Medicine Knowledge Flashcards
What does SAAG measure indirectly?
Portal pressure- can be used to determine if a patient’s ascitis is due to portal hypertension or other causes
Ascities causes if SAAG over 11g/L?
Liver disorders:
Cirrhosis/alcholic liver disease
Acute liver failure
Liver metastses
Cardiac:
Right heart failure
Constrictive pericarditis
Other causes:
Budd-Chiari syndrome
Portal vein thrombosis
Ascities causes if SAAG less than 11g/L?
Hypoalbuminaemia- nephrotic syndrome, severe malnutrition
Malignancy
Infections
Pancreatitis
Bowel obstruction
Management of ascities?
Reduce dietary sodium
Fluid restriction if sodium is <125mmol/L
Aldosterone antagonists e.g. spironolactone
Drainage if tense ascities- large volume paracentesis requires albumin cover to avoid paracentesis induced circulatory dysfunction
Prophylactic antibiotics
Transjugular intrahepatic portosystemic shunt (TIPS) in some patients
What are the features of idiopathic pulmonary fibrosis?
Progressive exertional dyspnoea
Bibasal fine end-inspiratory crepitations on auscletation
Dry cough
Clubbing
Idiopathic pulmonary fibrosis diagnosis?
Spirometery- classically a restrictive picture
Impaired gas exchange- reduced transfer factor
High resolution CT scan investigation of choice and required to make a diagnosis- ground glass or honeycombing seen on x-ray
Idiopathic pulmonary fibrosis management?
Pulmonary rehabilitation
Few medications give a benefit- small evidence pirfenidone
Many patients require supplementary oxygen and eventually a lung tranplant
Life expectancy of 3-4 years
Cluster headache management?
Acute- 100% oxygen
Subcutaneous triptan
Prophylaxis- Verapamil
(some evidence for tapering dose of prednisolone)
CKD and hypertension treatment?
ACEi first line - small fall in eGFR and small rise in creatinine is acceptable
Furosemide also useful, also lowers potassium, careful of dehydration
Types of necrotising fasciitis?
Type 1- mixed anaerobes and aerobes (often post surgery in diabetics) Most common type
Type 2- streptococcus pyogenesR
Risk factors for necrotising fasciitis?
Recent trauma/ burns/soft tissue infections
Diabetes mellitus- paticularly if treated with SGLT-2 inhibitors
IV drug use
Immunosuppression
Most common site for necrotising fasciitis?
Perineum
Features necrotising fasciitis?
Acute onset
Pain, swelling, erythema at the effected site- often presents as rapidly worsening cellulitis with pain out of keeping with physical features
Extremley tender with skin necrosis a late sign
Fever or tachycardia may be absent or occur late in presentation
Management necrotising fasciitis?
Urgent surgical debridement
IV antibiotics
Big side effect of spironolactone in men?
Gynaecomastia
Other causes:
Puberty
Syndromes with androgen deficiency: Kallman’s, Klinefelter’s
Testicular failure- mumps
Liver disease
Testicular cancer
Ectopic tumour secretion Hyperthyroidism
Haemodyalysis
Drugs
Drugs that cause gynaecomastia?
Spironolactone (most common)
Cimetidine
Digoxin
Cannabis
Finasteride
GnRH agonists- goserelin, buserelin
Oestrogens, anabolic steroids
What is the triad for nephrotic syndrome?
- Proteinuria
- Hypoalbuminemia
- Oedema
Causes of nephrotic syndome?
Primary causes: minimal change disease, focal segmental glomerulosclerosis (FSGS), membranous nephropathy
Secondary causes: DM, systemic lupus erythematosus (SLE), amyloidosis, infections (HIV, Hep B and C), drugs (NSAIDs, gold therapy).
Nephrotic syndrome and LMWH?
Loss of antithrombin 3 etc rise fibrinogen levels and predisposes to thrombosis- prphylactic LMWH required
Nephrotic syndrome and thyroid?
Loss of thyroxine- binding globulin lowers the total but not free thyroxine levels
Investigations for nephrotic syndrome?
Urine dipstick- proteinuria and microscopic haematuria
MSU to exclude UTI
Quantify proteinuria using early morning urinary protein:creatinine ratio or albumin: creatinine ratio.
FBC and coagulation screen
Urea and electrolytes
Amiodarone vs atropine?
Amiodarone bring the HR down
Atropine bring the heart rate up
Adverse signs in Peri-arrest bradycardia and the treatment required?
Shock- hypotension, pallor, sweating, cold clammy extremities, confusion or impaired conciousness
Syncope
Myocardial ischaemia
Heart failure
Atropine 500mcg is the first treatment in this situation- used up to a max of 3mg
If inadquate response also-
Transcutaneous pacing
Isoprenaline/adrenaline injection
Specialist led transvenous pacing if no response to above
Features of hepatitis A?
Flu-like prodrome
Abdominal pain- typically RUQ
Tender hepatomegaly
Jaundice
Deranged LFTs
What are the three types of multiple endocrine neoplasia (MEN)?
MEN type 1- 3 p’s- Parathyroid- hyperparathyroidism, Pituitary, Pancreas- insulinoma
MEN type IIa- 2 P’s- Parathyroid, Phaeochromocytoma
MEN type IIb- 1 P- Phaeochromocytoma
What are some red flag symptoms for trigeminal neuralgia?
Sensory changes
Deafness
FH multiple sclerosis
Age onset before 40
Pain only in opthalmic region
Management of trigeminal neuralgia?
Carbamazepine
Failure to respond=refer to neurology
Brief difference between Lambert-Eaton and Myasthenia Gravis?
Lambert-Eaton- Legs affected first/ gets better with movement- linked to SCLC
Myasthenia Gravis- eyes/ arms/ face affected first, worse with movement
Paraneoplastic features of small cell lung cancer?
ADH- SIADH
ACTH- Cushing’s
Lambert Eaton syndrome
Paraneoplastic features of squamous cell lung cancer?
Parathyroid hormone-related protein (PTH-rp) secretion causing hypercalcaemia
Clubbing
Hypertrophic pulmonary osteoarthropathy (HPOA)
Hyperthyroidism due to ectopic TSH
Acute management of SVT?
Vagal manoeuvres- valsalva manoeuvres- trying to blow into empty plastic syringe, carotid sinus massage
Intravenous adenosine- contraindicated in asthmatics- verapamil preferable
Electrical cardioversion
Prevention of episodes- beta blockers, radio-frequency ablation
Narrow complex vs broad complex tachycardia?
Narrow generally SVT- through normal conduction system- narrow QRS
Broad generally VT- outside normal conduction system- broad QRS
Exceptions SVT with abberrant conduction like BBB
Pain relief in palliative patients with renal failure?
Mild renal failure- oxycodone
Sever renal impairment- buprenorphine (or fentanyl) as not renally excreted
Starting treatment for pain relief in palliative medicine?
Regular oral modified release morphine with immediate release morphine for breakthrough pain- 1/6th normal dose
Laxatives prescribed for all patients starting strong opioids
Opioid caution in renal disease- oxycodone for mild-moderate, buprenorphrine/ fentanyl for moderate/severe
What is the main test used to screen for latent tuberculosis?
Mantoux test
What happens to sodium in SIADH?
Hyponatremia due to dilution from water retention
SIADH pathophysiology?
Excessive ADH secretion (vasopressin)- causes water retention and hyponatremia
Leads to decreased urine output- no signs of fluid overload due to equal distribution of fluid
Concentration of electrolytes in blood- particularly sodium- is depeleted
Causes of SIADH?
Malignancy- SCLC (also pancreas/prostate)
Neurological- stroke, SAH, subdural, meningitis
Infections- tuberculosis, pneumonia
Drugs- SSRIs, carbamazepine,
SIADH investigations?
Urine osmolality- inappropriately high when compared with serum osmolality
Urine sodium concentration- urine sodium concentration is high
SIADH mangement?
Fluid restriction
Demeclocycline- reduces collecting tubule responsiveness to ADH
What is Budd-Chiari syndrome?
Hepatic vein thrombosis
Causes:
Polycythemia rubra vera
COCP
Pregnancy
Thrombophilia also antiphospholipid syndrome
What is the triad for Budd-Chiari?
Abdominal pain- sudden onset, severe
Ascities- abdominal distension
Tender hepatomegaly
Investigation for Budd-Chiari syndrome?
Ultrasound with doppler flow studies
What is Hashimoto’s thyroiditis?
Chronic autoimmune thyroiditis
Typically hypothyroidism but may be period of transient thyrotoxicosis
10x in women
Features of Hashimoto’s thyroiditis?
Features of hypothyroidism
Goitre: firm, non-tender
Anti-thyroid peroxidase (TPO) and also anti-thyroglobulin (Tg) antibodies
Things associated with Hashimoto’s thyroiditis?
Other autoimmune conditions- coeliac disease, T1DM, vitiligo
Development of MALT lymphoma
What to do if cannot establish intavenous access in advanced life support?
Use intraosseous route to give drugs
Chest compression to ventilation ratio in ALS?
30:2
Defibrillation in ALS?
Single shock for VF/pulseless VT followed by 2 minutes of CPR
If cardiac arrest witnessed in a monitored patients then up to three successive stacked shocks rather than 1 shock followed by CPR
Adrenaline in ALS?
Adrenaline given as soon as possible for non-shockable rhythms
In VF/VT cardiac arrests adrenaline given once chest compressions have restarted after third shock
Repeat adrenaline every 3-5 mins whilst ALS continues
Amiodarone and ALS?
Amiodarone 300 mg should be given to patients who are in VF/pulseless VT after 3 shocks have been administered
A further dose of amiodarone 150 mg should be given to patients who are in VF/pulseless VT after 5 shocks have been administered
Lidocaine can be used as an alternative
(remember adrenaline needs to be given)
Thrombolytic drugs and ALS?
Should be considered if a pulmonary embolus is suspected
If given, CPR should be continued for an extended period of 60-90 minutes
Causes of a raised TLCO?
Asthma
Exercise
Male
Polycythemia
Pulmonary haemorrhage
Causes of reduced TLCO?
Pulmonary fibrosis
Pneumonia
Pulmonary emboli
Pulmonary oedema
Emphysema
Anaemia
Low cardiac output
What demographic does idiopathic intracranial hypertension occur in?
Obese, young females
Causes headaches/ blurred vision
Risk factors for idiopathic intracranial hypertension?
Obesity
Female
Pregnancy
Drugs:
COCP
Steroids
Tetracyclines
Features of idiopathic intracranial hypertension?
Headache
Blurred vision
Papillodema
Englarged blind spot
Sixth nerve palsy
Management of intracranial idiopathic hypertension?
Weight loss
Acetazolamide
Repeated lumbar puncture
Surgery
Most common precipitating factors for DKA?
Infection, missed insulin doses, MI
Features of DKA?
Abdominal pain
Polyuria, polydipsia, dehydration
Kussmaul respiration
Acetone-smelling breath
Diagnostic criteria for DKA?
Glucose > 11mmol/l or known DM
pH < 7.3
Bicarbonate < 15 mmol/l
Ketones > 3mmol/l or urine ketones ++ on dipstick
Management of DKA?
Fluid replacement- isotonic saline used initially
Insulin- IV infusion started at 0.1 unit/kg/hour
Once blood glucose is < 14 mmol/l an infusion of 10% dextrose should be started at 125 mls/hr in addition to the 0.9% sodium chloride regime
Correction of electrolyte disturbance- Serum potassium often high on admission despite total potassium low, falls on treatment so add potassium into replacement fluids
Long-acting insulin continued, short-acting insulin stopped
How is DKA resolution defined?
pH >7.3 and
Blood ketones < 0.6mmol/L and
Bicarbonate > 15 mmol/L
Both ketonemia and acidosis should have resolved within 24 hours
Complications from DKA/treatment?
Gastric stasis
Thromboembolism
Arrhythmias secondary to hyperkalaemia/iatrogenic hypokalaemia
Iatrogenic due to incorrect fluid therapy: cerebral oedema*, hypokalaemia, hypoglycaemia
Acute respiratory distress syndrome
Acute kidney injury
Which age group is most as risk of cerebral oedema in DKA?
Children/young adults- often need neuro observation- don’t overload with fluid
What is Barrett’s oesophagus?
Metaplasia of the lower oesophageal muscosa, with the usual squamous epithelium being replaced by columnar epithelium
Risk factors for Barrett’s oesophagus?
GORD
Male
Smoking
Central obesity
Management of Barrett’s oesophagus?
High dose PPI
Endoscopic surveillance with biopsies- for patients with metaplasia not dysplasia- endoscopy every 3-5 years
If dysplasia of any grade is identified endoscopic intervention is offered
What are the causes of anaemia in renal failure (CKD)?
Most significant- reduced erythropoietin levels- kidneys produce EPO
Reduced absorption of iron
More kidney specific reasons
Management of anaemia in CKD?
Determination and optimisation of iron status should be carried out prior to the administration of erythropoiesis stimulating agents (ESA)
Oral iron should be offered, if not reached target in 3 months switch to IV iron, those on ESA usually require IV
ESAs such as erythropoietin and darbepoietin
Glucose range for prediabetes?
HbA1c of 42-47mmol
Fasting glucose of 6.1-6.9
Glucose range for diabetes?
> =48mmol HbA1c
=7mmol fasting glucose
Management for prediabetes?
Lifestyle modification- exercise, diet, weight loss
At least yearly follow up with blood tests
Metformin for adults at high risk progressing towards T2DM despite lifestyle changes
Features of a lower UTI in adults?
Dysuria
Urinary frequency
Urinary urgency
Cloudy/offensive smelling urine
Lower abdominal pain
Fever- typically low-grade in lower UTI
Malaise
In elderly patients acute confusion is a common feature
Urine dipstick vs urine culture in lower UTI?
Urine dipstick- can be used to aid diagnosis in women under 65 years old with no risk factors for complicated UTI
Urine culture- should be sent in women >65, men or catheterised patients, reccurent UTI, pregnant patients
Hypospelnism causes and features?
Causes:
Splenectomy
Sickle-cell
Coeliac disease
Graves’ disease
SLE
Amyloid
Features:
Howell-Jolly bodies
Siderocytes
Diabetes diagnosis thresholds?
Fasting glucose greater than or equal to 7
Random glucose greater than 11.1 or after glucose tolerance test
If patient asymptomatic the criteria must be demonstrated on two seperate occasions
Also HbA1c above 48
Conditions where HbA1c may not be useful for diabetes diagnosis?
haemoglobinopathies
haemolytic anaemia
untreated iron deficiency anaemia
suspected gestational diabetes
children
HIV
chronic kidney disease
people taking medication that may cause hyperglycaemia (for example corticosteroids)
(High turn over of RBC)
What condition can cause a sudden deterioration following high pressure non-invasive ventilation?
Pneumothorax
What are the types of pneumothorax?
Primary spontaneous pneumothorax- those occuring in tall, young individuals without lung disease
Secondary spontaneous pneumothorax- occurs in patients with pre-existing ling disease such as COPD, asthma, cystic fibrosis, lunch cancer
Traumatic pneumathorax- penetrating or blunt chest trauma
Iatrogenic pneumothorax- complication of medical procedures such as- thoracentesis, central venous catheter placement, ventilation- including non-invasive ventilation or lung biopsy
What is a tension pneumothroax?
Severe pneumothorax resulting in the displacement of mediastinal structures
Clinical features of pneumothroax?
Sudden symptoms: dyspnoea, chest pain: often pleuritic
Signs:
Hyper-resonant lung percussion
Reduced breath sounds
Reduced lung expansion
Tachypnoea
Tachycardia
In tension pnemothorax:
Respiratory distress
Tracheal deviation away from side of the pneumothorax
Hypotension
First step in pneumothorax management?
Assess the size of the pneumothorax
No or minimal symptoms- conservative care, regardless of pneumothorax size
Symptomatic- assess for high-risk characteristics
Management for symptomatic pneumothorax?
Determine if there are high risk characteristics:
Haemodynamic compromise (suggesting tension)
Significant hypoxia
Bilateral pneumothroax
Underlying lung disease
Over 50 with significant smoking history
Haemothorax
If no high risk patients offered a choice of conservative, ambulatory or needle aspiration
If high risk and safe to intervene- chest drain
Pneumothroax conservative care summary?
Patient with primary spontaneous pneumothorax this is managed conservaively should be reviewed every 2-4 days as an outpatient
Secondary spontaneous managed conservatively should be monitored as an inpatient
Ambulatory care for pneumothorax?
Use an ambulatory device that allows controlled escape of air with one way valve
Needle aspiration for pneumothorax?
Chest drain should be inserted if unsuccessful
If resolved discharge and follow up as outpatient in 2-4 weeks
Chest drain insertion?
Daily review as an inpatient
Remove drain when resolved
Discharge and follow up in outpatients after 2-4 weeks
Persistent/recurrent pneumothroax?
Video-assisted thoracoscopic surgery (VATS) should be considered to allow for mechanical/chemical pleurodesis +/- bullectomy
Discharge advice for pneumothorax?
Avoid smoking
Avoid flight for 2 weeks after
Scuba diving should be permenantly avoided
What is acute interstitial nephritis?
Accounts for 25% drug induced AKI- inflammation in kidney
Causes of acute interstitial nephritis?
Drugs- most common cause, particularly antibiotics- penicillin, rifampicin, NSAIDs, allopurinol, furosemde
Systemic disease- SLE, sarcoidosis, Sjogren’s syndrome
Infection
What are the features of acute interstitial nephritis?
Fever, rash, arthralgia
Eosinophillia
Mild renal impairment
Hypertension
Difference between IgA nephropathy and Post streptococcus glomerulonephritis?
PSGN develops 1-2 weeks after URTI
IgA nephropathy develops 1-2 days after URTI
What criteria are used to calculate eGFR?
Serum creatinine
Age
Gender
Ethnicity
Factors affecting the result:
Pregnancy
Muscle mass (amputees, body builders)
Eating red meat 12 hours prior to the sample being taken
CKD stages 1 and 2?
If no sign of kidney damage on other test/ kidneys look normal then there is no CKD
CKD and anaemia?
CKD can cause a reduction in erythropeitin levels
This predisposes to LVH so can cause cardiovascular issues
