Absolute contraindications to fibrinolytic therapy in STEMI. (7)`
Risk of bleeding - Active bleeding - Significant head or facial trauma within 3 months - Suspected aortic dissection Risk of intracranial haemorrhage - Any prior intracranial haemorrhage - Ischaemic stroke within 3 months - Known vascular lesion (av malformation) - Known brain neoplasm
CURB-65
Confusion Urea >7mmol/L Resp. rate >30 BP <90/60 65 yrs or older
0-1 –> mild
2 - moderate
3-4 - severe
Rx of mild, moderate and severe CAP
Mild - outpatient management with oral amoxicillin (or doxy if atypical suspected)
Moderate - Admit for IV Benpen + doxy (or Gent and cephtriaxone if risk factors for Burkholderia pseudomallei)
Severe - admit for IV meropenem (wet season)
piptaz (dry season) + azithromycin
Causes of pleurisy
Viral/bacterial pneumonia Pulmonary infarction caused by PE Pneumothorax CT disease (lupus, RA) Asbestos pleurisity
Causes of pneumothorax
Spontaneous (young, thin men) Asthma COPD Pneumonia Lung abscess Carcinoma CF Lung fibrosis Sarcoidosis CT disorder Trauma Iatrogenic
Risk factors for DVT/PE
Bleeding disorders - Factor V leiden, Protein S/C deficiency, Antithrombin III deficiency, hyperhomocysteinemia Past hx of VTE Immobilisation Age Malignancy Obesity Trauma Surgery Pregnancy Smoking OCP/HRT Medical conditions - CCF, nephrotic sx, MI, stroke
Management of DVT
- Compression stockings
- SC Anticoagulation (enoxaparin 1.5mg/kg SC daily) for a minimum of 5 day AND until INR >2 on 2 consecutive days
- Oral anticoagulation with warfarin. Duration of rx depends on risk factors.
- VTE provoked by transient major RF –> 3m
- Unprovoked distal DVT –> 3m
- Unprovoked proximal DVT or PE –> 6m
- Unprovoked VTE with active cancer, multiple thrombophilias or antiphospholipid syndrome or recurrent unprovoked VTE –> Indefinite
Types of lung cancer
NSCC (Non-small cell carcinoma)- 90%
- Squamous cell carcinoma (20-30%) –> centrally located, well-demarcated
- Adenocarcinoma (30-40%)–> peripheral location, affects non-smokers and females
SCC (Small cell carcinoma) 15-20%–> patchy, extends into deep tissue around major bronchi
Ix for patient with haemoptysis
- CXR then chest CT if cause not found
- Bronchoscopy
- Lab: FBC with film, coags, ABG, UEC, urinalysis, sputum cytology/culture
- ECG and echo if cardiac causes suspected
DDx for haemoptysis
Acute/chronic bronchitis Pulmonary TB Pneumonia Lung abscess Primary lung ca or mets Anticoagulants Bronchiectasis PE Coagulopathy Thrombocytopenia DIC Cardiac causes - Mitral valve stenosis, CCF
Management of febrile neutropenia
Take blood samples from PIVC and lumens of intravascular devices before administering ABs
-Need coverage of pseudomonas.
-Give empirical ABs within 1hr of ER presentation
Use piptaz
CXR findings of COPD
- Increased bronchovascular markings
- Cardiomegaly
- Hyperinflation
- Flattened hemidiaphragms
- Bullae
- Barrel chest
Risk factors for febrile neutropenia
- Age (>65)
- Hypoalbuminaemia
- Pre-existing organ dysfunction
- Chemotherapy
- Haematological malignancy
Presentation of febrile neutropenia
Recent chemotherapy
Fever
Tachycardia
Hypotension
Types of common heart murmurs and features of each
Mitral stenosis - low rumbling diastolic murmur +/- AF, louder in left lateral position
Mitral Regurgitation - pansystolic murmur radiating to the axilla with displaced, hyperdynamic apex beat
Aortic stenosis - ejection systolic murmur radiates to the carotids
Aortic regurgitation - high pitched early diastolic murmur, collapsing pulse, accentuated by leaning forward
CHA2DS2-VASC score for AF
C - Congestive cardiac failure H - Hypertension A2 - Age > 65 +1, Age >75 +2 D - diabetes S - sex --> Female +1 S - stroke +2 Vasc - vascular disease hx
0 = low risk 1 = intermediate risk >1 = high risk
Causes of AF
PIRATE SHIV P - PE, pulmonary disease, post-operativ I- IHD R- rheumatic heart disease A - alcohol, age, anaemia T- thyroid E - endocarditis, echo changes (cardiomyopathies) S-sick sinus syndrome H - HTN I -idiopathic V - valvular
Management of AF
Long term
Acute
Long term:
-Rate control - metoprolol/atenolol
-Rhythm control - Digoxin
-VTE prophylaxis - warfarin or dabigatran (only if non-valvular) f
Acute
- TOE to check for thrombus formation if unsure of duration of AF or >24hrs
- IV or oral amiodarone or electrical cardioversion
- Anticoagulation with enoxaparin 1mg/kg SC BD
Clinical features of hypothyroidism
Fatigue, depression, lethargy, weight gain, decreased appetite, cold intolerance, constipation, menstrual disturbances, parasthaesias (carpal tunnel), hoarseness + deepening of voice. Dry skin, hair loss.
O/E: jaundice, pallor, wt gain, coarse, brittle hair, alopecia, periorbital oedema, macroglossia, goitre, hoarseness, bradycardia, pericardial/pleural effusion. Myxoedema, pitting oedema, hyporeflexia (hung-up reflexes)
Features of rheumatoid arthritis
- Persistent symmetric polyarthritis that affects the hands and feet
- Fatigue, malaise, morning stiffness, weight loss, low-grade fever
O/E: Stiffness, tenderness, pain on motion, swelling, deformity, limited ROM, extra-articular manifestations, rheumatoid nodules
Bony deformities seen in RA
- Ulnar deviation
- Boutonniere deformity –> flexion of PIP and extension of DIP
- Swan neck deformity –> extension at PIP and flexion DIP
- Hammer toes
- Joint ankylosis
