LEARN LEARN LEARN Flashcards
Antihistamine used in anaphylaxis
Chlorphenamine- piriton
(sedating)
Pheochromocytoma management
-
Initial
- alpha blockade e.g. phenoxybenzamine
- unopposed alpha-adrenergic receptor stimulation can precipitate a hypertensive crisis.
- beta blockade
- alpha blockade e.g. phenoxybenzamine
-
Definitive
- Surgical resection of tumour
how does renal cell carcinoma cause hypertension
- Renin secreting RCC
- physical compression of renal artery
management of COVID-19 in patient admitted
- Oxygen supplementation, some going on to CPAP or invasive ventilation
- Dexamethasone
- Antibiotics may be needed if suspected superadded bacterial infection
- REGEN -COV (antibody therapy for immunocompromised)
signet ring signs
- bronchiectasis
- gastric cancer
Allergic bronchopulmonary aspergillosis (ABPA)
- a combination of types 1 and 3 hypersensitivity reactions following inhalation of fungal spores i.e. it is not a fungal infection
- Repeated damage from these immunological reactions leads to bronchiectasis (often upper lobe)
- high IgE
Criteria for safe asthma discharge after exacerbation
- PEFR >75%
- Stop regular nebulisers for 24 hours prior to discharge
- Inpatient asthma nurse review to reassess inhaler technique and adherence
- Provide PEFR meter and written asthma action plan
- At least 5 days oral prednisolone
- GP follow up within 2 working days
- Respiratory Clinic follow up within 4 weeks
- For severe or worse, consider psychosocial factors
treatment if you suspect tension pneumothorax
if you suspect tension- do not wait to x-ray
Emergency needle decompression
- First site
- 2nd intercostal space, mid-clavicular line
- Just lateral to the nipple
- If first site doesn’t work
- 5th ICS
- Anterior axillary line, lateral to the nipple
- Remember to go over the rib to avoid the nerve, artery and vein bundle
investigation for TB
Tuberculosis can be very difficult to diagnose. The bacteria grows very slowly in a culture compared with other bacteria. It also can’t be stained with traditional gram stains and requires specialist stains like the Ziehl-Neelsen stain.
There are two tests for an immune response to TB caused by previous, latent or active TB. These are the Mantoux test and interferon‑gamma release assay. In patients where the active disease is suspected a chest xray and cultures are used to support the diagnosis.
Mantoux Test
The Mantoux test is used to look for a previous immune response to TB. This indicates possible previous vaccination, latent or active TB.
This involves injecting tuberculin into the intradermal space on the forearm. Tuberculin is a collection of tuberculosis proteins that have been isolated from the bacteria. The infection does not contain any live bacteria.
Injecting the tuberculin creates a bleb under the skin. After 72 hours the test is “read”. This involves measuring the induration of the skin at the site of the injection. NICE suggest considering an induration of 5mm or more a positive result. After a positive result they should be assessed for active disease.
Interferon-Gamma Release Assays (IGRAs)
This test involves taking a sample of blood and mixing it with antigens from the TB bacteria. In a person that has had previous contact with TB the white blood cells have become sensitised to those antigens and they will release interferon-gamma as part of an immune response. If interferon-gamma is released from the white blood cells then this is considered a positive result.
The IGRA test is used in patients that do not have features of active TB but do have a positive Mantoux test to confirm a diagnosis of latent TB.
management of pneumothorax
No shortness of breath and less than a 2cm rim of air on the chest x-ray:
- No treatment is required as it will spontaneously resolve
- Follow up in 2 – 4 weeks is recommended
Shortness of breath and/or more than a 2cm rim of air on the chest x-ray:
- Aspiration followed by reassessment
- When aspiration fails twice, a chest drain is required
chest drain insertion for pneumothorax
Chest drains can be inserted in the emergency department or on the ward. They are inserted in the “triangle of safety”. This triangle is formed by:
- The 5th intercostal space (or the inferior nipple line)
- The midaxillary line (or the lateral edge of the latissimus dorsi)
- The anterior axillary line (or the lateral edge of the pectoralis major)
The needle is inserted just above the rib to avoid the neurovascular bundle that runs just below the rib. Once the chest drain is inserted, obtain a chest x-ray to check the positioning.
how does chest drain work
The external end of the drain is placed underwater, creating a seal to prevent air from flowing back through the drain, into the chest. Air can exit the chest cavity and bubble through the water, but the water prevents air from re-entering the drain and chest. During normal respiration, the water in the drain will rise and fall due to changes in pressure in the chest (described as “swinging”).
signs of acute cholecystitis on CT
gallbladder distention, wall thickening
DMARD used in RA
anti- TNF e.g. infliximab
DD for inguinal lump
saphena varix
lymphadenopathy
lipoma
femoral artery aneurysm
reason to have epidural over general anaesthetic
- allergy to GA
- better post op pain
which layers of tissue is lidocaine injected between in an epidural
arachnoid layer and pia mater→ subarachnoid space
the layers of anatomy that are traversed (from posterior to anterior) are skin, subcutaneous fat, supraspinous ligament, interspinous ligament, ligamentum flavum, dura mater, subdural space, arachnoid mater, and finally the subarachnoid space.
layers which surround the spinal cord
dura mater
arachnoid mater
pia mater (closest to the spinal cord)
common nerve injured in knee surgery and its sign
common peroneal or common fibular
- foot drop
- numbness to the medial leg and heel
acute pancreatitis management
- Initial resuscitation (ABCDE approach)
- IV fluids
- Nil by mouth
- Analgesia
- Careful monitoring
- Treatment of gallstones in gallstone pancreatitis (ERCP / cholecystectomy)
- Antibiotics if there is evidence of a specific infection (e.g., abscess or infected necrotic area)
- Treatment of complications (e.g., endoscopic or percutaneous drainage of large collections)
which maneuver is used to diagnosed BPPV
Dix- Hallpike maneuver
outline the dix hallpike maneuver
which test is used to manage BPPV
Epley maneuver
cause of BPPV
BPPV is caused by crystals of calcium carbonate that become displaced into the semicircular canals.
- They may be displaced by a viral infection, head trauma, ageing or without a clear cause.
The crystals disrupt the normal flow of endolymph through the canals, confusing the vestibular system. Head movement creates the flow of endolymph in the canals, triggering episodes of vertigo.
preventing episodes of BPPV
move head slowly
management of constipation in children
- Correct any reversible contributing factors, recommend a high fibre diet and good hydration
- Start laxatives (movicol/ macrogol is first line)
- Faecal impaction may require a disimpaction regimen with high doses of laxatives at first
behaviour techniques for children with constipation
- bowel diary
- reward chart
- scheduling visits
health visitor
offer support and encouragement to families through the early years from pregnancy and birth to primary school
COCP MOA
- stop ovulation
- thickens cervical mucus
buergers disease
also known as thromboangiitis obliterans.
Inflammatory condition that causes thrombus formation in the small and medium-sized blood vessels in the distal arterial system (affecting the hands and feet).
RF
- young men
- smokers
- pain
Presentation
- painful, blue discolouration to the fingertips or tips of the toes. The pain is often worse at night. This may progress to ulcers, gangrene and amputation.
Management
- stop smoking!!!!
Buergers test
Buerger’s test is used to assess the adequacy of the arterial supply to the leg. It is performed in two stages.
With the patient supine, elevate both legs to an angle of 45 degrees and hold for one to two minutes. Observe the color of the feet. Pallor indicates ischaemia. It occurs when the peripheral arterial pressure is inadequate to overcome the effects of gravity. The poorer the arterial supply, the less the angle to which the legs have to be raised for them to become pale.
Then sit the patient up and ask them to hang their legs down over the side of the bed at an angle of 90 degrees. Gravity aids blood flow and colour returns in the ischaemic leg. The skin at first becomes blue, as blood is deoxygenated in its passage through the ischaemic tissue, and then red, due to reactive hyperaemia from post-hypoxic vasodilatation.
Both legs are examined simultaneously as the changes are most obvious when one leg has a normal circulation.
why does hyperaemia occur in buergers test
due to post-hypoxic vasodilation
- vasodilatory mediaters released by ischaemic tissue
A 75 year old woman is brought into the emergency department following a fall down 2 flights of stairs. She is opening her eyes to voice. She fails to answer your questions but is calling out random words and is unable to form a sentence. She moans and withdraws from painful stimuli. What is her GCS score?
E3 V3 M3
lowest score you can get is 3! do not be tricked
ASA anaesthetics
5
A 67 year old gentleman has just undergone an emergency Hartmann’s procedure for a perforated rectal cancer. He is now waiting in recovery. He has had a 1 litre bag of 0.9% saline IV over the last 24 hours with no oral intake. His catheter has drained 1500mL over the last 24 hours. His weight is 70kg.
Which of the following would be the most appropriate fluid volume to prescribe him over the next 24 hours?
2.5 l
need to think about maintenance and deficit
types of brain bleeds
Extradural- trauma and lucid interval before collapse
Subdural- older people- bridging veins
Arachnoid- AVN/berry aneurys, thunderclap headache
classic metastasis of renal cell carcinoma
“Cannonball metastases” in the lungs are a classic feature of metastatic renal cell carcinoma. These appear as clearly-defined circular opacities scattered throughout the lung fields on a chest x-ray.
paraneoplastic feature of renal cell carcinoma
- Hypertension – due to various factors, including increased renin secretion, polycythaemia and physical compression
- Polycythaemia – due to secretion of unregulated erythropoietin
- Hypercalcaemia – due to secretion of a hormone that mimics the action of parathyroid hormone
adjuvant intravesical therapy in those with non-muscle invasive bladder cancer during TURBT (transitional cell carcinoma of the bladder)
such as Bacille Calmette-Guerin (BCG) or Mitomycin C
RCC CAN NOT BE TREATED WITH
chemo
- radical nephrostomy
management of muscle invasive bladder cancer
radical cystectomy
+ cisplatin
diagnosis of T1DM
Q
diagnosis of type 1 diabetes
A
- Elevated plasma glucose- HbA1C, FBG, random plasma glucose of higher than 11.1mmol/l
- Presence of autoantibodies
- Islet cells- GAD65
- Presence of ketones is an indication for immediate insulin therapy
diagnosis of T1DM
Q
diagnosis of type 1 diabetes
A
- Elevated plasma glucose- HbA1C, FBG, random plasma glucose of higher than 11.1mmol/l
- Presence of autoantibodies
- Islet cells- GAD65
- Presence of ketones is an indication for immediate insulin therapy
HBsAg (Hepatitis B surface antigen)
- means person has Hep B and is detecting part of the virus, the surface antigen
- does not tell you if new or old though (acute vs chronic)
- you are infectious
- first marker in Hep B. appears around 1month
anti-HBs or HBsAb (Hepatitis B surface antibody)
Means you are protected against the virus either by:
- Have had Hep B vaccine
- Had Hep B in the past and are recovered
- you are not infected, infectious and considered immune
- appears after HbsAg disappears in those that have cleared the virus
anti-HBc or HBcAb (Hepatitis B core antibody)
- shows past or current Hep B infection
- you are not protected
- remains positive forever as marker of previous Hep B infection
Hepatitis B core antibody can be divided into
IgM- new acute HepB infection
IgG- remains positive indefinitely as a marker of past HBV infection
HBeAg (hepatitis B e-antigen)
means new acute Hep B infection
susceptible
immune due to natural infection
immune due to hepatitis B vaccination
acutely infected
chronically infected
- IgM negative i.e. had the infection for more than 6 months
A 66-year-old man presents with ongoing lower urinary tract symptoms despite starting Tamsulosin and Finasteride. He is listed for a transurethral resection of the prostate (TURP) which is performed under general anaesthesia due to patient preference. Post-operatively, he becomes increasingly restless and confused. Observations show the patient is bradycardic and his blood pressure is starting to fall.
Which electrolyte disturbance is responsible for his symptoms?
TURP syndrome
hyponatraemia due to absoprtion of irrigation fluids used intraoperatively
why is NaCL not used in TURP and what is used
NaCl conducts electricity- monopolar dithermy
- glycine is used
- however can cause TURP syndrome
management of gonorrhea
IM ceftriaxone
PO doxy
(will also cover chlamydia)
types of emolient used for eczema and psoriasis
- Ointments- has the highest oil content, therefor most effective at treating dry skin
-
Creams- lighter and easier to leave on skin (less oil on skin)
- Lots of people use creams in the day and ointment at night
- Lotions (least oil content)- least effect on dry skin
blood supply to the foregut
This is supplied by the coeliac artery.
The foregut includes
- stomach
- part of the duodenum
- biliary system
- liver
- pancreas
- spleen.
coeliac artery can be split into
left gastric
hepatic artery
splenic artery
midgut supplies by
Superior mesenteric artery: distal part of the duodenum to the first half of the transverse colon.
hindgut is supplied by
inferior mesenteric artery: second half of the transverse colon to the rectum. This is supplied by the
Acute mesenteric ischaemia presents
with acute, non-specific abdominal pain. The pain is disproportionate to the examination findings. Patients can go on to develop shock, peritonitis and sepsis.
malignant hyperthermia gene
autosomal dominant in ryanodine receptor 1
sign of pancreatic cancer in the limbs
migratory thrombophlebitis
A 18-year old woman presents to ED with abdominal pain. She has been unwell with a viral infection for three days, and this morning she has started to complain of pain in the right iliac fossa. Previously she was well and has no past medical history. She denies eating anything unusual and has not travelled recently. On examination she is tender in the right iliac fossa, but there is no guarding. An ultrasound scan shows a normal appendix.
What is the diagnosis?
mesenteric adenitis
- children and adolescents
- following bacterial or viral illness
- normal appendix and swollen lymph nodes
A 3 month old baby boy is brought to A&E because today he has been crying inconsolably and he had had strange poos. The stool is red and goopy. He has also vomited milky fluid twice today. He has not had a fever.
On inspection, the child appears unwell and is screaming. It is difficult to properly examine the chest or abdomen because he is inconsolable. An abdominal ultrasound shows concentric rings of hyper- and hypo-echogenicity.
What is the best option to manage this child’s condition?
rectal air insufflation
- current jelly stool→ INTUSSUSCEPTION
Gilberts syndrome
an inherited (usually autosomal recessive) metabolic disorder characterized by a mild and intermittent elevation of unconjugated (indirect) bilirubin levels, due to defective conjugating enzymes in the liver.
causes
- stress
- fasting
Unconjugated hyperbilirubinemia
occurs with increased bilirubin production caused by red blood cell destruction, such as hemolytic disorders, and disorders of impaired bilirubin conjugation, such as Gilbert syndrome.
hyperfiltration and hypertrophy in diabetic nephropathy
- Occurs early
- Related to hyperglycameia
- Reabsorption of glucose couple with reab of sodium
- More glucose reabsorbed therefore more sodium reabsorbed
- Less sodium left in tubule by DCT
- Macula densa senses reduction in delivery of NaCl
- Activation of RAAS
- Vasodilation of afferent arterial and vasoconstriction of efferent arterial hyperfiltration due to increased hydrostatic pressure
- Glomerular hypertension
- Increases GFR
stages of diabetic nephropathy
-
Hyperfiltration & hypertrophy
* Increased GFR - Latent stage- normal albumin
- Microalbuminuria (aka moderately increased albuminuria)
- Overt proteinuria (aka severely increased albuminuria)
- ESRD
stages of diabetic nephropathy
-
Hyperfiltration & hypertrophy
* Increased GFR - Latent stage- normal albumin
- Microalbuminuria (aka moderately increased albuminuria)
- Overt proteinuria (aka severely increased albuminuria)
- ESRD
malaria types
most severe cases: plasmodium falciparum
most common non-falciparum: P. vivax ‘benign malaria’
malaria prevention
drugs: Atovaquone/proguanil (Malarone), doxycycline, and mefloquine
non-drugs:
nets and DEET spray
alpha haemoloytic strep
step pneumoniae
beta haemolytic strep
lancefield group A-E
Group A- streptococcus pyogenes
well known side effect of epidural
hypotension due to lidocaine effect on sympathetics
A 53 year old woman arrives in the anaesthetic room. She is due to have a laparoscopic fundoplication.
Her past medical history includes polycystic ovarian syndrome and a severe hiatus hernia refractory to medical treatment. Her current medications include atorvastatin 20mg ON and omeprazole 20mg OD. Her pre-op assessment was normal.
What is the most appropriate method of anaesthetic induction in this patient?
rapid sequence induction- hiatus hernia icnreased risk of aspiration
