high-yield conditions Flashcards

Question

types of MI

Answer 1

Type 1: Traditional MI due to an acute coronary event Type 2: Ischaemia secondary to increased demand or reduced supply of oxygen (e.g. secondary to severe anaemia, tachycardia or hypotension) Type 3: Sudden cardiac death or cardiac arrest suggestive of an ischaemic event Type 4: MI associated with PCI / coronary stunting / CABG

Answer 2

non-reversible progressive obstructive airways disease almost always caused due to smoking. presentation - long term smoker presenting with chronic shortness of breath, cough, sputum production, wheeze and recurrent respiratory infections, particularly in winter. ddx - LUNG CANCER, fibrosis or heart failure. COPD does NOT cause clubbing. It is unusual for it to cause haemoptysis or chest pain. all these need investigating for a different cause.

Answer 3

used for assessing the impact of their breathlessness grades: 1 - breathless on strenuous exercise 2 - breathless on walking up hill 3 - breathlessness that slows walking on flat surface 4 - breathlessness on walking on flat which requires person to stop and catch breath after 100m 5 - unable to leave the house due to breathlessness

Answer 4

clinical presentation + spirometry spirometry - obstructive picture. The overall lung capacity is measured by forced vital capacity (FVC) and their ability to quickly blow air out is measured by the forced expiratory volume in 1 second (FEV1). Being able to blow air out is limited by the damage to their airways causing airway obstruction. Therefore in COPD: FEV1/FVC ratio <0.7 The obstructive picture does not show a dramatic response to reversibility testing with beta-2 agonists such as salbutamol during spirometry testing. If there is a large response to reversibility testing them consider asthma as an alternative diagnosis.

Answer 5

The severity of the airflow obstruction can be graded using the FEV1: Stage 1: FEV1 >80% of predicted Stage 2: FEV1 50-79% of predicted Stage 3: FEV1 30-49% of predicted Stage 4: FEV1 <30% of predicted

Answer 6

spirometry Chest xray to exclude other pathology such as lung cancer. Full blood count for polycythaemia or anaemia. Polycythaemia (raised haemoglobin) is a response to chronic hypoxia. Body mass index (BMI) as a baseline to later assess weight loss (e.g. cancer or severe COPD) or weight gain (e.g. steroids). Sputum culture to assess for chronic infections such as pseudomonas. ECG and echocardiogram to assess heart function. CT thorax for alternative diagnoses such as fibrosis, cancer or bronchiectasis. Serum alpha-1 antitrypsin to look for alpha-1 antitrypsin deficiency. Deficiency leads to early onset and more severe disease. Transfer factor for carbon monoxide (TLCO) is decreased in COPD. It can give an indication about the severity of the disease and may be increased in other conditions such as asthma.

Answer 7

support to stop smoking annual flu vaccine and pneumococcal vaccine 1. SABA or SAMA 2. without asthmatic or steroid responsive features - LAMA + LABA (UMECLIDINIUM AND VILANTEROL) 3. with asthmatic or steroid responsive features then LABA + ICS (BECLOMETASONE WITH FORMOTEROL) 4. if 2 and 3 insufficient - LABA + LAMA + ICS (FLUTICASONE WITH UMECLIDINIUM AND VILANTEROL) 5. Nebulisers (salbutamol and/or ipratropium) Oral theophylline Oral mucolytic therapy to break down sputum (e.g. carbocisteine) Long term prophylactic antibiotics (e.g. azithromycin) Long term oxygen therapy at home (used for severe COPD that is causing problems such as chronic hypoxia, polycythaemia, cyanosis or heart failure secondary to pulmonary hypertension (cor pulmonale). It can’t be used if they smoke)

Answer 8

Ix - ABG - resp failure? acidosis? high bicarb? (chronic retainer) Chest xray to look for pneumonia or other pathology ECG to look for arrhythmia or evidence of heart strain (heart failure) FBC to look for infection (raised white cells) U&E to check electrolytes which can be affected by infection and medications Sputum culture if significant infection is present Blood cultures if septic oxygen therapy - use venturi mask and aim 88-92% unless in acute emergency then high flow 15L and can change it later. if known to NOT retain then can aim 94-98% if well enough to be managed at home - Prednisolone 30mg once daily for 7-14 days Regular inhalers or home nebulisers Antibiotics if there is evidence of infection In hospital: Nebulised bronchodilators (e.g. salbutamol 5mg/4h 1st and if required add ipratropium 500mcg/6h) Steroids (e.g. 200mg hydrocortisone or 30-40mg oral prednisolone) Antibiotics if evidence of infection Physiotherapy can help clear sputum Options in severe cases not responding to first line treatment: IV aminophylline Non-invasive ventilation (NIV) Intubation and ventilation with admission to intensive care Doxapram can be used as a respiratory stimulant where NIV or intubation is not appropriate

Answer 9

insulin -produced by the beta cells in the Islets of Langerhans in the pancreas glucagon - produced by the alpha cells in the Islets of Langerhans in the pancreas. Ketogenesis occurs when there is insufficient glucose supply and glycogens stores are exhausted, such as in prolonged fasting. The liver takes fatty acids and converts them to ketones

Answer 10

1. ketosis and related acidosis 2. dehydration - Hyperglycaemia overwhelms the kidneys and glucose starts being filtered into the urine. The glucose in the urine draws water out with it in a process called osmotic diuresis. This causes the patient to urinate a lot (polyuria). This results in severe dehydration. 3. potassium imbalance - Insulin normally drives potassium into cells. Without insulin potassium is not added to and stored in cells. Serum potassium can be high or normal as the kidneys continue to balance blood potassium with the potassium excreted in the urine, however total body potassium is low because no potassium is stored in the cells. When treatment with insulin starts patients can develop severe hypokalaemia (low serum potassium) very quickly and this can lead to fatal arrhythmias.

Answer 11

``` Polyuria Polydipsia Nausea and vomiting Acetone smell to their breath Dehydration and subsequent hypotension Altered Consciousness abdo pain They may have symptoms of an underlying trigger (i.e. sepsis) ``` priority is fluid resuscitation to correct the dehydration, electrolyte disturbance and acidosis. This is followed by an insulin infusion to get the cells to start taking up and using glucose and stop producing ketones.

Answer 12

Check the local DKA diagnostic criteria for your hospital. To diagnose DKA you require: Hyperglycaemia (i.e. blood glucose > 11 mmol/l) or sometimes known T1DM or T2DM on SGLT2i Ketosis (i.e. blood ketones > 3 mmol/l) or ketones on urine dipstick Acidosis (i.e. pH < 7.3)

Answer 13

FIG-PICK F – Fluids – IV fluid resuscitation with normal saline and continued IV fluids (e.g. 1 litre stat, then 4 litres with added potassium over the next 12 hours) I – Insulin – Add an insulin infusion (e.g. Actrapid at 0.1 Unit/kg/hour) G – Glucose – Closely monitor blood glucose and add a dextrose infusion if below a certain level (e.g. 14 mmol/l) P – Potassium – Closely monitor serum potassium (e.g. 4 hourly) and correct as required I – Infection – Treat underlying triggers such as infection C – Chart fluid balance K – Ketones – Monitor blood ketones (or bicarbonate if ketone monitoring is unavailable) Establish the patient on their normal subcutaneous insulin regime prior to stopping the insulin and fluid infusion. Remember as a general rule potassium should not be infused at a rate of more than 10 mmol per hour.

Answer 14

MDT pt education Subcutaneous insulin regimes Monitoring dietary carbohydrate intake Monitoring blood sugar levels on waking, at each meal and before bed Monitoring for and managing complications, both short and long term insulin usually prescribed as a basal bolus regime with a long acting insulin once or twice a day and rapid-acting insulin analogue injected before meals. Injecting into the same spot can cause a condition called “lipodystrophy”, where the subcutaneous fat hardens and patients do not absorb insulin properly from further injections into this spot. For this reason patients should cycle their injection sites.

Answer 15

tremor sweating irritability pallor more severe hypoglycaemia - reduced consciousness, seizures, coma and death

Answer 16

combination of rapid acting glucose such as glucose tablets/lucozade if pt is conscious and cooperative and slower acting carbohydrates such as biscuits and toast for when the rapid acting glucose is used up. Options for treating severe hypoglycaemia are IV dextrose and intramuscular glucagon.

Answer 17

Chronic exposure to hyperglycaemia causes damage to the endothelial cells of blood vessels. diabetes causes suppression of the immune system and hyperglycaemia provides good environment for microorganisms ``` macrovascular - CAD peripheral vascular disease causing poor healing, ulcers,etc. increased risk of stroke hypertension ``` microvascular - retinopathy peripheral neuropathy nephropathy - especially glomerulosclerosis infection related complications - UTI pneumonia skin and soft tissue infections particularly in feet fungal infections - oral and vaginal candidiasis in particular other complications - increased risk of DKA hypoglycaemia depression and anxiety

Answer 18

diagnosis can be made without any investigations if the patient is over 45, has typical pain associated with activity and has no morning stiffness (or stiffness lasting under 30 minutes).

Answer 19

patient education Weight loss if overweight to reduce the load on the joint Physiotherapy Occupational therapy Orthotics (e.g., knee braces) analgesia - stepwise - Oral paracetamol and topical NSAIDs Add oral NSAIDs (consider co-prescribing a proton pump inhibitor) Consider opiates such as codeine Topical capsaicin Intra-articular steroid injections provide a temporary reduction in inflammation and improve symptoms. Joint replacement can be used in severe cases. The hip and knee are the most commonly replaced joints.

Answer 20

total joint replacement hemiarthroplasty partial joint resurfacing