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Lecture Notes Flashcards

1
Q

3 step Mx to high BMs in T2DM

A
  1. Review drug chart + oral hypoglycaemics
  2. Check ketones if BM >12 (more than 2x in 24hrs)
  3. Ask diabetes specialist nurse
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2
Q

Mx of T2DM on steroids

A

Causes hyperglycaemia

May have high BM pattern

Double dose oral hypoglycaemics

OR

add 2nd agent

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3
Q

Target BM in hospital

A

6-10 (4-12 acceptable)

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4
Q

Insulin dependent T2DM

A

Usually 2x daily regime Increased insulin by 10%

Monitor BMs

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5
Q

T1DM -Mx if hypos overnight?

A

Reduce basal insulin (night dose) - Decrease by 20%

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6
Q

Short Acting Insulin

  • Examples
  • Mode of Action
  • Use?
A

Act-rapid, Humilin-S

Onset: 30mins

Peak: 2-4 hours

Lasts: 8 hours

Use: IV in variable rate insulin
Mx of DKA, high K+

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7
Q

Rapid Acting Insulin

  • Examples
  • Mode of Action
  • Use?
A

Novarapid/humalog

Onset: 15 mins Peak: 40 mins

Lasts: 4 hours

Use: bolus insulin in T1DM (before meals/correction)

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8
Q

Mixed Insulin

  • Examples
  • Mode of Action
  • Use
A

Rapid + Intermediate Number = percentage of rapid acting insulin e.g. Novomix 30

Used in BD dosing (e.g. T2DM)

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9
Q

Long Acting Insulin

  • Examples
  • Mode of Action
  • Use?
A

Lantus, glargine, degludec

Onset: 2 hours Offset: 24-42 hours (brand dependent)

Often no real peak
Usually OD basal dose

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10
Q

Emergency Op in T1DM Mx

BM Target?

A

NBM
Continue basal insulin
Stop rapid acting
Start VR infusion using table

BM target = 6-10mmol

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11
Q

Indications for VR infusion

A

T1 DM - If missing 1 meal due to fasting - No background insulin

T2DM

  • If missing 1 meal and BM >12
  • Poor control with HbA1c >49
  • Emergency surgery
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12
Q

What is a VR infusion?

A

50 units act rapid in 49.5 ml normal saline

Run alongside Dex/sal infusion

Continue basal insulin in T1DM (at 80%)

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13
Q

T1DM Pre-Op

A

Admit night before

First on list

Stop short acting insulin

Start on VR infusion
80% basal insulin (DO NOT STOP)

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14
Q

T2DM Pre-Op

A

Omit oral hypoglycaemics (day before)

VR infusion if BM >12

If insulin dependent: - Stop insulin, give VR

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15
Q

VR infusion? Post Op

A

Stop VR 30 mins after giving short acting insulin

Increase basal dose to 100% when E+D

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16
Q

Mnemonic for Venturi’s

A

Barry White Yearns for Right-wing Government

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17
Q

Colour, % and L of venturi’s

A 
Blue = 24% = 2L 
White = 28% = 4L 
Yellow = 35% = 8L 
Red = 40% = 10L 
Green = 60% = 15L
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18
Q

Right Hemicolectomy

A

Ascending colon removed

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19
Q

Anterior Resection

A

Sigmoid colon removed

Proximal Rectum removed

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20
Q

Abdominal-Perineal resection

A

Sigmoid colon
Rectum and anal canal removed

Anus is closed, colostomy created

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21
Q

Hartmann’s

A

Emergency - Sigmoid and rectum removed

Colostomy made
Can be reversed at a later date

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22
Q

Sub-total colectomy

A

Asc, trans, desc and sigmoid colon removed

Anastamosis with rectal stump to create storage pouch

Good as avoids stoma

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23
Q

Intra Op Complications

A

Bleeding
Damage to tissue
Anaesthetic risk
Allergy

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24
Q

Post Op Complications 1-3 days

A

Bleeding
Atelectasis
MI/Stroke

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25
Q

Post Op Complications 3-7 days

A

Infection - Wound, chest, urine
Anastamotic Leak
VTE

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26
Q

Post Op Complications >1 month

A

Hernia
Chronic Pain
Recurrence

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27
Q

Requesting Scans?

- Criteria

A

What question are we asking?

How will that change management?

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28
Q

MRI Scans

- Co-morbidities to bear in mind?

A

MRI - pacemaker, metal fragments (eye)

Orthopaedic plates/replacements ETC ok as not magnetic material

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29
Q

CT/AXR

- Co-morbidities to bear in mind?

A

Do PT in woman of childbearing age

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30
Q

CT with Contrast

- Co-morbidities to bear in mind?

A

Check eGFR
Review Meds e.g. metformin
May need to run IV fluids.

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31
Q

PRN Meds for Acute Abdo patient

A

Paracetamol
Weak opiate - codeine
Strong Opiate - Oramorph
Anti-emetic - cyclazine

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32
Q

Acute Abdo Bloods

A

FBC, UEs, LFTs, Clotting, G+S, VBG

CRP, Amylase

PT

ABG or cultures if indicated.

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33
Q

Gallbladder disease and Charcot’s Triad

A

Biliary Colic = RUQ pain
Cholecystitis = RUQ and fever (low grade)
Cholangitis = RUQ, high fever and jaundice

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34
Q

Amylase in acute Abdo

A

Double normal = diagnostic of pancreatitis

Raised <2x = PUD, AAA, gastritis

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35
Q

Glasgow Scoring

PANCREAS

A 
PaO2 <8
Age >55
Neutrophils >15
Ca <2
Renal: urea >16
Enzymes: LDH>600, AST >2000
Albumin <32
Sugar >10

Score 3+ in first 48 hours = significant pancreatitis

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36
Q

Examination in Surgery

  • Heart
  • Lungs
  • Testicular
A

Heart

  • Murmur = need ECHO
  • AF= think bowel infarct

Lungs
- Decreased air entry: effusion or infection

Testicular
- In all men with lower abdo pain: must rule out torsion!

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37
Q

Acute Indications for Dialysis

A

A = Acidosis pH <7.2

E = Electrolyte e.g. refractory high K+

I = intoxication = lithium, anti-freeze, barbituates

O = overload, fluid not responding to meds

U = Uraemia = pericarditis/encephalopathy
OR lethargy, decreased appetite, metallic taste

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38
Q

Acute Mx of Hyperkalaemia

A

30ml of 10% calcium gluconate

10U actrapid in 50ml 50% glucose

Salbutamol 5mg neb

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39
Q

Follow Up Mx of high K+

A

Treat cause

Give fluids

Review Nephrotoxics

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40
Q

Pre-Renal AKI

A

Decreased intake

Fluid loss

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41
Q

Renal AKI

A

IV Contrast
Toxins
Vasculitis

Do Urine Dip for BLOOD and PROTEIN

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42
Q

Post-Renal AKI

A

Usually urological cause
- obstruction, UTI

Urine Dip
Bladder scan
Refer urology

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43
Q

Fluid Status Assessment

A

BP, HR, CRT, JVP
Urine output
Mucous membranes and skin turgor

FLUID BALANCE CHART

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44
Q

STOP AKI

A

treat SEPSIS
avoid TOXINS
OPTIMISE BP
PREVENT harm

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45
Q

Haematemesis Hx

A

When they last ate or drank (for endoscopy)

BG sx:
Weight loss/dysphagia/change of bowel habit = cancer
Dyspepia = gastritis, GORD
Abdo pain

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46
Q

SHOCK: what impairs physiological response?

A

Age
Drugs e.g. beta blockers
CV co-morbidity

leads to organ failure as cannot increase HR or BP

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47
Q

Drug Hx in Haematemesis

A

NSAIDS? ulcer
Antiplatelets: clopidogrel, aspirin, ticagrelor, dipyridamole
Anticoagulants: warfarin, DOAC

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48
Q

Post GI Bleed Complications

A

MI
Stroke
Renal Failure
Intestinal/liver ischaemia

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49
Q

Glasgow Blatchford

A

Do they need endoscopy?

Used in A+E to discharge patients
Score 0-1 = OGD endoscopy

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50
Q

Rockall Score

A

Post endoscopy, with diagnosis

Co-morbidities = very high scoring e,g, organ failure, malignancy

51
Q

Hb and Blood transfusion in GI bleed

A

Hb >100 = do not transfuse

Hb <70 = aim for 70-90 Hb, unless anginal sx (can give more)

52
Q

Pharmacotherapy for ulcer vs variceal bleed

A

Ulcer:
- IV PPI post endoscopy

Varicieal

  • Terlipressin, can be given in A+E
  • Gastro would give to any pt with stigmata of liver disease O/E, as likely to be hepatic cause for bleed
53
Q

Chronic Liver Disease Definitions

Comp vs De-Comp

A

Compensated
- peripheral stigmata of liver disease, functioning well, normal synthetic function

Decompensated
- Ascites, encephalopathy, jaundice, varices

54
Q

Acute Liver Failure Definition

A

Jaundice, encephalopathy +/- ascites

NO peripheral stigmata of liver disease

55
Q

Causes of Acute Liver Failure

A

Drugs: Paracetamol OD
Pregnancy (HELLP)
Budd-chiari (hepatic vein thrombus)
Virus

56
Q

Ix in Acute Liver Failure

A

Pro-thrombin time
- PT MOST IMPORTANT IN LIVER FAILURE

If >30 secs, contact gastro
>50 secs = liver unit

AST may be in 1000s, irrelevant

57
Q

Causes of Chronic Liver Failure

A

Alcohol
Fatty liver disease
Viral hepatitis (IVDU, abroad = Hep C)

Rare

58
Q

Fluids in Liver failure

A

Avoid normal saline as will follow osmotic gradient and go straight to abdomen, increase ascites

Only give in resus scenario

Give 5% dex

59
Q

Why do liver patients decompensate?

A

Infection
- UTI, chest, SBP

Medications
- opiates, diuretics

AKI
- Hepato-renal syndrome

Disease progression
- Increased alcohol intake, do not cease drinking

GI bleed

60
Q

Child Pugh Score

A

Albumin

PT

Bilirubin

Ascites

Encephalopathy

Grade A, B, C (most serious)

61
Q

Viral causes Acute LF

A

Serology for Hep B and C

62
Q

USS and Dopplers in Acute LF

A

Rule out hepatic vein thrombus (budd chiari)

63
Q

Immune Causes Acute LF

A

IgA
- Alcohol

IgG

  • Autoimmune hepatitis
  • ASMA

IgM (M disease)

  • Primary biliary cirrhosis
  • Anti- mitochondrial antibody
64
Q

Genetic Causes Acute LF

A

Wilson’s disease
Haemochromotosis
Alpha a1 antitrypsin

65
Q

Causes of Metabolic Acidosis

A
  1. Lactic = tissue hypoxia
  2. Keto = DKA
  3. Renal = high urea and creatinine
66
Q

BTS Oxygen Guidelines

- Critically ill?

A

15L NRB Mask, 60% 02

67
Q

BTS O2

- Seriously ill

A

Mod O2 if hypoxic

2-6L via Nasal canula/face mask

68
Q

BTS O2

  • COPD/scholiosis/obesity hypoventilation
  • Risk of loss of resp drive if oxygen toxicity
A

CONTROLLED O2 THERAPY

Venturi mask and titrate

69
Q

Judgement of PaO2

A

Below 8 = RESP FAILURE

Work out if low
% of oxgen inspired -10

Therefore:
if patient on 15L NRB mask (60%)
- PaO2 should be at least 50

70
Q

PE: ECG

A

Sinus tachy, fast af
RBBB (right heart strain)

S1Q3T3

71
Q

PE: ABG

A

Low PaO2
Low CO2
- due to increased work of breathing

72
Q

PE: CXR

A

May be normal

May have small pleural effusion

73
Q

Causes of COPD in a young person?

A

Heroin smoking

Alpha A1 anti tripsin

74
Q

Secondary pneumothorax

A

Known resp. disease

> 50 with smoking hx

75
Q

What is the Management?

COPD patient on 15L NRB Mask

ph 7.29
PaCO2 7.1
PaO2 8.9
HCO3 28
Base Excess +1
A

Oxygen toxicity

TRY ON CONTROLLED O2 Therapy
e.g. venturi mask

76
Q

What is the management?

COPD patient on 28% venturi mask

ph 7.29
PaCO2 7.1
PaO2 8.9
HCO3 28
Base Excess +1
A

Need NIV!

Indication for NIV = resp acidosis NOT hypoxia

77
Q

NIV Principles

A

Biphasic pressure
Inspiratory (IPAP) and expiratory (EPAP)

Difference between IPAP and EPAP
= increase tidal volume and decreased CO2

78
Q

Indications for NIV

A

Resp Acidosis
On controlled O2 therapy
Recieved medical rx

79
Q

Contraindications for NIV

A

Pneumothorax

- Will cause tension

80
Q

CPAP

A

Continuous Positive airway pressure

Used to splint open upper airway in
Obstructive sleep apnoea

81
Q

Life-Threatening Asthma

A

33 92 CHEST

<33 Peak flow
<92 O2 sats

Cyanosis
Hypotension
Exhaustion
Silent Chest
Tachycardia
82
Q

Near Fatal Asthma

A

33 92 CHEST

+++ HIGH CO2 LEVELS

Need ICU involvement and potentially ventilation

83
Q

Criteria for Asthma discharge

A

Off Nebs
Peak flow >75% best

Check

  • Inhaler technique
  • PEFR meter and diary
  • Self management plan
84
Q

RED FLAGS Headache

A

Thunderclap - SAH

Positional = raised ICP

Malaise = meningitis

Weight loss = Cancer

85
Q

SNOOP 4Ps

A

Systemic features
Neuro: arm weakness
Onset? sudden - bleed
Older: >50 years

Pattern

  • Getting worse
  • Precipitated by valsalver
  • Papilloedema
86
Q

Migraine Criteria

A

> 5 episodes with 2 of:

  • unilateral
  • pulsating
  • worsened by moving
  • N+V
  • photophobia
87
Q

Seizures? What medications cause?

A

Meds that cause long QT

  • Anti-histamines
  • Anti-psychotics
  • Anti-depressants
  • Anti-microbials
  • Anti-emetics
  • Anti-arrhythmics

Not taking normal Anti-Epileptics

88
Q

Epilepsy: Psychiatric

A

Ask re mental health problems

Psychogenic seizures more common

89
Q

Epilepsy: Lifestyle

A

DRIVING, alcohol, relationships, occupation

90
Q

Epilepsy: Pregnancy

A

DO NOT PRESCRIBE SODIUM VALPROATE

if Female <50 years

91
Q

Epilepsy: Ix

A

DO AN ECG (look for long QT)

MRI for mesotemporal sclerosis

EEG only if primary generalised seizures (usually children)

92
Q

Tests for Bradykinesia

A

Touch each finger to thumb in turn
Finger tapping together (slower and smaller)
Foot tapping on floor

93
Q

SE Levo-dopa

A

Reduced efficacy
Freezing
Disinhibition - gambling etc.

94
Q

Differences between Myesthenia Gravis and Guillain Barre

A

GB = Sensory loss, myesthenia does not

GB = progressive, Myesthenia = worse with fatigue

GB = demyelination after viral illness
Myesthenia = autoimmune to Ach Receptor
95
Q

Causes of Pancreatitis

I GET SMASHHHED

A

I - Idiopathic

G - Gallstones
E - Ethanol (alcohol)
T - Trauma

S - Steroids 
M - Mumps
A - Autoimmune
S - Scorpion/Spider bite
H - High PTH
H - High Lipids
H - High Calcium
E - ERCP
D - Drugs
96
Q

Ewing’s Sarcoma

A

Rare, 5-15 years

lytic bone lesion with periosteal rxn
‘onion skinning’

97
Q

Chrondrosarcoma

A

Middle aged
bone destruction and calcification
rx with excision and chemo

98
Q

Osteosarcoma

A

Young people

Comomn

99
Q

Direct inguinal Hernia

A

Through abdo wall, not ing. canal
Medial to inguinal ligament
Alway acquired

RF: smoking, obesity, heavy lifting
Rarely strangulates

100
Q

Indirect Inguinal Hernia

A

Through canal inyo scotum

Young active men and prem babies
Hernia above and medial to pubic tubercle

Descent into scrotum on standing or coughinh

101
Q

Hydrocele

A

Fluid in tunica vaginalis
Tense, painless, fluctuant
Transilluminates

In adult, USS to rule out pathology

102
Q

Varicocele

A

Left sided
Bag of worms, heavy and dragging
Harmless, supportive underwear

103
Q

Hashimoto Goitre

A

Enlarged, firm, non-tender

104
Q

MEN T1

A

Pituitary
pancreas
parathyroid

105
Q

MEN T2 + T3

A

Pheochromocytoma
parathyroid
thyroid ca

Type 3 = with marfans as well

106
Q

Cystic Hygroma

A

benign lymph proliferation in post. triangle

Transillumates brightly

107
Q

Ant. Cord Syndrome

A

Loss of pain temp and motor
Lower and upper limbs (worse in lower)

Bad prognosis

108
Q

Central Cord Syndrome

A

Weakness of upper limbs, not lower
Good prognosis

Older people with cervical spondylosis

109
Q

Jones Fracture

A

5th metatarsal

110
Q

Lis-Franc Fracture

A

2-4th metatarsal with dislocation

111
Q

March Fracture

A

Stress/hairline fracture

Callus on Xray

112
Q

Snellen Test?

A

Visual Acuity

113
Q

Pupillary light reflex

RAPD

A

Damaged optic nerve e.g. optic neuritis

114
Q

Ischihara Plates

A

Colour vision

115
Q

Amsler Grid

A

Straight lines = curved

Sign of macular degeneration

116
Q

Schirmer’s Test

A

Tear production

<5mm = abnormal e.g. dry eyes in sjrogens

117
Q

Fluroscein Dye

A

Corneal ulcer,

Dendritic shows green

118
Q

H Test

A

CN III, IV and VI

119
Q

Tonometry

A

Raised intra-ocular pressure (IOP) in glaucoma

120
Q

Daily Na2+ requirements

A

1-2mmol/kg

121
Q

Daily K+ requirements

A

0.5-1mmol/kg

122
Q

Daily Fluid requirements

A

25-30ml/kg

123
Q

Daily Fluid requirements

  • CCF
  • Small
A

20-25ml/kg

- FINALS: Presentations (30 decks)

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