Important OSCE topics Flashcards
What are the first rank features of schizophrenia?
Auditory hallucinations (running commentary, 2+ voices discussing the patient, thought echo)
Delusions (e.g. persecutory)
Thought disorders (thought insertion, broadcasting and withdrawal)
Passivity phenomena (bodily sensations controlled by external influence, feelings/thoughts/mood/actions under someone else’s control)
What are other features of schizophrenia?
Negative symptoms (catatonia, blunting, anhedonia, alogia (poverty of speech), avolition
Impaired insight
Incongruency/blunting
Neologisms
What should you initially offer for pain relief in palliative care?
Regular MR morphine PO (can also give immediate release) and immediate release PO for breakthrough pain
What dose of morphine should patients generally start at?
20-30mg MR morphine PO daily dose
5mg breakthrough, e.g. 15mg MR morphine PO BD + 5mg breakthrough PRN
When prescribing morphine what side effects should you make the patient aware of and how can you counteract these?
Drowsiness
Nausea - antiemetic
Constipation - always give laxative
What fraction of the total daily dose of morphine should the breakthrough dose be?
1/6th
What opioid is preferred in patients with mild-moderate renal impairment?
Oxycodone
What opioid is referred in patients with severe renal impairment?
Fentanyl, buprenorphine, alfentanil
What is the management of metastatic bone pain?
Strong opioids
Bisphosphonates
Radiotherapy
When you are increasing the dose of morphine, by how much should you increase it at a time?
30-50%
What is the conversion rate for:
oral codeine –> oral morphine?
/10
What is the conversion rate for:
oral tramadol –> oral morphine?
/10
What is the conversion rate for:
oral morphine –> oral oxycodone?
/1.5
What is the conversion rate for:
oral morphine –> IV morphine?
/2
What is the morphine dose equivalent of a 12 microgram fentanyl patch?
30mg
What is the morphine dose equivalent of a 10microgram buprenorphine patch?
24mg
What are important points to remember for administering morphine?
It is in a locked cupboard, use needs to be logged in logbook, two people need to sign out the morphine
What are features of an UGI bleed?
Haematemesis, malaena, epigastric discomfort, sudden collapse
What are causes of UGI bleed?
Mallory weiss tear Oesophageal/gastric cancer Peptic ulcer Oesophagitis Oesophageal varices (tends to be large vol, haemodynamic compromise)
How is UGI bleed managed?
Admit
Cross match, FBC, UE, LFT, clotting
Airway management, A–>E
Suspected varices –> terlipressin + prophylactic antibiotics, endoscopy within 24 hours, banding/sclerotherapy, sengstaken-blakemore tube, portal pressure should be managed with medical therapy +/- TIPSS
All those who received intervention should be on continuous PPI IV for 72 hours
How long can a sengstaken-blakemore tube stay in?
Only for 12 hour, after that risk of necrosis
How is risk assessed in UGI bleed?
Blatchford score at risk, then with full rockall score after endoscopy
What vital signs/blood results would you expect to see in UGI bleed?
High urea, low Hb, low BP, high pulse
Remember patients likely to have hepatic dx hx
What are the causes of meningitis in ages 0-3 months?
Listeria monocytogenes
E. coli
GBS
What are the main causes of meningitis in ages 3 months-6 years?
H. influenzae
Strep pneumonia
N. meningitidis
What are the main causes of meningitis in ages 6 months-60 years?
Strep pneumonia
N. meningitidis
What are the main causes of meningitis in those >60?
Strep pneumonia
N. meningitidis
Listeria
What is a common cause of meningitis in those who are immunocompromised?
Listeria
What does the CSF analysis look like in someone with a bacterial meningitis?
Appearance: cloudy
White cells: polymorphs
Glucose: <50% plasma
Protein: high
What does the CSF analysis look like in someone with a viral meningitis?
Appearance: clear/cloudy
White cells: lymphocytes
Glucose: 60-80% plasma
Protein: normal/high
What does the CSF analysis look like in someone with a TB meningitis?
Appearance: fibrin webs
White cells: lymphocytes
Glucose: <50%
Protein: high
What does the CSF analysis look like in someone with a fungal meningitis?
Appearance: cloudy
White cells: lymphocytes
Glucose: low
Protein: high
How should you investigate suspected meningitis?
FBC, UE, LFT, CRP, coag, PCR, blood gas, blood cultures
LP if no signs of raised ICH (do not do LP in suspected meningococcal disease)
How should you manage suspected meningococcal disease?
IM benzylpen
What is the empirical management of meningitis in those aged <3 months?
IV cefotaxime + amoxicillin
What is the empirical management of meningitis in those aged 3 months-50 years?
IV cefotaxime
What is the empirical management of meningitis in those aged >50?
IV cefotaxime + amoxicillin
How is known listeria meningitis managed?
IV gentamicin and amoxicillin
What other non-antibiotic drug is sometimes given in meningitis?
IV Dex (not if septic shock, immunocomp or following surgery)
What drug is used instead of amoxicillin in meningitis if there is a pencillin allergy?
Chloramphenicol
Who should be offered prophylaxis for meningitis? What drugs is it?
Close contacts (<7 days) of meningococcal meningitis Rifampicin or ciprofloxacin (one dose)
What are the ECG changes in hyperkalaemia?
Tall tented T waves
Small p waves
Broadened QRS complexes
What are causes of hyperkalaemia?
AKI Drugs - spironolactone, K sparing diuretics, ACEi, ARB, heparin, ciclosporin Addisons disease Massive transfusion Metabolic acidosis
How is hyperkalaemia managed?
Stabilise myocardium - calcium gluconate
Shift K intracellularly - NEB salbutamol, insulin/dextrose infusion
Excrete K - calcium resonium, dialysis (for persistent hyperkalaemia in AKI), loop diuretics
What are the three types of causes of AKI?
Pre-renal
Intrinsic
Post-renal
What are some pre-renal causes of AKI?
Hypovolaemia, e.g. due to vomiting/diarrhoea
Renal artery stenosis
What are some intrinsic causes of AKI?
Glomerulonephritis ATN Acute interstitial nephritis rhabdomyolysis Tumour lysis syndrome
What are some post-renal causes of AKI?
External compression of ureter
Kidney stone in bladder/ureter
Name some drugs with nephrotoxic potential?
NSAIDs, ACEi, ARB, diuretics, aminoglycosides, iodinated contrast
What are features of AKI?
Fluid overload
Oliguria (<0.5ml/kg/h)
Rise in molecules kidney usually excretes (Cr, U, K) –> arrhythmias, uraemia (pericarditis, encephalopathy)
How should you investigate AKI?
UE - rise in serum Cr >26micromol/l in last 48h, rise in serum cr >50% in last 7 days, oliguria (<0.5ml/kg/h)
Urinalysis
Imaging - USS renal tract (within 24h)
How should you manage AKI?
Stop drugs - those making AKI worse (aminoglycosides, NSAIDs, ARBs, ACEi, diuretics), and those putting at risk of toxicity (lithium, metformin, digoxin)
Only use loop diuretics for significant fluid overload
Management hyperkalaemia
Referral (urologist/nephrologist)
RRT if not responding to medical management of complications (e.g. hyperkalaemia, uraemia..)
What is acute tubular necrosis?
Necrosis of renal tubular epithelial cells
What are the two main causes of ATN?
Toxins - aminoglycosides, myoglobin secondary to rhabdomyolysis, contrast agents, lead)
Ischaemia - sepsis/shock
What do you see in the urine of someone with ATN?
Brown muddy casts
What can cause acute interstitial nephritis?
Drugs, esp antibiotics (rifampicin, penicillin, NSAIDs, allopurinol, furosemide)
Systemic dx: SLE, sjogrens
Infections: Hanta virus, staph
What are features of acute interstitial nephritis?
Fever, rash, eosophilia, arthalgia, mild renal impairment, HTN
White cell casts, sterile pyuria
What is the CHADSVASC score?
Used to assess need for anticoagulation (DOAC or warfarin) in those with AF C - congestive cardiac failure (1) H - HTN (1) A2 - age >=75 (2) D - DM (1) V - vascular disease (1) A - age 65-74 (1) Sc - sex - female (1)
Score 0 = no anticoagulation, score 1 + male - consider Rx, score 2 - start treatment
What are the two types of bleeds causing epistaxis?
Anterior bleeds - usually from kiesselbacks plexus, often visible
Posterior bleeds - usually not visible, bleeding from deeper structures
What can cause epistaxis?
Trauma
Platelet disorder - ITP, thrombocytopenia, splenomegaly, leukaemia
How is epistaxis managed?
Haemodynamically stable –> sit forward, mouth open, pinch cartilaginous region of nose – if stops –> naseptin (peanut/soy/neocmycin allergy –> use mupirocin) to prevent crusting/vestibulitis
If doesn’t stop bleeding after 10-15 min attempt packing/cautery
Haemodynamically unstable/posterior/unknown bleeding source –> ED
What are causes of SBO?
Intrabdominal adhesions, hernias, neoplasms, IBD
What are features of SBO?
NV, bloating, constipation, abdominal pain
How do you image SBO?
Abdominal x-ray
How do you manage SBO in the first instance?
NG tube to decompress
A-E
Foley catheter to measure urine output
Fluids
What things can you not do on an AV fistula arm?
Cannulas
Take bloods
Do BP on that arm
What are causes of parkinsonism?
PD Drug induced, e.g. metoclopramide, antipsychotics Progressive supranuclear palsy Multiple system atrophy Wilson's disease Post-encephalitis
What causes parkinsons disease?
Progressive degeneration of dopaminergic neurons in the substantia nigra
What are the classic triad of features in PD?
Bradykinesia
Tremor
Rigidity
What features of PD symmetrical?
Classically asymmetrical
What are the features of bradykinesia in PD classically?
Poverty of movement (hypokinesia)
Short, shuffling steps
Reduced arm swing
Difficulty initiating movement
What kind of tremor is seen in PD?
Pill rolling, asymmetrical, low frequency, at rest
What are other features of PD?
Mask like facies Stooped posture Micrographia Drooling Psychiatric features - depression, sleep disturbance Impaired olfaction REM sleeping disorder Fatigue Postural hypotension
What may give clues that parkinsonism is drug induced?
Rapid onset, bilateral
Rigidity and tremor uncommon
How is parkinsons disease diagnosed?
Clinically
If uncertainty SPECT can be used
What drugs can be used in the management of PD?
Levodopa with carbidopa
Dopamine receptor agonists, e.g. bromocriptine, ropinirole
MAO-B inhibitors, e.g. selegiline
Amantadine
COMT inhibitors, e.g. entacapone
Anti-muscarinics, more used for drug induced parkinsonism
What is the most common type of cancer in the west?
Basal cell carcinoma
What is the most common type of BCC?
Nodular
What do BCC look like?
Exist in sun exposed sites, especially head and neck
Initially pearly, flesh coloured papule with telangiectasia
May ulcerate leaving central cater
How are BCC managed?
Referral to derm Surgical removal Curettage Cryotherapy Topical cream - imiquimod, fluorouracil Radiotherapy
What is compartment syndrome?
Raised pressure within a closed anatomical space
Raised pressure –> compromises tissue perfusion –> necrosis
What are the two main fractures that are implicated in compartment syndrome?
Supracondylar fractures
Tibial shaft injuries
What are the features of compartment syndrome?
Pain (especially on movement, even passive)
Excessive use of breakthrough analgesia
Paraesthesia
Pallor
Arterial pulsation may still be felt as necrosis occurs due to microvascular compromise
Paralysis
How is compartment syndrome diagnosed?
Measurement of intracompartmental pressure (excess of 20mmHg abnormal, >40 diagnostic)
How is compartment syndrome managed?
Prompt + extensive fasciotomies
Aggressive IV fluids to avoid myoglobulinuria
Debridement of necrotic tissue, amputation may occur
Death of muscle groups occurs within 4-6 hours
What are the two most common causes of acute pancreatitis?
Alcohol
Gallstones
What is the pathophysiology of acute pancreatitis?
Autodigestion of pancreatic tissue by pancreatic enzymes –> necrosis
What are features of acute pancreatitis?
Severe epigastric pain, radiating to back
Vomiting
Epigastric tenderness, low grade fever
Periumbilical discolouration (Cullens sign) and flank discolouration (Grey-Turners sign)
What investigations should be done in suspected acute pancreatitis?
Serum amylase - raised
Serum lipase
Imaging (diagnosis can be made without imaging if serum amylase/lipase >3x upper limit)
USS imaging important to assess aetiology
What scoring systems can be used to identify cases of severe pancreatitis which may require ITU management?
Ranson score
Glasgow score
APACHE II
What mnemonic can be used to remember the causes of acute pancreatitis?
GET SMASHED Gallstones Ethanol Trauma Steroids Mumps Autoimmune Steroids/scorpion venom Hypertriglyceridaemia, hypercalcaemia, hypothermia ERCP Drugs (azathioprine, mesalazine, furosemide...)
What are local complications of acute pancreatitis?
Pancreatic fluid collections Pseudocysts Pancreatic necrosis Pancreatic abscess Haemorrhage
What systemic complication can occur in acute pancreatitis?
ARDS
What are the key aspects in the management of acute pancreatitis?
Fluid resus (aggressive)
Analgesia (IV opioids)
NBM, enteral nutrition in moderate/severe pancreatitis within 72h of presentation
Surgery -
Gallstones –> cholecystectomy
Obstructed biliary system –> ERCP
Necrosis + worsening organ failure –> debridement and FNA, surgical necrosectomy
What factors predispose to obstructive sleep apnoea?
Obesity
Macroglossia
Large tonsils
Marfans
What are consequences of sleep apnoea?
Daytime somnolence
Compensated resp acidosis
HTN
How can you assess sleepiness in OSA?
Epworth sleepiness scale
Multiple sleep latency test
Sleep studies
What is the management of OSA?
Weight loss
CPAP first line for moderate/severe OSA
Intra-oral devices (e.g. mandibular advancement) can be used in mild OSA or is CPAP not tolerated
Do they DVLA need to be informed if a patient has OSA?
If it is causing excessive daytime sleepiness
What epworth scores correlated with moderate and severe daytime sleepiness?
13-15 moderate
16-24 severe
What are differentials for OSA?
Asthma COPD GORD Heart failure Depression
What is sjogren’s syndrome?
Autoimmune disorder affecting exocrine glands –> dry mucosal surfaces
Can be primary or secondary to RA etc.
What malignancy is there an increased risk of in sjogrens?
Lymphoid
What are features of sjogren’s?
Dry eyes (keratoconjunctivitis sicca) Dry mouth Vaginal dryness Arthralgia Reynaud's, myalgia Sensory polyneuropathy Recurrent parotitis
What do investigations of sjogrens generally find?
RF +ve ANA +ve Anti Ro, Anti La \+ve Schirmer's test (filter paper near conjunctival sac to measure tear formation) Low C4
What does histology show in sjogren’s?
Focal lymphocytic infiltration
How is sjogren’s managed?
Artificial tears and saliva
Pilocarpine may stimulate saliva production
What wells score indicates a PE is likely?
> 4
If PE is likely how is it managed/investigated?
Immediate CTPA (if delay DOAC in interim)
If CTPA +ve –> PE diagnosed
If CTPA -ve –> consider proximal leg vein USS if DVT suspected
If PE is unlikely how is it managed/investigated?
D-dimer
+ve –> immediate CTPA (delay –> give DOAC)
-ve –> PE unlikely, stop anticoagulation
What is the investigation of choice in suspected PE in renal impairment?
VQ scan
What are the classic ECG changes seen in PE?
Sinus tachycardia (most common)
S1T3T3 - large S wave in I, large Q in III, inverted T wave in III
RBBB and RAD may also be seen
What score is used to assess suitability of outpatient treatment in low risk PE patients?
PESI (pulmonary embolism severity index) score
What two anticoagulants should be offered first line in PE?
Apixaban
Rivaroxaban
If renal impairment severe –> LMWH/UFH
How long should patients who have had a provoked PE be on anticoagulation?
3 months
How long should patients who have had an unprovoked PE be on anticoagulation?
6 months
How is PE with haemodynamic instability managed?
Thrombolysis
What may patients who have repeat PEs be considered for?
IVC filters
What wells score indicates DVT is likely?
2+ points
How should you manage a patient where DVT is likely?
Proximal leg vein USS within 4 hours
+ve –> DOAC
-ve –> D-dimer
If USS cannot be done in 4 hours - DOAC in interim
If scan negative, D-dimer positive -> stop DOAC and repeat USS in 6-8 days
How should you manage a patient where DVT is unlikely?
D-dimer
+ve –> proximal leg vein USS wihin 4h
-ve –> DVT unlikely
What common pathogens are implicated in cellulitis?
Strep pyogenes
Staph aureus
How is cellulitis diagnosed?
Clinically
Bloods and blood cultures may be done if patient septicaemic
What classification is used to guide how we manage patients with cellulitis?
Eron
What is the first line treatment for cellulitis?
Mild/moderate - flucloxacillin
Clarithromycin/erythromycin (pregnancy) or doxycycline in penicillin allergic patients
Severe cellulitis - co-amoxiclav/clindamycin
What is the most common organism causing septic arthritis?
Staph aureus
What is the most common organism causing septic arthritis in young sexually active individuals?
N. gonorrhoea
Where is the commonest location to get septic arthritis?
Knee
What are the features of septic arthritis?
Acute, swollen joint
Restricted movement
Fluctuant
Fever
How do you investigate septic arthritis?
Synovial fluid sampling
Blood cultures
Joint imaging
How is septic arthritis managed?
IV antibiotics, e.g. flucloxacillin
Needle aspiration to decompress joint
Arthroscopic lavage may be req.
What are the early causes (0-5 days) of post-operative pyrexia?
Blood transfusion Cellulitis Urinary tract infection Physiological systemic inflammatory reaction (usually next day) Pulmonary atelectasis
What are late causes of post-operative pyrexia (>5 days)?
VTE
Pneumonia
Wound infection
Anastomotic leak
What dose of adrenaline is used in ALS?
1ml 1:10, 000 IV
What dose of adrenaline is used in anaphylaxis?
0.5ml 1:1000 IM
How often can adrenaline be repeated in anaphylaxis?
Every 5 minutes
What are the drugs and doses that should be given in anaphylaxis?
Adrenaline: 0.5ml 1 in 1000
What are the drugs and doses that should be given in anaphylaxis?
Adrenaline: 0.5ml 1 in 1000
Hydrocortisone 200mg
Chlorphenamine 10mg
What enzyme level can be measured to determine in a patient has had a true anaphylactic reaction?
Serum tryptase
How should you give oxygen therapy in those with COPD?
If critically unwell - 15L nonrebreath mask with reservoir bag
If not use 28% venturi mask at 4l/min to aim for sats of 88-92% before you have a blood gas (if pCO2 normal can aim for sats of 94-98%)
What is immune thrombocytopenia?
Immune mediated reduction in platelet count
Abs are directed against glycoprotein IIb/IIIa
What is the presentation of ITP?
Petechiae, purpura
Bleeding
How is ITP managed?
Oral pred
Pooled normal human Ig
What are the 4 Hs in ALS?
Hypoxia
Hypovolaemia
Hyperkalaemia
Hypothermia
What are the 4 Ts in ALS?
Thrombosis
Tension pneumothorax
Tamponade
Toxins
What is involved in the diagnostic workup of acute heart failure?
Blood tests - ?anaemia ?abnormal electrolytes ?infection
CXR - ?pulmonary venous congestion, ?cardiomegaly, ?interstitial oedema
Echo - ?tamponade
BNP
What is involved in the management of acute heart failure?
Oxygen IV loop diuretics Opiates Vasodilators Inotropic agents CPAP Ultrafiltration Mechanical circulatory assistance
What test should be done in all those who present with suspected chronic heart failure?
NT-proBNP
If levels of BNP are high in suspected heart failure what should you do?
Arrange specialist assessment (including TTE) within 2 weeks
If levels of BNP are raised in suspected heart failure what should you do?
Arrange specialist assessment (incl TTE) within 6 weeks
List a few things that may also increase BNP levels other than heart failure
Tachycardia Ischaemia Hypoxaemia (incl. PE) Sepsis GFR <60 Diabetes COPD Age >70 Cirrhosis
What classification system is used to classify heart failure?
NYHA (should look over this?)
How is chronic heart failure managed?
1st line: ACEi and Beta blocker
2nd line: aldosterone antagonist
3rd line: start by specialist, e.g. ivabradine, digoxin, nitrates
Remember annual influenza vaccine + 1 off pneumococcal
What are unmodifiable risk factors for ACS?
Increased age
Male gender
FH
What are modifiable risk factors for ACS?
Smoking DM HTN Hypercholesterolaemia Obesity
What are the two most important investigations in patient presenting with suspected ACS?
Troponin
ECG
What ECG changes and coronary artery are associated with an anterior MI?
V1-4
Left anterior descending
What ECG changes and coronary artery are associated with an inferior MI?
II, III, aVF
Right coronary artery
What ECG changes and coronary artery are associated with an lateral MI?
I, V5, 6
Left circumflex
What is involved in the management of ACS?
MONA (morphine, oxygen if sats <94%, nitrates (e.g. GTN), aspirin (300mg PO))
STEMI –> give 2nd antiplatelet (e.g. ticagrelor), PCI
NSTEMI –> GRACE, high score –> coronary angiography during admission, if not at later date
What is standard secondary prevention in those who have had an ACS?
Aspirin Second antiplatelet, e.g. clopidogrel Beta blocker ACEi Statin
How is STEMI managed?
PCI possible in 120 min?
Yes - prasugrel + PCI
No - fibrinolysis, antithrombin, ticagrelor (if ongoing myocardial ischaemia consider PCI)
What investigations should be done in suspected COPD?
Post-bronchodilator spirometry
CXR
FBC (exclude secondary polycythaemia)
BMI
What are CXR signs of COPD?
Hyperinflation
Bullae
Flat hemidiaphragm
What FEV1/FVC is diagnostic of COPD?
<0.7
What are the classifications of COPD?
FEV1>80% predicted - stage 1 (mild)
FEV1 50-79% - stage 2 (moderate)
FEV1 30-49% - stage 3 (severe)
FEV1 <30% - stage 4 (very severe)
What is involved in the general management of COPD?
Smoking cessation advice
Annual flu, one of pneumococcal vaccine
Pulmonary rehab if functionally disabled by COPD
What is the first line treatment of COPD?
SABA/SAMA
What is the second line treatment of COPD?
Steroid responsive features (atopy, eosinophilia, variation in FEV1, diurnal variation in PEFR) –> LABA + ICS (if still breathless triple therapy (LAMA, LABA, ICS)
No asthmatic features –> LABA + LAMA
What other medications may be given in stable COPD?
Theophylline
Azithromycin prophylaxis in those who do not smoke, have optimised medical management and continue to have exacerbations
How is cor pulmonale managed?
Loop diuretics
Long term oxygentherapy
Which patients with COPD should be offered long term oxygen therapy?
Those with pO2 <7.3kPa or those with pO2 7.3-8 + 1 of: secondary polycythaemia, peripheral oedema, pulmonary hypertension
What is the most common organism causing COPD?
H. influenzae
How is AECOPD managed?
Increase bronchodilator use (maybe give NEB)
30mg pred 5 days
Give amoxicillin if signs of pneumonia
What are causes of MR?
Post-MI/CAD (if papillary muscles/chordae tendinae damaged) Mitral valve prolapse IE Rheumatic fever Congenital
What are signs of MR?
Pansystolic blowing murmur best heard at apex, radiates into axilla
Quiet S1
What might you see on CXR in MR?
Cardiomegaly due to enlarged left atrium and ventricle
How is MR managed?
Nitrates, diuretics, positive inotropes, intra-aortic balloon pump
Surgery - replacement, repair
What are clinical features of aortic stenosis?
Chest pain
SoB
Syncope
Murmur - ejection systolic radiating to carotids
What are features of severe aortic stenosis?
Narrow pulse pressure Slow rising pulse Soft/absent S2 S4 Thrill LVH or failure
What are causes of aortic stenosis?
Degenerative calification
Bicuspid aortic valve
Post-rheumatic disease
HOCM
How is aortic stenosis managed?
Asymptomatic –> observe
Symptomatic –> valve replacement
Asymptomatic but valvular gradient >40mmHg and LVF –> consider surgery
What are features of AR?
Early diastolic murmur Collapsing pulse Wide pulse pressure Quincke sign (nail bed pulsation) Demusset sign (head bobbing) Austin flint (mid-diastolic murmur) in severe AR
What are causes of AR?
Rheumatic fever IE Connective tissue dx, e.g. SLE Bicuspid aortic valve Aortic dissection AS HTN
What are the signs of tricuspid regurg?
Pansystolic murmur
Pulsatile heptomegaly
Left parasternal heave
What are causes of tricuspid regurg?
RV infarction Pulmonary hypertension Rheumatic heart disease IE (esp IVDA) Ebstein anomaly Carcinoid syndrome
What are the causes of mitral stenosis?
Rheumatic fever
Rheumatic fever
Rheumatic fever
What are the features of mitral stenosis?
Mid-late diastolic murmur best heard in expiration
Loud S1
Malar flush
AF
What might you see on CXR in mitral stenosis?
LA enlargement
What are the 4 features of tetralogy of fallot?
Overriding aorta
Right ventricular outflow tract obstruction
Right ventricular hypertrophy
VSD
What are the features of acute moderate asthma?
PEFR 50-75% best or predicted
Speech normal
RR < 25 / min
Pulse < 110 bpm
What are the features of acute severe asthma?
PEFR 33 - 50% best or predicted
Can’t complete sentences
RR > 25/min
Pulse > 110 bpm
What are the features of acute life-threatening asthma?
PEFR < 33% best or predicted Oxygen sats < 92% Silent chest, cyanosis or feeble respiratory effort Bradycardia, dysrhythmia or hypotension Exhaustion, confusion or coma Normal pCO2
What are the features of near fatal asthma?
A raised pCO2 –> req. mechanical ventilation
When should you do an ABG in acute asthma?
If oxygen sats <92%
When should you do a CXR in acute asthma?
Life-threatening asthma
Suspected pneumothorax
Failure to respond to Rx
How is acute asthma managed?
15L non-rebreath mask with reservoir bag (target SpO2 94-98%)
SABA - NEB
Corticosteroids - 40-50mg pred daily until 5 days post-attack
Severe/lifethreatning - ipratropium bromide NEB, Mg sulphate IV
May require intubation/ventilation/ECMO
Who should now have objective tests for asthma?
> =5 years
How is asthma diagnosed in >=17 years?
Bronchodilator reversibility test, fractional exhaled nitric oxide test
How is asthma diagnosed in 5-17 years?
Bronchodilator reversibility test
If -ve –> FeNO test
How is asthma diagnosed in <5 years?
Clinically
What is a positive bronchodilator reversibility test?
Improvement in FEV1 12%+ (or 200ml+ improvement in adults)
What is the ladder of treatment of stable asthma in adults?
- SABA
- SABA + low dose ICS
- SABA + low dose ICS + LTRA
- SABA + low dose ICS + LABA + LTRA (if still helpful)
- SABA +/- LTRA, switch ICS/LABA for MART that includes low dose ICS
- SABA +/- LTRA + medium dose ICS MART
- SABA +/- LTRA + 1 of: high dose ICS, additional drug, e.g. theophylline, specialist referral)
What is the stepwise treatment of asthma in kids?
- SABA
- SABA + low dose ICS
- SABA + low dose ICS + LTRA
- SABA + low dose ICS + LABA + LTRA (if helpful)
- SABA + MART with low dose ICS
- SABA + moderate dose ICS MART
- SABA + 1 of: High dose ICS, theophylline, specialist referral