Intro Lectures Flashcards
What are the 6 domains of Health Quality? Consider what?
STEEEP: safe, timely, effective, efficient, equitable and patient-centred
LEAN models
What is geroscience? What is senescence? What is autophagy?
A research paradigm based in addressing the biology of ageing and biology of age-related diseases together
The condition or process of deterioration with age
Your body’s process of reusing old and damaged cell parts
What makes a safe prescription?
Date, identification of the patient, name of the drug, formulation, dose, frequency of administration, route of administration, amount to be supplied, prescribers signature, must be legible
What are never events?
Serious and avoidable medical errors for which there should be preventative measures in place to stop their occurrence
Legal responsibility for prescribing lies with who?
The doctor who signs the prescription
How should prescriptions be written? Prescription for controlled drugs have additional what? Wherever appropriate the prescriber should state what? Consideration also to what?
Written legibly in ink or otherwise so as to be indelible, should be dated, should state the name and address of the patient, the address of the prescriber, an indication of the type of of prescriber, signed in ink by the prescriber, age and DOB of the patient, age for <12 y/o
Additional legal requirements
Current weight of the child to enable the dose to be checked, dose per unit mass e.g. mg/ kg or dose per m2 body-SA
What should be noted on a prescription?
Strength/ quantity to be contained in capsules, lozenges, tablets etc- liquid preps in particular
Avoid unnecessary decimal points- <1g in mg, <1mg in micrograms
Micrograms/ nanograms/ units should not be abbreviated
The term millilitre is used
Dose and dose frequency should be used- minimum dose interval for preparations to be taken ‘as required’
doses other than multiples of 5 mL are prescribed for oral liquid preparations the dose-volume will be provided by means of an oral syringe, (except for preparations intended to be measured with a pipette). Suitable quantities:
Elixirs, Linctuses, and Paediatric Mixtures (5-mL dose), 50, 100, or 150 mL
Adult Mixtures (10 mL dose), 200 or 300 mL
Ear Drops, Eye drops, and Nasal Drops, 10 mL (or the manufacturer’s pack)
Eye Lotions, Gargles, and Mouthwashes, 200 mL
The names of drugs and preparations should be written clearly and not abbreviated
The quantity to be supplied may be stated by indicating the number of days of treatment required in the box provided on NHS forms
it is recognised that some Latin abbreviations are used.
Prescriptions for Schedule 2 and 3 controlled medicines must include specific details about the medicine such as what?
It’s name and what form it’s in, strength and dose, total quantity or number of doses, shown in both words and figures
https://www.gov.uk/government/publications/controlled-drugs-list–2
How to perform a medication review?
Assess each medicine individually, identify the indication for the medication, if the medicine requires any monitoring ensure this is up to date
Assess for any CIs and interactions for each medicine
Review the suitability of the medication in the context of the patient’s current medical presentation- can be considered by weighing up the risks and benefits of each medication
What is the STOPP START Toolkit? What risk score predicts bleeding risk in patients on anticoagulation for AF?
Screening Tool of Older People’s potentially inappropriate prescriptions
Screening tool to alert doctors to right treatments
ORBIT bleeding risk score- similar to HASBLED
2 points for what on ORBIT bleeding risk score?
Reduced Hb<13 mg/dL in men and <12 mg/dL in women, haematocrit<40% in men and <36% in women or hx of anaemia
Bleeding history
1 point for what in ORBIT bleeding risk score? Low, medium and high risk groups?
Older 75 y/o, insufficient kidney function eGFR<60mg/dL/1.73m2
Tx with an antiplatelet agent
0-2/ 3/ 4-7
Go-to model for clinical reasoning? Context of a consultation that has an impact on our clinical reasoning?
Dual process model
Location of the consultation, background noise, clinical presentation, affect of both parties, additional people in the consultation, skill of the clinician, knowledge of the patient, expectations of both parties
What is inductive reasoning? What is deductive reasoning?
The premise provides some evidence for the validity of the conclusion but not all- we induce the conclusion
Based on the assumption of two factually correct statements allowing a valid conclusion- more analytical
What is abductive reasoning?
The realistic norm of most clinical encounters- plausability is determined based on the evidence presented with the most plausible explanation sought(continuum between inductive and deductive reasoning)- fall onto this based upon the context in which we are functioning
What is probabalistic reasoning? What is categorical reasoning?
The probability of some conditions is much higher than others
If something fits a clear category then a specific approach is applicable- fits well with EBM
What is bounded rationality in relation to clinical reasoning? What are heuristics? What is cognitive biases?
The process by which we are happy that we have a good enough answer- linked to heuristics and biases
Rules of thumb or mental short cuts- can be linked to pattern recognition/ non-analytical reasoning
A systematic pattern of deviation from norm or rationality in judgement
What is the framing effect? What is anchoring bias? What is confirmation bias? What is search satisficing?
Who/ how story previous info “triage cueing”
Early salient feature- we rely on the first piece of information
Searching for info supporting hypothesis- ignoring info refuting
Where a clinician call off a search once they’ve identified a cause for a patient’s complaint
What is availability bias? What is representativeness?
Easily recalled experience dominates evidences
When we’re trying to assess how likely a certain event is, we often make our decision by assessing how similar it is to an existing mental prototype
Causes of raised ALP?
HPB disease, bone disease: Paget’s disease, osteomalacia + rickets, renal osteodystrophy, bone mets, primary bone tumour e.g. sarcoma, recent fracture, growing child- especially at puberty, pregnancy, vitamin D deficiency, drugs: penicillin derivatives, erythromycin, aminoglycosides, carbamazepine, phenoarbital, phenytoin, cetirizine, captopril, dilitiazem, felodipine, penicilliamine, sulfa drugs, OCP, steroids, MOIs, chlorpromazine
What is osteolytic bone mets characterised by? Osteoblastic? Mixed?
Destruction of normal bone present in MM, RCC, melanoma, non-small cell lung cancer, non-Hodgkin’s lymphoma, thyroid cancer or Langerhans- cell histiocytosis
Deposition of new bone, present in prostate cancer, carcinoid, small cell lung cancer, Hodgkin lymphoma or medulloblastoma
Both lesions types/ individual metastasis has both osteolytic and osteoblastic components- in BC, gastrointestinal cancers and squamous
Complications of untreated coeliac disease?
Malabsorption and malnutrition, iron, B12 and folate deficiencies, osteoporosis, lactose intolerance, mild increase in lymphoma + small bowel cancer risk, neurological disorders- ataxia, brain fog, migraines, peripheral neuropathy
Function of the spleen? Causes of splenomegaly?
Filters out old and damaged RBC, produces lymphocytes, stores RBC and platelets
Viral infections- EBV, bacterial infections- syphilis, endocarditis, parasitic- malaria, liver disease, haemolytic anaemia, metabolic- Gauchers disease(build up of fatty substances,) Niemann- Pick disease(inability to metabolise fat in cells)
When is prognosis worse in infective endocarditis? Increased mortality? Most common cause of death?
When the organism isn’t identifiable/ there’s a resistant organism
Fungal infections and prosthetic valve endocarditis
Intractable heart failure
Causes of AF? What can amiodarone cause? Suspect what if new/ progressive SOB?
Stretch: HTN, PE, cardiomegaly
Rub: pericarditis, tamponade, tumour
Toxins: alcohol, drugs, infection
Thyrotoxicity and hepatotoxicity
Pneumonitis
What does the liver do?
Protein, clotting factors, bile and glucagon
Detoxification: alcohol, drugs, ammonia, bilirubin
Storage: energy, vitamins and minerals
Part of the immune system
Components of acute liver failure?
A complex multisystem illness occurs after an insult to the liver: jaundice, coagulopathy INR>1.5, hepatic encephalopathy, absence of chronic liver, within 12 weeks
When does hyperacute acute liver failure occur? Acute? Sub acute? Causes?
Within 7 days (best prognosis)- paracetamol, drugs, viral hepatitis
8-28 days- viral hepatitis, ischaemic hepatitis
29 days- 12 weeks- seronegative and autoimmune hepatitis
Most common cause of ALF in the UK and in developing countries? Types of viral hepatitis? Rarely what viruses?
Paracetamol, viral hepatitis, mushrooms- amanita phalloides
Paracetamol, viral hepatitis, mushrooms- amanita phalloides
A, E and B
Herpes simplex virus, CMV, EBV and parvoviruses
Rare causes of ALF?
Ischaemic hepatitis, AI hepatitis, acute fatty liver of pregnancy, Wilson’s disease, Budd Chiari syndrome, mushrooms- amanita phalloides, post hepatectomy
Factors leading to poor prognosis without liver transplant for ALF?
Female 20-40 y/o
Recent jaundice and coagulopathy with previously normal LFT, liver biopsy, trial of steroids, liver transplant
Ix for hepatitis A? Hep B+D? Hep E? Paracetamol? Idiosyncratic drug reactions? Autoimmune? Pregnancy fatty liver? HELLP syndrome? Toxaemia? Wilson’s disease? Budd-Chiari syndrome? Malignancy? Ischaemic hepatitis?
IgM anti-HAV
HBsAg- may be negative, IgM anti-core, HBV DNA
Anti-HEV
Drug concs in blood
Eosinophil count
Autoantibodies, IgGs
US, uric acid, histology
Platelet count
Serum transaminases
Urinary copper, ceruloplasmin, slit-lamp examination
US or venography
Imaging and histology
Transaminases
Factors increasing paracetamol hepatotoxicity?
Staggered overdose, excessive alcohol consumption, malnutrition, HIV, cancer, CLD, liver enzyme inducers drug- antiepileptics, rifampicin, spironolactone
POD treatment?
IV NAC, IV crystalloids, IV broad spec ABx and antifungal if patient has encephalopathy, call liver transplant centre
Complications of ALF?
Grades 1-4 of encephalopathy, high levels of ammonia may–> cerebral oedema
CR= hypotension, acute respiratory distress syndrome and pneumonia
Renal failure- multifactorial
Sepsis- immune-suppressed, bacterial and fungal infection in 80% and 30%
Malnutrition- hypermetabolic state
Who is the critically ill patient? How to assess them?
Patient with impaired organ failure which can progress to organ failure and the need for critical care treatment
ABCDE- do not move on quickly from one thing to the next: look, listen, feel
Causes of gurgling, snoring, stridor, wheeze, silent airway noises?
Secretions, tongue obstructing pharynx, perilaryngeal obstruction, airways collapse, complete obstruction
Tx for airway obstruction? Caution with what? What if gurgling noises continue?
Headtilt and chintilt, jawthrust
Gurgling and secretions= gentle suction
C-spine injury
Guedel airway
Other options for airway management?
Recovery position, nasal airway, intubation, gentle suction
Things to consider for breathing in A-E approach for look? Listen? Feel?
RR, dyspnoea, SATs, cyanosis, symmetry of chest expansion
Air entry, added sounds
Trachea, percussion, symmetry of chest expansion, generally before listening
Breathing treatments? If respiration absent or inadequate?
High flow O2 with reservoir mask + 15 l/ min O2, bag and mask ventilation
Things to look for in circulation part of A-E approach? Listen? Feel?
Perfusion- CRT, SATs, peripheral cyanosis, bleeding, other organ perfusion, brain: reduced LOC, kidneys urine output, trauma/ surgical patient= blood or fluid loss
Heart sounds
Peripheral= radial and central= femoral and carotid, rate, volume, rhythm, BP
When is someone hypotensive?
If SBP<90mmHg systolic, >40mmHg lower than normal, MAP<65mmHg(DBP+ pulse pressure/3)
How to tx circulatory problems? Circulation tx aims? After fluid challenge check for what volume overload signs? Max volume to give? If still hypotensive?
Fluid challenges- large bore IV access, take bloods- FBC, U&E, coag, cultures, glucose
Fluid replacement, haemorrhage control, restoration of tissue perfusion
Increases resp distress, bulging neck veins, crackles in the chest
2000mls- may need critical care for invasive monitoring and vasoactive drugs
3 components to measure for disability in A-E approach? Exposure? Scoring system designed to identify early patients at risk of deterioration? If NEW 2>7, obs how often?
Level of consciousness, pupils, glucose
Focussed clinical examination
NEWS 2- RR, O2, pulse and BP, level of consciousness, temperature
Every 30 minutes- escalate to nurse in charge, immediate medical/ HOOH review within 15 minutes, escalation to senior clinician if no attendance within 30 minutes, hourly fluid monitoring, complete sepsis screening tool, critical care outreach team
No improvement after 2 hours= contact patient’s consultant to review management plan
What is sepsis defined as? Patients with suspected infection who are likely to have a prolonged ICU stay or to die in the hospital can be promptly identified at the bedside with what? What is septic shock?
Life-threatening organ dysfunction caused by a dysregulated host response to infection- acute change in total SOFA score 2 points consequent to that infection
qSOFA i.e. alteration in mental status, systolic BP 100mmHg or RR 22/ min
Subset of sepsis in which underlying circulatory and cellular/ metabolic abnormalities are profound enough to increase mortality- persisting hypotension requiring vasopressors to maintain MAP 65mmHg and having serum lactate>2mmol/L despite adequate volume resus
Inflammatory cytokines involved in sepsis? Recommendations for sepsis?
TNF, IL-1, IL-6, IL-8
ABx within 1 hour- MRSA, infusion> bolus, don’t rely on qSOFA alone, use lactate to guide fluid resus, 30ml/kg crystalloid within 3 hours- not saline
HFNO>NIV
6ml/kg Vt
30cmH20 peak pressure
PEEP good
Prone >12hrs
Bolus NMBD > infusions
Cardiovascular aims in sepsis?
CO Monitoring ?POCUS ?LiDCO
Aim MAP >65mmHg
Noradrenaline +/- Vasopressin +/- Adrenaline
Dobutamine for CF
Add steroids if you’re not winning
Start vasopressors peripherally of delay to central access
Arterial line
Any patient with a SHEWS>3 should be screened for what? Anyone with red flags for sepsis should get what done?
Sepsis
BUFALO 6- blood cultures, urine output, IV fluid challenges, broad spec Abx, serum lactate, high flow oxygen
What is osmolality? Osmolarity? Tonicity?
Osmoles per kg of solvent- usually water
Osmoles per litre
Ability of a solution to cause water movement
Examples of crystalloid fluids? Colloids- artificial, organic?
Any salty water- 0.9% saline, Hartmann’s, or not: 5% dextrose, 10% dextrose
Gelofusine, Hetastarch
Blood, albumin solutions
Requirements of sodium and potassium in a 70kg adult? Approach to fluid prescribing?
70-140mmols, 70mmols
Calculate deficit, ongoing requirements, monitor results of therapy
New fluid charts
Causes of coma? (CNS, CVR, Resp, metabolic, pharmacological)?
Seizure, infection, SOL, CVA
Low CO state
Hypoxia, hypercapnia, CO poisoning
Uraemia, hepatic encephalopathy, hypoglycaemia, hypo/ hypernatraemia, hypothyroidism, hypothermia
Opiates, benzos, tricyclics & alcohol
How to assess level of consciousness? What does AVPU stand for?
AVPU, GCS, glucose
Alert, voice, pain, unresponsive
What does a secondary survey involve?
Head-to-toe evaluation of the trauma patient and involves taking a thorough history and performing a comprehensive examination
What RFs should warrant a CT head scan within 1 hour of them identified after sustaining a head injury?
GCS<13 on initial assessment
GCS<15 at 2 hours after injury on assessment in the ED
Suspected open or depressed skull fracture, any sign of basal skull fracture, post-traumatic seizure, focal neurological deficit, more than one episode of vomiting since the head injury
Risks of EDH?
Airway at risk
Secondary brain injury- hypo/ hyperperfusion, autoregulation loss/ CO2 reactivity loss, vasospasm, oedema/ inflammation, metabolic dysfunction, excitotoxicity, oxidative stress, necrosis/ apoptosis
Indications for intubation?
Failure to maintain and protect airway- GCS 8 and below, seizures, hypoxia, hypercarbia, agitation, pain (polytrauma pts,) anticipatory
What does the Monroe-Kellie doctrine describe? What 3 components exist in equilibrium within the cranium? If the volume of one increases, what must happen? An increase of any one of these components will also cause what? Normal ICP value? Above what value may intervention be required?
The relationship between the contents of the cranium and intracranial pressure
Blood volume, brain parenchyma volume, CSF fluid
The volume of another must be decrease
An increase in pressure
5-15mmHg, 20mmHg
What are the main compensatory mechanisms that can be used to maintain a normal ICP? What happens when the equilibrium is disrupted? What’s it called when the brain parenchyma shifts position?
Increased drainage of CSF fluid/ blood from the intracranial cavity
ICP will begin to rise
Herniation