GP + palliative Flashcards
people at risk of CKD who should be screened regularly
DM
HTN
Sx of CKD give 5
ankle oedema breathlessness [fluid + anaemia] pallor/ jaundice lethargy anorexia N+v RESTLESS LEGS weakness pruritus bone pain amenorrhoea/impotence osteoporosis epistaxis, bruising confusion/fits/coma (uraemia)
why do CKD patients get anaemia
reduced erythropoetin production by kidney
what is lymphoma
neoplasia of B + T cells in lymphoid tissue
signs and Sx of hodgkins lymphoma
enlarged lymph nodes (rubbery) hepatosplenomeg fever, night sweats pruritis weight loss anorexia fatigue
what are the B Sx of hodgkins lymphoma
night sweats
fever
weight loss
patient group commonly affected by hodgkins
young adults + >50s
Ix for hodgkins
FBC [low Hb] ESR [^] LFT [deranged] lactate [^ - cell turnover] urate Ca2+ blood film CXR [enlarged nodes = mediastinal widening] lymph node biopsy + histology CT/PET for staging
what cells found on histology of lymph node biopsy confirm hodgkins?
reed-sternberg cells [malignant B lymphocytes]
differentials of lymphadenopathy
infection [TB, tonsilitis] mets HIV leukaemia EBV [glandular fever]
CMV SLE sarcoid toxoplasma RA drug Rn [phenytoin]
Mx of hodgkins
chemo
radio
stem cell transplant
PET scan to assess Tx efficacy (active disease vs necrosis)
in the Ann Arbor staging system for hodgkins,
how many stages are there? what does A, B, X and E mean?
4 stages [from single lymph node to diffuse]
B. with B Sx
A. without
X. bulky
E. extranodal
local causes of pruritis
psoriasis eczema scabies dermatitis herpetiformis urticaria fungal e.g. athletes foot allergic contact dermatitis lichen planus
systemic causes of itch
cholestatic jaundice iron def. anaemia polycythaemia vera paraneoplastic [lymphoma, leukaemia, brain, colon, lung] hypercalcaemia hypo/hyperthyroid pregancy anxiety renal failure [^urea] dialysis opoids, statins HIV
treatment for the itch ass. w/ cholestatic jaundice
cholestyrimine
psoriasis Mx
calcipotriol (vit D analogue) topical steroid emollient phototherapy coal tar
eczema Mx
emollients
topical steroid
topical steroids mild to strong
hydrocort
eumovate
betnovate
dermovate
when might you see a ^Hb
polycythaemia - primary [rubra vera], or secondary to hypoxia e.g. smoking
dehydration
high WCC =
low WCC =
high = infection, haematological CA, steroids, preg
low = imm. supp.
name 2 lymphoid organs affected by hodgkins + 2 non-lymphoid
spleen, thymus
non-lymph: liver, lung
migraine Mx
PCM/NSAIDs + metoclop
triptans
serotonin agonists
pitozifen/BB/amitrip for prophylaxis
[others: valproate, topiramate, verapamil, naproxen]
Sx of cluster headache
rapid onset unilateral multiple over weeks/months + remission periods pain starts round eye/temple lacrimation red eye rhinnorhoea
mx of cluster headache
triptans
100% O2
verapamil
causes of obstruction of the sinuses
deviated septum
polyps
viral - mucosal oedema + reduced cilia action
acute bacterial rhinosinusitis is suggested by the presence of at least 3 symptoms and signs. list 4
discoloured discharge/ purulent secretion [unilat predominance]
severe pain [unilat predominance]
fever
elevated ESR/CRP
‘double sickening’-deterioration after initial mild phase
swelling is uncommon in sinusitis, what other pathologies might this suggest
carcinoma
dental root infection
differentials of sinusitis [non-sinus pain]
migraine TMJ dysfn. dental neuropathic temporal arteritis herpes zoster
causes / risk factors for bacterial sinusitis
most follow viral infection dental root infection swimming in infected water septal deviation polyps mechanical ventilation NGT immunodef
common organisms for bacterial sinusitis
strep pneum
Haem infl.
staph aureus
Ix in recurrent / chronic sinusitis
CT
nasal endoscopy
Mx sinusitis
analgesia
nasal saline irrigation
intranasal decongestants [ephedrine]
amox/doxy
surgery
smoking cessation
complicaitons of sinusitis
orbital cellulitis/abscess intracranial [meningitis, enceph, cerebral abscess, cavernous sinus thrombosis] mucocoeles/pyocoeles osteomyelitis pott's puffy tumour
Sx of trigem neuralgia
unilateral knife like pain
^ed by washing shaving eating
Mx of trigem neur
carbamazepine
metoclopramide + domperidone are D2 receptor antagonist antiemetics. Give 2 SEs.
In what condition might you need to reduce the dose?
extrapyramidal SEs
QTc prolongation
hepatic impairment
cyclizine is an H1 antagonist / antimuscarinic anti-emetic. Give some SEs + in what condition would you consider reducing the dose?
drowsy, headache, dry mouth, constipation
renal impairment
hyoscine butylbromide is an antimuscarinic antiemetic. SEs?
dry mouth, constipation
physiology of nausea:- which 4 body systems trigger nausea? Also give the receptor responsible / that is targeted by anti-emetics
- vestibular [motion sickness/vertigo] - H1, ACh(musc)
- gut wall [vagus nerve - constip/obstruction/chemo] - 5HT3
- limbic system [emotions/ hyponat] - 5HT3, GABA, neurokinin 1
- chemoreceptor trigger zone [uraemia/ drugs/ chemo/^Ca2+] - 5HT3, D2
most common cause of B12 deficiency
pernicious Anaemia
pernicious anaemia is the most common cause of B12 deficiency, give 3 other causes
diet [meat + dairy i.e. vegan] gastrectomy congenital intrinsic factor def crohns in ileum ileal resection coeliac NO [inactivates B12]
causes of folate def
diet [green veg, cereals] alcohol excess coeliac crohns anticonvulsants [phenytoin] trimethoprim [ie. can give in preg!] sulfasalazine [RA/UC/crohns] methotrex
when would you increase a pregnant woman’s folic acid dose?
obesity
diabetic
hx of neural tube defect
what is the most common cause of peripheral neuropathy in the UK?
DM
peripheral neuropathy causes symmetrical or asymmetircal Sx?
symmetrical
name 2 metabolic causes of neuropathy
B12, folate def
DM
uraemia
hypocalc
name 2 inflamm cause of neuropathy
GBS CIDP SLE vasculitis polyarteritis nodosa
name 3 drugs that can cause neuropathy
chemo [vincristine/vinblastine/cisplatin] phenytoin nitrofurantoin metro amiodarone quinine
give 3 factors that increase the risk of someone with DM getting neuropathy
poor control
smoking
^age
alcohol
can peripheral neuropathy be ass. w/ hypo or hyperthyroidism?
hypo
chronic disease of which 2 organs can cause peripheral neuropathy?
liver, kidney
name 2 infections that can cause peripheral neuropathy
lyme disease
HIV
shingles
diptheria
cancer that can cause periphera neurop
lymphoma
myeloma
Pt experiences rapid onset limb weakness, loss of reflexes, with a recent Hx of infection. Diagnooiss?
GBS
name 2 side effects of neurpathic pain killers
tired
dizzy
drowsy
blurred vision
on exam, what is pes cavus
excessively arched foot with unnaturally high instep
on hand exam in peripheral neuropathy, you might se wasting in what areas?
thenar eminence
hypothenar eminence
what is the name of the deformed weight bearing joint in diabetic neuropathy
charcot joint
2 blood tests you may arrange in a patient with neuropathy
glucose TFT CRP LFT U+E B12/folate
how would speed in a nerve conduction study be affected for a patent with guillain barre or CIDP
slow
amaurosis fugax can present in ischaemic events i.e. TIA/pre-stroke. In what other condition might it occur?
migraine
causes of “tired all the time”/ pathologies to rule out
hypothyroid anaemia food intolerence/ coeliac DM sleep apnoea insomnia CFS/ME depression
give 8 health problems ass. w/ obesity
OA hip/knee psych/depression gallstones back pain IHD HTN stroke ^CA risk DM GORD hiatus hernia infertility incont pregnancy complications surgical complications sleep apnoea HF
complications of NAFLD
cirrhosis
HCC
causes of high ferritin
haemochromatosis
supplements
infection/inflamm
Sx of neuropathy
pain loss of sensation burning pins and needles deformity
causes of a high MCV and neuropathy
alcohol
folate/B12 def
give 5 causes of cirrhosis
alcohol NAFLD haemochrom hep B/C PBC autoimmune hep budd-chiari wilsons drugs [metho] alpha1 antitripsin def CF
what ix.s best indicate liver fn?
INR/PT
albumin
which of AST and ALT is more specific to liver damage? and what othrer factors can incerase the other?
^ALT = liver
^AST = hepatic necrosis, MI, muscle injury, CCF. present in liver, heart, muscle, kidney, brain
on LFT, which aspects look at liver disease and which at biiliary?
liver = AST, ALT + fn [albumin, PT] biliary/cholestasis = alk phos, GGT
which class of Abx related to fatty liver?
tetracylcines e.g. doxy
rare disorder developing days after viral infection, thought to be linked to aspirin use, causing liver and brain damage
reyes
most effective Tx for CFS?
CBT
red flags for patient who is “tired all the time”
weight loss
CA hx
fever/night sweats
jaundice
give 5 red flags for sinister back pain.
what does the patient need?
<20 / >55 ^^^trauma trauma + osteoporosis bilat/alternating sciatica weak legs weight loss/fever oral steroids progressive/continuous/non-mechanical systemically unwell HIV/IVDU pain unrelated to mechanical events local bony tenderness CNS deficit at more than 1 root level thoracic worse supine CA Hx
need MRI in <4hrs
localised sacro-iliac joint tenderness indicates?
spondyloarthropathy
causes of sciatica
herniated disc [L4-S1]
spinal stenosis
cauda equina
pregnancy
non-mechanical causes of back pain
duodenal ulcer AAA osteomyelitis [from local infection/ TB] renal colic/pyelonephritis myeloma pancreatic CA bone mets [breast/bronchus/prostate/thyroid/kidney]
cancers that metastiatize ot bone
BLT with koscher pickles, mustard and mayo Breast Lung Thyroid Kidney Prostate Multiple myeloma
causes of kyphosis
congential ank spond osteoporosis spina bifida CA [wedge fracture] TB, polio paget's
complicoaitons/ problems in adolescent idiopathic scoliosis
pain
cosmesis
impaired lung fn
10 day old baby, bright green vomiting. Tummy swollen, seems to be in pain and is drawing up his legs. Diagnosis?
malrotation
7 week old baby vomiting. Irritable/ experiencing discomfort when feeding. Cries a lot. She also has a cough and the mother is concerned she’s lost weight.
Diagnosis?
GORD
6 week old baby vomiting after feeds. Vomit shooting over the far end of the cot. No diarrhoea, less wet nappies than usual.
Diagnosis?
pyloric stenosis
lethargic baby, ^RR, vomiting, becoming more sleepy and hot, not feeding.
Diagnosis?
sepsis
iX and Mx of suspected malrotation
abdo XR
r/f to surgery
paeds Mx of GORD
GAVISCON
Ix and mX OF septic baby
Abx e.g. ben pen + gent/ cefotaxime fluids ABG, cultures, urine culture, LP, CXR. FBC, U+E, glucose, CRP. O2
Mx of paeds gastroenteritis
encourage fluids
ORT
consider giving ORT via NG
electrolyte disturbance in pyloric stenosis?
hypochloraemic, hypokalaemic, met acidosis
Mx of pyloric stenosis
correct electrolytes, then R/F to surgeons
differentials of infant vomiting
posseting GORD gastroenteritis cows milk allergy UTI sepsis pyloric stenosis hirsprungs congenital atresia/stenosis malrotation intesusuption food intolerance over feeding
Ix in faulire, to thrive
MSU coeliac serology U+E, glucose, LFT, Ca, Ig, CRP, TSH, FBC, sweat test stool MC+S CXR skeletal survey [abuse] ECG, echo
how would you manage AF in a haemodynamically unstable patient
DCCV + heparin
if cardioversion fails, try IV amiodarone
how would you manage AF in a haemodynamically stable patient
rate control: bisoprolol/verapamil/digox
[rhythm control: CV, amiod, sotalol/flecainide]
ablation
pakemaker
anticoag: warf/rivaroxaban/apixaban
in what situation would you give rhythm control in AF [alongside anticoag + rate control]
<65
CCF
symptomatic
recent onset AF <48hrs
causes of hyponatraemia with fluid overload
nephrotic syndrome
CCF
liver failure
causes of hyponatraemia with dehydration
diarrhoea
addisons
renal salt wasting
causes of hyponatraemia with normal fluid volume
diuretics
D+V then drinking ^water
ACEi
Ix in TIA
CT/MRI ECG [AF] doppler carotid cholesterol LFT [monitor statin] glucose/HbA1c
what 4 Sx would you consider prescribing pre-emptive meds for in a palliative pt? give an example med for each
Pain [morphine, oxyc, fent, buscopan]
secretions [buscopan, hyosine BUTYLBROMIDE, glycopyronium bromide]
agitation [midaz, haloperidol]
nausea [metoclop, halop, ondan, domper, levomepromazine]
levomepromazine is a good antiemetic, but what is a possible unwanted side effect?
sedating
briefly outline the pain ladder
PCM ibup aspirin
codeine
tramadol
morphine/oxy/diamorph/methadone
fentanyl/ alfentanil
[neuropathic - pregab/amitrip/gabapent]
Mx of faeculant vomiting due to bowel obstruction in palliative care
NG drainage
reduce secretions using buscopan/glycopyronium bromide
how do steroids affect sleep
reduced
how does radiotherapy affect wound healing?
reduced
what is the purpose of an advanced directive
lets health prof.s, family, carers know patient’s wishes about refusing Tx, if they’re unable to make or communicate them themselves
give examples of things patients are allowed to refuse [even if they might keep them alive] in an advanced directive
CPR
ventilation
antibiotics
logistically, what is required in an advanced directive for it to be valid?
written down, signed by patient, signed by witness.
rules for opoids and driving
stable dose - can drive
new altered dose or recently taken PRN - advised not to drive
Mx of new stridor in palliative care [head / neck/ lung/ upper GI tumour]
dex
urgent ENT r/v
stent/ tracheostomy
non-invasive: steroids, opoids, midaz
Mx of massive haemorrhage in palliative pt.
stop anticoag
dark towels
midaz
stay with the patient
palliative pt. with:
Reduced conscious level Reduced respiratory rate/SpO2 Myoclonic jerks Pinpoint pupils Confusion Hallucinations
whats happened?
opoid overdose
