Miscellaneous Flashcards
When should we not offer PEP to a patient who has unprotected sex with a patient who is HIV positive?
If partner has been on ART > 6 months and has had an undetectable viral load in last 6 months
When should PEP be offered routinely (4)
If unknown or detectable vial load and:
1. Receptive anal sex
2. Receptive vaginal sex
3. Occupational exposure
4. Needle sharing
When should PEP be considered? (2)
Unknown or detectable viral and:
1. Insertive vaginal sex
2. Insertive anal sex
When is PEP not recommended? (2)
- Sex/splash/injection in high risk group but not known HIV
- Human bite in HIV positive
What PEP should be offered?
Tenovir + emtricitabne (Truvada) combination and raltegravir OD for 28 days
When should PEP be started?
ASAP (ideally <24hours)
After what period is PEP not effective?
> 72 hours
What is a tetanus prone wound? (5)
- Puncture wounds occurring in contaminated enviroment
- Wounds with foreign body
- Compound #s
- Wounds/burns with sepsis
- Certain animal bites
What are high risk tetanus prone wounds? (3)
- Heavy contamination with soil containing spores
- Wounds/burns with significant devitalised tissues
- Wounds/burns requiring surgery that are delayed over 6 hours
What is full tetanus immunisation? (3)
- > 11 year priming course and last dose < 10 years ago
- 5-11 years and priming course pre-school booster
- < 5 years and priming course
What is partial tetanus immunisation? (2)
- Over 11 years, priming course but last dose >10 years
- 5-11 years with priming course but no pre-school booster
If fully immunised against tetanus what do you require following a:
1. clean wound
2. tetanus prone wound
3. high risk tetanus prone wound
Nothing
If partially immune against tetanus what do you require following a:
1. clean wound
2. tetanus prone wound
3. high risk tetanus prone wound
1.Nil
2. Vaccine dose
3. Vaccine and TIG
If no immunisation against tetanus what do you require following a:
1. clean wound
2. tetanus prone wound
3. high risk tetanus prone wound
- Vaccine
- Vaccine and TIG
- Vaccine and TIG
What dose of TIG should be given in tetanus? (4)
- 250 IU IM
- 500 IU IM if :
- heavy contamination
- burns
- > 24 hours
NB do not given vaccine and TIG at same site
What is a clean wound re: tetanus risk?
< 6 hours
non-penetrating
What values are considered mild/mod/severe hypercalcaemia?
- <3
- 3-3.5
- > 3.5
What ECG changes do you see in hypercalcaemia? (4)
- Short QTc
- Bradycardia
- 1st degree HB
- Broad T waves
What is first line treatment for hypercalcaemia?
- 4-6 L of IVI over 24 hours
What is second line tx for hypercalcaemia?
- Zolendronic acid 4mg
- Pomidronate 30-90mg
What is third line for hypercalcaemia?
- Steroids
- Parathyroidectomy
- Dialysis or diuresis
What is pituitary apoplexy?
Haemorrhage +/- infarction of a tumour within the pitiutary gland
What are the features of pituitary apoplexy? (4)
Acute severe headache
Ocular palsy
Bitemporal hemianopia
Meningism
What is the management of pituitary apoplexy? (2)
- Steroids +/- neurosurgery
What clotting factors are in the intrinsic pathway?
IX
X
XI
XII
What clotting factors are in the extrinsic pathway?
II, VII, X
What is the final pathway of the clotting cascade?
Prothrombin (II) - Thrombin (IIa) - Fibrinogen (I) soluble - Fibrin mesh (insoluble)
What are the vitamin K dependent factors?
II
VII
IX
X
Protein C + S
What is the mechanism of action of UFH and LMWH?
Indirect thrombin inhibitors
What are the factor Xa inhibitors? (4)
Fondaparinox
-bans
Rivoroxaban
Apixiban
Edoxaban
What is a direct thromin inhibitor
Dabigatran
If minor bleeding how long should UFH be observed for?
6 hours
If minor bleeding only how long should LMWH be observed for?
24 hours
In significant bleeding what should be given to reverse UFH?
Protamine
What is the reversal agent for fondaparinox?
Recombinant factor VIIa
With LWMH (dalteparin/tinzaparin/enoxaparin) and bleeding what needs to done? (2)
- Anti Xa assays
- Protamine
How effective is protamine with LMWH?
60%
What makes a patient on warfarin high risk? (7)
- > 65
- HTN
- Diabetes
- Renal failure
- Hepatic failure
- Anti-plts concurrently
- Surgery/trauma
If there is no bleeding, how should high INR be managed in patients taking warfarin? (2)
INR <8 in low risk or <6 in high risk withold warfarin 24 hours and recheck
INR >8 in low risk of >6 in high risk then 1-2.5mg PO vit K and consider admission
When is it acceptable to simply withold warfarin and recheck in 24 hours?
- No bleeding
- INR <6 in high risk or < 8 in low risk
In minor bleeding on warfarin what tx should be given? (2)
- 2mg vit k orally
- 1mg vit K IV
In severe bleeding on patients on warfarin what tx should be given? (3)
- 5-10mg vit K IV
- PCC 30-50units/kg over 10mins
- Recheck clotting after 20 mins
What is the specific assay for dabigatran?
ECT + HDTI
What is the specific assay for factor Xa inhibitors?
CAX
What is the antidote for dabigatran?
Idarucizumab
What is the antidote for rixoroxaban/apixaban?
Andexanet
What is the reversal for edoxaban?
PCC + vit K
What assessment tool do NICE recommend for identification of those at risk of alcohol dependence?
AUDIT
What assessment tool does NICE recommend for severity of dependnce?
SADQ
When should inpatient alcohol detox be considered? (4)
- SADQ >30
- Hx of epilepsy
- Hx of withdrawal seizures or DTs
- Previous assisted withdrawal programmes
If benzos are being used in patients with liver impairment what should be used?
Lorazepam and go slowly
What is first line for DTs?
PO lorazepam
What is second line for DTs? (3)
- IV lorazepam
- IV haloperidol
- IV clozapine
In adrenal crisis what is the initial bolus of hydrocortisone dose?
100mg IV
What is the maintenance hydrocortisone give in adrenal crisis?
200mg infusion/24 hours
or
50mg QDS
How much IVI should be given over 24 hours to rehydrate a patient with adrenal crisis?
3-4 L
What are the severe features of hyponatreamia? (4)
- Vomiting
- Arrest
- Seizures
- Reduced GCS
In presence of severe symptomatic hyponatreamia what is the initial treatment?
- 150ml 3% normal saline or equivalent over 20mins
- Repeat twice or until sodium increases by >5mmo/L
What is the follow up management of severe hyponatreamia following initial management?
- Stop hypertonic but continue normal saline
- Limit sodium increase to 10mmol/l over 24 hours
How is osmsolality calculated?
2 (Na + K) + urea + gluc
How should we manage HHS?
-Fluids until glucose not dropping by 5units/hour, then fixed rate insulin
-Unless significant ketonuria then start insulin after a period of rehydration, never straight away - can lead to circulatory collapse)
What is first and second line for complicated/severe malaria in UK?
IV artesunate first
IV quinine second
What is first and second line for uncomplicated malaria in UK?
Artemisinin combination therapy (ACT) first
Atovaquone-praguanil second
How does infantile botulism present?
Constipation is often the first sign, along with a dry mouth. Then facial palsy can occur.
Following this, there is a worsening weakness with poor suck, poor head control, hypotonia, hyporeflexia, and a weak cry.
Why does botulism infect <1 year olds more than older children
Spores can germinate in stomach and produces toxin, older children would need to ingest the actual toxin
How to infants normal contract infantile botulism?
Ingesting honey
Which type of electrical current causes:
1. Tetany
2. Forceful ‘jolt’ that can throw a patient a distance from power source
- AC (usually higher voltage)
- DC
Which type of electrical current causes
1 VT/VF
2. Asytole
- AC (70ma or higher)
- DC
What 3 things make up a diagnosis of HHS?
- Hypovolaemia
- Marked hyperglycaemia without significant ketonaemia or acidosis
- Osmolality >320 mosmol/kg
What makes up the FeverPAIN score?
Fever in last 24hours
Purulent tonsilts
Attends within 3 days
Inflamed tonsils (Severe)
No cough or coryza
What is qSOFA made up of?
BP <100mmHg
RR over 22
Altered mental state
1 for each
2 or more suggests greater risk of death
What abx do NICE not recommend giving empirically for neutropenic sepsis?
Aminoglycosides
What does the road traffic act say about doctors taking blood samples for alcohol and drug testing?
Lawful - regardless of patients consent and has to be given to constable
Describe the serious incident framework?
- Confirm serious incident -report to commissioners (2 days)
- Confirm level of investigation required (3 days)
- Investigation - root cause analysis ( 60 days)
- Final report and action plan (20 days)
Describe the serious incident framework?
- Confirm serious incident -report to commissioners (2 days)
- Confirm level of investigation required (3 days)
- Investigation - root cause analysis ( 60 days)
- Final report and action plan (20 days)
What is MHA section 4?
Emergency holding powers (72 hours)
What is MHA section 5 (2)
Doctors holding powers (only a ward)
What is MHA section 5 (4)
Nurse holding powers
What is section 2 MHA?
Nature of illness unclear
What is section 3 MHA?
Nature of illness clear
What condition is non IgE mediated but can can lead to angio-oedema and GI symtoms?
C1 esterate deficiency
What is the treatment for CI esterase deficiency? (3)
- Berinert (c1 esterase inhibitor)
- Icatibant (bradykinin receptor blocker)
- FFP contains C1 esterase
NB: adrenaline/anti-histamines will not work
What is the cause of Scromboid?
- histamine poisoning from unrefrigerated fish (esp dark-flesh)
- Cooking does not kill the histamine
What are the features of Scromboid poisoning and when do they present/relieve?
- Sx within 10-30 minutes after eating fish + resolved within 12 hours
- Symptoms = pruritis, skin flushing, peppery taste, headache, palpitations, D+V
- Rare to have A/B/C involvement
What is the management of Scromboid poisoning? (2)
- Mx = supportive care, antihistamines
-can eat fish in future, inform PHE as case of food poisoning
Describe the 4 types of immunological skin reactions?
- Type 1 reaction (IgE mediated) = anaphylaxis
- Type 2 reaction = cytotoxic
- Type 3 reaction = immune complex
- Type 4 reaction = delayed, cell mediated e.g. contact dermatitis
What is steven-johnson syndrome?
Severe erythema multiform >10% TBSA.
Vesicles in mucous membranes of eyes and mouth.
-
What is toxic epidermal necrolysis (TEN)
Severe erythema multiform >30% TBSA. Painful rash and fever.
Widespread desquamation.
7-14 days after 1st drug exposure
What does DRESS stand for?
DRESS (Drug Reaction with Eosinophilia and Systemic Symptoms; also called drug
hypersensitivity syndrome).
What are the signs/symptoms of DRESS/drug hypersensitivity syndrome? (5)
2-6 weeks after 1st drug exposure -
Maculopapular rash
Fever
Abnormal LFTs
Lymphadenopathy
Eosinophilia
What is erythroderma?
> 90% TBSA erythema
What is the management for erythroderma?
- Bed rest
- IVI
- Emollients
What is erysipelas?
Skin infection distinct from cellulitis
Only superficial dermis so distinct borders
Painful, red and raised
What are the causes of a bitemporal hemianopia? (3)
- Pituitary adenoma
- Glioma
- Carotid artery aneurysms
Act on the optic chiasm
What is the predominant cause of a homonymous hemianopia?
CVA
What acts on the optic nerve directly causing loss of vision?(2)
- MS
- Ethylene glycol
What does a complete 3rd nerve palsy looks like? (3)
- Down and out pupil
- Proptosis
- Dilated pupil
What does on differentiate between compressive and medical causes of third nerve palsy?
Pupillary involvement - compressive/surgical (bleed/aneurysm/SOL) usually cause pupillary dilatation as the parasympathetic fibres are on the outside of the nerve and are compressed.
What do patients with a CN IV (trochlear) present with?
- Weakness of downward gaze - difficulty walking downstairs or reading
- Vertical diplopia
Which muscle does CN IV (trochlear) innervate?
Superior oblique
What muscle does CN VI (abducens) innvervate?
Lateral rectus
What will patients suffering from CN VI palsy present with?
- Convergent squint at rest (pupil moves towards nose)
- If complete palsy will be unable to abduct eye past midline
- Horizontal diplopia on affected eye
What does vitreous haemorrhage present like?
Painless visual changes - from floaters/black spots to light perception only
What is the hx for CRAO and CRVO?
Sudden, painless visual loss
What does this suggest and describe the findings?
- CRAO
- Pale optic disc / retina with ‘cherry red spot’ of the macula
What does this finding suggest?
CRVO
What is the ED management for CRAO?(2)
Digital massage of eye in supine position (patient should do to themselves)
IV acetazolamide
What laboratory criteria are needed to confirm tumour lysis syndrome? (4)
2 or more of:
1. Hyperkalaemia
2. Hyperphosphataemia
3. Hyperuricaemia
4. Hypocalcaemia
How long after a dive do the bends normally present?
< 6 hours (90%)
What increases your risk of the bends? (7)
1.Deep dive, long dive, missed decompression stops, multiple dives
2. Age
3. Exercise during or after a dive
4. Flying/ ascending to altitude after diving
5. Obesity
6. Dehydration
7. Alcohol use prior to dive
What are is mainstay of treatment for the bends?
- High flow oxygen
- Rehydration
Decompression chamber gold standard - obvious practical issues
What should be avoided in in the bends? (2)
Analgesia - oxygen normally enough and risks with opiates and NSAIDs
No entonox!
What distinguishes keratitis/keratoconjunctivitis from conjunctivities?
- Pain worse
- Photophobia
- Worsening visual acuity
More likely if contact lens wearer
How does acute angle glaucoma present in terms of the eye?
- Painful + red
- Decreased visual acuity
- Mid-dilated pupil
- Non-responsive pupil
How should acute closed angle glaucoma be managed? (3)
- 500mg IV acetazolamide
- Opiates/analgesia
- After one hour of treatment topical miotic such a pilocarpine every 5 mins (pupil unlikely to respond until this point)
What is episcleritis? (3)
1.Engorgement of the superficial episcleral plexus
2. More irritating than painful
3.Self limiting
Describe the features of scleritis?
- Either localised of generalised blue-ish/violet discolouration
- Deep, dull ocular pain
- Pain worse on movement of eye
Associated with rheumatological diseases
What serotype is anterior uveitis associated with?
HLA-B27
How does anterior uveitis present? (4)
- Painful red eye, worse on accomodation
- Photophobia, can be consensual
- Pupil maybe an unusual shape
- Can have keratitic precipitates
Which commonly used drugs can precipitate acute closed angle glaucoma?
- Anticholinergics
- Chlorphenamine (has some anticholinergic propertis)
- Salbutamol
- SSRIs
Who is more prone to getting acute closed angle glaucoma?
Elderly and far sighted
What is the difference between monocular and binocular diplopia?
Mononuclear diplopia does not resolve when one eye closed, binocular is present with both eyes open and resolves when either eye is closed.
Binocular suggests concerning pathology, monocular suggests issue with eye
How does acetazolamide help treat acute closed angle glaucoma?
It decreases the production of aqueous humour
