initial revision points (mainly renal) Flashcards
what are the potential causes of secondary hypertension?
endocrine disorders:
- Cushing’s
- Conns
- phechromocytoma
renal a. stenosis
coartation of the aorta
acromegaly
A 36 year old female is seen in clinic because she is complaint of moderate hearing loss that began 4 months ago. She has become aware of an annoying ringing sound in her right ear. She denies having any recent ear infections, fevers, runny nose, or any sick contacts. She explains that she does not use Q-tips and has never had any head trauma. Her family history is notable for her father who had bilateral hearing loss that was attributed to old age. A physical exam reveals that both auditory canals are patent, and that the tympanic membranes are grey in color and each have a well visualized light reflex. Hearing is dimisnehd on the right side during the finger rub test. A neurological exam reveals right sided facial numbness, right sided facial drooping, and a decreased afferent and efferent corneal reflex on the right side. What might be responsible for the patient’s symptoms?
Hearing loss + facial paresis + absent corneal reflex + facial numbness = acoustic neuroma (in cerebellopontine angle, affecting CNV, CNVII, and CNVIII)
what initial Ix are appropriate for a returning traveler with 2day hx of headache//diarrhoea/mailaise/fever/myalgia?
FBC U+Es blood cultures stool cultures thick and thin films will look for malaria parasites and aid distinguishing the differential diagnosis (inlcuding typhoid, gastroenteritis, chikungunya, influenza, malaria, urosepsis)
LFTs CRP MSU culture throat swab for viruses serum for lab testing for chikingunya and other tropical infections would be useful
HIV should not be missed
CT brain if localising neurological signs (but not 1st line Ix)
plasmodium falciparum is the commonest cause of malaria in sub-Saharan Africa. it can cause severe malaria. what are the symptoms?
cerebral involvement (fits/ reduced concious level
severe anaemia
renal failure
hypoglycaemia
pulmonary oedema
DIC/ bleeding
hypovolaemia
acidosis
hyperparasitaemia
what is the management of falciparum malaria?
quinine (oral or IV)
oral for 5-7days, together with or followed by either doxycycline for 7days or clindamycin for 7days
*interference with the parasites ability to digest haemoglobin
what public health action should you take with a pt with acute meningococcal meningitis?
-ensure ot is being managed in a side-room with droplet precautions (initially infectious via droplet route, until he has had 24 hrs appropriate antimicrobial therapy)
inform the hospital infection control team
inform the local health protection consultant by phone even if out of hours
treat his gilfriend who is in the hospital with him with prophalactic antibiotics
what rash is associated with meningococcal sepsis
purpuric and non-blanching
- AKA petechial
- also seen in other forms of bacterial sespsis e.g. pneumococcal/staphylococcal
how would you treat an adult pt with suspected menincococcal meningitis?
ceftriaxone
*treating N.meningitidis, but covering the possibility of oneumococcal and staphylococcal disease. if it is confirmed N.meningitidis then benzylpenicillin may be best
what two organisms are likely to cause cellulitis
staph aureus strep pyogenes (A)
what medication is usually used to treat proteinuria as there is evidence that it prevents progression to kidney failure?
ACEi/ARB
ciprofloxacin, gentamicin, floxacillin
sensitive to staph aureus
what is the treatment of symtomatic bradycardia?
atropine - anti-muscarinic
> also used in eye drops to dilate pupil
used in Rx of diarrhoea
what is metabolic syndrome?
a combination of cardiovascular risks
- diagnose 3/5 of the following: high BP (130/85), obesity (BMI >30), high plasma glucose, high triglycerides, reduced HSLs, T2DM, NFLD, Ca
- symptoms = brain fog/ lack of concentration, fatigue, acanthosis nigricans (hyperpigmentation under armpits)
what is the test if you suspect metabolic syndrome?
oral glucose tolerance test
what are the causes of the following?
- radial-radial delay
- collapsing pulse
- slow-rising pulse
- aortic dissection, aortic coarcticaton, subclavian artery stenosis
- aortic regurg
- aortic stenosis
how do you calculate the anion gap?
(+vely charged ions) - (-vely charged ions)
normal anion gap is 8-14 mmol/L
NB: primarily used for the evaluation of metabolic acidosis. urea and creatinine are not ions
list causes of a normal anion gap or hyperchloraemic metabolic acidosis (decrease in bicarbonate concentration, and an increase in plasma chloride concentration)
- GI bicarbonate loss: diarrhoea, uterosigmoidostomy, fistula
- renal tubular acidosis
- drugs: acetazolamide (carbonic anhydrase inhibitor)
- addisons disease
list causes of a raised anion gap metabolic acidosis
- lactate: shock, hypoxia
- ketones: diabetic ketoacidosis, alcohol
- urate: renal failure
- chronic paracetamol use
what is the most common type of kidney stone?
calcium oxalate:
- intermittent sharp flank pain causing restlessness in pts
- haematuria
- nausea
- hypercalciuria and hyperparathyroidism, obesity = risk factors
primary amyloidosis can be seen in patients with immune dyscrasias such as multiple myeloma. amyloidosis is a term describing the extracellular deposition of an insoluble fibrillar protein termed amyloid. it can affect any organ in the body. how is it diagnoses?
via biopsy with Congo red staining showing apple-green birefringence under polarised light
what causes sterile pyuria ?
broadly defined as the presence of leucocytes in the urine in absence of demonstrable UTI. e.g. chlamydia/gonorrhoea, kidney stones,
adult pKD increases the risk of brain haemorrhage. what is the most likely cause of the bleed?
ruptured berry aneurysm
what is Sheehan’s syndrome?
occurs due to pituitary ischaemia secondary to blood loss during childbirth. it presents with symptoms consistent with global hypopititarism, such as agalactorrhoea (prolactin), amenorrhoea (FSH and LH), cold intolerance and constipation (thyroid hormones) and weight loss (steroid hormones)
what alpha antagonist is used to help hot flushes in menapausa?
clonadine - alternative to HRT
- alpha 2 selective drug (adrenergic receptors found on neurons and responsible for decreasing NT release)
- use in HTN Rx
- prevent vasoconstriction
following fluid resuscitation (0.9% sodium chloride) and analgesics… what tests are important in the immediate management of a hip fracture and long lie in an elderly pt?
- blood sugar (vital to check in any sick pt, easily correctable)
- ECG (give clue to the cause of the problem i.e. MI or electrolyte disturbance)
- group and save (possibility bled into muscle)
- pass urinary catheter (clue of Dx +/or allow accurate fluid balance assessment
- bone (calcium, phosphare, alkaline phosphate) and liver profiles can give a clue as to the cause of the problem e.g. hypercalcaemia in malignancy or hypocalcaemia in crush injury
- CK
- FBC
- U+E
what is the emergency Rx of hyperkalaemia?
calcium chloride or calcium gluconate followed by insulin and dextrose
- the later activate the co-transporters on cells which move K+ back into cells and lowers serum K+ for 30-45mins. Calcium stabalises the myocardium
what drug is completelt contraindicated in AKI?
NSAIDs
what is flumazenil?
benzodiazepine antidote
what are the indications for urgent dialysis?
- uraemic encephalopathy:
- usually urea >40 - hyperkalaemia resistant to medical Rx:
- insulin/dextrose doesnt get rid of the K+… appropriate use of IV fluids for rehydration will achieve K+ loss in most cases. check K+ 4 hrs after insulin/dextrose and repeat if still high. after 2-3 rounds it is resistant - metabolic acidosis uncontrolled by medical Rx:
- usually will resolve with appropriate use of fluids (0.9% NaCl) to restore circulating volume.
- once rehydration has begun could consider giving IV sodium bicarbonate - pulmonary oedema with oliguria:
- most cases of AKI result in oliguria - usually improves with fluid rehydration. however, oliguria + fluid overload can develope (diuretics will only work if there is urine ouput)
- one of the commonest reasons for acute haemodialysis
what type of renal failure is suggested with low Hb, low Ca++ and elevated phosphate
CKD
- suggest he has significant renal impairment GFR <30mls/min for several months
what features distinguish acute and chronic bladder outflow obstruction?
chronic - large bladder up to umbilicus/ abdo mass. painless.
acute - very very uncomfortable/ wouldnt let bladder stretch as much
what Ix would be helpful after a urinary catheter has been placed in pt with chronic bladder outflow obstruction?
*aim towards uncovering where the obstruction is:
- USS KUB (usually 1st)
- CT chest abdo pelvis (will give more info about any lesions as well as distant mets)
- PSA (useful to distinguish benign from malignant. BUT must be done before catheter or 2 weeks after)
- MSU/CSU (exclude and treat infection is important. often co-exist as urine becomes stagnant in a non-draining system. also check bowel function as constipation makes this worse)
with low GFR phosphate excretion by the kidney is considerably reduced. what are the consequences of hyperphosphataemia?
itching
reduced production of active calcitriol
hypocalcaemia
hyperparathyroisism
what interventions are improtant in the long term managment of CKD?
- low phosphate diet
- review in a pre-dialysis clinic
- renal transplant consideration/work up in younger pts
- strict BP control
- referral to urology team
- treat renal anaemia with regular SC injections of recombinant EPO
- resection of prostate to allow catheter removal
40 year old female with low TSH, high T4 and raised CRP and ESR. one month hx of palpitations, fever and weight loss. radio-iodine uptake on thyroid uptake scan. what is the Dx?
acute thyroiditis
rare acute inflammatory disease of the thyroid, usually caused by a virus. It typically presents with discomfort in the thyroid gland, alongside symptoms of hyperthyroidism and later symptoms of hypothyroidism. Other symptoms may include fever, fatigue, weakness, hoarse voice and difficulty swallowing
what should you do to prevent DVT/PE in an imobile acute stroke pt?
intermittent pneumonatic compression (flowtrons) within 3days of admission to hospital.
(not be routinely given LMWH or graduated compression stockings. LMWH increases the risk of bleeding into the intracranial infarct (haemorrhagic transformation). There is no evidence to suggest graduated compression stockings have a significant impact on VTE prevention in stroke patients)
what is the definitive treatment of diabetic ketoacidosis?
fixed rate insulin given at a rate of 0.1units/kg/hr
gullian-barre syndrome
acute inflammatory demyelinating polyneuropathy
- a few weeks after an infection a symmetrical ascending weakness starts
- triggers = cmv (MC), campylobacter jejuni ( mycoplasma, zoster, HIV, EBV)
- trigger causes antibodies that attack nerves
- proximal muscles are more affected, eg trunk, respiratory and CN’s (esp VII)
- progressive phase for up to 4weeks, then recovery
- It is important to monitor FVC (spirometry) as the condition can result in diaphragmatic weakness which requires urgent discussion with ITU for intubation and ventilation
- Rx = plasmapheresis or IV Immunoglobulin and has a good prognosis overall
borehaaves syndrome
oesophageal rupture caused by vomiting, such patients would be very unwell with hypotension, tachycardia, tachypnoea and dyspnoea due to rupture often leaking oesophageal contents into the mediastinum. Boerhaave syndrome also typically presents with pain that extends retrosternally
list causes of peripheral neuropathy
A = alcohol B = B12/folate definciency C = cancer and CKD D = diabetes and drugs (amiaderone) E = every vasculitis - hypothyroidism
come left and right BBB
LBBB:
- prolonged QRS (normal = <120ms)
- deep S wave in V1 due to the right to left direction of depolarisation
- notched R wave in V6
- rarely occurs without background CVS such as HTN, AS, IHD
RBBB:
- prolonged QRS
- additional R wave in V1
- wide slurred S wave in V6
what is the most important Ix to perform if the likely diagnosis is subconjunctival haemorrhage?
blood pressure
- RFs for this condition are age, female
- usually idiopathic but can be trauma, HTN, bleeding disorders, wearing lenses
- in the absence of trauma, BP must be checked!
- FBC and coag studies would be appropriate in recurrent subcon haem.
discuss the following brain tumours:
- glioblastoma multiforme
- meningioma
- pilocytic astrocytoma
- craniopharyngioma
- schwannomas
- most common type of malignant primary brain tumour. also the most aggresisve. more common in older men and median survival is 15months
- common benign brain tumour. can still be problematic if it grows and invades improtant local structures. in some cases can become malignant
- benign brain tumor that arises from astrocytes, the supportive cells in the nervous system. slow-growing brain tumour that occurs mostly in children and teenagers
- slow growing benign tumour that grows near pituitary gland. causing problems with its function
- benign tumours of the cells which wrap around nerves to produce myelin. can arise intraranially or around peripheral nerves
what are the indication for urgent CT head (within 1 hour of injury)?
- GCS <13 on initial assessment
- GCS <15 at 2hours after injury on assessment in ED
- suspected open or decompressed skull fracture
- any sign of base of skull fracture
- post-traumatic seizure
- focal neurological deficit
- more than one episode of vomiting since head injury
when should you perform ct head within 8hrs of head injury?
- currently on anticoag Rx
- loss of conciousness or amnesia since HI
- RFs present: age >65/ hx of bleeding or clotting disorder/ dangerous mechanism of injury/ >30mins of retrograde amnesia of events immediately before HI
what is the first line treatment of iron def anaemia
oral ferrous sulfate 200mg td
ferius fumerare or ferrous gluconate are 2nd line if 1st not tolerated. repeat FBC at 2-4 weeks once Rx has started. likely 3mnth of Rx
what are indications for acute dialysis?
severe metabolic acidosis pulmonary oedema serum creatinine >300 hyperkalaemia uraemia
what is first line Ix of dysphagia?
endoscopy 2ww
(barium swallow not the gold-standard. in achalasia shows a narrowing of the lower oesophagus with proximal dilation ‘bird beak sign’)
what is the gold-standard diagnostic test for achalasia?
manometry
would demonstrate increased pressure across the lower oesophageal sphincter
what hormone abnormality contributes to lactating/no periods… but not pregnant?
hyperprolactinaemia
- prolactin is secreted from the anterior pituitary and is responsible for stimulating milk production from the mammary glands. it also inhibits FSH and therefore prevents ovulation, often presenting with amenorrhoea
- causes = pregnancy, abnormalities of the pituitary gland e.g. prolactin-secreting pituitary adenomas, various meds e.g. dopamine receptor blockers (i.e. risperidone (anti-psychotic)), those affecting the thyroid
gilberts syndrome
inherited metabolic disorder that causes intermittent, isolated raised unconjugated bilirubin levels, due to defective conjugating enzymes in the liver. patients with GS have otherwise normal LFTS and no evidence of haemolysis. clinical examination reveals no hepatosplenomegaly or stigmata of chronic liver disease
what is the ASIA score used for?
assessment of neurological and functional status on patients with spinal cord injury; also to quantify the consequences of SCI
identifies the level of injury (C1-S5) and severity (A-E)
examination of the pt’s neurological system - sensory tracts, motor power, refleces to establish the last intact spinal cord level before damage occurs . the severity can be assessed on if sensory or motor or both functions are lost
A- complete. no motor or sensory function in the lowest sacral segment S4-5
B- incomplete. sensory function below neurologic level and in S4-5, no motor function below neurologic level
C- incomplete. motor function is preserved below n.level and > 1/2 of the key muscle groups below the n.level have a muscle grade <3
D- incomplete. motor function is preserved below n.level and at least half of the key muscle groups below the n.level have a muscle grade >3
E- normal. sensory and motor function is normal
what is the first line anti-emetic in parkinsons?
domperidone!
peripherally acting anti-dopaminergic medicine which works by increasing gut emptying. doesnt cross BBB and is considered safe in the context of PD. metoclopramide is a similar agent but also acts centrally, potentially worsening the PD
what is the first line imagine investigation for suspecred RCC (flank pn; haematuria; palpable abdo mass)?
abdo CT with contrast
what Ix is first line for renal colic?
CT KUB
USS KUB in children
what is a common complication of liver cirrhosis and presents with abdominal pain, vomiting, ascites and high fevers in a patient with underlying risk factors
spontaneous bacterial peritonitis
- can become septic and rapidly decompensate
- Ix = paracentesis ans ascited fluid sent for microscopy, culture/sensitivities
- An ascitic absolute neutrophil count of 250/mm3 or greater is diagnostic of SBP
what ecg findings suggest hyperkalaemia
tall tented twaves increased PR small or absent pwaves widened QRS sine wave pattern (can --> VF)
what medications should be stoped in hyperkalaemia
spirnolactone
ACEi/ARB
NSAID
trimethaprime
what are the top 3 medications to cause hyponatraemia?
diuretics
SSRI
PPI
