ICM Flashcards
List causes of Microcytic anaemia
Iron deficiency anaemia (most common); Thalassaemia; Sideroblastic (rare), aneamia of chronic disease (may be normocytic)
List causes of Normocytic anaemia
Pregnancy; Acute blood loss; Haemolysis (can be macro); Hypothyroidism (can be macro); Bone marrow failure; Renal failure; Chronic disease
List causes of Macrocytic anaemia
B12 or folate deficiency; Myelodysplastic sydromes; Alcohol excess; Reticulocytosis; Cytotoxic drugs (e.g. chemo, hydrocarbamide); Marrow infiltration; Antifolate drugs; Hypothyroidism
Interpret these ABG results
pH: 7.29 (7.35-7.45)
PaCO2: 25 mmHg (35-45 mmHg)
HCO3-: 12 mEq/L (22-26 mEq/L)
Metabolic acidosis with partial respiratory alkalotic compensation
Interpret these ABG results
pH: 7.45 (7.35-7.45)
PaCO2: 63 mmHg (35-45 mmHg)
HCO3-: 30 mEq/L (22-26 mEq/L)
Metabolic alkalosis will full respiratory compensation
Interpret these ABG results
pH: 7.21 (7.35-7.45)
PaCO2: 56 mmHg (35-45 mmHg)
HCO3-: 22 mEq/L (22-26 mEq/L)
Respiratory acidosis without compensation
Interpret these ABG results
pH: 7.35 (7.35-7.45)
PaCO2: 41 mmHg (35-45 mmHg)
HCO3-: 22 mEq/L (22-26 mEq/L)
Normal ABG
Interpret these ABG results
pH: 7.52 (7.35-7.45)
PaCO2: 16 mmHg (35-45 mmHg)
HCO3-: 13 mEq/L (22-26 mEq/L)
Respiratory alkalosis with partial metabolic acidotic compensation
Interpret these ABG results
pH: 7.22 (7.35-7.45)
PaCO2: 58 mmHg (35-45 mmHg)
HCO3-: 23 mEq/L (22-26 mEq/L)
uncompensated respiratory acidosis
What is a melanocytic naevus?
A mole.
Made from a collection of melanocytes - dark pigmentation which gives them their colour.
What features distinguish a malignant melanoma from a mole (melanocytic naevus)?
Asymmetrical
Irregular border and colour
Increasing size
What are the features of a BCC?
Pearly lesion Central ulceration on with rolled edges Telengectasia (dilated spidery venules) (Bleed > ulcerate > heal again) Almost never mets, commonest skin cancer, sunlight exposure
What are the characteristics of a Squamous Cell Carcinoma?
Rapidly expanding Painless (though often loo painful!) Ulcerated nodule, rolled margin Commonly ulcerate and bleed Potential to metastasize!
What does psoriasis look like?
Scaly, thickened, red patches with silvery-white accumulations
Frequently appear around elbows and knees
What does erythema multiforme look like?
Target lesions typically on arms and hands but anywhere
Heals in 3 weeks
What causes erythema multiforme?
Barbiturates, aspirin, sulphonamides, herpes simplex, TB, mycoplasma, typhoid, pregnancy, Vit C def, collagen vascular disease, IBD
What features may help you diagnose a shingles rash?
Unilateral
Follows dermatome
Pustular
How do you treat shingles and what causes it?
Caused by varicella zoster
Treated with aciclovir (800mg five times a day for 7 days)
How do you diagnose a neck swelling as a thyroglossal cyst?
By asking the patient to stick their tongue out. If it is it will move up with the tongue.
When would surgical resection be indicated for a thyroglossal cyst?
Dyspnoea Dysphagia Cyst infection To prevent malignant change Cosmesis
How does the appearance of ringworm differ to erythema multiforme?
The lesions are not target-like although they are circular, tend to have a wider inner radius than EM and often isolated lesions rather than clusters of lesions
How would you treat ringworm?
Topical anti fungal therapy
Oral terbinafine/itraconazole
What does erythema nodosum look like?
Red painful nodules originally then on healing become bruise-like patches on the skin (typically front of legs below knee)
What is Erythema Nodosum and what causes it?
Reactive process of unknown pathogenesis
Strept infectin, sarcoidosis, pregnancy, oral contraceptive pill, IBD, TB
(In 50% of cases no cause identified)
Do bloods and CXR
What does pretibial myxoedema look like and what causes it?
Graves Disease (rare complication) Sore, swollen, cracked skin down shins
What is the ‘Butterfly Rash’ associated with?
SLE
Pellagra
Dermatomyositis
What would you feel on palpation of an arteriovenous fistula?
A thrill (buzzing sensation) Also audible bruit
What does impetigo look like and what is the most common cause?
It has honey coloured scabs on an erythematous background
Staph aureus is the most common cause
It’s highly contagious!
Where is eczema most common and what conditions is it commonly associated with?
Head, neck and creases (flexure areas)
Asthma and hayfever
List 4 ways in which venous disease presents
1) varicose veins
2) superficial thrombosis
3) deep vein thrombosis
4) chronic venous insufficiency and ulceration
Name the 4 Cardinal symptoms of lower limb venous disease
Pain
Swelling
Discolouration
Ulceration
Describe the 4 different presentations of pain for the 4 presentations of venous disease
1) varicose veins - aching, itchy, feeling of swelling - worse on standing and end of the day
2) DVT - deep-seated with assoc swelling below point of obstruction
3) sup. venous thrombophlebitis - red painful area overlying vein involved
4) varicose ulceration - may be painless, if pain elevation may help
Which venous disease presentations may present with swelling (oedema)?
DVT and varicose veins
In chronic venous insufficiency what causes the discolouration of the skin (blue/black, purple or red)?
Deposition of haemosiderin (from breakdown of extravasated blood) in the skin leading to lipodermatosclerosis
Which area of the leg is generally affected by colour changes associate with chronic venous insufficiency?
Medial lower third of leg
occasionally lateral if superficial reflux predominates in short saphenous vein
Where does venous ulceration occur and with what is it always associated?
Usually above medial malleolus
Lipodermatosclerosis / severe venous disease
List causes of chronic leg ulceration
Venous and / or arterial disease(1in 5 with venous ulcer will have significant arterial disease) Pyoderma gangrenosum Syphilis Sickle cell TB Leprosy
List the 4 major ways in which peripheral arterial disease presents
Limb symptoms
Neurological symptoms
Abdominal symptoms
Vasospastic symptoms
Which limbs are 8x more commonly affected by peripheral arterial disease than the other?
Legs
What is the main reason for PAD?
Underlying atherosclerosis
What are the 4 classifications of lower limb ischaemia?
I) asymptomatic
II) intermittent claudication
III) night / rest pain
IV) tissue loss (ulceration / gangrene)
What ankle:brachial pressure index (ABPI) figure defines haemodynamically significant lower limb ischaemia?
<0.8 at rest
Name 5 types of oxygen delivery system?
Nasal cannula Hudson mask (rebreather) Venturi non-rebreather Laryngeal mask airway AMBU bag / bag valve mask -
List 4 ways I which venous disease presents
1) varicose veins
2) superficial thrombosis
3) deep vein thrombosis
4) chronic venous insufficiency and ulceration
Name the 4 Cardinal symptoms of lower limb venous disease
Pain
Swelling
Discolouration
Ulceration
Describe the 4 different presentations of pain for the 4 presentations of venous disease
1) varicose veins - aching, itchy, feeling of swelling - worse on standing and end of the day
2) DVT - deep-seated with assoc swelling below point of obstruction
3) sup. venous thrombophlebitis - red painful area overlying vein involved
4) varicose ulceration - may be painless, if pain elevation may help
Which venous disease presentations may present with swelling (oedema)?
DVT and varicose veins
In chronic venous insufficiency what causes the discolouration of the skin (blue/black, purple or red)?
Deposition of haemosiderin (from breakdown of extravasated blood) in the skin leading to lipodermatosclerosis
Which area of the leg is generally affected by colour changes associate with chronic venous insufficiency?
Medial lower third of leg
occasionally lateral if superficial reflux predominates in short saphenous vein
Where does venous ulceration occur and with what is it always associated?
Usually above medial malleolus
Lipodermatosclerosis / severe venous disease
List causes of chronic leg ulceration
Venous and / or arterial disease(1in 5 with venous ulcer will have significant arterial disease) Pyoderma gangrenosum Syphilis Sickle cell TB Leprosy
List the 4 major ways in which peripheral arterial disease presents
Limb symptoms
Neurological symptoms
Abdominal symptoms
Vasospastic symptoms
Which limbs are 8x more commonly affected by peripheral arterial disease than the other?
Legs
What is the main reason for PAD?
Underlying atherosclerosis
What are the 4 classifications of lower limb ischaemia?
I) asymptomatic
II) intermittent claudication
III) night / rest pain
IV) tissue loss (ulceration / gangrene)
What ankle:brachial pressure index (ABPI) figure defines haemodynamically significant lower limb ischaemia?
<0.8 at rest
Name 5 types of oxygen delivery apparatus
- nasal cannula
- Hudson mask (rebreather)
- Venturi non-rebreather
- laryngeal mask airway
- AMBU bag (artificial mechanical breathing …)
What % of oxygen can you deliver via a nasal cannula?
24-40% (closer to 38% max)
What % of oxygen can you deliver via a simple face mask (Hudson rebreather)?
40-60% (some say 35-50%)
What % of oxygen can you deliver via a Venturi non-rebreather mask?
60-90% (Venturi 24-60; non-rebreather 80-95%)
What are the advantages and disadvantages to nasal cannula oxygen delivery?
D: Cannot control precisely how much oxygen is reaching the lungs
Can be uncomfortable
Can dry out nasal mucosa
A: Allow pt to eat and speak with ease; well tolerated
How would you treat a pt having a severe asthma attack?
High percentage, high flow oxygen
Include a salbutamol nebuliser
Oral or IV steroids
IV magnesium to relax smooth muscle (sometimes theophylline)
What increases the risk of cardiac arrest in the treatment of the previous patient (severe asthma)?
Arrhythmia risk associated with B agonists (salbutamol)
Hypoxia if oxygen therapy inadequate
Electrolyte imbalance may prevail as salbutamol can reduce potassium
If a known COPD patient is admitted with 86% O2 sats, RR 26, HR 109 and a temp of 35.5 and ABG showing pH normal with slightly raised CO2 how should you treat?
~28% oxygen via Venturi mask
Repeat ABG 20mins after oxygen therapy started and cont to monitor
WHY: hypoxia kills quicker than hypercapnoea so if in doubt give oxygen. When monitoring look for O2 sats to increase and pH to remain normal. CO2 can remain the same but do not want to increase
List at least 3 causes of hypercalcaemia
Kidney failure; hyperparathyroidism; cancer; increased calcium intake
List at least 3 causes of hypocalcaemia
Vit D deficiency; kidney failure; thyroid disorders; drugs such as heparin
List at least 3 causes of hyperkalaemia
MI; GI bleed; kidney failure; drugs such as lithium, beta-blockers and diuretics
List at least 3 causes of hypokalaemia
Eating disorders; severe D&V (severe dehydration); drugs such as laxatives, diuretics and penicillin; adrenal gland problems
List at least 3 causes of hypernatraemia
Dehydration; excessive sodium intake; decreased water intake
List at least 3 causes of hyponatraemia
Excessive sweating; water intoxication; kidney disease; illicit drugs
List at least 3 causes of hypomagnesaemia
Chronic alcoholism; malnutrition; malabsorption; Drugs such as some ABx, diuretics and cyclosporin
List at least 3 causes of hyperphosphataemia
Bone breaks; intestinal obstruction; kidney disease
List at least 3 causes of hypophosphataemia
Trauma (severe burns / injuries); alcoholism; malnutrition
Define a hernia
Condition in which part of or entire viscera protrudes thought the wall of the cavity ordinarily containing it
(often involving intestine at a weak point in the abdominal wall)
Which type of hernia is most common?
Indirect inguinal hernias (85%)
In which group of patients are femoral hernias more common?
Women
In which group of patients are direct inguinal hernias more common?
Older patients (men and women)
Describe the root of an indirect inguinal hernia
An indirect inguinal hernia leaves the abdominal cavity via the deep inguinal ring, travels down the inguinal canal and can reach the scrotum
Describe the root of a direct inguinal hernia and explain where you would expect to find the hernia
A direct hernia protrudes “directly” out of the abdominal cavity (not down the inguinal canal) via the weak posterior wall of the inguinal canal in “Hesselbach’s Triangle” - medial to the inferior epigastric vessels and lateral to the Rectus Abdominis muscle
What anatomical landmarks would you use to define a hernia as femoral?
The inguinal canal and pubic tubercle. Femoral hernias will be inferior to the inguinal canal and lateral to the pubic tubercle
(As opposed to a direct hernia which will be found superior and medial to the pubic tubercle) note fem. can be above inguinal ligament but will take course laterally not medially as inguinal would
After reducing an inguinal hernia, you put your fingers over the deep inguinal ring and ask the patient to cough. The hernia is NOT controlled? What sort of hernia is most likely?
A direct inguinal hernia
Where will you locate the deep inguinal ring?
a) halfway between the pubic tubercle and ASIS
b) ~2cm above inguinal ligament
c) halfway between b) and pubic tubercle
(Other sources simply say 2cm above mid-inguinal point!)
What characteristics of a hernia make it a surgical emergency?
An irreducible one as it is at risk of strangulation, ischaemia and necrosis.
(The strangulation is what makes it the surgical emergency but irreducibility puts it at greater risk of strangulation so worth a referral)
What examination findings might be indicative of strangulation or obstruction of a hernia?
Reduced or absent bowel sounds are likely with both
Obstruction of small bowel likely to illicit high-pitched tinkling on auscultation
Where is the superficial inguinal ring located?
1cm above and medial to pubic tubercle
Ŵhere would you expect to feel the femoral pulse?
~2cm below mid inguinal point
What are the common causes of small bowel obstruction?
Post surgical adhesions
Hernias
Less common = tumours and volvulus
What are the common causes of large bowel obstruction?
Tumours (particularly at splenic flexures or caecum)
Strictures
Diverticular disease
Less common = adhesions
Why do Venturi masks tend to be preferable to Simple face masks (Hudson)?
More control over amount of oxygen delivery to patient
Particularly useful in COPD patients where adjustment is so important
Describe the main features of a non-rebreathing mask and in which types of patient this form of oxygen mask is usually indicated?
Has an oxygen reservoir which must be filled before applied to patient and does not collapse with inspiration. A one-way valve prevents patient berthing expired air - can achieve flow rates of 15L/min
Indicated in seriously ill patients who can still self-ventilate (e.g. Severely hypoxaemic WITHOUT risk factors for hypercapnic respitatory failure)
What does a bag valve mask entail and when should it be used?
A self-refilling bag, jam-proof valve which prevents rebreathing that can be used to provide artificial ventilation. Designed to either deliver air directly from atmosphere or pure oxygen from supplemental system
Indicated in respiratory arrest or respiratory failure (where breathing I’d inadequate to support life)
