Misc Flashcards
What is the analgesic ladder?
1 - paracetamol +/- NSAID
2- + weak opioid for mil to mod pain (codeine, tramadol, dihydrocodeine)
3- change to strong opioid - for mod - severe pain
Pain management for vertebral metastasis
Vertebral mets - from breast, prostate
Severe pain
All steps might be consumed
Mod-severe pain in vertebral mets after initial pain meds prescribed what can be added?
Radiotherapy as adjuvant if there is still mod-severe pain
Radio fails or inappropriate - use Bisphosphonates
What should you use if pain is neuropathic in nature?
Gabapentin or amitriptyline
Simple analgesics
NSAIDs (diclofenac)
Aspirin
Paracetamol
Weak opioids
Codeine
Tramadol
Strong opioids
Morphine
Fentanyl
Oxycodone
Bone pain due to mets
Radiotherapy
Neuropathic pain
Gabaoentin
Pregabalin
Amitriptyline
After open surgery - what pain meds are given?
Patient controlled morphine (weaned off later)
Visceral pain
Antispasmodic - Mebeverine
Capsular pain (liver)
NSAIDS - ibuprofen/Naproxen
Muscle spasm
Baclofen
Diazepam
Trigeminal neuralgia
Carbamazepine
Tx for intractable hiccups due to liver mets
Metaclorpromide
Peripheral causes of hiccups -
Liver mets - peripheral cause of hiccups due to gastric stasis and dilation - irritation of the vagus nerve.
Diaphragmatic irritation in liver mets - phrenic nerves irritated
Central causes of intractable hiccups
Tx-
Cerebral lesion
Tx - chlorpromazine/haloperidol/midazolam
Tx of constipation secondary to opioids
Senna - stimulant laxative
Vomiting secondary to opioids
Metoclopramide
Vomiting secondary to increased intracranial pressure or due to bowel obstruction
Cyclizine
Itching due to jaundice
Cholestyramine
What antiemetic should be used in
renal failure
Hypercalcemia (metaobolic cause)
Drug/toxin induced vomiting
Haloperidol
When can haloperidol not be used?
In that case what is the second line?
Parkinson’s - haloperidol is contraindicated
Metoclopramide can’t be used either
2nd line - levomepromazine
Antiemetic used in chemo/radio - therapy
Ondansetron
Post op intractable nause and vomiting
IV ondansetron
Antiemetics in hyperemesis gravidarum
1- cyclizine, promethazine
2- IV metoclopramide, ondansetron
3- steroids
Medication to shrink peri-lesional oedema and and alleviate ICP symptoms
Dexamethasone - preferred glucocorticoid in intracerebral oedema
Symptoms improve within several hours
Usual does = 4mg, 4x a day PO or IV
What is SVC obstruction commonly associate with?
Lung cancer
Another cause is lymphoma
SVC obstruction is an oncological emergency
Features of SVC syndrome
Dyspnoea
Swelling of face neck and arms - conjunctival and peri orbital oedema
Distension of veins of upper neck and chest
Facial plethora
Headache
Visual disturbance
Pulseless jugular venous distension
Causes of SVC obstruction
Common malignancies - non small cell lung ca, lymphoma
Other malignancies - metastatic Seminoma, kaposi’s sarcoma, breast ca
Aortic aneurysm
Mediastinal fibrosis
Goitre
SVC thrombosis
Management of SVC obstruction
Dexamethasone - most appropriate immediate management
Endovascular stenting - treatment of choice
Treat the cause.
Most appropriate investigation of SVC obstructions
CT Chest w/ contrast
What is Charcots triad ?
Acute ascending cholangitis
Triad - FRJ - fever, Right upper quadrant pain, Jaundice
+- leukocytosis and Hypotension
Investigations for ascending cholangitis
Abdominal US
Blood cultures
Patient with history of myeloma presents with back pain and urinary incontinence as well as lower limb weakness.
What diagnosis do you suspect?
What is your next step?
Malignant spinal cord compression
Urgent MRI of the whole spine
MSCC - history of ca - breast prostate myeloma + back pain_ neurologic sx
Most appropriate investigation for lipoma
What is the management?
US
Reassure
Management of lipoma
Typical not growing or interfering with life - reassure
Doubts of liposarcoma - >5cm, increasing in size, painful, deep anatomical location —— perform US - if suspicious - MRI referral +- surgical removal
Diagnosis of osteoporosis
T score
- 1 or higher - normal
- 1 - -2.5 - osteopenia
- 2.5 or lower - osteoporosis
Management of osteoporosis
Follow up
1st line - bisphosphonates
Alendronate, risedronate, zoledronic acid
70mg once weekly OR 10mg once daily.
F/U
Already on BIS - DEXA every 3-5 years
Stopped taking BIS - DEXA after 2 years
Side effects of HRT
VTE
Stroke
Breast ca
Coronary disease
Prescribing oral bisphosphonate
Explain the following to patient -
Dyspepsia and reflux are common in 1st month, improves with use
To reduce severity of sx - take bis in upright position and stay until 30 mins after
What is C8
Nerve root that emerges below C7
There is no C8 vertebra
Nerve root of Median nerve
C5-T1
Nerve root of Ulnar nerve
C8 - T1
What nerves are responsible for weakness of the hands?
Median and ulnar
What is the lowest level needed to be seen after a neck in injury on a lateral neck X-ray ?
C7 - T1
In a suspected cervical fracture what cervical vertebrae should be present in X-ray ?
C1-C7
What junction sometimes does not appear on AP lateral and Peg view X-rays?
What view can be used to view it?
C7 -T1
Use Swimmer’s lateral view
If still unable to view — CT scan
40 year old woman with menorrhagia, unable to conceive the past 2 years. TVUS drones showed thick-walled unilocular cyst with acoustic enhancement and diffuse homogenous ground glass opacities on the left ovary
What is the likely diagnosis?
Ovarian endometrioma
Snowstorm appearance with mixed echogenicity
Bilateral cystic masses
What is your dx?
Hydatidiform mole
Bilateral cystic masses = large theca lutein cysts
What is the US finding in PCOS
Multiple follicles, cysts
Features of dermoid cyst on US
Iceberg tip sign
Flat-fluid level
Mostly unilocular
Dermoid mesh
US shows ground glass appearance of ovary, thick wall uniloculat cyst, chocolate cyst
Dx?
Ovarian endometrioma
Echogenic tubercle projecting into cyst lumen seen on US of ovary, what is you diagnosis?
Ovarian teratoma
How does a tubo-ovarian abscess appear on US?
Multilocular
Separations
Irregular thick walls
Echogenic debris in pelvis
ECG features of TCA overdose?
Widened QRS,PR,QT
Broad complex tachycardia
What metabolic abnormality is seen in TCA overdose?
Treatment
Metabolic acidosis - severe
Tx - IV fluid bolus = .9% NaCl + IV sodium bicarbonate 50ml of 8.4%**
Aim for pH 7.5-7.55
Electrolyte disturbances seen in refeeding syndrome?
Hypophosphatemia
HypoK+
HypoMg+
Cardiac + pulmonaary+neurological symptoms - can be severe if fatal
Unilateral flank pain/loin pain + HCG +ve / amenorrhoeic
What should you suspect?
Ectopic pregnancy
What tests should be done before commencing lithium ?
Thyroid function test **
Kidney function test
What tests should be done before prescribing amiodarone?
Serum electrolytes
Urea
What is useful thyroid cancer marker?
What does it indicate?
When is it used?
Thyroglobulin (Tg)
Recurrent or metastasis of thyroid cancer after successful removal of thyroid
Used after thyroidectomy
*not useful in diagnosis of thyroid cancer
Patient with his of metastasis colorectal ca , presents with persistent vomiting of fecal content and has colicky abdominal pain
O/E - abdomen distended + high pitched sounds
What is the initial step in management?
What is the most palliative (definitive) step?
How would you manage the fecal vomiting?
Initial step - NGT decompression
Definitive/ most palliative step - stoma
Vomiting of fecal contents -NGT
Features of pleural effusion
Dullness on percussion
Absent breath sounds
Features of consolidation
Inspiration crackles + dullness on percussion
What is a teratoma?
Tumour made up of several different types of tissue - hair muscle teeth epithelium cartilage or bone.
Typically form in the ovary, testicle , tailbone etc
Presentation
Complications
Of teratoma
Symptoms - minimal
Testicular teratoma - painless lump
Complications - ovarian torsion, testicular torsion or hydrous fetalis
*males = ALWAYS MALIGNANT
females - usually benign
What is Capecitabine?
Side effects
Chemotherapy drug
Profuse diarrhoea - to avoid severe dehydration =
requires fluid replacement
Anti-diarrhoeal meds - loperamide
If the diarrhoea and dehydration continue - stop the drug.
Electrolyte imbalance seen in prostate ca
Hypercalcemia
Symptoms - depression, lethargy, constipation, polyuria, polydipsia
**SERUM CA should be requested in breast and prostate ca
Long term meds for TIA
Clopidogrel + atorvastatin
Long term management - TIA
Control BP Statins - atorvastatin 80mg Anti platelets/ anticoagulations - depending on presence or absence of AF = warfarin or DOAC DOAC - apixaban, rivaroxaban, edoxaban
If no AF - Clopidogrel 75mg
Acute ischemia stoke management
Aspirin 300 mg - 2 weeks
Clopidogrel 75mg for life
Hydropneumothorax vs pleural effusion
Hydropneumothorax - air fluid levels within pleural space
Fluid level well defined extends whole length of hemithorax
-4S = straight line dullness, shifting dullness, splash, sound of coin
Cause of hydropneumothorax
Treatment
Iatrogenic - during pleural fluid aspiration in effusion
Presence of gas forming organism
Thoracic trauma
Treatment
Intercostal drainage
Fatigue weight loss high ALP and Ca++
Likely diagnosis?
Metastatic bone ca
What chemotherapy drugs can cause peripheral neuropathy?
Vincristine
Crisp Latin
Carboplatin
Taxanes
Small vs large bowel obstruction
LBO- peripheral, 8cm diameter, haustration
SBO - central, 5 cm , valvular coniventae
-ileum may appear tubeless
Appearance of bronchiectasis (imaging)
Bronchial dilation and wall thickening with ground glass opacities
CXR -**Tramlines “cysts/ring opacities”
However CXR is often normal
Clinical features of bronciectasis
Chronic persistent cough
Copious excessive sputum
Recurrent respiratory tract infections
Clubbing. - drumstick shaped fingers - not specific
“Irreversible dilatation of small and medium sized bronchi”
How do you confirm a dx of bronchiectasis?
***HIGH RESOLUTION CT SCAN (HRCT)
What is a post dural puncture headache?
How do you treat it?
Headaches after spinal anaesthesia
Caused by CSF leakage - leads to decreased intracranial pressure
Observe and encourage oral hydration
Usually self limited (goes within a week)
Management of acute exacerbation of COPD
Nebuliser bronchodilators - salbutamol 5 mg (consider + ipratropium .5mg)
Corticosteroids - 30mg prednisolone, OD, for 1-2 weeks OR 100mg hydrocortisone
Oxygen via Venturi mask - FiO2 24-48% maintain stats 88-92%
Antibiotics - if FEVER, purple to sputum, raised CRP, signs of pneumonia
IV aminophylline - no adequate response to nebs
***** low pH, high CO2 = NIV
Normal pH + high CO2 = fiO2 24-48% Venturi mask
(COPD) If there’s no response to medical treatment and the pt develops respiratory acidosis what should be done?
NIV - CPAP BiPAP
(COPD) when should invasive ventilation be used?
If NIV fails (still rising CO2)
Or if NIV is contraindicated
Contraindications of NIV
Respiratory arrest
High aspiration risk
Impaired mental status
Initial investigations of neck mass
US +FNAC
Pt with chronic cough , haemoptysis.
Chronic smoker
CXR - solitary coin lesion RUL
Most likely dx?
Lung cancer
Management of status epilepticus
1st step - 2 separate doses (10-20 in b/w)of
- IV lorazepam (in hospital with iv access)
- buccal midazolam or rectal diazepam - no iv access or outside hospital
2 sep doses given with no effec move to step 2
- IV phenytoin (preferred over phenobarbital)
- Refer ICU - intubate, IV phenobarbital
Features of CO poisoning
Red pink or cherry red skin/mucosa
+
Altered mental status
Management of CO poisoning
Conscious 0 100% O2 via FM (tight fit)
Unconscious- intubate + ventilate w/ IPPV on 100% O2
*** hypotensive SBP <100 or unconscious = INTUBATE
What anti-hypertensive drugs need to be stopped before surgery?
When should they be stopped?
ACEi + ARBs
24 hours before
*they can lead to severe hypotension after induction of GA
Pt on corticosteroids - med adjustment for surgery
Same dose pre-op
Double dose post op to avoid adrenal insufficiency
