Cord Compression?
  2. Non-specific = MSK
  3. can jump to others if you do not think msk (XRAY/MRI)
  4. If not MSK then tx is surgery based on sx and lifestyle

Thoracic back pain is a red flag symptom

acute = <6w, subacute = 6-12 and chronic >12

MSK

lower backpain first line NSAID (ibuprofen/naproxen)

+ ppi if >45

encourage exercise ( print excercise sheet) but physiotherapy only if sx no resolving or likely to become disabled.

after 2-4 weeks encourage graded return to work even if pain . . .. won’t make worse

Spinal cord compression - seems the same as cauda equina syndrome (this can be caused by massive disk herniation) - surgical emergency

  • sensory loss, lowe limb weaknes
  • urinary incontinence/retention
  • reduced sensationin perianal area
  • reduced anal tone

MRI spine WHOLE spine in 24hr

urgent oncology referal

high dose dex

Cauda Equina vs cord compression

Cauda equina = flaccid paralysis + loss of reflexes

Cord compression = spastic paralysis + brisk reflexes.

Both = sensory + power loss.

Sciatica = shooting pain from bottom down back of legs to toes

Do not offer X-ray in UK - MRI only if you suspec someting sinister - red flag symptoms

pseudoclaudication (spinal stenosins - only upper thigh and buttocks - don’t get climbing stairs or bent over on bike

  • resolves on sitting down

Herniation- AKA prolapsed disk

Leg pain usually worse than back

pain worse on sitting

pain ins dermantological according to which level affected

NSAIDs/exercise/physiotherapy . . MRI if no imporovement after 4-6 weeks

nerve route compression unlikely if SLR not limited or pain does not extend below knee on slr

look for L5/S1 compression (loss of sensatino of lateral border of lower leg and foot, weakness of dorsiflexion and plantarflexion of foot or impaired ankle reflex)

Compression fracture - dont forget f/u dexa scanand osteoporosis tx

Ankylosing Spondylitis should be here:

Typically a young man who presents with lower back pain and stiffness
Stiffness is usually worse in morning and improves with activity
Peripheral arthritis (25%, more common if female)

NSAIDS - remember PPI if over 45

psoas abscess

Back/flank pain worse which is worse when the hip is flexed, with associated fever and raised inflammatory markers in an IVDU. ix CT Abdo

TX = IV abx and percutaneous drainage

EXTRAS

Previous hx of Ca? - always orthopaedic referal

Discitis

CF

backpain, fever, sepsis, lower limb neurological sx

RF: IVDU MC Staph Aureus . . . may present with endocarditis

Dx: MRI

Tx: 6-8w abx

34
Q

Hyperlipedaemia

A

QRISK2 score calculated for >40y and <84y to assess CVD risk

More specific guidlines or DM, CKD and Familial hyperlipidaemia

Safetynet for muscle pain and weakness .. .. check cK if the complain of it. >10 times upper limit stop immediatelly (rhabdo). <5 times rarely significant.

Might underestimate for HIV,

NICE suggest QRISK2 may underestimate CVD risk in the following population groups:

people treated for HIV, SLE, antipsychotics, steroids and immunosuppresent drugs

Measuring lipid levels

A full lipid profile should also be checked (i.e. including triglycerides) before starting a statin. The samples does not need to be fasting.

Can feed lipid measurements into QRISK score. Consider familial hyperlipidaemia if very high

If >10% statin indicated (offer period of lifestyle modification first)

also offer statin for DM as above and CKD

Other tests

TFTs - can be caused by hypothyroidsim

Bloood Glucose: DM can cause

Anorexia nervosa can also cause
Secondary prevention

All patients with CVD should be taking a statin in the absence of any contraindication.

Atorvastatin 80mg should be offered first-line.

Follow-up of people started on statins (asthenia (physical weakness), flatulance, headaches)

NICE recommend we follow-up patients at 3 months

repeat a full lipid profile

if the non-HDL cholesterol has not fallen by at least 40% concordance and lifestyle changes should be discussed with the patient

NICE recommend we consider increasing the dose of atorvastatin up to 80mg

Familial Hyperlipidaemia

Ezetimibe inhibits the absorption of cholesterol

Bezafibrate reduce serum triglycerides.
Lifestyle modifications

These are in many ways predictable but NICE make a number of specific points:

Cardioprotective diet

total fat intake should be <= 30% of total energy intake

saturated fats should be <= 7% of total energy intake

intake of dietary cholesterol should be < 300 mg/day

saturated fats should be replaced by monounsaturated and polyunsaturated fats where possible

replace saturated and monounsaturated fat intake with olive oil, rapeseed oil or spreads based on these oils

choose wholegrain varieties of starchy food

reduce their intake of sugar and food products containing refined sugars including fructose

eat at least 5 portions of fruit and vegetables per day

eat at least 2 portions of fish per week, including a portion of oily fish

eat at least 4 to 5 portions of unsalted nuts, seeds and legumes per week

Physical activity

each week aim for at least 150 minutes of moderate intensity aerobic activity or 75 minutes of vigorous intensity aerobic activity or a mix of moderate and vigorous aerobic activity

do musclestrengthening activities on 2 or more days a week that work all major muscle groups (legs, hips, back, abdomen, chest, shoulders and arms) in line with national guidance for the general population

Weight management

no specific advice is given, overweight patients should be managed in keeping with relevant NICE guidance

Alcohol intake

again no specific advice, other than the general recommendation that males drink no more than 3-4 units/day and females no more than 2-3 units/day

Smoking cessation

smokers should be encouraged to quit

35
Q

Hypertension Dx

A

can ix primarty hyperaldosteronism after two drugs if suspected (aldo:renin ratio)

Stage 1 hypertension

  • Clinic BP >= 140/90 mmHg and subsequent ABPM daytime average or HBPM average BP >= 135/85 mmHg*
  • lifestyle changes + consider antihypertensives*
  • *Stage 2 hypertension**
  • Clinic BP >= 160/100 mmHg and subsequent ABPM daytime average or HBPM average BP >= 150/95 mmHg*

Antihypertensives regardless

Severe hypertension

  • Clinic systolic BP >= 180 mmHg, or clinic diastolic BP >= 110 mmHg*
  • immediate tx*

admit if worryig signs (pappilodema, retnal haemorhages, confusion)

if no worry signs do urgent ECG, urine tests and bloods lookinf for end-organ damage

Clinic BP

Take readings in both arms (if >20 dif recheck then go with highest if persistent)

Take two readings in consultation and use lowest

Ambulatory blood pressure monitoring (ABPM)

at least 2 measurements per hour during the person’s usual waking hours (for example, between 08:00 and 22:00)

use the average value of at least 14 measurements

If ABPM is not tolerated or declined HBPM should be offered.

Home blood pressure monitoring (HBPM)

for each BP recording, two consecutive measurements need to be taken, at least 1 minute apart and with the person seated

BP should be recorded twice daily, ideally in the morning and evening

BP should be recorded for at least 4 days, ideally for 7 days

discard the measurements taken on the first day and use the average value of all the remaining measurements

If however the blood pressure is >= 180/110 mmHg:

immediate treatment should be considered

if there are signs of papilloedema or retinal haemorrhages NICE recommend same day assessment by a specialist

NICE also recommend referral if a phaeochromocytoma is suspected (labile or postural hypotension, headache, palpitations, pallor and diaphoresis)

36
Q

Hypertension Mx

A

ACEi - enalapril, lisinopril, perindopril and ramipril.

ARBs - candesartan, irbesartan, losartan, valsatan

CCBs - amlodipine, felodipine and nifedipine.

Diuretics - indapamide and bendroflumethiazide.

Bendroflumethiazide

first, check for:

  • confirm elevated clinic BP with ABPM or HBPM*
  • assess for postural hypotension.*
  • discuss adherence*

Step 1 treatment

patients < 55-years-old or a background of type 2 diabetes mellitus: ACE inhibitor or a Angiotension receptor blocker (ACE-i or ARB): (A)

angiotensin receptor blockers should be used where ACE inhibitors are not tolerated (e.g. due to a cough)

patients >= 55-years-old or of Afro-Caribbean origin: Calcium channel blocker (C)

ACE inhibitors have reduced efficacy in patients of Afro-Caribbean origin are therefore not used first-line

If CCB give peripheral oedema it can be switched for 2nd line indapamide to relieve symptoms

Step 2 treatment

if already taking an ACE-i or ARB add a Calcium channel blocker or a thiazide-like Diuretic

if already taking a Calcium channel blocker add an ACE-i or ARB

for patients of Afro-Caribbean origin taking a calcium channel blocker for hypertension, if they require a second agent consider an ARB in preference to an ACE inhibitor

(A + C) or (A + D)

Step 3 treatment

add a third drug to make, i.e.:

if already taking an (A + C) then add a D

if already (A + D) then add a C

(A + C + D)

Step 4 treatment

NICE define step 4 as resistant hypertension and suggest either adding a 4th drug (as below) or seeking specialist advice

if potassium < 4.5 mmol/l add low-dose spironolactone

if potassium > 4.5 mmol/l add an alpha- or beta-blocker

37
Q

Approach To Dyspnoea

A

Acid base balance not a Dx but a catch all

Bad blood = carboxyhaemoglobin/ Methemoglobinemia

Anaemia - don’t worry about the type at first. Just Dx

  • SOB, fatigue, tiredness, pale skin, dizziness

Same w CHF - exacerbation the same whichever type

-SOB, Orthopnoea, PND, Crackles, chest pain

Pleuritic Pain + SOB narrows it

  • pneumothorx, pneumonia, PE, pulmonary effusion, CA
  • Obstructive and restrictive
  • DAH = diffuse alveolar Haemorhage

IX

Always these (BNP debatable)

ABG - covers top two

CXR - covers bottoms two

ECG - arythmia/MI

BNP- CHF

SATS - also do these. generally want >92%

order all before you get there and cancel if you don’t need

Pneumothroax

<2cm rim and not SOB discharge

if <2cm SOB then aspiration

if >2cm and >50 or SOB after aspiration then instert chest drain

38
Q

Approach To Abdo Pain

A

Type + Location = Shortlist

Somatic Pain = pinpoint pain (correct target)

Neuropathic pain (tingling/burning) - not frome target

Visceral organs = no innvervation . . hijack somatic overlay from EMBRYOLOGICAL origin

Feel obstruction/stretch/inflammation (not stabbing/buring)

Obstructive

Hollow organs

-increase pain as peristalsis approachs obstruction

Restless trying to find position of comfort

Inflammatory

Constant and restlesss with inflammatory markers

Perforation

Peritoneal does have innvervations and very sensitve so SAS , very paifull, motionless

peritoneal pain will illicit rebound tenderness (percuss non tende area and tender area will hurt) hollow viscous to perf - PUD/ Diverticulitis

Ischaemic

POOP - ie very painful but not at all tender to touch . . . . lactate gives it away

Some sort of vascular history (AF/CAD/PVD) or ischaemic colits?

Functional

Reffered pain - can have pain from bad constipation or bloating from periods

ANGRY ROBOT

PM BAD BRUNG = randos . . .NOT periumbilical

Epigastric Chest and Epigastric Abdo (remember Qs for both)

RUQ = US

Everwhere else use CT

O/E

not very useful except

peritoneal pain/ absent bowel sounds

Rovsing’s Sign = pain in LIF when palpation of RIF

boas’ sign = hyperaesthesia below right scapula in Cholecystitis

PM BAD LUNCH:

  • *Porphyria**
  • *Mediterranean** Fever (Familial Mediterranean Fever): Armenian heritage; FHx of FMF. History paroxsymal fever/abdominal pain x 72 hrs.
  • *Black Widow** Spider bite
  • *Addison’s:** Associated hypotension; history of steroid use, auto-immune disease, or tuberculosis (the most common causes of Addison’s disease)
  • *Diabetic Ketoacidosis**
  • *Lead** poisoning
  • *Uremia**
  • *Narrow angle glaucoma**: Red, painful eye.
  • *Calcium:** Hypercalcemia causes chronic constipation due to chronic bowel contraction.
  • *Herpes Zoste**r: Dermatomal pain may precede vesicular rash by 1-2 days.
39
Q

Cough Approach

A

Acute = always infection

subacute = alwasys post infection

dex/benz = sx releief

don’t worry in practice if <8weeks

ACEi/Cigs = stop

-smoking cessation initial worsening for 8 weeks

CXR to see if primary pathology (resp referal if +ve)

  • empirit tx if not (8 weeks each)

Further ix if not

primary pathology missed by CXR

if still nothing then idiopathic and tx symptoms

40
Q

ENT infections +

A

OM

URTIs - S. pneumoniae, H. influenzae, M. catarrhalis

erythromycin or clarithromycin if pen allergy

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*

If an antibiotic is given, a 5-day course of amoxicillin is first-line. In patients with penicillin allergy, erythromycin or clarithromycin should be given.

OE

swimmers ear from not drying after - pseudomonas

digital - cotton buds

Tx - usully resolves spontaneously

1st line - topical abx or topical abx/steroid combo

cipro topical if bad

Flucloxacillin if sreading

Ref to ENT if toical abx not working

Consider malignant OE in diabetes and immunocompromised -CT and emergerncy ent ref + IV antiseudomonal

Mastoiditis

hx of OE/OM

CT often not needed

Sinusitis

vral v bacterial

purulent thick bilateral discage

don’t really need imaging

TX - analgesia + nasal decongestants

maybe steroids if >10 days

phenoxymethylpenicillin first-line, co-amoxiclav if very unwell

Consider causes of poor drainage (predisposes) eg polyps

Double sickening indicates bacterial sinusitis (initial recovery before worsening

Nasal virla - coryzal

bilateral copius and clear

supportive

Pharyngitis

viral vs strep A

tx strep A to avoid rhematic fever

EBV? - do the monospot

centor criteria (3 or 4 = more likely to benefit from antibiotics);

  • presence of tonsillar exudate*
  • tender anterior cervical lymphadenopathy or lymphadenitis*
  • history of fever*

absence of cough

Tx: Penicillin V (erythromycin/clarithromycin in pennicilln allergy)

epistaxis

normal = unilateral for <30mins

if posterior bleed then pack + prophylactic Abx for toxic shock

anterior = 1st silver nitrite cautery and 2nd line rapid rhino for 24hrs (tampon thigng . . . . different ones for anterior and posterior bleed

Choanal atresia

= blockage from nose to throat

blue on feeding

dx - fail to cathetarise

tx surgery

foreign body

remove it and tx infection with abx

homeless may be insect – do not use light - lidocaine to parylise first.

Perforated Tympanic membrane

ENT referal if does not heal in 6-8 weeks

abx if caused by acute OM

Infectious Mononucleosis

EBV aka HVV-4

Classic triad = sore throat, pyrexia, lymphadenopathy

Also: palatial petechiae, splenomegaly, hepatitis, lymphocytosis, haemolytic anaemia, maculopapular rash with amoxicilin/ampicillin

Ix: Monospot tests and FBC in second week of illness (NICE)

Tx: rest/fluids/avoid alcohol, simple analgesia for aches and pains, avoid contact sports for 8 weeks

41
Q

Approach to dysphagia

A

Diffulculty swallowing (not pain)

often desribed as getting stuck - ask where they feel its getting stuck (above or below clavicle

Oropharyngeal

  • ENT laryngoscope
  • usually a neuro problem
  • problem with initiating (cough/choke/gag)

Vagus nerve

MS - multiple sclerosis

TM = transverse myolitis

Stroke is most common

SALT referal (automatic if stroke)

Pharyngogram = radiolabel different cosistencies

If NBM then NG tube

PEG you would still need to get gastro involved

OESOPHAGEAL

GI referall and endoscope

Motility

funcitional (muscle fine)

liquid and food problems from get go

Mechanicl

obstructive worsening and progessive

food then liquid

BOTH - barium swallow and OGD

monometry - maybe in the community but wont as OGD in hospital if admitted

IX UK

All OGD, FBC

maybe barium

ambulatory oesophageal ph and monometry for GORD and achalesia

causes

oesophageal cancer

oesophagitis

oesophageal candidasis

achalasia

pharyngeal pouch

systemic sclerosis

myasthesia gravis

globus hystericus

42
Q

Rashes

A

EI

Slapped cheek syndrome is giveaway . . .but can be on arms and legs

Aplastic crisis if Sicle Cell disease

Keep away from pregnacy

M

the 4 Cs giveaway

remember subacute sclerosing Panencephalitis later in life ( brain problems)

Maccular

otitis media = MC complication

Rubella

Genralised Tender Lymphadenopathy is the giveway.

Maccular

Roseola

High spiking fever THEN rash

paracetamol for high temperature

febrile seizures more likely as higher temperature v quickly

Varicella

Rash w/o fever?

Adults - never croses midline

can be painfull before and after (gabapentin/ pregabalin)

Can give varicella vaccine in old too

acyclavir to reduce length in elderly

exclude from school until all lesions dry and crusted over

Mumps pretty obvious

Hand foot and mouth disease

Like Varicella but on the hands, feet and face

no need to stay away from school if feels well

43
Q

Skin Lesion Examination

A

WIPE

chaperone if intimate area

General Inspection (Distribution)

Check for meds, bandages etc

Acral = distal areas eg hands and feet

Extensor = elbows and knees (psoriasis)

Flexural = axillae, genital region, cubital fossa (eczema)

Follicular = areas with increased sebaceous glands eg face, chest and axillae (acne)

Dermatomal = dermatomes don’t cross the midline (herpes zoster)

Seborrhoeic= increased density of sebaceous glands eg face and sculp (seborrhoeic dermatitis)

Stocking distribution = status

Close Inspection

Assess size

Configuration

Discrete lesions = seperate (normal mole)

Confluent = merging together (urticaria)

Linear = in a line (excoriations)

Discoid lesion = coin shaped (discoid eczema/ discoid lupus)

Target Lesion = rigns of varying coloure eg bullseye

annular = ring like (tinea corporis)

Colour

Erythematous: red and blanches

Purpuric: red/purple don’t blanche pertechiae(<2mm) and purpura (>2mm- bruise)

Hyperpigmented lesion: diffuse (addison’s) or discrete (linea nigra)

Depigmentation = white due to absent melanin (vitiligo)

Morphology (flat raised or depressed)

Macule= altered colour < 1.5cm

Patch = altered coloure >1.5cm

Papulle = raised palpable

nodule = raised and >0.5cm diametre

Plaque = palpable flat lesion >1cm

vesicle: fluid filled <0.5 cm

bulla = fluid filled > 0.5cm

pustule = pus filled < 0.5cm

abscess = localised accululation of ppus

Wheal = oedematous papulae or plaque

Boil/furuncle = staph within a hair follicle

Carbuncle = staph in adjacent follicles (multiple boils/furuncles)

Secondary Lesions (modification of primary)

Excoriation

Lichenification (thickening of normal skin 2ary to scratching)

Scales = shedding skin

Crust = rough surface from dried fluid

Scar (atrophic, hypertrophic and keloidal)

Ulcer = dermis lost

Fissure = sharp linear wedge

Striae (stretch marks) purple lines from rapid growth/ stretch (pink then white)

Pigmented lesion

ABCDE

regional lymph nodes if malignancy suspected

Palpate

Don gloves

surface characteristics = texture elevation, crust and temperature)

Deep characteristics = consistency, fluctuance, mobility, tenderness)

Systemic Consideration

Nails (pitting, onycholysis, or klilonychia)

Elbows (plaques, xanthomas and rheumatoid nodules)

Hair: loss (alopecia areata/totalis) excess (hirsutism, hypertrichhosis)

Scalp: psoriasis/seborhoeic dermatitis

Mucous (hyperpigmented macules (ppeutz jeghers) or bullae (blisters)

Complete

Thank patient

dispose of ppe

wash hands

summarise

Consider

relevent systems examinations

swabs and scrapings

dermatoscopy

Biopsy

44
Q

Joint Pain Approach

A

REMEMBER THESE ARE GENERAL RULES

First differentiate by numbers then acuity/ toxicity
High acuity/toxicity you admit - low one harder to spot
Ser -ve = PAIR

Poly = VIRUSSSSS

SLEs like big joints. RA likes small joints

AP = lower back OA = weight bearing joints (shoulder/hip) or joints with previous trauma/surgery Acute = red hot swollen tender and immobile

Reactive = ive got gonorhoea and my joint hurts.

Infective = I have gonourhea in my joint

The (A)s are for acute toxicity

Abs most important to learn from top to bottom

45
Q

Asthma

A

Not all wheezing asthma but should always consider

Ominous = lots of air trapping and not much room for air movement

PFTS = spirometry

ach agonist = Methacholine

Negavite Spirometry does not exclude asthma: ix further with fractional exhaled nitric oxide (FeNO) testing

Tx

Bronchoconstricion with bronchodilators

Inflammation with anti-inflammatories

Stabalisers can be used for athletic asthma as you can take pre-emptivly (cromolyn/ nedocromil)

short course of prednisolone for acute episodes (eg 5day hx of wheeze and cough and already on medicaiton)

Adult Tx

2- jump in here if Newly-diagnosed asthma with symptoms >= 3 / week or night-time waking

Salmeterol = LABA aka a ‘controller’

Child 5-16 tx

The same as adult but stop LRTA at 4

Jump to 2 if Newly-diagnosed asthma with symptoms >= 3 / week or night-time waking

8 week trial:

After 8-weeks stop the ICS and monitor the child’s symptoms:

if symptoms did not resolve during the trial period, review whether an alternative diagnosis is likely

if symptoms resolved then reoccurred within 4 weeks of stopping ICS treatment, restart the ICS at a paediatric low dose as first-line maintenance therapy

if symptoms resolved but reoccurred beyond 4 weeks after stopping ICS treatment, repeat the 8‑week trial of a paediatric moderate dose of ICS

Exacerbation

Life threatening:

SpO2 <92%
PEF <33% best or predicted
Silent chest
Poor respiratory effort
Agitation
Altered consciousness
Cyanosis

Nebs = Ipratropium (muscarinic antagonist)/ salbutamol

PEFR = peak espiratory flow rate ( they should know their best)

All patients to receive PO prednisolone

Oxygen through non rebreath

MDI = metered dose inhalors

Rescue medication :

Racemic adrenaline neb, subq adrenaline, IV magnesium all used to try and prevent intubation

Grades

1 - intermitent

2/3/4 = intermittent

  1. mild
  2. moderate
  3. severe

Refractory = tx not working

Adult Corticosteroid Doses

<= 400 micrograms budesonide or equivalent = low dose

400 micrograms - 800 micrograms budesonide or equivalent = moderate dose

> 800 micrograms budesonide or equivalent= high dose.

Paeds Corticosteroid Doses

<= 200 micrograms budesonide or equivalent = paediatric low dose

200 micrograms - 400 micrograms budesonide or equivalent = paediatric moderate dose

> 400 micrograms budesonide or equivalent= paediatric high dose.

Maintenance and reliever therapy (MART)

a form of combined ICS and LABA treatment in which a single inhaler, containing both ICS and a fast-acting LABA, is used for both daily maintenance therapy and the relief of symptoms as required

MART is only available for ICS and LABA combinations in which the LABA has a fast-acting component (for example, formoterol)

Criteria for discharge

been stable on their discharge medication (i.e. no nebulisers or oxygen) for 12–24 hours

inhaler technique checked and recorded

PEF >75% of best or predicted

46
Q

Oesophagitis

A

Oesophagitis in general

As you often have to do a biopsy and take a PIECE

E for GORD and everything else

MC presents with odynophagia but sometimes just dysphagia

Give some sort of antacid for all as if its not the cause it can make it worse

Pill induced

Gets stuck and inflames surface

Non-entric coated NSAIDs notorious for it

Pill often not still there but remove if it is

Should recover with PPI

PPX but taking pills with a whole glass of water adn not when lying down

Infectious

Pretty much anything can cause but remember these four

Candida - oral candidasis with oesophagitis symptoms (tx with fluconazol

HSV = herpes = painful prodrome, vesicles on erythematous base and ulcers at multiple stages of healing cal or acyclavir

CMV - wont see anything

HIV - opportunitstic infections and to remind you infectious oesophagitis often in immunosuppressed

Eosinophilic

allergic reaction in oesophagus

EGD with >15eos per high powered field then you trial PPI as GORD often causes . . .. if they were origionally tx for GORD before biopsy then they now get oral aerosolised steroids

Caustic

Kid eg drinking drain cleaner

Aduld = suicide attempt

Touches all on way down inc larynx

OGD to determine severity

Low = trial liquid diet and monitor

High severity = strictures with necrotic black looking oesophagus

Never neutralise pH as it can cause a exothermic reaction and burn again . .. .. or expose again on induced emesis

NGT and flush and suck multiple tiems

47
Q

Incontinence

A

Initial IX in general

bladder diaries should be completed for a minimum of 3 days

vaginal examination to exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles (‘Kegel’ exercises)

urine dipstick and culture

urodynamic studies

Stress

have to have given birth

cardinal ligament hlds uterus/bladder/vagina in place

Leads to cystocel and IAP thne only increases bladder pressure and not sphincter

anything that IAP (coughing, laughing, running)

no nocturnal as no IAP

Q-tip test = apply q tip to urethra and IAP .. . . if it rotates >30 degress then you have urethral mobility

Strengthen pelvic floor with kegal exerises then use pessaries if fails

surgery MC calposuspension (NICE = retropubic mid-urethral tape procedures)

Duloxetine 2nd life if decline surgical procedures

ALL the following applicable to men and women

Hyertonic

random spasms of detrussor (not predictable)

nocturnal (as random)

U/A to ro infection

Cystometry = empty and then allow to fill . . . random detrusor activity throughout

Too much antispasmotics can lead to hypotonic

Bladder training by graduall increasing intervals

oxybutynin (avoid in old frail women), tolterodine or darifenacin

mirabegron (a beta-3 agonist) if concern anticholinergic burden

Hypotonic (neurogenic bladder)]

leak before you explode (bladder pressure intermittently exceeds sphincter pressure)

nocturnal (if bladder full)

Physical might also find underlying FND (eg multiple in MS)

Bethanacol induces spasms but in chronic irreversibele conditions consider intermittent/indwelling catheters

Cystometry shows no activity

Irritated

FUD = frequency/urgency/dysuria

not neccessarily incontinence

might wake up with bladder symptoms but not incontinence

U/A gives the answer (use in other to r/o)

WBC = infection and RBC = stones, Ca

UTI abx (amoxicillin, nitrofurentoin, trimethrorim sulphate)

Fistula

Epithelial line tract between bladder and anything

from inflammation/radiation (so look for hx of Surgery, Ca, IBD-crohns)

Physical . ..look for fistula

Tampton test = put tampon where you think it is and inject dye up urethra

Vagina = vaginal leak

skin = they might have ad to catch it

rectum = air/stool in urin (or urin in rectum)

tx with fistulotomy

48
Q

Vaginal Bleeding Overview

A

Differentiate by age

Most common causes

foreign body mc inserted by herself

vaginal atrophy esp after sex

What you most worry about

sexual abuse if trauma or STI

Pregnancy = PAD

DUB (dysfunctional uterine bleeding) = AUB (abdnormal uterine bleeding)

also be aware of

= precocious puberty/HRT

what to do

speculum can be traumatising in young so under GA

UPT = urinary pregnancy test

post menopausal = Ca until proved otherwise

Bleeding a lot

ABC including two peripheral cannulae, 14 gauge

IV syntocinon (oxytocin) 10 units or IV ergometrine 500 micrograms

IM carboprost

  1. for access
  2. support BP until blood
  3. crossmatch and transfuse as needed
  4. IV oestrogen to stop bleeding
  5. if above fail some sort of surgical intervention

Assess

Hb key but assess after IVF as before normal

<7 = absolute transfusion indicaiton

orthostatics to assess haemodynamic stablity

surgical intervention

Intracavitary Tamponade = absolute tamponade

Dilattion and cuterage = get at source to stop bleeding and preserve fertility

Uteine arter embolisation reserved for AVM and fibroids (by intervential radiology)

TAH = definitive tx for unrelenting haemorhage ( does not preserve fertility)

49
Q

Headache

A

Secondary

want to first consider secondary and ask RED FLAGS

SAH = worst HA

Tumour = FND with progressive N/V

Abscess = fever/HA/FND

Meningitis = Fever and HA

will proabbly follow up with one or more of those IX

Primary HA

Tension

Common one that people usualy tx themselves

Bilateral vice like pain that starts in the front and radiates backt to the neck

might be exacerbated by loud noise and exercise but no photo/phonophobia

If they have > 2 days a week consider prophylaxis (10 sessions of accupuncture or amitriptyline 25mg-150mg ON). trail of prphylaxis after 4-6 months.

Analgesic Rebound or medication overuse

most at risk are those using triptans barbituates and opiates >10/month to tx HA

can also be caused by withdrawl from NSAIDS/Paracetamol and even caffeine

tx = push through withdrawl

consider if HA 15 days a month for three months

advised to stop abruptly, not gradually and push through at least a month (but can also do naproxen 250mg TDS for 4 weeks first?!)- give antiemetics

Cluster HA

Asx for months and then a cluster of HAs

increased duration means decreased frequence and vice versa

same each time

unilateral eye pain associated with horner’s syndrome:

rhinorhea, lacrimation, conjunctival injection and lid sags

2nd line triptans

MRI to r/o 2are HA

give parenteral triptan (IN zomitriptam 5-10mg or SC sumatriptan 6mg to terminate or 100% oxygen no rebreath 12l/min for 10-20 mins to terminate in ED) no paracetamol, nsaids, opioids, ergots or oral triptans

Migraine

do dual treatment of NSAID and triptan straight away

nsal triptan in 12-17yo

give antiemetic if naeusea eg prcholorperazine3-6mg bucacal tablets or domperidone 10mg po

prophylaxs with topiramate or propanaol

vascular . . .generally vasodilation

Aura can be any FND

Trigger : eg MSG, menstrule cycle, chocolate, caffeine

Sleep usually aborts but ‘hangover’ following day

NSAIDs best if you get in early

Triptans (can cause vasospasm in CAD)

Idiopathic Intracranial Hten

increased ICP w/o cause

ICP sx esp papiilloedema

associated OCPs

CT scan will be -ve

LP has high opening pressure and releives sx

tx = acetazolamide

refractory tx = serial LPs

last resort = VP shunt

Migraine triggers include the mnemonic CHOCOLATE: chocolate, hangovers, orgasms, cheese/caffeine, oral contraceptives, lie-ins, alcohol, travel, exercise

Menstrual Migraine

ID relationhip with period for at least two cycles. give triptans or nsaids a couple of days before and after expected HA

Trigeminal Neuralgia

ear to chin shooting pain on eating or cold liquids

tx with carbamazapine

Temporal arteritis

Typically patient > 60 years old
Usually rapid onset (e.g. < 1 month) of unilateral headache
Jaw claudication (65%)
Tender, palpable temporal artery
Raised ESR

Asoociated with polymyalgia

Low Pressure Headache

post lumbar puncture

worse on standing up

tx with caffeine and fluids

50
Q

Vertigo

A

r/o syncope and disequilibrium (syncope can pose immediate risk)

Vestibular system begins in semi circular canal of ears and connected to brainstem by CN8

Central

NS = neighbourhoods sx, esp FND

FND usually cerebellar

MC MS, CVA and tumour

IX: MRI head looking at posterior Fossa

Peripheral

Benign paroxysmal positional vertigo

lasts <1min, eg every time i lie on my left side

Dx: Hallpike manouvre looking for rotary nystagmas

Tx: Epley Manouvre

Labrynthitis and vestibular neuritis

the same but labrynthitis has hearing loss

vertigo lasts 1-10 mins

horizontal nystagmus

can confuse for central but will be negative scan

can tx with steroids if get straght awau but mosly wait it out with antivertigo meds

URI = URTI

tx: prochlorperazine for sx mx but only for 3 days (vertigo and nausea sx)

Vestibular neuronitis urgernt referal to balance specialist for rehabilitation in the first week

Menier’s

Triad of . . .

last for life so prescribe anti vertigo meds

Stop driving until sx under control

sx tx with prochlorperazine

ppx with betahistine

51
Q

Anxiety Disorders

A

Anxiety

Feeling + Physical

Individual experience

Bad experience so risk of mood disorders and to self medicate

Generalised Anxiery Disorder

At least 6 months

somatic sx ie impairs normal fxn

chronic problem so psychotherapy best

Panic Disorder

Presents like physical problem so r/o others

Benzos to abort attack

SSRIs can be used to decrease frequency

CBT can be used to get out of panic attack

agoraphobia = fear of leaving home alone

Phobias

Irrational or/and irrational fear

Flooding = medicate then rapid exposure to stimulus

Desensitisation = gradual exposure (floor by floor analagy

Social Phobia

non selective BB eg propanalol

52
Q

GAD Criteria

A

A) 6 months of worry/anxiety about most things, most days

  • can justify several weeks

B) At least 4 of: (including at least 1 from STAM)

Sweating

Trembling (shaking)

Accelerated HR (palpitations)

Mouth = dry

Sx think brain, chest, abdo, muscles, nerves

or think apprehension + motor tension + autonomic overactivity

A) A period of at least six months with prominent tension, worry, and feelings of apprehension, about everyday events and problems.

B) At least four symptoms out of the following list of items must be present, of which at least one from items (1) to (4).

Autonomic arousal symptoms

(1) Palpitations or pounding heart, or accelerated heart rate.
(2) Sweating.
(3) Trembling or shaking.
(4) Dry mouth (not due to medication or dehydration).

Symptoms concerning chest and abdomen

(5) Difficulty breathing.
(6) Feeling of choking.
(7) Chest pain or discomfort.
(8) Nausea or abdominal distress (e.g. churning in the stomach).

Symptoms concerning brain and mind

(9) Feeling dizzy, unsteady, faint or light-headed.
(10) Feelings that objects are unreal (derealization), or that one’s self is distant or “not really here” (depersonalization).
(11) Fear of losing control, going crazy, or passing out.
(12) Fear of dying.

General symptoms

(13) Hot flashes or cold chills.
(14) Numbness or tingling sensations.

Symptoms of tension

(15) Muscle tension or aches and pains.
(16) Restlessness and inability to relax.
(17) Feeling keyed up, or on edge, or of mental tension.
(18) A sensation of a lump in the throat or difficulty with swallowing.

Other non-specific symptoms

(19) Exaggerated response to minor surprises or being startled.
(20) Difficulty in concentrating or mind going blank, because of worrying or anxiety.
(21) Persistent irritability.
(22) Difficulty getting to sleep because of worrying.

53
Q

Spine Examination

A

WIPE

LOOK

pt standing

From back: muscle wasting, assymetry, scoliosis of spine, scars, skin changes, hairy patches

Frome side: Cervical lordosis, thoracic kyphosis and lumbar lordosis

Front: head, shoulders, hands level and no lower limb abnormality

Gait: four phases present? normal armswing? symetricle, smooth, stable and good speed?

MOVE

 Assess lumbar flexion and extension by placing two or three fingers over the lumbar spine. Ask the patient to bend to touch their toes. Your fingers should move apart during flexion and back together during extension.

 lateral flexion: run leg down side of legs- extent/quality/pain?

 Cervical spine: lateral flexion (ear to soulder), rotation, extention (back and forwards). Extent/quality/pain?

 Thoracic Rotation: sit, cross arms and rotate. extent/quality/pain?
 With the patient lying as flat as possible, perform straight leg raising (see Figure 20). Dorsiflexion of the foot with the leg raised may exacerbate the pain from a nerve root entrapment or irritation such as that caused by a prolapsed intervertebral disc.

 Assess limb reflexes (upper and lower) and dorsiflexion of the big toe.

FEEL

lying face down (sitting if this is not possible)

feel spinal process for tenderness, pain, swelling and stiffness (and steps indicating possible subluxation)

feel paraspinal mucles for tenderness/spasm

Compress sacroiliac joint for tenderness

SPECIAL TESTS

Dermatomes, Myotomes and reflexes of the upper and lower limbs

Femoral Nerve Stretch: face down, flex at knee, extend hip while compresses SI joint. reproduce anterior thigh pain = maybe compression of upper lumbar spinal nerve routes

SLR: lift until symptoms reproduced, then lower a for degrees, then passive dorsiflexion = maybe compression of lower lumbar pinal nerve route or sciatic nerve

SI joint Distraction test: +ve if reproduces pain

Hip to shoulder test (assess SI joint also) - flex knee up to oppostie shoulder . .+ve test reproduces pain

Hoffman’s Sign (for UMN lesion eg Cervical cord compression): tap middle finger, +ve if involuntary contraction of thumb and index finger flexures

Can also examine pulses if indicated.

Complete

Thank pt, ask to redress and summarise

Summary

“Today I examined Mr Smith, a 32-year-old male. On general inspection, the patient appeared comfortable at rest, with no stigmata of musculoskeletal disease. There were no objects or medical equipment around the bed of relevance.”

“General inspection of the spine revealed normal spinal curveture, no scars or muscle wasting and symetrical alignment of back and joits”

“No tenderness, swelling, stiffness was noted on palpating the spinous processess and no tenderness or spasms on palpation of paraspinal muscles. No tenderness of Sacroiliact joint was ilicited”

“Movement ofcervical, thoracic and lumbar spine was normal.”

“In summary, these findings are consistent with a normal examination of the spine.”

“For completeness, I would like to perform an upper and lower limb neurological examination, examine hips and shoulder joints and consider imaging of the spine.”

54
Q

ABG interpretation

A

Normal Ranges

pH: 7.35 – 7.45

PaCO2: 4.7 – 6.0 kPa || 35.2 – 45 mmHg

PaO2: 11 – 13 kPa || 82.5 – 97.5 mmHg

HCO3–: 22 – 26 mEq/L

Base excess (BE): -2 to +2 mmol/L

Hypoxic?

<10 kPa on air = hypoxaemic

<8 kPa on air = severely hypoxaemic

Type 1 or 2?

Type 1 respiratory failure involves hypoxaemia (PaO2 <8 kPa) with normocapnia (PaCO2 <6.0 kPa).

V/Q (ventilation/perfusion) mismatch>hypoxia + hypercapnaei > increased RR then blows off CO2

causes: alveolar hypoventilation (pneumonia, ARDS, pulmonary oedema), distribution/diffusion) (pulmonary fibrosis), perfusion (pulmonary embolism)

Type 2 respiratory failure involves hypoxaemia (PaO2 <8 kPa) with hypercapnia (PaCO2 >6.0 kPa).

Alveolar hypoventilation:

Central (coma, intracerebral haemorhage), Neuromuscular (muscular dystrophy), obstruction (COPD/ Asthma), restriction (pulmonary fibroisis, pneumothorax)

-airway obstruction (COPD) -reduced compliance (pneumonia/rib fracturs/ obesity - reduced respiratory muscle strength (Guilian-barre/MND) -Drugs reducing resp rate (opiates)

pH?

Acidotic: pH <7.35

Normal: pH 7.35 – 7.45

Alkalotic: pH >7.45

imbalance in the CO2 (respiratory) or HCO3– (metabolic).

PaCO2?

Does it correlate or not>

Bicarbonate?

Does this correlate?

(Base Excess)

High base excess = > +2mmol/L = high HCO3- = primary metabolic alkalosis or compensated respiratory alkalosis

Low base excess = < -2mmol/L = low HCO3- =

primary metabolic acidosis or compensated respiratory alkalosis

respiratory compensation is quicker than metabolic (days)

Compensation?

Assess compared to primary disturbance

Anion Gap?

Normal = 4-12 mmol/L

Anion gap formula: Anion gap = Na+ – (Cl- + HCO3-)

An increased anion gap indicates increased acid production or ingestion:

Diabetic ketoacidosis (↑ production)

Lactic acidosis (↑ production)

Aspirin overdose (ingestion of acid)

A decreased anion gap indicates decreased acid excretion or loss of HCO3–:

Gastrointestinal loss of HCO3– (e.g. diarrhoea, ileostomy, proximal colostomy)

Renal tubular acidosis (retaining H+)

Addison’s disease (retaining H+)

Mixed acidosis/alkalsosis

CO2 and HCO3- will be moving in oppositie directions

tx each primary acid/base disturbance

Context

A ‘normal’ PaO2 in a patient on high flow oxygen: this is abnormal as you would expect the patient to have a PaO2 well above the normal range with this level of oxygen therapy.

A ‘normal’ PaCO2 in a hypoxic asthmatic patient: a sign they are tiring and need ITU intervention.

A ‘very low’ PaO2 in a patient who looks completely well, is not short of breath and has normal O2 saturations: this is likely a venous sample.

55
Q

Examination of Eyes And Vision

A

WIPE

Visual Acuity

6metres from snellen chart

one eye to the lowest possible line

improvement through pin-hole indicates refractive component

6 (distance read)/ 6(lowest line read) -2 (two letters wrong)

if more than two letters wrong go to previous line

U/A = unnaided, PH = pinhole

3metres >1 metres > fingers holding up

Can assess near vision with fine print reading

Decreased accuity differentials

Refractive errors

Amblyopia

Ocular media opacities such as cataract or corneal scarring

Retinal diseases such as age-related macular degeneration

Optic nerve (CN II) pathology such as optic neuritis

Lesions higher in the visual pathways

Colour Vision

Ischihara plates

wear reading glasses if they have

number of plates corrctly idied = x/13

Visual fields

Bitemporal Hemianopia (optic chiasm pressure)

Homonymous Field defects = same side of visual field in each eye

Scotoma = area of reduced vision surrounded by normal

Monocular vision loss = total loss of one eye . . . secondary to optic nerve pathology (vascular neuropathy) or occular diseae (retinal detachment or retinal artery/vein problems)

External Eye Inspection

Eyelids (lumps/oumps/ ectropions)

Eyelashes

diffuse conjunctival injection (whole conjunctive: viral, bacterial , allergic)

Cicumcilliary injection (circular around cornea suggesting intraocular inflammation

Discharge: watery (corneal abraisn/foreign body/ viral/allergic) or purulent (bacterial)

Hyphema = blood in anterior chamber eg trauma

Hypopyon (pus in anterior chamber)

Periorbital erythema and swelling (preseptal cellulitis or orbital cellulitis

foreign bodies

corneal abrasion

corneal ulcer

Inspect pupil (size, shape, symmetry)

Pupil reflexes

Direct

Consensual

accommodation

swinging light test (relative afferent pupillary defect)

  • normally both constrict same amount on shining light in either eye*
  • if efferent damage then when light shone in affect eye both constrict a reduced amount*
  • shining light in swinging eye test gives the effect of relative dilation*
  • either significant retinal damage (retinal vein/artery occlusion or large retinal detachment) or optic neuropathy (optic neuritis, unilaterlal advanced glaucoma, compression of secondary tumour or abscess and ischaemic optic neuropathy)*

Strabismus

  • Light reflex test/ corneal reflex test/ hirschbeg test:*
  • focus on half a metre away and shine light in both eyes . .. should reflect equally*

Cover test

If contralateral eye does not move then orthotropic (normal alignment) if it does then heterotropia . .. see diagram for specifics

Eye movments

H pattern

restricted movement or nystagmus?

Fundoscopy

darkened room, ideal with short acting mydriatic eye drops (tropicamide 1%)

ask to look straight ahead for duration of test

Red light reflex

about arms length

absent in adults :cataracts vitreous haemorrhage and retinal detachment

absent in children = congenital cataracts, retinla detachment, vitreous haemorrhage and retinoblastoma

white reflex (lekocoria) in any age can be above pathologies

Anterior segment

use green 10 or 15

hand on forehead to prevent colision

idealy with dye . .. white opacities can be coreanl ulcer

Fundus

Optic disk

45 degree angle slighlt temportal

follow vessels to optiv disc

comment on 3 Cs:

Contour (clear and well defined . . .blurrred = papilloedema secondary to raised ICP)

Colour: disc should be orange pink doughnut with pale centre . .. pale disc = aptiv atrophy (optic neuritis, advanced glaucoma and ischamic vascular events)

Cup: cup to disc ratio should be around 3 Iie cup occupies 3rd of disc) . .. . if increaseed ratio reduced neural teinal tissue (glaucoma)

Retina

clockwise/anticlockwise: superior temportal, superior nalsa, inferior nasal, inferior temportal

Look for arteriolar narrowing, arteriovenous nipping.bicking, dot and blot haemorhages, flame haemorrhages, cotton wool spots, hard exudates, neovascularisation, pan retinal photocoagulation, branch retinal vein occlusion

assess macula

fovea should be same size as optiv disk

look for haed exudates, drusen, cheery red spot

Complete

thank patient

remind can’t drive if had mdriatic drops for 3-4 hours till wear off

for completeness : slit lamp exam, cranial nerve examination, blod pressure, capilliary blood glucose, retinal photography

56
Q

Obstructive Jaundice (Painless)

A

Prehepatic

Haematoma (reabsorption of it)

Conjugation = bilirubin rate limiting step (2,3 UDP gluconyltransferase)

Intrahepatic

Liver three main steps (entry, conjugation, excretion (genetic rotors, duben johnson etc)

Post hepatic = obstruction

Gallstones

choledocholithiasis = stone from GB stuck in biliary tree

sudden so only mild dilation of tree but inflammation of biliary tree and gallbladder (cholecystitis)

Inflammation = mild fever, leukocytosis, pain and maybe murphy’s sign

US first, MRCP best (ERCP w/o ro complication)

ERCP usually opted for as faster than cholecystectomy with retrogrrade cholangiopancreatography

Stricture/cancer

Slowly obstruction so system has time to adapt

massivly dilated and thin walled distended gallbladder

courvoisier sign = painless jaundice and enlarged gallbladder

Flow

all three things point ot obstructive jaundice

Bili levels higher (20-26 as opposed to single digits of gallstones)

Workup = CT first in test if not sure?

Pacnreatic

grows in peritenium so asx till large or mets (terrible prognosis)

Migratory thrombophlebitis = clot moves around body (eg leg) = pancreatic cancer (or maybe lung cancer?)

Endoscopic US with biopsy as outside the biliary tree

Double duct sign on CT (dilated common bile duct and dilated pancreatic duct)

Monitor with Ca 19-9

Cholangiocarcinoma

biliary tree mass

associated with primary sclerosing cholangitis which would have beeds on a string sign

ERCP as in biliary tree

Ampulla of Vater

as too small on CT but entrance to biliary tree so can cause significant obstruction

FOBT would be positive but nothing on colonoscopy as too far up

ERCP as in biliary tree

57
Q

Gall Bladder

A

Cholelithiasis

means gallstones in gallbladder

stones in two forms: cholesterol = green and haemolysis = black

does’t really matter as present the same

Fat makes GB squeeze out bile but squeezes stones

US great as solid against liquid

Ursodoxycholic acid if not surgical candidate

Cholecystitis

inflammation

US to look for 1,2,3

Murphy’s sign (hand on ribs and thumb on GB . . . big breath in and out and then put thumb in. . . will stop breathing out in positive)

HIDA san if US not all 1,2,3 (gallbladder won’t fill with ijected isotope)

tx with urgent (<72hrs) cholecystectomy as could perforate

Cholecystotomy in non surgical candidate

Boas sign refers to this hyperaesthesia (increased sensitivity). It occurs because the abdominal wall innervation of this region is from the spinal roots that lie at this level. (beneath right scapula)

Choledocolithiasis

Gallstones in CBD presents with painful jaundice (consider everyting else a maybe)

might have gallstone pancreatitis or hepatitis too

US looks for dilated CBD

Want ERCP (but ok to NP,E VF, IVabx as don’t know if infective and can progress to cholangitis)

tx with urgent ERCP and can do cholecystectomy at a later date (can do straight away but ERCP quicker)

Ball-valve . . . .painful and deranged LFTs correct then come back as its acting as a valve

Cholangitis

Dilated ducts with stagnant fluid is ready for infection . . .. SAS

GNR = gram -ve rods

Don’t bother with MRCP and ERCP as this is emergency tx (ERCP diagnostic)

can give IVF, IV abx and NPO when prepping for surgery

Cholecystectiomy still urgent after

ABX p cipro (GNR) and metronidazole (anaerobe) - pip tazo wastes the +ve coverage

Extra

Pigmented Stones associated with Sickel Cell Anaemia

58
Q

Diabetes

A

Who

CVD RFs : old fat and hypertensive

Thrush: sore itchy foreskin in men

polyuria, polydipsia, blurred vision

How

The randam blood glucose is useful for the T1DM who comes in with all the sx

The tests are better as they go down.

HbA1C measures glycosylated end products so is therefore an average over 90 days

But cannot r/o diabetes as haemaglobinopathies affect levels

IFG/IGT

Impaired fasting glucose = FPG >6.1 but <7.0 mmol/L and should be offered OGTT to r/o DM

Impaired glucose tolerace = Pre-diabetes

T1 DM

AI desruction of pancrease

old person with normal BMs last year presenting with polydisia, polyuria and very high BMs is same as young

anti-GAD (anti-glutamic acid decarboxylase) and IA-2 are antibodies (to differentiate from T2DM in older patients)

Tx with insulin

Monitor at least 4 times a day, including before each meal and before bed

Pre-Diabetes

Mx

lifestyle modification = weight loss, increase exercise, change diet

At least yearly F/U blood tests

Metformin for their FPG or HbA1c is progressing towards T2DM

T2DM

Mx

Check HbA1c q3-6 months then every 6 months when stable

  1. Lifestyle: target = 48 mmol/mol
  2. Add metformin: target = 48mmol/mol
  3. If >58 add another drug: target = 53 mmol/mol
  4. If still >58 add another or consider Insulin

Keep metformin when starting insulin and consider the others

If metformin not initially tolerated then:

First try modified release meformin

  1. Lifestyle: target = 48 mmol/mol
  2. Add another drug: target = 48mmol/mol
  3. If >58 add another drug: target = 53 mmol/mol
  4. If still >58 consider Insulin

Drugs

Metformin: the diarhoea will go away

Sulfonylureas (pick as cheap and been around ages): watch out for the hypoglycaemia esp in CKD pts- increases insulin expression

TZD = thiazolidinedione = pioglitazone : can cause CHF

GLP1 mimetic (exenatide) criteria = BMI>35 and unable to lose weight or <35 but insulin would have significant occupational implicatons . . . only continue if a 1% HbA1c reduction or weight loss of 3% in 6 months

SGLT-2i can cause DKA so avoid

Alpha Glucosidase inhibitors mean that glucose not absorbed so dirahoea and smeel flatulance

RF modification

Htn: 1st line ACEi

<80 target 140/90 clinic (135/85)

>80 target 150/90 (145/85)

Antiolatelets offered

Lipids = QRISK2 score = atorvastatin 20mg ON

Retinopathy - sudden vision loss = vitrious haemorhage

Nephropathy

All diabetic patients require annual screening for albumin:creatinine ratio (ACR) in early morning specimens

ACR > 2.5 = microalbuminuria

Mx: Start ACEi

diet restrict protein

gd control of BP, BM, Lipids

Neuropathy

1st line: amitriptyline, duloxetine, gabapentin or pregabalin

2nd- try another one of the drugs

  1. tramadol can be used as rescue therapy

4 - refer to pain mx clinic]

Charcot Foot

Mild pain considering of joint dysruption

swollen, red and warm

DM sick day rules

increase frequency of BG monitoring

drink at least 3 litres/24hrs

have sugary drinks if struggling to eat

keep phone on you

MODY

maturity onset diabetes of the young (MODY) - type Hepatic Nuclear Factor 1 Alpha (HNF1A). HNF1A accounts for 70% of MODY cases. Sulfonylureas (e.g. gliclazide) are the optimal treatment in HNF1A-MODY.

Small bowel bacterial overgrowth syndrome (SBBOS)

DM at ro this

excessive gut bateria

sx: chronic diarhoea, bloating, flatulance, abdo pain
dx: hyrodogen breath test
tx: rifaximin and DM control

Dietary advice

encourage high fibre, low glycaemic index sources of carbohydrates

include low-fat dairy products and oily fish

control the intake of foods containing saturated fats and trans fatty acids

limited substitution of sucrose-containing foods for other carbohydrates is allowable, but care should be taken to avoid excess energy intake

discourage use of foods marketed specifically at people with diabetes

initial target weight loss in an overweight person is 5-10%

59
Q

Peptic Ulcer Disease

A

Gastric usully H pylori

Duodenal always H pylori

H. pylori usually single ulcer (malignancy can start like this though)

Malignancy - necrotic as outgrowing blood supply (can present with gastric outlet obstruction)

Curling irons burn and cushions are squishy

Presentation

20% asx so present with the complications:

GI bleed, perforation, G/O obstruction

Sx worsened by eating in gastric and improve with duodenal (this is unreliable in life though)

Almost always OGD

TX for everyone

stop smoking and drinking (not direct RF but inhibit healing)

PPI almost everyone

Flow

if its NSAIDs presentation don’t need to bx but probs will

(tx with high dose PPI then lower dose ppx if you restart NSAID)

if bx shows normal then PPI tx

H-pylori

often present with complications as Asx

OGD best: rapid urease, histology (expensive and time consuming), histology (best . ..actually see it)

Stool ag: check it eradicated

serology - will be positive if had once (Tx if +ve + sx + not previously dx)

Urea breath test need to be off PPI so not that much in practice (good for initial dx though)

Tripple therapy; use metro if pennicillin allergy

ZE

gastrin stimulates parietal cells to produce acid . .. acid inhibits gastrin production

Gastrinoma produces gastrin regardless

OGD will see lots . .. high dose PPI doesn’t work. . . .. repeat OGD and still loads . . . suspect gastrinoma

Gastrin in triple digits diagnostic

if in between secretin stim test will lead to increased gastrin

Locate with CT but best is somatostatin receptor scintography

resect for ulcers but also it can induce gastric carcinoma

60
Q

IBS

A

Consider in pt with >6months of ABC (abdo pain/discomfort, bloating or change in bowel habit)

ROME III diagnostic criteria =

≥ 3 days/month of abdo pain/discomfort in last 3 months with ≥ 2 of

  • improvement with defectation
  • onset associated with change in stool frequency
  • onset assciated with change in form (appearance)

sx onset should be at least 6 months before diagnosis

refer to secondary care for any red flag symptoms including family hx of bowel or ovarian cancer

IX:

FBC, ESR, CRP tTG (tissue transglutaminase)

faecal calprotectin to differentiate between IBD and IBS if Ca not suspected

mx

bda ibs factsheet pdf

dietician referal for FODMAP diet may help

peppermint oil (antispasmodid)

laxative (but not lactulose aas can make bloating worse)

loperamide best for antispasmodic for diarhoea predominent

consider TCA if above measures unseuccessful (then ssri)

61
Q

Syncope Approach

A

Tx:

W- BB

O- IVF or stockings if ANS - (Volume down from th e4 Ds (dehydration, diarhoea, diuresis or haemorage) - LOOK AT MEDS)

M- Surgery

LOC?

  • How long did it take them to come round?
  • 2010 rule for shakes-
  • the rest ask for sake of OSCE but pretty useless

WOMAN 3-2-1 PE (321 for first three sub categories)

W- acetylcholline released by cagus leads to bradycardia and vasodilation

Orhostatics - Volume down from th e4 Ds (dehydration, diarhoea, diuresis or haemorage) - LOOK AT MEDS

- sitting/standing BP 5 minutes lying down, then in 1st minute standing, then after 3 minutes standing

ANS - old, PD, DM . . . if IVF does not help its this . . . stockings

MA - admit as heart ones . . . . M usually valvular and old eg aortic stenosis (old man shovling ice) could be Hypertrophic obstruct cardiomyopathy in young.

N - very rare- . . . only consider if focal deficit

P = psych . . . faking it . . . arm drop test

E= electrolytes Na and ca for altered mental staus and K and mg for weakness

If you suspect cardiac, admit and do echo and ecg (inc 24hr)

PE - different as if they fall to the floor it won’t help them

62
Q

Valvular Disease

A

Only work up if diastolic or systolic 3+

MS

aortic dilation thereofre af

Only one you can do ballo valvuloplasty as not calcified. Want ot avoid valve replacement until older

AI (aka aortic regurgitation)

May have chest pain as less blood coronary artery ostia

Acute and chronic both need replacement

Floppy valve leads to floppy heart

AS
atherosclerosis leads ot calcium deposition

also leads to ventricuolar dilation

Mostly old men but bicuspic valve in younger

tx as soon as symptomatic (syncope)

Nitrates contraindicated due to theoretical hypotension

narrow pulse pressure
MI

aortic dilation therefore af

holosystolic so may not hear s1 or s2

  • all above improve worsen with increase venous return (squatting/leg lift increase and valsalvar decreases)*
  • Following are opposite*
  • Pansystolic murmur can also be caused by ventricular septal defect following an MI*

HCM

less blood and ventricle smaller so ventricle outlet closes (can kill)

you won’t see the sudden deaths

Like Aortic stenosis but more blood makes better

beta blockers increase preload

MVP (mitral valve prolapse)

Like MS but better with more blood

valve too big so ends don’t touch . . .more blood means they can
Endocarditis

The most common valvular abnormality in infective endocarditis is tricuspid regurgitation. Combined with the fact that this man is showing sings of right sided heart failure (peripheral oedema)

Holosystolic murmur louder during inspiratio
Replacement for all 1st four but can medically manage by afterload reduction and diuresis

Patterns of the 4

Left diastolic/ right systolic

up is heart apex+aortic dilation/ down is base +VD

Insufficiency = more acute/ stenotic = more insidius

Extra

Venous hum is a benign murmur heard in children and sounds like a continuous blowing noise heard below the clavicles

A pansystolic murmur is associated with mitral regurgitation.

An ejection systolic murmur is associated with aortic stenosis.

A continuous ‘machinery’ murmur is associated with a patent ductus arteriosus.

A late diastolic murmur is associated with mitral stenosis.

63
Q

ECG take 2

A

What it represents

P wave = depolorisation of atrial muscle

PR interval = time for electricle impulse to spread from atria to ventricles (3-5 small squares)

QRS = depolorisation of the ventricles (<3 squares)

ST segment = period when ventricles are completely activated

T wave = repolorisation of ventricular muscle

U wave = repolorisation of pappilary muscles (abnormal if after flattened T wave)

Context

note BP/HR consciouness when taking ECG

RRPWQST

RATE: 300, 150, 100, 75, 60, 50 (small = 4ms and large = 200ms

RHYTHM: regular = equal distance between QRS complexes

P WAVES: P wave before every QRS = sinus (impulse from SAN to ventricles) - no P = abnormal rhythm. >1 P = heart block (abnormal coduction to the ventricles)

WIDTH: QRS >3 squares = slow ventricle conduction (abnormal conduction or eronously starting in ventricular tissue)

Q WAVE: if QRS starts with deep downward deflection could be old MI

ST segment: should be level with baseline. elevated = MI and depressed = MC Ischaemia

T wave: normally upside down in VR and V1 .. in other leads could be ischamie or ventricular hyertrohy

QT interval: varies with heart rate, prolonged with some drugs (>12 small squares)

Calibration: 1 square wide and two high . . .. . should be included on every record (25mm/s)

AXIS

serves to alert of other pathology eg PE/ conudction abnormality

Normal = +ve I and II

Left leaving = positive in I and Negative in II

Right reaching = -ve in 1 and +ve in 2

90 degrees from isoelectric lead, see if +ve at +90 or -90

RAD ax Right ventricluar hypertrophy (2ary pulmoary conditions causeing right heart strain)

LAD ax wtih conduction abnormalities

V leads

V1,V2 look at right ventricle

V3/V4 look at septum

V5/V6 look at left ventricle

V leads QRS - first septal depolorisation from left to right (intial R wave in V1/V2 but q wave in V5/V6) then ventricular depolorisation

RS trasition point represents the position of interventricular septum (normal V3/V4), right ventricle hypertrophy pushes to V4/V5/V6

Reporting ECG

Always:

  1. rhythm
  2. conduction intervals
  3. cardiac axis
  4. description of QRS complexes
  5. description of ST segments and T waves

eg:

  1. Simus rhythm, rate 50bpm
  2. normal PR interval (100ms)
  3. Normal QRS complex duration (120ms)
  4. Normal Cardiac Axis
  5. Normal QRS complexes
  6. Normal T waves (inverted in VR is normal)

Setup

attache electrodes to correct limbs

ensure ggod elecrical contact

check the calibrationand speed settings

make patient comfortable and relaxed

64
Q

ECG red flags

A
65
Q

Paeds Hx

A

Systems Review

Head – History of injury, headaches or infection?

Eyes – Visual acuity/glasses? History of injury, headaches or surgery?

Nervous system – Fits, faints, or funny turns? History of hearing concerns, seizures (febrile or afebrile), abnormal or impaired movements, tremors or change in behaviour? School performance? History of hyperactivity?

ENT – Earache, throat infections, snoring or noisy breathing (stridor)?

Chest – Cough, wheeze, breathing problems? Smokers in the family? Exposure to smoke?

Heart – Cyanosis, exercise tolerance, chest pain, fainting episodes? History of heart murmurs or rheumatic fever in the child or the family?

GIT – Vomiting, diarrhoea/constipation, abdominal pain? Rectal bleeding?

Genitourinary – Dysuria, frequency, wetting/accidents, toilet training?

Joints/Limbs – Gait, limb pain or swelling, other functional abnormalities?

Skin – General rashes? Birthmarks or unusual marks?

Pubertal development – Age of menarche?

HEEADSSS

Home and relationships

Who lives at home with you?

Do you have your own room?

Who do you get on with best and/or fight with most?

Who do you turn to when you’re feeling down?

Education and employment

Are you in school/college at the moment?

Which year are you in?

What do you like the best/least at school/college?

How are you doing at school?

What do you want to do when you finish?

Do you have friends at school?

How do you get along with others at school?

Do you work? How much?

Eating

Are you worried about your weight or body shape?

Have you noticed any change in your weight recently?

Have you been on a diet? Do you mind telling me, how?

Activities and hobbies

How do you spend your spare time?

What do you do to relax?

What kind of physical activities do you do?

Drugs, alcohol and tobacco

At this stage – reassure about confidentiality

Does anyone smoke at home?

Lots of people your age smoke. Have you been offered cigarettes? How many do you smoke each day?

Many people start drinking alcohol around your age. Have you tried or been offered alcohol? How much/how often?

Some young people use cannabis. Have you tried it? How much/how often?

What about other drugs, such as ecstasy and cocaine?

Sex and relationships

Are you seeing anyone at the moment?

Are they a boy or a girl?

Young people are often starting to develop intimate relationships? How have you handled that part of your relationship?

Have you ever had sex?

What contraception do you use?

Self-harm, depression and self-image

How is life going in general?

Are you worried about your weight?

What do you do when you feel stressed?

Do you ever feel sad and tearful?

Have you ever felt so sad that life isn’t worth living?

Do you think about hurting or killing yourself?

Have you ever tried to harm yourself?

Safety and abuse

Do you feel safe at school/at home?

Is anyone harming you?

Is anyone making you do things that you don’t want to?

Have you ever felt unsafe when you’re online or using your phone?

66
Q

Cardiovascular Examination

A

WIPE

Postion/Exposure

General Inspection

General Examination

Chext examination:

Inspection

Palpation

Auscultation

Special Manouvres

Additional Examination

Bedside Investigations

Proffesionalism

Presentation

Name and Age

5 things of general inspection/ exam:

warm peripheries, pulse rate was xxx, regular rhythm and normal volume, CRT <2s, non cyanotic and no appreviable JVP

On Inspection of the chest there were not notable scars

On Palpation . . . .

On auscultation . . ..

There was no eveidence of peripheral oedema

My THREE top differentials are:

For further Ix I would like . ..

WIPE

Correct position and adequate exposure

General Inspection

General Examination (vital signs)

Hands and anils

radial pulse

BP

Eyes

Face/mouth

Neck

Carotid pulse

Inspection

Palapation

Apex Beat

Heaves and thrills

Auscultation

Mitral

Aortic

Tricuspid

Pulmonary

Special Manouvres

Mitral stenosis

Aortic Regurgitation

Mitral regurgitation

Aortic stenosis

Additional Examination

Lung bases

periperal pulses

Peripheral odema

Abdominal Examination

Bedside Investication

Professionalism

Look, point and touch everything you exam eg scars/marks

Ankle oedema

Hold for 10s, look at face to see if painful, then check how pitted

Anaemia

Remove glasses and pulldown eyelids yourself.

get patint to look dows and check for icterus

JVP

‘No appreciatable JVP’

Extra

Collapsing pulse is a feature of aortic regurgitation, PDA, and hyperdynamic states (anaemia, thyrotoxicosis, fever, exercise/pregnancy)

A pansystolic murmur is associated with mitral regurgitation.

An ejection systolic murmur is associated with aortic stenosis.

A continuous ‘machinery’ murmur is associated with a patent ductus arteriosus.

A late diastolic murmur is associated with mitral stenosis.

67
Q

CXR approach

A

Projection

PA = best (check scaulae are lateral

AP = crAP (for haemodynamically unstable)

Patient details

Name, gender, DOB, date of xray (check previous xrays)

technical Adequacy

Nothing imortant cut off/ RIP

Obvious Abnormalities

Where, size, texture, density

Systemic r/v of xray

Zoom out first then close up for subtle abnormalities

ABCDD

Airway

Trachea Central? check not rotation

deviates towards lobar/lung collapse

Deviates away from pleural effusion/mediastinal mass

Breathing/Borders

Apices down to costrophrenic angles comparing both sides

left hilum should never be lower than right (look for volum pulling right u or or pulling left down)

Hila should be same density with no lumbs or convex margins

look at edge of lung for pneumotharaces (if you dont look for it you wont see it

Cardiac and Mediastinum

Heart size - cardiomegally = heart >50% maximal internal thoracic diametre (on technically adequate PA . . . but if not enlarge on AP then won’t on PA)

Mediastinal borders should be clearly visible (look for lung pathology if not)

heart/mediastinum should be positioned over thoracix vertebra . . . . assess volume change in lungs if not

Mediastinal weidnicg (technical factors, masses or haemorhage)

Heart should have uniform density (consider retrocardiac pathology if not)

linear lucencies in suerior mediastinum = pneumomediastinum

Diaphragm

Both hemidiaphragms should be seen

Upwardly convex (flattened in COPD)

Righ should be slightly higher due to liver

lungs can distend beyone diaphragm so look behind

look for free air under diaphragm (stomach bubble would have thicker membrane and on the left)

costrophrenic angles should be sharp (fluid if not)

Delicates

Ax for fracturs

intercostal spaces should be equal

soft tissues - gas = surgical emphysaema

Lines

Endotracheal tube must have tip b4 carina ( if goes down a bronchi the other can collapse)

Tip of NG tube well below diaphragm

Central lines in midlower SVC

review areas

Apices, Hila, Behind the heart, Costrophrenic Angles, Under diaphragm

summary

Maind finding with differentialss

state will r/v any previous

suggest further investigations

suggest mx plan

Presenting

This is a PA chest radiograph

which has been anomynised - i would like to confirm date and patient details

No important areas have been excluded, there is no rotation, there is adequate inspiration and penetrance therefore the chest radiograph is technically adequate

What strikes me about the xray is . . . .

on review airway is central, lung fields are clear, there a clear cardiac borders w/o evidence of cardiomegally, diaphragms are bilaterally convex with no free air below, there are no discernable abnormalities of bony or soft tissue.

HEART FAILURE

A - alveolar oedema (bat wing opacities)

B - Kerley B lines.

C - cardiomegaly.

D - dilated upper lobe vessels.

E - pleural effusion.

68
Q

ALS

A

PULSE
In practice not may options - its about team managment

Sinus bradycardia is kind of an arythmia

Stable is not emergency management

Unstable = they will die unlesss you do something

CP = chest pain

AMS = altered mental status (same time as arythmia

Shock = synchronised cardioversion (not during T wave)

F+W = likely VTAC - amiodarone

F+N = likely SVT - adenosine

Slow get atropine to prepare pace

Only pattern you need to know is Afib/flutter

-but even if you missed this you still go to BB/CCB after adenosine

NO PULSE (if in doubt always CPR)

Shockable (120-150j then same or higher in subsequent)

CPR = 30:2 (2mins)

Ventilation = supraglottic airway continuous 10/min if excessive leak then do breaths very 30 compressions

Rhythm check should be <5s (only check at appropriate time unles signs of ROSC (ie not if normal rhythm on defib)

  • 1mg IV adrenaline (1mg/10mls, 1:10,000) after 3rd shock (then alternate) - flush with 20ml for 10-20s after every drug)
  • 300mg amiodarone after 3rd shock (consider 150mg after 5th)

Non shockable

  • adrenaline IV asap and then every 3-5m (2 CPR cycles)

ALL THIS ONLY WORKS IF YOU TREAT THE CAUSE

4 Hs and 4Ts

  • Hypoxia (ensure ventilation with 100% o2, equal expansion, correct tracheal placement)*
  • Hypovolaemia (most common severe haemorhagh . . obvious (trauma) or occult (GI, ruptured AAA)*
  • Hyperkalaemia, hypokalaemia, hypoglycaemia, hypocalcaemia, acidaemia and other metabolic disorders (blood tests)*
  • Hypothermia/ Hyperthermia (suspec in drowning and low thermometre reading)*
  • Thrombosis (coronary or pulmonary)*
  • Tension pneumothorax*
  • Tamponade – cardiac*
  • Toxins*

Airway Managment

choking without efffective cough = 5 back blows and 5 abdominal thrusts back to back

simple airway manouvres = head tilt + chin lif or jaw thrust

guedel = from incisors to angle of mandible. too big>too small. if suspect cervical spine injury then maintain immobilisation of head and neck

oxygen: max possible ie non-rebreath
suction: caution in gag reflex. fine bor flexible suction tubes if limited mouth opening

EXTRAS

Precordal thump: if no interuption and no defib immediately available (VT/VF)

If you see person go into VT/VF in before any ALS intiiated call for help and deliver 3 shocks back to back (check for ROSC each time)

?true asystole: check for p waves . . . . if present pacing may be effective

Waveform capnography helps with: esure tarcheal tube placement, monitoring ventilation rate, monitoring quality of chest compressions, identifying ROSC and ? prognostication during CPR

Intraosseous access: requires training, prox tibial, prox humerus and distal tibia, contraindicated if trauma, infection or prosthesus at site, withdraw blood to confirm position and flush to conifrm patency.

inspiratory wheeze = laryngeal level or above

snoring = phaynx parially occluded by tongue or palate

blood oxygen (on blood gas) shoud be about 10 less that fio2

i
69
Q

Acid- Base Interpreation

A

-aemia not -osi as you can have lots of osi but eventually something wins

Look at PH to see what it is

Look at CO2 to determine type

Hypoventilation

Look for air trapping disease

osa = obstructive slee anoea

muscle strenght eg intubated too long

Hyperventilation

look for high RR (could be tidal volume related though)

Metabolic Alkalosis

Do a urine chloride to determine if volume resonsive or not (Volume down means activated RAS and increased aldo which means retention of Na AND Cl- ) . . . tx with colume

Emesis especialy bad as volume down and acid lost

Not low see if hypertensive or not

hyperaldo = Conn’s or RAS/MDS

Metabolic acidosis

Calculate anion gap (Na - Cl - Bicarb)

Non Gap do a Urine anion gap (Na + k - Cl) - >20 think RTA, normal/-ve think diarhoea/vom

positive is renal tubular acidosis and -ve = diarhoea (yes volume down but loses bicarb)

MUDPILERS (rhabdomyolysis)

70
Q

CAD

A

Angina is Demand ischaemia - reducing load will help

ANGINA

Tx: GTN spray, BB or CCB (titrate up till max tolerated) > BB + CCB

Diagnosis

Work from STEMI back

Troponins only for initial presentation as they do not go back down

Stable chest pain : Contrast-enhanced CT coronary angiogram is the first line investigation for stable chest pain of suspected coronary artery disease aetiology

Types of MI

Type 1 = acute palaque rupture (ischaemia/infarction)

Type 2 = supply and demand (whole body problem - sepsis/hypoxia)

Cath lab

>3 or big and proximal = surgery (stents for everything else)

stop metformin 24hr (contrast media decreased renal clearance and along with metformin can cause lactic acidosis)
General ACS

Aspirin 300mg

Nitrates (sublinguinal glyceryl trinitrate - avoid if hypotensive though) and morphine to relieve pain

Anti-emetic eg metoclopromide

02 if sats <94%

STEMI

above and:

P2Y12-receptor antagonist = Prasugrel>Ticagrelor>Clopidogrel

Unfractionated heparin if PIC (LMWH is an alternative)

tPA (Alteplase/Tenecteplase) if PCI <120mins of presentation not possible (perform ECG 90 mins after and if ST elevation not reduced by 50% then rescue PCI better than repeat tPA) - give antithrombin (fonadparinux) at same time and ticagrelor after

Blood glucose < 11.0 mmol/L

NSTEMI

Unstable = immediate coronary angiography

Fondaparinux (antithrombin) - if no immediate PCI planned

Estimate 6 month mortalitly (GRACE)

if low risk (<3%) then give Ticagrelor

If intermediate/high (.3%) :

PCI immediate if unstable and within 72hrs if stable

give prasugrel/ticagrelor

give unfractionated heparin

drug elucidating stents prefered.

Ticagrelor and prasugrel antiplatelets prefered to clopidogral. continue for at least 12m Prasugrel if going to have PCI (also 12m if stented.

Complications

DARTH VADER

Death

Arrythmia/Heart block

Ruptured Aneurysm

Thrombus

Heart Failure

VSD

Another MI

Dressler’s Syndrome

Embolus

Regurgitant Valve

RIGHT SIDED INFRACTS = PRELOAD DEPENDENT

RS = V1>V2

ST eleveation in V1 and depression in V2 is highly specific to RSHF

Lead III > Lead II

Give IV fluids and do not give nitrates as they cause hypotension

Extra

Diclofenac Contraindicated

deeply inverted or biphasic waves in V2-3 in a person with the previous history of angina is characteristic of Wellen’s syndrome. This is highly specific for a critical stenosis of the left anterior descending artery

71
Q

CAD Tx

A

aspirin

a second antiplatelet if appropriate (e.g. clopidogrel)

a beta-blocker

an ACE inhibitor

a statin

72
Q

Paediatrics Upper Airway

A

Croup

Classic Presentation

Racemic Adrenaline is the diagnositc step

Steelple sign (subglottic narrowing not sensitive or specific so don’t bother with xray)

CKS recommend giving a single dose of oral dexamethasone (0.15mg/kg) to all children regardless of severity

adrenaline/ O2 for emergency

Bacterial Tracheaitis

Almost always S.aureus following viral prodrome

presents like not improving croup (esp Racemic adrenaline)

IX- ENT scope eg laryngoscopy (purulent = abx + culuture)

Epiglotitis

quirte rare - SAS

classic presentation - check if had HIB vaccine

if not straight to ER (diagnosis will be on scoping to secure airway)

Retropharyngeal Abscess

Pretty much the same but lump on neck

CT instead of OR

PT (quinsy)

going to be older - mainly adolescents

deviated uvela = key

urgent ent referal (maybe tonsillectomy)

trismus = dificullty opening mouth

Laryngomalacia

Congenital abnormality of the larynx.

Infants typical present at 4 weeks of age with:

stridor

Noisy breathing . . . worse on eating

73
Q

Paeds Lower Airway

A

Four seperate entities here as opposed to upper airway

Foreign body Airway obstruction

Intrathoracic location + stridor as airways narrow on exhalation

Extrathoracic = oposite true

Coin sign +ve lateral as floppy bit is at back

Depending on these clues it tells you who to contact for help

Asthma (high yield summary)

OLD = obstructive lung disease

Dx on spirometry (reversible on bronchodilator)

  • if normal can induce with Methacholine

GET PARENTS TO STOP SMOKNIG

Bronchiolitis

Beta agonists don’t do anything as its not bronchoconstriction but cells sloughing off.

non of the investigations or Tx really help

even o2 and IVF is just so they are well enough to eat so they don’t FTT

BUT not a nonsense illness as can lead to acute hypoxic respiratory failure and ARDS

Immediate hospital referal

>70 breaths per min

central cyanosis

looks SAS

persistent <92% O2 saturation

Grunting

Consider hospital referal

>60 breaths per minute

dehydration

feeding <50% normal

TX

O2, consider NGT, consider suction (upper airway secretions)

CF

Triad of;

Typical pulmonary and/or gastrointestinal tract manifestations

A family history

A positive result on ‘sweat-test’ (based on Cl-ion concentration). (pilocarpine given to induce sweating. . >60 diagnostic and >30 in infant is highly suggestive

Common infections:

S.aureus

Klebsiella Pneumoniae

Pseudeomonas Aeruginosa

Burkholderia Cepacia

50-55y life expectancy

74
Q

Cirhosis

A

VW Happens

Viral

Needs to be chronic infection

both transmitted via blood (eg transfusions)

Hep C can now be treated with Direct acting antogonists and cured (no longer year long SEs of rubavirin and interferon)

Wilson’s

sx depending where Cu deposited

also speach, behaviour and psychiatric problems

IX ceulopkasmin or urinary cu

pencillamine to bridge to transplant (which cures the disease as well as cirhosis)

Haemochromatosis

iron deposition in skin, pancreas, liver and heart

usually switch in gut to stop absorbing Fe

Ix Ferritin >1000 w/o inflammation or hepatic necrosis

transferin is a better test

tx with phlebotomy

deferoxamine is a chelator

transplant treats the cirhosis but not the disease asa its in the gut

Alpha-1 anti-trypsin deficiency

look for the young non smokers iwth COPD and Cirhosis

this enzyme opposies elastase in the lungs

it can’t get out of liver so causes cirhosis

elastase unchecked in lungs so causes COPD

transplant stops further lung damage

Primary Sclerosing Cholangitis

(S for son’s of bitches)

manly and overt so extrahepatic and dx on imaging

painless jaundice

Don’t need ERCP if beads on a string on MRCP

tx with transplant and bridge with ursodeoxycholic acid

don’t stent as althought provides relief makes transplant harder

Primary Billiary CIrhosis

B is for bitches

coy therefore intrahepatic and have to dx with imaging (AMA not always detectable)

the M rule = IgM, anti-Mitochondrial antibodies, M2 subtype ,Middle aged females

Sicca Syndrome: 70% cases : dry moyth (xerostomia)

ETOH

long alc hx

stop drinking or can’t get transplant

NASH = non alcoholic steatohepatitis

NAFLD = non alcoholic fatty liver disease

75
Q

Liver Function Tests

A

TP = total proptein

tp - alb = protein gap

TB = total bili. d bili = direct

thinks in black form hpuse. . .stuff liver makes therefore an assessment of chronic liver disease

t - direct = unconjugated

d bili and alp green as linked and post hepatic

TAKE 2

blue are things you should order

alb made by liver but used and lost elsewhere (think ossi)

nephrosis = nephropathy

gastrosis = protein losing enteropathy or probs malnutritianb

pre albumin = tells if its just nutritional statis

u/a or u proteinm tells us if its coming from kidney

protein gap over 4 tells us something is wrong (lots of immunoglobulins eg hiv hep c , mm) but can also be sepsis

ast also made in muscle (check cpk or ck to see if from mjscle)

alt can be from bone (check ggt) but rarely need to do these extra steps as can tell from patterns/context

2:1 ratio esp if not that elevated

if get into 1000s then think of the 6 as

aflatoxin = mushrooms

bud chiari you can check with doppler

Hepatocellular = 1ary intrahepatic (large increase ast and alt). ALP/ Bili also a little as has portal triads etc

alk phos and d bili = post . . .

painful almost always gallstones (at lwat choledocolithiasis to be affecting liver) small numbers as acute

small alt/ast as back up to liver

jaundive

haemolysis needed to generate haemoglobin

pre = mostly from haemolysis

intra = 3 steps (uptake, conjucation, release) . .. mix probs intra

infiltrative (islolated alp not from bone do a liver bx). . . more for completedness

76
Q

Falls History

A

PC

When (time and what they were doing)

Where (inside/outside)

What (before, during and after)

  • Before: any warning/ dizziness/chest pain/ palpitations*
  • During: LOC/incontinence/ tongue biting/ palor/ what hit the floor*
  • After: Got up/ long lie/ how long till back to normal/ weakness/numbness/ speach/ confusion*

Why: why do you think? (trip/medication)

How: How many over the last month (seriousness of problem)

Sysyems Review (inc joint pain/muscle weakness)

PMH

Dhx

Beta-blockers (bradycardia)

Diabetic medications (hypoglycaemia)

Antihypertensives (hypotension)

Benzodiazepines (sedation)

Antibiotics (intercurrent infection)

SHx

Alcohol

Support at home: friends/family/.carers

Mobility: aids and when they are used

ICE

DDx

WOMAN PE, also strokes, vertigo

IX

Exams: AtoE (murmurs, stenosis, injuries, eyes and ears, , timed up and go test, BP)

Bedside: obs, sitting/standing BP, urine dip (infxn/abdo), ECG, cognitive screening, blood glucose

Bloods: FBC (infxn/anaemia), U&Es (hydration, electrolytes, abdo), LFTs (chronic alcohol), Bone profile (malignancy/over supplementation)

Imaging: CXR, CT Head, Echo(valvular)

Specialist: Tilt table test, epley, cardiac monitoring (48hr tape)

Management

Get your ears and eyes checked, good light, good shoes, review medication and reduce alchohol

1Gait

Physiotherapy

2Visual problems

Eye test and ensure wears glasses

3Hearing difficulties

Remove earwax

Hearing assessment

4Medications review

Reduce unnecessary medication

5Alcohol intake

Alcohol cessation advice

Alcohol service referral

6Cognitive impairment

Referral to a psychiatric team

7Postural hypotension

Review medication

Improve hydration

8Continence

Treat or rule out infections

Continence assessment

9Footwear

Ensure good fitting footwear

10Environmental hazards

Turn on lights

Take up rugs