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Lancaster FINALS _slide > Medicine (6) > Flashcards

Medicine (6) Flashcards

1
Q

DKA

  • triad (biochemical)
  • predisposing factors
A

Biochemical triad of:

  • ketonaemia (ketosis)
  • hyperglycaemia
  • acidaemia

Precipitating factors:

  • Infection
  • Missed insulin
  • MI
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2
Q

Presentation of pt with DKA

A
  • abdominal pain
  • polyuria, polydipsia, dehydration
  • Kussmaul respiration (deep hyperventilation)
  • Acetone-smelling breath (‘pear drops’ smell)
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3
Q

Diagnostic criteria of DKA

A
  • glucose > 11 mmol/l or known diabetes mellitus
  • pH < 7.3
  • bicarbonate < 15 mmol/l
  • ketones > 3 mmol/l or urine ketones ++ on dipstick
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4
Q

Management of DKA

A
  • fluid replacement: most patients with DKA are deplete around 5-8 litres. Isotonic saline is used initially
  • insulin: IV infusion 0.1 unit/kg/hour. Once blood glucose is < 15 mmol/l an infusion of 5% dextrose should be started
  • correction of hypokalaemia
  • long-acting insulin should be continued, short-acting insulin should be stopped
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5
Q

The differential diagnosis for goitre

A
  • Physiological (puberty/pregnancy)
  • Thyroid disease (autoimmune)
  • Simple colloid/Multinodular goitre
  • Thyroiditis
  • Tumours
  • Infiltrative (TB/sarcoidosis)
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6
Q

Clinical features being specific for Grave’s (3)

A
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7
Q

Investigations for hyperthyroidism

A
  • Bedside – ECG (tachycardia/AF)
  • Bloods – TFTs (low TSH, high T3), Autoantibodies (anti-TSH), FBC (anaemia), HbA1c (associated diabetes), lipids
  • Imaging – USS Scan thyroid (if lump)
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8
Q

Management of hyperthyroidism

A
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9
Q

Causes of hypothyroidism

A
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10
Q

Digoxin MoA

A
  • Inhibits the Na/K ATPase pump
  • Positively inotropic
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11
Q

Digoxin toxicity

  • presentation
  • predisposing factors
  • management
A

Presenting features:

  • generally unwell
  • anorexia
  • yellow-green vision
  • fatigue/nausea + vomiting
  • arrhythmias
  • gynaecomastia

Precipitating factors:

  • ↓K+
  • renal failure
  • ↑Ca2+
  • loop diuretics

Management:

  • Digibind
  • correct arrhythmias
  • monitor potassium
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12
Q
A
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13
Q

Symptoms of hypercalcaemia

A

bones, stones, groans, thrones and psychic moans

  • Bones (bone pain)
  • Stones (renal calculi)
  • Groans (abdominal pain, tiredness/weakness)
  • Thrones (polydipsia, constipation)
  • Psychic moans (confusion)
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14
Q

Causes of hypercalcaemia

A
  • Malignancy (breast/myeloma/lung) - 90% causes
  • Primary hyperparathyroidism - 90% causes
  • Sarcoidosis
  • Vitamin D toxicity
  • Thyrotoxicosis
  • Lithium
  • Tertiary hyperparathyroidism
  • Milk-Alkali syndrome
  • Familial benign hypocalcinuric hypercalcaemia
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15
Q

Management of hypercalcaemia

A

Correct dehydration:

  • Fluids
  • Bisphosphonates
  • Treat underlying cause
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16
Q

Causes of prolonged and shortened QT interval

A
17
Q

What’s that ECG suggestive of?

A
18
Q

Causes, signs and management of hypocalcaemia

A
19
Q

Causes and levels of (Ca, PTH, phosphate) of hypoparathyroidism (3)

A
20
Q

Ix in Cushing’s syndrome

A

Confirmation tests
• Overnight dexamethasone suppression test
• 24hr urinary free cortisol

Localization tests
• Plasma ACTH
• If low: CT adrenals (look for adrenal tumour)
• If high: perform high-dose dexamethasone suppression test (if cortisol low →
cushings disease, if high → look for ectopic ACTH source)

21
Q

Causes of Cushing’s syndrome

A

ACTH dependent causes

  • Cushing’s Disease
  • Ectopic secretion from tumour (e.g. lung ca)

ACTH independent causes

  • Iatrogenic: steroids
  • Adrenal adenoma
  • Adrenal carcinoma
22
Q

Dexamethasone suppression test results

A
23
Q

Ix for Addison’s disease

A

ACTH stimulation test

(short Synacthen test)

  • Plasma cortisol is measured before and 30 minutes after giving Synacthen 250ug IM
  • If an ACTH stimulation test is not readily available (e.g. in primary care) then sending a 9 am serum cortisol can be useful:
  • > 500 nmol/l makes Addison’s very unlikely
  • < 100 nmol/l is definitely abnormal
  • 100-500 nmol/l should prompt a ACTH stimulation test to be performed
24
Q

Causes of adrenal insufficiency

A

Primary (Addison’s disease)

Autoimmune, Tuberculosis, metastases (e.g. bronchial carcinoma),

meningococcal septicaemia (Waterhouse-Friderichsen syndrome), HIV, antiphospholipid syndrome

Secondary

pituitary disorders (e.g. tumours, irradiation, infiltration)

Tertiary (stopping exogenous steroid)

25
Q

Treatment of adrenal insufficiency (Addison’s)

A

Combination of:

  • hydrocortisone: usually given in 2 or 3 divided doses. Patients typically require 20-30 mg per day, with the majority given in the morning dose
  • fludrocortisone

Patient education is important:

  • emphasise the importance of not missing glucocorticoid doses
  • consider MedicAlert bracelets and steroid cards
  • discuss how to adjust the glucocorticoid dose during an intercurrent illness

Management of intercurrent illness

  • in simple terms the glucocorticoid dose should be doubled
26
Q

Causes of Addisonian crisis

A

Causes:

  • sepsis or surgery causing an acute exacerbation of chronic insufficiency (Addison’s, Hypopituitarism)
  • adrenal haemorrhage eg Waterhouse-Friderichsen syndrome (fulminant meningococcemia)
  • steroid withdrawal
27
Q

Management of Addisonian crisis

A
  • hydrocortisone 100 mg IM or IV
  • 1 litre normal saline infused over 30-60 mins or with dextrose if hypoglycaemic
  • continue hydrocortisone 6 hourly until the patient is stable. No fludrocortisone is required because high cortisol exerts weak mineralocorticoid action
  • oral replacement may begin after 24 hours and be reduced to maintenance over 3-4 days
28
Q

Electrolyte imbalance in hyperaldosteronism (Conn’s)

A
29
Q

(3) structures of the adrenal cortex and what they produce

A
30
Q

Primary hyperaldosteronism

  • features
  • investigations
  • causes
  • management
A
31
Q

Causes of hypernatraemia

A
  • Reduced fluid intake
  • Fluid loss without replacement
  • Diabetes insipidus
  • Primary hyperaldosteronism
32
Q

Causes of hyperkalaemia

A
  • AKI
  • Drugs (ACEi, K+ diuretics, NSAIDs)
  • Adrenal insufficiency (e.g. Addison’s)
  • Rhabdomyolysis
33
Q

Causes of hypokalaemia

A
  • Vomiting and diarrhoea
  • Drugs (e.g. diuretics)
  • Primary hyperaldosteronism
  • Cushing’s syndrome
34
Q

Causes of hyponatraemia

A
  • Fluid loss
  • Adrenal insufficiency (e.g. Addison’s)
  • Drugs (thiazide diuretics)
  • SIADH
  • Organ failure
35
Q

Tests for phaeochromocytoma

A
  • 24 hr urinary collection of metanephrines
  • this has replaced a 24 hr urinary collection of catecholamines
36
Q

Management of phaeochromocytoma

A

Surgery is the definitive management. The patient must first however be stabilized with medical management:

  • alpha-blocker (e.g. phenoxybenzamine), given before
  • beta-blocker (e.g. propranolol)

Lancaster FINALS _slide (31 decks)

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