HFD Flashcards
Scoring system to evaluate likelihood of appendicitis
Alvorado score
What is the psoas sign and what does it indicate?
RIF pain on right hip extension
Appendicits
What is the obturator sign and what does it indicate?
RIF pain on right hip internal rotation
Appendicits
Antibiotics in appendicitis
May be used as conservative treatment in uncomplicated appendicitis
All surgical patients should have pre-operative antibiotics and post-operative antibiotics if there is evidence of peritonism found in surgery
Management of sigmoid volulus
24 hour flatus tube
Surgery if recurrent
Management of cecal volvulus
Surgery
Endoscopic management in some patients with large bowel obstruction who are too frail for surgery
Endoscopic stenting
Acute bowel ischaemia on X-ray
Thumbpriniting
First line in diagnosis of acute bowel ischaemia
CT angio
Management of stable acute bowel ischaemia
first line is endovascular therapy such as thrombolysis, embolectomy or stenting
If these are ineffective, surgical intervention such as bowel resection may be needed
Signs of unstable acute bowel ischaemia
signs of perforation, peritonitis or infarction
Management of unstable acute bowel ischaemia
Emergency exploratory laparotomy to assess extent of the ischaemia
Depending on the severity, treatment may be endovascular such as thrombolysis, embolectomy or stenting if less severe or surgery such as an arterial bypass or if very severe then bowel resection may be indicated
Key investigations in biliary colic
Abdominal USS
LFTs to exclude other pathology
MRCP if USS inconclusive but high suspicion
Indications for surgery in biliary colic
All patients
Causes of acalculous cholecystitis
hypovolaemia, trauma or systemic illness which leads to gallbladder stasis and bile duct blockage
Management of acute cholecystitis
NICE guideline is that patients should have a laparoscopic cholecystectomy to remove the gallbladder within a week, though typically this surgery is done within 3 days. Patients will also need IV fluids, analgesia and antibiotics
Management of acute cholecystitis in patients where surgery is contraindicated
temporary cholecystostomy can be due to drain the gallbladder until a cholecystectomy can be performed later
LFTs in acute cholecystitis
Relatively normal
Imaging in ascending cholangitis
First line is abdominal USS
CT may be done if inconclusive or to rule out other pathology
MRCP is diagnostic
Management of ascending cholangitis
Initial management is IV fluids, analgesia, antiemetics and antibiotics
ERCP to remove stone within 24-48 hours
Stenting / surgery if this is ineffective
Followed by elective cholecystectomy
Key imaging in renal colic
CTKUB
Surgical options in AAA repair
open surgery in younger patients or endovascular aneurism repair in older patients
Score to assess severity of acute pancreatitis
Glasgow score
Management of acute pancreatitis
Most of the management is conservative, with aggressive fluid resuscitation and analgesia, an anti-emetic, oxygen, enteral feeding, abx if infection.
Underlying cause should be identified and treated
Management of exacerbation of COPD
O2 via venturi
First line meds are salbutamol and ipratropium nebulisers which are initially back-to-back stat doses then 2-4 times per day with extra salbutamol as needed
Five-day course of corticosteroids such as prednisolone
Abx
In severe cases, IV theophylline
Non-invasive ventilation such as BiPAP if severely unwell and in respiratory failure
Management of primary pneumothorax
If it is smaller than 2cm and they aren’t breathless, discharge with outpatient follow up
If it is over 2cm or the patient is breathless, management is aspiration with a 16-18 gauge cannula
If the aspiration was successful and the pneumothorax is now less than 1 cm and they aren’t breathless, they can be discharged with outpatient follow up
If it was unsuccessful, insert a chest drain
Management of secondary pneumothorax
If it is smaller than 1cm, they can be admitted for 24 hours for observation and oxygen
If it is 1-2cm, aspiration with a 16-18 gauge cannula
If the aspiration was successful and the pneumothorax is now less than 1 cm and they aren’t breathless, admit for 24 hours for observation and oxygen
If it was unsuccessful, insert a chest drain
If it is larger than 2cm, insert a chest drain
Management of tension pneumothorax
managed as an emergency with high flow oxygen and urgent needle decompression with a 14-gauge needle, followed by chest drain insertion
Management of recurrent pneumothoraces
May be eligible for preventative pleurectomy surgery
Score to exclude PE diagnosis
PERG
First line management of massive PE
Thrombolysis with alteplase
Second line management of massive PE
Embolectomy
Management of non-massive PE
anticoagulation with warfarin or a DOAC (or low molecular weight heparin if the patient has active cancer)
Pathogens in hospital acquired pneumonia
Pseudomonas aeruginosa, Staph aureus or Legionella pneumophilia
Interpretation of CRB-65 score
0 is low risk and outpatient treatment
1-2 indicated intermediate risk and inpatient treatment
3-4 suggests high risk and urgent admission
Interpretation of CURB-65 score
0-1 suggests low risk and outpatient care
2 suggests intermediate risk with inpatient care
3-5 indicates high risk and ICU care
Follow-up for pneumonia
Patients aged over 50 should have a follow-up X-ray a couple of months after discharge to screen for underlying lung cancer
Marker for anaphylactic reaction
Mast cell tryptase
Scoring system in nSTEMI
GRACE
Name for gastritis caused by bacterial infection
Phlegmonous gastritis
Limitation of urea breath testing for H.pylori
Must be off PPI
Limitation of serological testing for H.pylori
Will be positive if there has been a previous infection
Limitation of stool antigen testing for H.pylori
Must be off PPI
Management of phlegmonous gastritis
Supportive care and IV abx
Score to assess GI bleeds prior to intervention
Blatchford
Score to assess GI bleeds after endoscopy
Rockall
What prophylactic meds are needed in variceal bleeds?
Abx
Treatment of gastric variceal bleed
endoscopic injection of N-butyl-2-cyanoacrylate
Testing of gastric ulcers
All gastric ulcers should be biopsied to look for underlying malignancy
Follow-up in peptic ulcer disease
Gastric ulcers should have a follow-up endoscopy after 6-8 weeks to ensure healing but duodenal ulcers don’t usually need follow-up
Most common cause of upper GI bleeds
Peptic ulcer disease
Causes of acute lower GI bleeds
Around half of all lower GI bleeds are caused by diverticulosis
Next most common cause is ischaemic colitis
Anal pathology such as haemorrhoids, fissures or fistulae
Malignancy
Less common causes include arteriovenous malformations, polyps, IBD and infective colitis
Imaging in patients with active acute lower GI bleeding
CT angio
Management of stable patients with minor lower GI bleed that has self-terminated
discharge with safety-netting advice and outpatient follow up
Management of stable patients following a major lower GI bleed
Admit for colonoscopy
If lesion is seen, treat endoscopically.
If no lesion is seen and they have stopped bleeding, discharge with safety-netting advice and outpatient follow up
If no lesion is seen and they are actively bleeding, admit for further investigation
Management of unstable patients with lower GI bleed
CT angio
If the site of the bleed is identified, it can be treated endoscopically or with interventional embolization
If no bleeding site is seen on the angiogram, do a colonoscopy then either endoscopic treatment if bleeding site identified or further investigations if not
Medication that may be considered in subarachnoid haemorrhage
Nimodipine (for a few weeks)
Complications of subarachnoid haemorrhage
Vasospasm is a common complication whereby the cerebral arteries can spasm in the week following the subarachnoid haemorrhage, causing a stroke. Nimodipine is given for a few weeks following the subarachnoid haemorrhage to reduce the likelihood of this.
Other common short-term complications are re-bleeding, and hydrocephalus
Long-term neurological complications may develop such as SIADH
Score to assess likelihood of complications after subarachnoid haemorrhage
Modified Fisher score
Symptoms of third nerve palsy
pupils pointing “down and out” with ptosis, pupil dilation and double vision
Prophylactic meds in intracranial haemorrhage
Anticonvulsants
Antibiotics if open skull fracture
Gold standard for diagnosis of GCA
Temporal artery biopsy
Imaging that may be useful in GCA
Duplex ultrasound
If atypical vessel involvement is suspected, PET scan may be done
What emergency referral should be considered in patients with GCA?
Same day ophthalmological assessment if visual symptoms
Second line medication in migraine prophylaxis
Topiramate or amitriptyline
Complications of migraines
psychiatric conditions such as depression, anxiety and bipolar disorder
increased risk of cardiovascular events, in particular stroke
Most common bacterial causes of meningitis
N. meningitidis, S. pneumoniae and H. influenzae (children)
What is Kernig’s sign and what does it indicate?
inability to extend knees when hip is flexed due to pain
Meningitis
What is Brudzinski’s sign and what does it indicate?
flexion of knees and hips on neck flexion due to pain
Meningitis
Non-infectious causes of meningitis
malignancy, systemic inflammatory conditions, head injury and medications
Medications in bacterial meningitis
Abx (ceftriaxone first line)
Dexamethasone
Cerebral abscess treatment
Empirical abx (may be adjusted once cultures returned)
Prophylactic anticonvulsants
Steroid in deteriorating patients
Consider surgery
Indications for surgery in cerebral abscess
mass effect on imaging
decompensation
an abscess over 2.5cm in a surgically accessible place
failure to respond to medication
Definition of tonic siezure
Muscle stiffening
Definition of clonic seizure
Muscle jerking
Definition of myoclonic seizure
Shock like jerks
Definition of atonic seizure
Loss of muscle tone (leads to collapse)
Investigations after a seizure
CXR to look for aspiration pneumonia
ECG
Bloods to look for underlying cause e.g. electrolyte imbalance and to check levels of anti-epileptic drugs
Airway management in a seizure
Ideally insert oropharyngeal or nasopharyngeal airway and start on high-flow oxygen
Route of administration of diazepam in seizure
Rectal
Route of administration of midazolam in seizure
Buccal
When to repeat benzodiazepines in seizure
after 10-20 mins if still seizing
Indications for other meds with benzodiazepines in a seizure
IV thiamine (pabrinex) if there is a suspicion of alcohol abuse IV glucose if there is a suspicion of hypoglycaemia
Second line meds in seizure
Phenytoin / phenobarbital
Management of seizure lasting over an hour
anaesthetist will give general anaesthetic with propofol, midazolam or thiopental and they will be transferred to ICU
Acute complications of seizure
aspiration, hyperthermia, pulmonary oedema and arrhythmias
Driving restrictions in epilepsy
Complex criteria but in general:
Cars: 6 months ban after first seizure and 1 year after subsequent seizures
HGVs: 5 years after first seizure and 10 years after subsequent seizures
First line in most epilepsy
Sodium valproate
First line in focal seizures
Carbamezepine
Second line anti-epileptics
carbamazepine, lamotrigine, levetiracetam and phenytoin
Driving restrictions in non-epileptic attacks
Patients should be advised to inform the DVLA who will make a decision around whether it is safe for them to drive based on the nature of the symptoms
Scoring system for likelihood of stroke
ROSIER score
Most likely site of a stroke if aphasia is a symptom
Middle cerebral artery (in dominant hemisphere, which is usually the left)
Visual changes in MCA stroke
Contralateral homonymous hemianopia
Visual changes in PCA stroke
Contralateral hemianopia with macular sparing
Driving restrictions after stroke
Patients aren’t able to drive cars for 1 month or HGVs for 1 year after a stroke
Contraindication to thrombolysis in stroke
over 4.5 hours form symptom onset
active bleeding, a recent cranial bleed / trauma or recent surgery
Criteria for thrombectomy in stroke
Present within 24 hours
Angiography shows clot is proximal in the artery
Medication after a stroke
All patients with a stroke will be put on an antiplatelet (unless contraindicated). This is typically 300mg aspirin for 2 weeks which is then switched to 75mg lifelong clopidogrel after 2 weeks. If the patient has AF, a DOAC will be used rather than clopidogrel.
Lifelong statin
Drug for other predisposing conditions e.g. HTN
TIA management
TIA should be started on 300mg aspirin (swapped to clopidogrel after 2 weeks) and referred to a TIA clinic to be seen within 24 hours
Symptoms of Kawasaki disease
The main symptoms are a fever lasting more than 5 days, polymorphic rash, conjunctivitis, mucosal erythema with a strawberry tongue, pain in the hands and feet and unilateral cervical lymphadenopathy
Treatment of Kawasaki disease
IV IgG and aspirin (continued for a few months)
Corticosteroids in severe cases
Monitor and treat cardiac complications
Imaging in dental abscess
OPG X-ray (X-ray of the teeth)
Management of airway compromise secondary to dental abscess
Dexamethasone
Anaesthetic review
Classification of risk in cellulitis
Eron
Long term complications of cellulitis
persistent leg ulceration, recurrent cellulitis and lymphoedema due to damage to the lymphatic system
DVT treatment
Treatment for a DVT is anticoagulants. If a delay in imaging or diagnosis is expected this may be started before the diagnosis is confirmed. The anticoagulant used is typically a DOAC or a LMWH if a DOAC is contraindicated
What is post-thrombotic syndrome?
chronic pain, swelling and skin changes secondary to venous stasis (within 2 years of a DVT). Varying severity
What metabolic abnormality is a common complication of alcohol withdrawal?
Hypoglycaemia
Symptoms of opioid overdose
constricted pupils, respiratory depression, hypotension, reduced consciousness and coma
Symptoms of cocaine, ecstasy or amphetamine overdose
sweating, hyperthermia, hypertension, dilated pupils, tachycardia, agitation and anxiety and seizures
Symptoms of antipsychotic or amitriptyline overdose
confusion, hyperthermia, dilated pupils, flushing, urinary retention, dry mouth and hypotension
Treatment of opioid overdose
Stat naloxone then infusion
Treatment of cocaine, ecstasy or amphetamine overdose
benzodiazepines, fluids, GTN and cooling
Treatment of amitriptyline or amphetamine overdose
benzodiazepines, fluids and cooling
management of aspirin overdose
Urinary alkalisation
Management of benzodiazepine overdose
supportive care and flumazenil if severe
