Lightning round Flashcards
MgSO4 dose
iv MgSO4 2g (in 10ml D5)
Ticargrelor dose
180mg loading, then 90mg BD
Heparin dose for PPCI
50-70 IU/kg, max 5000 IU
Drugs for Dressler syndrome
Aspirin 750 mg q6h, then taper weekly over 3 months
colchicine 0.5mg BD for 3 months
Lignocaine dose for VT
0.5mg/kg iv push +/- repeat another dose
then infuse 1mg/min
only for VT, not for supraventricular arrhythmias
Lignocaine dose for VF
1-1.5mg/kg iv push, can repeat 0.5mg/kg at 5-10min
Nitroprusside dose
0.5mcg/kg/min and then titrate to max 10 mcg/kg/min
Not to use in pregnant ladies / use more than 48h
PRES associations
- HT crisis, PET
- Acute / chronic kidney disease
- TTP / HUS
- Vasculitis (includes SLE, PAN)
- Immunomodulatory drugs, chemotherapy drugs (includes anti-VEGF incl Bevacizumab, Platin chemo, CyA / RTX / MTX / FK)
- iodine contrast (cerebral angiography)
- severe sepsis
Features of complicated type B aortic dissection
- evidence of malperfusion - renal artery involvement, limb or visceral ischemia
- hemoperitoneum, mediastinal hematoma
- rapid expansion or aneurysmal degeneration of the aortic wall / progression of dissection
- impending or frank rupture
- uncontrolled pain, or refractory hypertension (despite ≥3 classes of anti-HT at max doses)
VTE screen
- APS antibodies (LA, B2GP, ACL)
- protein C/S, anti-thrombin III deficiency, factor V leiden
- malignancy
- MPN (ET, PCV)
- nephrotic syndrome
- cushing; OCP, HRT
- immobilization
Empirical Abx for treatment of IE
- Ampicillin 2g q4h + Gentamicin 1mg/kg Q8H
Prosthetic valve
- cloxacillin 2g q4h + Rifampicin (300mg tds) + Gentamicin 1mg/kg Q8H
- MRSA - switch cloxacillin for Vancomycin 15-20mg/kg/dose
Abx prophylaxis for IE
- ampicillin 2 gram x1 dose (oral or iv)
- alternatively consider vancomycin 15mg/kg x 1 dose, or zithromax 500mg x 1 dose
High risk drugs for SCAR
allopurinol (HLA B5801), carbamazepine (HLA B1502), phenytoin, NSAID, septrin
Insulin infusion dose
0.1 unit/kg/hr
Metabolic syndrome components
- dysglycemia (FG >5.6)
- HDL <1 (M) or <1.3 (F)
- TG >1.7
- waist circumference >90 (M) or >80 (F)
- HT >130/85
Friedewald equation for LDL
TC - HDL-C - (TG/2.2 in mmol/L)
assumes a 5:1 relationship between TG and VLDL
cannot use if TG >4.5 or <1.1
Alirocumab, Evolocumab and inclisiran dose
Alirocumab / Praluent 150mg q2wk
Evolocumab / Repatha 140mg q2wk
Inclisiran 284 mg at 0,3m and then q6m
Agents for LDL
- statin
- ezetrol
- PCSK9i
- bempedoic acid
- cholestyramine
significant alcohol consumption definition
70g/week for women
140g/week for men
(ie <1 and <2 standard drinks/day respectively, 1 standard drink being 10g)
Exercise for weight loss
- At least 150min moderate intensity aerobic exercise per week
- spread over at least 3 days per week
- no more than 2 consecutive days of rest
Doses of osteoporotic agents
- Alendronate
- Zoledronic acid
- Prolia
- Teriparatide
- Romosozumab
- ALN - 70mg weekly
- ZOL - 5mg yearly
- Dmab - 60mg q6m
- TPT - 20 mcg daily
- Rmab - 210mg q1m
Calcium correction for albumin
Correction factor - (40-Alb) x 0.02
Thyroid storm parameters
Fever, HR, presence of AF, CHF, neurological symptoms, GI symptoms (N/V/D/Jaundice), precipitant
Thyroid storm treatment
- supportive, monitoring
- PTU 150mg q6h
- lugol’s 0.3ml tds
- beta-blocker if not CI eg inderal
- hydrocortisone
- may consider lithium and cholestyramine
- panadol for fever
- plasmapharesis
- treat any precipitants
Causes of elevated PRL
- exclude pregnancy
- stress
- hypothyroid, ESRF
- antipsychotics (eg risperidone)
- PRLoma / stalk effect of non-functioning tumors
- macroPRL
Features of Acromegaly
- Enlarged hands and feet, nose
- Frontal bossing, supraorbital bulging, macroglossia, prognathism, increased interdental space
- Goitre; cardiomegaly; hepatosplenomegaly; colonic polyps
- carpal tunnel syndrome, OA of joints
- DM, HT, OSA; osteoporosis
- local mass effect of tumor - headache; VF; hypopituitarism; co-secreting PRLomas
Diagnosis of PCOS
Rotterdam Criteria for PCOS (any 2 of following)
- oligo- or anovulation (<21d or >35d menses); consider mid-luteal progesterone
- hyperandrogenism (clinical - hirsutism with Ferriman-Gallwey >7, acne; but usually NO signs of virilization) (biochemical - total or free testosterone)
- polycystic ovaries on USG examination: presence of 12 or more follicles in either ovary measuring 2-9 mm in diameter and/or increased ovarian volume (>10ml)
Exclude thyroid, hyperPRL, non-classical CAH (mainly 21OH)
Consider androgen secreting tumors if serum testosterone >2x ULN
Contraindiations to HRT
- unexplained vaginal bleeding; CA breast, CA endometrium risk
- stroke / TIA, ACS, PE / DVT, thrombophilia
- active liver disease
- TG >5.6; uncontrolled DM / HT
- SLE, migraine with aura
- Caution in CV risk, active gallbladder disease,
PPI infusion dose
iv pantoloc 80 mg stat then 8mg/h for 72h
King’s college criteria for liver transplant in paracetamol overdose
pH <7.3, INR >6.5, Cr >300, Grade III / IV HE
HE precipitants
- excessive alcohol / protein intake
- constipation / vomiting
- infection
- GIB
- diuretics / large volume paracentesis
- vascular occlusion
Child-Pugh score for cirrhosis - criteria
Albumin
Bilirubin
Coagulopathy
Distended Abdomen
Encephalopathy
SAAG interpretation
High SAAG >11 g/L
- low protein (25g/L) - cirrhosis
- high protein - Budd-chiari, CHF
Low SAAG < 11 g/L
- nephrotic syndrome
- pancreatitis, biliary leak
- peritoneal carcinomatosis
- TB peritoneum
Alcoholic hepatitis management
- monitor GC and HE
- thiamine
- ativan for DT prophylaxis
- laxatives
- high dose prednisolone if high DF
Causes of pancreatitis
- Alcohol, Hypertriglyceridemia
- Gallstone
- Post-ERCP
- HyperCa
- IgG4
- drugs - DPP4, GLP1RA, azathioprine, 5-ASA, sulphonamide
- infections - mumps, Cox, salmonella
- idiopathic
Chronic diarrhoea ddx
- inflammatory bowel disease
- infections including CDT
infections in HIV - Giardiasis, cryptosporidiosis, MAC, CMV - chronic pancreatitis
- hyperthyroidism
- laxative use, orlistat, other med SE
- IBS
Meds for urinary incontinence
OAB
- oxybutynin (antimuscarinic)
- mirabegron (Betmiga) (beta3 agonist)
UAB
- distigmine (Ubretid) (AChE inhibitor)
Males - alpha antagonist (eg terazosin), 5a-reductase inhibitor (eg finasteride)
Dementia drugs
- Cholinesterase inhibitor - Aricept / Donepezil (CI asthma; SE bradycardia, nausea), Rivastigmine patch
- NMDA receptor antagonist - Memantine (SE constipation)
- Aducanumab
ITP treatment
Prednisolone 1mg/kg if Plt <30 and minor symptoms
Sig bleed - IVIG 1g/kg/day + iv MP 1g/day x3 days
Consider RTX, Eltrombopag, Splenectomy
May give transamin, anti-D
Management if suspect TTP
Ix
- low haptoglobin, high retic, LDH, urate, bili
- measure ADAMTS13 level & activity (<10%)
Mx
- Plasma exchange + steroid (iv MP 1g/day x 3 days)
- contraindicated to any Plt transfusion
if not ADAMTS13 but Shiga toxin from ETEC –> likely to be HUS; supportive management only
prolonged APTT causes
- APS
- hemophilia (factor 8 and 9)
- vWD (esp severe vWD)
- heparin contamination
- part of mixed picture (warfarin, DIC)
Vitamin K factors, APTT factors, PT factors
vitamin K - 2,7,9,10
APTT - 8,9,10,11
PT - 2,5,7,10
vWD bleeding
- DDAVP can raise vWF levels in mild vWD (not useful if absent vWF)
- transfuse vWF concentrate, or recombinant vWF + factor 8
- or consider FFP + factor 8 + additional Plt transfusion for type 2 / 3 vWD
- or consider cryoprecipitate (if factor concentrate inappropriate) (contains fibrinogen, factor 8, vWF)
- consider transamin
Hemophilia bleeding
- factor concentrate
- consider novoseven
90microgram/kg/dose every 2-3h until bleeding stops - PCC transfusion
- DDAVP may be used for mild hemophilia
- consider transamin
- long-term consider steroids / CYC in acquired hemophilia to remove inhibitors
vWD diagnosis
- mucocutaneous bleeding
- vWF antigen levels and vWF activity
- may also check factor 8 activity in severe (type 3 vWD)
- acquired vWD in malignancies (eg MPN), congenital vWD is autosomal dominant
Hemophilia diagnosis
- prolonged APTT
- factor activity levels
- 1:1 mixing study - not improve with mixing means presence of antibody
(Severe) Bleeding in
- Dabigatran
- Xaban
- warfarin
- thrombolytics
- Idarucizumab 2.5gram iv infusion 2h apart
- PCC 50 IU/kg (+ consider novoseven 90mcg/kg)
- iv vitamin K 5-10mg + PCC 50 IU/kg
- cryoprecipitate (up to 10 units per dose) + transamin x1 dose
SBP dx and Mx
- WCC >500, ANC >250
- Rocephin 5 days
- lactulose; watch out for HE
- iv albumin 1.5g/kg on D1, 1g/kg on D3
- withhold beta-blockers
- consider long-term ciprofloxacin if recurrent attacks
Post-needle stick blood checking
HBV - 24 wks
HCV - 6-8, then 24wks if first blood test is -ve
HIV - 6, 12, 24 wks
Definition of resistant HT
- blood pressure that remains above goal in spite of concurrent use of 3 antihypertensive agents of different classes with good compliance
- ideally, one of which should be a diuretic, and all 3 at their maximally tolerated dose
(Remember to check compliance)
Differences between SJS / TEN / DRESS
- SJS and TEN have epidermal necrosis and detachment with mucosal involvement
DRESS has rash progressing to erythema with eosinophilia and prominent systemic involvement; may also have mucosal involvement - SJS and TEN differ in BSA (>30% for TEN, <10% for SJS; middle is overlap)
- systemic steroid for DRESS with slow taper
Empirical Abx for pneumonia
CAP - Augmentin + Zithromax / Doxycycine +/- Tamiflu
HAP - consider augmentin; or Tazocin
Bronchiectasis - Tazocin
Empirical Abx for CAPD peritonitis
Cefazolin / Vancomycin + Ceftazidime / Amikacin
with nystatin
with fluimucil if use aminoglycosdes
heparin flush into each PDF
Empirical Abx for necrotizing fasciitis
Meropenem + Levofloxacin + linezolid
mero - GNB, strep, anaerobes
levo - vibrio
linezolid - group A strep, MRSA
May consider clindamycin if strep sensitivity known
Consider daptymycin if high vancomycin MIC needed for MRSA
Empirical Abx for septic arthritis
- consider cloxacillin or rocephin as initial Tx
- Cloxacillin + Rocephin if more frail / Hx of UTI
- Vancomycin + rocephin if known MRSA carrier
- doxycycline adjuvant for 7 days if known gonorrhoea arthritis
Vaccine for splenectomy
Meningococcal, pneumococcal, hemophilus vaccine
(and all the other regular vaccines incl COVID)
Contact tracing for hemophilus and meningococcus
- Hemophilus - rifampicin / Hib vaccine
- Meningococcus - rifampin / rocephin
Fever in returning traveler
- CBC/dc LRFT RG clotting c/st
- CXR, NPS x flu, covid, resp virus
- smear for malaria
- serology for - dengue, rickettsia, Mpox (lesion)
- urine c/st
- stool c/st, ova and cyst
- consider - coxiella (q fever) serology, psittacosis serology, borrelia (lyme disease) serology
- cryptosporidia, giardia, strongyloides and coccidiodomycosis in diarrheoa
- others incl - legionella, TB, HAV and HEV
AIDS defining illness
- occurs at CD4 <200
- pTB usu at CD4 >200
- PCP, non-TB mycobacerium, cryptosporidiosis, toxoplasmosis, esophageal candidiasis, disseminated CMV, Kaposi sarcoma, CNS lymphoma
PCP vaccine
Age >65
- single dose PCV13 (conjugate vaccine)
- single dose 23vPPV (polysaccharide vaccine)
High risk
- PCV13 → 23vPPV 1 year later (can also give reverse if 23vPPV was given first)
Horner syndrome
partial ptosis, miosis (small pupil) +/- anhidrosis
classically pancoast tumor
Specific causes for CN3, CN6 palsy
CN3 - PCOM aneurysm, tentorial herniation
CN6 - NPC, raised ICP (false localizing sign), basal meningitis
Cardinal features of Parkinson’s Disease
- Bradykinesia + resting tremor / rigidity (in the past also incl postural instability)
Obstructive vs restrictive lung disease on spirometry
- obstructive - FEV1/FVC <70%
- restrictive - FEV1/FVC >70%, and FVC <80%
Grading of COPD by FEV
GOLD 1 - FEV1 >80%
GOLD2 - FEV1 50-80%
GOLD 3 - FEV1 30-50%
GOLD 4 - FEV1 <30%
(cf diagnosis of COPD - by RATIO of FEV1/FVC <70%)
Gauging symptoms of COPD
mMRC (Modified Medical Research Council) and CAT (COPD assessment tool)
- mMRC 0-4 - 2 is slower than same age ppl or stop for breath on level walking; 4 is homebound and SOB with dressing
- Group B COPD is mMRC 2+ or CAT >10
Vaccination suggested for COPD patients
- Influenza
- COVID
- PCV13 → 23vPPV
- Shingrex (if age >50)
- Pertussis (if not vaccinated in childhood)
Diagnosis of asthma
- clinical diagnosis
- VARIABLE symptoms of SOB / cough / wheezing
- eg by exercise / change in weather / URI; diurnal variation
PFT
- variability of lung function
- post-BD increase in FEV1 >12% and >200ml (not in acute attack)
Others incl - atopy march, daily PEF variability >10%, improvement of parameters after treatment; worse with provocation (eg exercise)
Assessment of asthma control
Compliance, technique & environment; review diagnosis (eg COPD, EGPA)
GINA assessment
- daytime symptoms >2x per week
- night waking
- SABA reliever >2x per week
- activity limitation
ACT score (asthma control test)
Pseudogout causes
3H - haemochromatosis, hyperparathyroidism, hypomagnesaemia
Indications for urate lowering therapy in gout
2+ attacks in 1 year or polyarticular attack
Gouty tophi (target <0.3 instead of 0.36)
Radiological joint changes
Renal calculi or eGFR <60
Typical RA features on PE
Swan neck deformity
Boutonneire deformity
Z deformity of thumb
Volar subluxation
Ulnar deviation
Rheumatoid nodules
Splenomegaly - felty syndrome
Management of adult Still’s disease
- NSAID at antiinflammatory dose
- Anakinra if mod-severe disease
P20-60 if Anakinra is not available - long-term tail steroids and step up DMARDS
Management of HLH
- treat underlying disease (eg lymphoma, infection, autoimmune disease)
- HLH94 - etoposide + dexamethasone
Drugs that may worsen lupus / drug-induced lupus
- hydralazine, methyldopa, diltiazem, procainamide
- isoniazid, quinidine, minocycline
- chlorpromazine
- anti-TNF (esp. infliximab), interferons
Rhabdomyolysis management
- volume repletion (NS 1-1.5L/h if anuric), then 1D1S to maintain u/o 200ml/h
- continue fluid until CK <5000
- add NaHCO3 50 mmol/L to every other bag of IVF to keep urine pH >6.5;
Stop if ABG pH >7.5, or HCO3 >30 or hypoCa - dialysis for AKI
- Ca replacement should be avoided unless symptomatic
Risk factors for / causes of fall in the elderly
- neurological (eg Parki, stroke; cerebellar disease; neuropathy; myopathy less)
- cognitive impairment, poor safety awareness (eg dementia)
- poor eyesight and environment hazards
- cardiac postural hypotension, arrhythmias, AS
- meds - postural hypotension (eg alpha blockers / diuretic), sedating (eg anti-histamines, BZD, psychiatric med)
- OA knees, fraility, sarcopenia
empirical Abx for skin and soft tissue infection (not NF)
consider cefazolin 1 gram q6h
or ampicillin 2g q4h + cloxacillin 500mg q6h (simple infection; sepsis dose 2g q4h)
