Important conditions investigations and treatments Flashcards

Question

What are the 2 shockable and 2 non shockable rhythms? (In cardiac arrest)

Answer 1

Shockable - Ventricular tachycardia - Ventricular fibrillation Non Shockable - Pulseless electrical activity - Asystole

Answer 2

INVESTIGATIONS 1st line + GS - ECG Saw toothed pattern (F wave?), often with a 2:1 block (2 P waves for 1 QRS) - atrial rate at about 300bpm TREATMENTS Acutely unstable (Shock, syncope, MI) --> Synchronised DC cardioversion Stable - 1st line - rate control BB - Bisoprolol + DOAC depending on CHADSVASC score (Permanent - Radiofrequency ablation)

Answer 3

INVESTIGATIONS 1st and GS - ECG - Short PR interval - Delta waves (in QRS complex) - slurred upstroke - Wide QRS TREATMENT 1st line - Vagal maneuvers - Carotid massage - Valsalva maneuver 2nd line - IV adenosine CI asthma give CCB - verapamil Definite - last resort - Radiofrequency ablation of bundle of Kent.

Answer 4

INVESTIGATIONS If BP in hospital >140/90 mmHg, do Ambulatory blood pressure monitoring to confirm diagnosis (135/85 mmHg throughout the day) Assess for end organ damage - Fundoscopy - Papilloedema - Urinalysis + eGFR - Kidney function - Echo - LVH TREATMENT If <55 YO or T2DM (Not a black African) 1) Ace inhibitor NO MATTER WHAT AGE/ETHNICITY, if patient has T2DM give Ace-Inhibitor If >55 YO or Black African 1) CCB 2) Ace inhibitor + CCB 3) Ace inhibitor + CCB + Thiazide

Answer 5

1st degree Sx - Usually asymptomatic Tx - Asymptomatic so no treatment (Mobitz 1 also no treatment unless very symptomatic then give PACEMAKER) 2nd and 3rd degree Sx - Syncope, fatigue, hypertension, chest pain, dyspnoea MOBITZ 2 Tx--> Pacemaker 3rd degree Tx --> IV atropine and pacemaker

Answer 6

INVESTIGATIONS If Wells Score is 1 or less (Unlikely DVT) --> Do a D-dimer test - If its normal - DVT excluded - If its elevated do a venous duplex ultrasound - where a reduced or absent spontaneous flow CONFIRMS the diagnosis If Wells score is 2 or more (likely DVT) --> Do a venous duplex ultrasound (Diagnostic) TREATMENT 1st line - DOAC (Apixaban, rivaroxaban) LMWH if CI (renal impairment) Non pharmacological treatment - Physical activity - mobilisation, walking exercises - Compression stockings

Answer 7

INVESTIGATIONS 1st line If Wells score >4 (likely PE) --> CT pulmonary angiogram (diagnostic) If Wells score <4 (unlikely PE) --> D-dimer test : - If raised --> CTPA - If not raised --> Not PE ECG - Sinus tachycardia + S1Q3T3 (also sign of cor pulmonale) T wave inversion of anterior and inferior leads + new RBBB Chest X-ray - normal TREATMENT Non massive PE (usually this) 1st line DOAC - Apixaban LMWH if CI (renal impairment) Massive PE Thrombolytics e.g. alteplase, streptokinase

Answer 8

INVESTIGATIONS First line - Ankle brachial pressure index. (ratio of BP) <0.9 = intermittent claudication <0.5 = Chronic limb ischemia Buerger's test - elevate leg at 45 degree angle for 1-2 minutes, if there is pallor, test is positive TREATMENT Intermittent claudication - Graded exercise therapy - RF modification - Stop smoking, balanced diet, increase physical activity - Pharmacological: Atorvastatin, clopidogrel Chronic limb ischaemia - Revascularisation surgery PCI - if small Bypass surgery - if bigger

Answer 9

TREATMENT If non viable limb (Sign of tissue loss, nerve damage or significant sensory loss) --> Amputate If limb is viable on assessment --> Urgent revascularisation within 4-6 hours (Endovascular thrombolysis/thrombectomy, bypass surgery)

Answer 10

INVESTIGATIONS FBC - ESR elevated, leukocytosis GS - ECG - Localised PR depression + Global Saddle shaped ST elevation TREATMENT NSAIDS + colchicine

Answer 11

INVESTIGATIONS 1st line - ECG Chest X-ray - Big heart GS - Transoesophageal echocardiogram Treat pericardial effusion with NSAIDS + colchicine Treat cardiac tamponade with URGENT PERICARDIOCENTESIS SYMPTOMS of cardiac tamponade BECK's Triad - Hypotension - Increased Jugular venous pressure - Muffled S1+S2 heart sounds + Pulsus paradoxus

Answer 12

NVESTIGATIONS 1st line - 3 sets of blood cultures at 3 different sites over 24 hours FBC Urinalysis GS - Transoesophageal echocardiogram DIAGNOSIS MADE WITH MODIFIED DUKES CRITERIA (2 major, 1 major 3 minor, 5 minor) TREATMENT S.viridans (S.bovis) - Benzylpenicillin (Pen G) + Gentamicin S.aureus - Flucloxacillin Enterococci --> Amoxicillin + Gentamicin

Answer 13

INVESTIGATIONS First - Liver function test - Increased bilirubin, increased PT/INR and decreased serum albumin - Increased ALT and AST Additional but not really required? - FBC - (for haemolytic anaemia associated with Wilson's disease) - Abdominal ultrasound - to eliminate budd chiari syndrome - EEG - electroencephalogram - assess hepatic encephalopathy MANGEMENT 1st - Intensive care management - Tracheal intubation - Analgesia - IV fluids Then treat underlying cause - Paracetamol causes - N acetylcysteine - Budd chiari syndrome - LMWH Treat complications - Cerebral oedema - IV mannitol - HE - Lactulose - Ascites - Spironolactone - Haemorrhage - vitamin K Definitive - Liver transplant

Answer 14

INVESTIGATIONS First - LIVER FUNCTION TEST - Increased bilirubin, decreased albumin, increased PT - AST:ALT >2 FBC - Macrocytic anaemia (increased deposition of cholesterol on RBC membrane) GS - Liver biopsy - shows extent of alcoholic liver disease (Can do AUDIT and CAGE questionnaire) TREATMENT 1st - STOP DRINKING ALCOHOL + give diazepam for alcohol withdrawal symptoms (delirium tremens) - Consider prednisolone based on Maddrey's discriminant function (>32 positive, poor prognosis) Tranexamic acid (to reduce/prevent bleeding)- reduces mortality risk in GI bleeds Definitive - Liver transplant Complications - HE, Acites, hepatocellular carcinoma, Wernicke krsakoff syndrome

Answer 15

INVESTIGATIONS Liver function test - Increased ALT (but ALT:AST <0.9) GS - Liver biopsy Liver ultrasound - use fibrosis 4 score to estimate risk of advanced fibrosis and need for liver biopsy TREATMENT First - Lifestyle modification- Healthy diet and exercise for weight loss (no smoking and alcohol) Vitamin E to improve histological fibrotic liver appearance. (Can lead to HCC, HE, Ascites, portal hypertension)

Answer 16

INVESTIGATIONS LFT - low albumin, raised bilirubin, raised prothrombin time - Platelet count reduced (liver has impaired ability to produce thrombopoietin) Abdominal ultrasound - liver surface nodularity, ascites, splenomegaly (Transient elastography for determining degree of fibrosis) GS - Liver biopsy (Use child pugh score for prognosis of patients with chronic liver failure/cirrhosis - severity of liver cirrhosis) TREATMENT 3 things 1) Treat underling cause - avoid alcohol, NSAIDS, high dose paracetamol, treat any hep B and C 2) Monitor complications e.g. use ultrasound to monitor ascites and endoscopy to monitor oesophageal varices 3) Manage complications e.g. spironolactone/diuretics for ascites 2nd line - Liver transplant

Answer 17

Check with notesCh

Answer 18

INVESTIGATION Abdominal ultrasound - where you may find: - Gallstones in the gallbladder/ducts - Dilation of the ducts - Acute cholecystitis LFT - show a large increase in ALP (in an obstructive picture) - maybe slight increase in transaminases Can do Endoscopic retrograde cholangiopancreatography (ERCP_ = endoscope inserted through oesophagus and stomach to sphincter of oddi. (can inject contrast) TREATMENT Analgesia - diclofenac/paracetamol + LAPAROSCOPIC CHOLECYSTECTOMY

Answer 19

INVESTIGATIONS - Abdominal ultrasound scan - shows evidence of cholecystitis: + Thickened gallbladder wall + Stones in gallbladder + Pericholecystic fluid (fluid around the gallbladder) - caused by the inflammation GS - MRCP FBC - leukocytosis (inflammation triggers immune response) TREATMENT Laparoscopic cholecystectomy - (should be done within 1 week of diagnosis according to NICE) + Analgesia - (ibuprofen/diclofenac) (Antibiotics -Piperacillin and tazobactam..... Ciprofloxacin)

Answer 20

INVESTIGATION First - Abdominal ultrasound - dilated bile duct, common bile duct stones LFTs - increased conjugated bilirubin GS - MRCP (magnetic resonance cholangiopancreatography) - non invasive (ERCP is invasive but can be used for treatment) TREATMENT 1st - IV antibiotics (for E.coli ceftriaxone) After 24 hours- Endoscopic retrograde cholangiopancreatography (ERCP) - places a drainage stent to allow for biliary tree decompression and stone extraction. (Consider cholecystectomy to prevent recurrence once stable)

Answer 21

Investigations - LFT - increased ALP, increased conjugated bilirubin Serology for autoantibodies - Anti mitochondrial antibodies (AMA) - most specific to PBC - (Anti nuclear antibodies present sometimes) FIRST LINE IMAGINE - ABDOMINAL ULTRASOUND (to rule out other causes of cholestasis - obstructive mass, PSC) TREATMENT 1st line - Ursodeoxycholic acid (decreases toxicity thus decreasing inflammation and reducing cholestasis -- and dampens immune response) Cholestyramine - give for pruritus

Answer 22

INVESTIGATIONS - LFT - increased ALP, increased GGT supports liver origin rather than bone origin (for raise in ALP) (pANCA positive but not helpful in diagnosis) GS - MRCP - beaded appearance of bile ducts TREATMENT - no proven effective treatment Conservative treatment (lifestyle changes - maintain healthy wait, limit alcohol) - ERCP can be used to treat strictures - Colestyramine given for pruritus relief Definitive treatment - liver transplant LEADS TO CHOLANGIOCARCINOMA

Answer 23

INVESTIGATIONS GS - Blood test for serum lipase/serum amylase (Lipase - elevated for longer more specific) --> Leakage from pancreatic cells LFT - Elevated ALT (suggests gallstone pathology) Ultrasound - diagnostic for gallstones Assess severity - using glasgow score TREATMENT ABCDE - IV fluid resuscitation - Analgesia - IV antibiotics if infection Nil by mouth Use ERCP for gallstones

Answer 24

INVESTIGATIONS 1st - Faecal fat - increased (indicator of exocrine function) GS - Abdominal US and CT scan --> shows pancreatic calcification + dilated pancreatic duct (diagnostic) (unlikely to see increased lipase and amylase) TREATMENT 1st - Alcohol and smoking cessation + analgesia (ibuprofen) For patients with exocrine pancreatic insufficiency --> Pancreatin (pancreatic enzyme replacement therapy) (Insulin regime for diabetes)

Answer 25

Investigations 1st line - Serology for anti-TTG IgA antibodies (above normal range) - ALSO total IgA to EXCLUDE IgA deficiency (because if you have IgA deficiency, you will have a low anti-TTG leading to a false negative) GS - Endoscopy and biopsy --> Showing crypt hyperplasia and villous atrophy (and epithelial lymphocyte infiltration) TREATMENT 1st line - Gluten free diet (+ vitamins and mineral supplementation to replace for malabsorption)

Answer 26

INVESTIGATIONS If no red flags - straight to treatment (clinical/symptomatic diagnosis) If red flags present (dysphagia, haematemesis, weight loss) - Endoscopy --> may show oesophagitis or barrett's oesophagus (stratified squamous to simple columnar) Oesophageal manometry --> to measure LOS pressure and function TREATMENT 1st - lifestyle modifications (stop smoking, avoid heavy meals before bed, lose weight, reduce coffee and alcohol) 2nd - PPI (H2 receptor antagonist if CI) Last resort --> Surgery - Nissen fundoplication (laparoscopic fundoplication) --> tightens the junction between the esophagus and stomach to prevent acid reflux.

Answer 27

INVESTIGATIONS 1st line - X ray (dilated bowel loops) GS - Abdominal contrast CT scan ABG including lactate - elevated lactate indicates poor tissue perfusion TREATMENTS ABCDE - mainly supportive care 1st LINE (DRIP AND SUCK) - - Fluid resuscitation - Antiemetics and analgesia - Nasogastric decompression + nil by mouth (NG tube is to prevent aspiration of vomit + deliver substances to stomach) (Give catheter to measure urine output) For people with closed loop bowel obstruction/evidence of bowel ischemia --> Urgent surgery (mostly laparoscopy)

Answer 28

INVESTIGATIONS Spirometry - A FEV1/FVC ratio less than 0.7 would indicate airflow obstruction Diffusing capacity of the lung for carbon monoxide (DLCO) - Low in COPD -< 60% predicted (normal in asthma) Genetic test for A1AT deficiency ABG - TYPE 2 RESPIRATORY FAILURE (Hypercapnia, hypoxia and respiratory acidosis) Chest X-ray --> flattened diaphragm and hyperinflation of the lung - Barrel Chest TREATMENT Actual 1st line treatment - Smoking cessation and preventive vaccines for influenza and pneumococcal (as airway obstruction increases risk of infection) 1st line - Salbutamol (SAB2A) 2nd line - Salbutamol + Salmeterol (LAB2A) + Tiotropium bromide (LAM3A) If still doesn't work - add ICS

Answer 29

INVESTIGATIONS 1st line - Spirometry An FEV1:FVC ratio <70% indicates obstructive pathology (asthma/COPD) Bronchodilator reversibility - Improvement in FEV1 post bronchodilator administration (irreversible in COPD) >12% improvement in FEV1 Fractional exhaled nitric oxide - Increased (biomarker for asthma - eosinophilic inflammation?) Expiratory peak flow >20% (checking diurnal variation) Sputum microscopy - Charcot leyden crystals - eosniophil breakdown products - Curshmann spirals- plugs formed from bronchial epithelial shedding TREATMENT Algorithm 1) SAB2A (salbutamol) PRN 2) SAB2A + Inhaled corticosteroids (budesonide) --> Check compliance and inhaler technique if still does not work. If still not ok --> Step 3 3) SAB2A + inhaled corticosteroids + Leukotriene receptor antagonist (montelukast) 4) SAB2A + inhaled corticosteroids + Leukotriene receptor antagonist + LAB2A (salmeterol) 5) Everything + increase dose of inhaled corticosteroid

Answer 30

INVESTIGATIONS 1st line - Chest X-ray Shows lung cavitations Ghon focus/complex Appearance of millet seeds distributed across lung firlds - indicated disseminated milliary tuberculosis GS Sputum culture (3 separate samples collected) - They are acid fast bacilli that stains bright red on a Ziehl-Neelson stain Lung biopsy - Caseous granulomas Two tests to look for an immune response to tuberculosis (positive means has an immune response) Mantoux skin test - (people with latent TB have a positive tuberculin skin test with an induration >5mm after 72 hours) Interferon Gamma release assays - If WBC have become sensitised to the bacteria antigen in a previous infection/contact with M.tuberculosis, there will release interferon gamma on further contact. TB TO SPINE - POTT disease TREATMENT RI6PE2 (Ripe) - all to be taken at same time Rifampicin - 6 months Isoniazid - 6 months Pyrazinamide - 2 months Ethambutol - 2 months

Answer 31

INVESTIGATION 1st line - Chest X-ray --> shows consolidation (accumulation of fluid filled (exudate) alveoli and adjoining ducts) Sputum culture + stain with Ziehl Neelson - Identify the causative organism ABG - Type 1 respiratory failure CURB 65 - Assessses severity of penumonia TREATMENT Community acquired pneumonia (mild- CURB is 0-1) 1st line - Oral Amoxicillin If penicillin allergy -- Clarithromycin CURB=2 Oral Amoxicillin + clarithromycin Community acquired pneumonia (high severity - CURB 3-5) IV Co amoxiclav + Clarithromycin For legionnaires disease - clarithromycin (A NOTIFIABLE DISEASE)

Answer 32

INVESTIGATIONS GS - Sweat test (measures amount of chloride in the sweat- more chloride than usual) >6ommol/L Faecal elastase test - decreased due to pancreatic insufficiency Genetic test for CFTR gene- delta F508 mutation - Screened for at birth with the newborn bloodspot test (New borns might have high immunoreactive trypsinogen) TREATMENT No cure Conservative --> Chest physiotherapy (clears mucus), exercise (improves resp function), no smoking Drugs --> Mucolytic drugs (N acetyl cysteine), CREON tablets (+ ADEK fat soluble vitamins for patients with pancreatic insufficiency), bronchodilator (salbutamol) P.aeruginosa - Ciprofloxacin S.aureus - Flucloxacillin

Answer 33

INVESTIGATIONS Imaging --> 1st line - Chest X ray - Dilated bronchi with thickened walls GS --> HIGH RESOLUTION CT scan - SIGNET RING SIGN + tram track sign - dilated bronchioles next to each other. (bronchus markedly dilated compared to the pulmonary artery) Spirometry --> Obstructive with FEV1:FVC ratio <0.7 Sputum culture --> to check for infection (Most common H.influenzae, P.aeruginosa) TREATMENT No treatment Conservative --> Chest physiotherapy (e.g. postural drainage), stop smoking, vaccines against infections (influenza) Drugs --> Bronchodilators During infections P.aeruginosa --> Ciprofloxacin

Answer 34

INVESTIGATIONS 1st line + GS Chest X-ray --> blunting of costophrenic angle, fluid in lung fissures and tracheal deviation To establish the underlying caused via Light's criteria --> Pleural aspiration (thoracocentesis) --> analyse for protein count, WBC+RBC cell count, pH, glucose, lactate dehydrogenase TREATMENT Small effusion Conservative management --> Treating the chest infection with antibiotics Large effusion (commonly will be chest drain) Chest drain Last resort - Pleurodesis --> surgical fusion of pleural layers to prevent fluid buildup (obliterate pleural space)

Answer 35

NVESTIGATIONS 1st line + GS Erect Chest X-ray (patient standing upright) --> Visible rim between lung margin and chest wall, absent lung markings, tracheal deviation to the other side, darker area (collapsed lung) British thoracic society guidelines to measure the size of a pneumothorax CT thorax --> can help detect small pneumothorax and accurately assess size of the pneumothorax TREATMENT Check the document Pleural aspirate Chest drain (tension pneumothorax - needle aspiration 2nd ICS midclav)

Answer 36

INVESTIGATIONS 1st line - Spirometry shows airway restriction - FEV1:FVC ratio is >0.7 but FVC is reduced (<0.8 of normal) Restriction --> difficulty getting air into the lungs (reduced chest expansion) - TLC is reduced GS - High resolution CT scan of chest = Ground glass/honeycomb appearance with traction bronchiectasis - dilation of bronchioles TREATMENT 1st line - Pirfenidone (Anti-fibrotic medication) or Nintedanib (Both growth factor inhibitors) Smoking cessation Last resort - Lung transplant

Answer 37

INVESTIGATIONS 1st line - Chest x-ray - Bilateral hilar lymphadenopathy High resolution CT U and E - Hypercalcemia GS- Histology Biopsy of affected area - shows non caeseating granulomas (with epithelioid cells) Urine dipstick - proteinuria (renal) LFTS - liver ECG - Heart - Serum ACE - elevated - Serum calcium - elevated - Soluble IL-2 - elevated - CRP - elevated MANAGEMENT Mild - No treatment First line - Corticosteroids (consider giving bisphosphonates to prevent bone loss) 2nd line - Immunosuppressants - methotrexate, azathioprine

Answer 38

NVESTIGATIONS 1st - Chest X-ray --> Right ventricular hypertrophy ECG - P pulmonale - Peaked P waves RVH --? Tall R waves in V1 and 2, Deep S waves in V5 and 6 (RVH) + right atrial enlargement Echocardiogram - Right ventricular hypertrophy GS - Right heart catheterisation demonstrating the mean pulmonary arterial pressure is >20mmHg TREATMENT Phosphodiesterase 5 inhibitors - Sildenafil (Also used for treating sexual dysfunction) Calcium channel blockers Endothelin receptor antagonists - Bosentan

Answer 39

INVESTIGATIONS First line- Chest x-ray, CT GS - Bronchoscopy AND biopsy MRI staging via TNM TREATMENT More aggressive If early - Chemotherapy, radiotherapy If metastasised - Palliative

Answer 40

INVESTIGATIONS 1st line imaging - Chest X-ray, CT GS - Bronchoscopy + biopsy MRI staging - TNM TREATMENT Less aggressive than SCLC Early - Surgical excision of tumour Metastasised - Chemotherapy, radiotherapy

Answer 41

INVESTIGATIONS 1st line - Chest x-ray - pleural thickening with or without effusion CT scan would provide more detail. GS - pleural biopsy TREATMENT Mostly palliative care (can try surgery + chemotherapy if found early and operable) - generally resistant to radiotherapy