Mixed Flashcards
STEMI
<90 mins: PCI
If not feasible: Thrombolytic Rx
Contraindications for Thrombolytic rx
Previous ICB
BP > 180/110
Recent major surgery
Aboriginal ( Antibody+ to streptokinase)
Dual antiplatelet duration post PCI
12 months
Prognostic FX for systolic heart failure
Raised JVP+ S3 gallop
Microangiopathic hemolytic anemia
Indirect bilirubin
Decreased haptoglobin
LDH elevated
Schistocytes on PBS
HUS
Shiga toxin
Renal symptoms predominant with microangiopathic hemolytic anemia
von Wiilebrand disease
Autosomal dominant
Bleeding 🩸 time increased
Normal platelet
vWF Ag: low in type 1
PTT normal/high
vWD rx
DDAVP
Factor VIII 8 concentrate
Platelet transfusion only in severe cases
Best initial study for oropharyngeal/motility related dysphagia
Barium study
Hypocalcemia Mx
Based on symptoms √
•sympromatic : IV Calcium gluconate
Based on levels ✓
•less than 1.9 : IV Ca gluconate
> 1.9: oral calcium+ vitamin D
SCFE
Rx
Stop weight bearing
Gentle reduction with pinning
Cocaine vs smoking
Effects on foetus
Cocaine No anomaly but IVH
Smoking cause anomalies such as IUGR, GI malformations
Postural hypotension
Test
Initial supine and standing BP:
Less than 10 bpm increased and hypotension: autonomic
+ table tilt test
> 30bpm and hypotension: hypovolemia
> 30bpm increased, NO hypotension: POTS
Commonest cause of obstructive jaundice
Stone
Periampullary Tumor: head of the pancreas commonest
Strictures
Open wound #
CARATXO
Clean wound
Analgesia
Reduction by traction
Antibiotics
Tetanus prophylaxis
Xray
Operation theatre
OCP with antiepileptics
Stop the OCP and use condom
IUCD or Depot MPA
If refused to discontinue OCP:
✓Increase the dose
✓Tricycle phase
Implanon, ocp
Not advised for patients on antiepileptics as it’s enzyme inducers
GBS bacteruria
Vs GBS vaginal swab
Bacteruria:Needs treatment (by order wise)
Cephalexin
Nitrofurantoin
Augmentin
Vaginal: normal colonisation, no need Rx
GBS bacteruria but asymptomatic
Asymptomatic bacteruria needs Abx!!!
AV block
1: constant pr
2: type 1: pr longer longer drop
Type 2: pr constant & drop
3 constant P-P and constant Q-Q
VT pulse +
Hemodynamic unstable
Cardioversion
JVP normal physiological response
Expiratory: rise
Inspiration: drop
Pericarditis
Reverse in JVP, expiratory: drop inspiration: rise Kussmaul sign
Pericarditis
ECG ∆
Diffuse ST elevation
Pr depression in lead 1 especially
TCA toxicity
Widening qrs complex
Prolonged qt
Kussmaul sign
Seen in constrictive pericarditis
✓JVP reversed
✓Edema
✓Congestive hepatomegaly
✓Ascites
Patient missed his CHF medications, comes back with hypervolemic sx
Initial: ace (-) to reduce after load
Diuretics to improve symptoms
NOT to give beta blockers yet. To be given once euvolemic only
EF reduced/ systolic dysfunction
Hypervolemic
Ace -/ARB
MRA
EF reduced/systolic dysfunction
Euvolemic
Ace (-) / ARB
Diuretics or MRA
B- blockers
Preserved EF/diastolic dysfunction
Beta blockers
CCB
Diuretics: in congestion cases
HOCM
Echo 1st
Rx: beta blockers + verapamil+ dispyramide
Catheter with alcohol to infarct septum
Bradycardia
Asymptomatic: reassurance
Symptomatic: initial: IV atropine 1st line 0.6 mg then 0.5mg every-5 mins
IV adrenaline infusion: 2nd line
In ED: temporary pacing with percutaneous or IV pacemaker
Elective permanent pacemaker later
AV block
Best initial
Transcutaneous Pacing
PSVT symptomatic young man
1st choice: adenosine
2nd: verapamil
3rd: beta blockers
AF Stable without decompensated HF:
Beta blockers 1st choice
Add Digoxin of not well controlled
Flecainide for rhythm control
AF with decompensated HF
Digoxin initial choice
Avoid beta blockers !!!
AAA surveillance
3-3.9 : 24 mth
4- 4.5: 12 mth
4.6- 5: 6 mth
> 5: 3 mth
AAA indication for surgery
> 1cm /year
Male> 5.5
Female> 5.0
Symptomatic
Thoracic> 6.0
Acute limb ischemia
Most common Cause?
Thrombosis
Acute limb ischemia
Post embolectomy mx
Heparin initiated, then bridging with Warfarin. Once INR of 2-3 achieved, omit heparin
Warfarin for 6 months
*Cardiac origin emboli needs lifelong treatment
Perioperative high mod low risk for VTE prophylaxis
Q142
Medical high risk: CASHSTD
AF asymptomatic
Aspirin 1st
CHA2DS2 VASc
For Warfarin or NOAC if =/>2
Others eg b blockers if Symptomatic
Ace (-) , smoking cessation, statin
ABI< 0.9
For <0.4 : urgent referral to vascular
Dazzling with sunlight
Cataract
Needle stick injury
Patient status unknown
Medical personnel not immunised
Ivig+ 3 dose hepatitis B vaccine
Colonoscopy
Asymptomatic
Cat 1: ifobt every 2 yrs from 45
Cat 2: ifobt every 2 yrs from 40
Cat 3: ifobt every 2 yrs from 35
Cat 2
Cat 3
Asymptomatic
Colonoscopy every 5 yrs
Low dose aspirin
Definition of category in colon cancer
Cat 1 ✓1fdr or 1 FDR +;1 SDR> 55
Cat 2 ✓1fdr <55 or 2 FDR any age
✓1fdr +2fdr any age
Cat. ✓3fdr or 3sdr ( at least 1 before 55)
Parvovirus monitoring in exposed pregnant women
IgG and IgM
If both negative: repeat in 2 weeks
IgG+ IgM - : immune mother ,no need follow up
IgG - IgM + :infected
IgG + IgM+ : recent infection
Parvovirus+
1-2 weekly USG for 6-12 weeks look for hydrops
If seen, for umbilical cord sampling and intrauterine blood transfusion may be required
Hemochromatosis
Ix
Iron studies: high ferritin, high transfering saturation> 50%
If 1° : gene studies: HFE gene testing
Liver biopsy or CT scan ( Ferriscan) : iron deposits seen
Hemochromatosis
Rx
Phlebotomy: weekly then 4l3-4 monthly
✓done prior to liver cirrhosis, good outcome
Lithium
Action
Cautions:
Modulation of phosphoinostitol pathway
Nephrogenic DI, thyroid, CKD , Ebstein anomalies
Valproic acid
Action
Cautions
- Na channel
Transaminitis, pancreatitis , neural tube and cardiac anomalies, PLT low
Lamotrigine
Actions
Cautions
Glutamate inhibition
Steven Johnson syndrome SJS
Carbamazepine
Actions
Cautions
Na channel inhibition
Agranulocytosis, SIADH, enzyme inducer
Hemangioma liver
✓Most common cause hyperechoic mass on USG
✓CT : hypodense : arterial phase shows uniform enhancement peripherallu
Restrictive lung disease
FVC affected
FEV1 normal
Obstructive lung disease
FVC : NOT 🚫 affected
FEV1: affected
FEV1/FVC LOW
Obstructive lung
Normal FEV1/FVC ratio
0.75 - 0.85
Ipratropium
Used in acute exacerbations if not relieved by Salbutamol
0-5 yes: 4 puffs 250mcg neb
6-12: 8 puffs 500mcg neb
Exercise induced asthma
Montelukast
BiPAP or CPAP I’m COPD
Used if Venturi mask doesn’t help to increase oxygen to paO2 = 60mmhg
Split S2
Seen in AS & MR
AS
Elderly, calcified valve
Split S2
Best heard at apex (mimic MR)
Stenotic and calcified valve may cause diastolic murmur at left upper sternal edge
Mycoplasma pneumoniae
Atypical, Headache,malaise, cough
CXR: bilateral patchy infiltrates
Rx: Doxycycline 100mg BD 10 to 14 days
Hypersensitivity pneumonitis
Sx
Rx
Sudden onset after few hours of exposure to allergen, fever cough, breathlessness, crackles om auscultation
Allergen: mould hay( farmers lungs), bird 💩
Rx: Avoid allergen, steroids
Interstitial lung disease
What
Sx
Ix
✓Heterogeneous lung conditions progression to restrictive lung disease
✓sob, dyspnoea,slow course,dry cough, clubbing
✓ x-ray reticonodular(ground glass)
HRCT : honeycomb
Mesothelioma
What?
Ix?
Rx?
✓Recurrent pleural effusions, weight loss,
✓Cancer of pleural wall
✓Thoracoscopic plural biopsy
✓palliative care
Can Patient with Previous LSCS go for breech delivery?
Contraindicated !!!
Common cause of LSCS in Australia
Past hx of LSCS
Hyperemesis gravidarum
IV fluids with metaclopramide
Ondansetron reserved for recurrent cases, hx admission for hyperemesis , not responding to metaclopramide
Serotonin syndrome
Name answered: excess serotonin so GI sx predominant diarrhea and CNS sx clonus , hyperreflexia
Common : fever , tachycardia, hpt
Colon tumor general sx
Right sided: anemia,fatigue,
Left sided: rectal bleeding, altered bowel habits
Acute cholangitis
Initial Rx: IV fluids+IV abx
Neuroleptic Malignant Syndrome
✓Neuroleptics: antipsychotic
✓fever , tachycardia hpt
✓Rigidity , WBC, CK high
✓
Scoliosis
Causes?
Sx?
Rx?
Idiopathic 75% : child < 10yrs ; adolescent> 10yrs
Non operative
20°: 6 mth r/v
20°-40°: bracing
Surgery:
> 50°
Risperidone
Side effects
Rx
✓Galactorrhoea (hyperprolactinemia)
✓ weaning & switch to Quetiapine
Adjustment Disorder
Main sx ( compared to PTSD)
✓Intensity of stressor isn’t bad as PTSD
✓No re-experiecing traumatic event
✓within 3.mth of onset of stressor
✓significant impairment of occupational functioning
Prodromal Schizophrenia
Onset
1st symptom
Early prodrome of psychosis
SX of Early prodrome
SX of late prodrome
✓4 years from pre psychotic prodrome of psychosis
✓Recurrent depression SX
1-2 yrs before psychotic SX occurs:
✓Loss of motivation
✓Social isolation
Late prodrome :
✓paranoid ideation
✓odd beliefs
Chronic insomnia
Def
Rx
> 4 weeks
CBT
Acute insomnia
BZD: Temazepam
BZD receptor agonists: zolpidem
( no tolerance or dependence)
OCD
CBT, response & exposure, SSRI
Delirium tremens
Diazepam
Age onset of depression < 25, family HX of Bipolar, psychomotor retardation
Bipolar depression
% of risk of Schizophrenia in children
Both parents +: 45%
One parent: 13%
NONE: 1%
Olanzapine
Side effects
Increase risk of type 2 DM
and Triglycerides level
But normal serum cholesterol level
Capgras Syndrome
Known as delusional misidentification syndrome.
False belief close person has been replaced by some identical looking impostor
Psychodynamic psychotherapy
OCD, BPD, avoidant personality
CBT
Depression, phobia, schizo, anxiety
Consent from Mental Health Tribunal
Vs
Consent form higher authority/without consent under duty of care
For ECT
ECT for depressed , with refused Rx and not taking anything orally but stable
Vs
Depressed, hemodynamic unstable poor intake , dehydration
Laurence Moon Biedl
Sx
Rx
✓Autosomal recessive
✓Obesity,mental retardation, polydactyly, retinitis pigmentosa, hypogonadism
✓No treatment 😭
SSRI and aspirin interaction
Higher risk of bleeding
TCA is preferred antidepressant for these patients
DIGFAST 4/7
Fun for 1 week
Mania
Distracted
Impulsive
Grandiosity
Flight of ideas
Appetite
Sleep
Talkative
DIGFAST
3/7
No mania or psychosis
Hypomania
Positive psychotic symptoms
Rx
Typical antipsychotics
Haloperidol
Chlorpromazine
Negative symptoms of schizophrenia
Rx
Atypical antipsychotics
Risperidone
Olanzapine
Atypical antipsychotics
R O C A Q A
A : Aripiprazole and Amisulpride
Immature defence mechanism
Projection
TCA
Side effects
Anticholinergic side effects
Atropine like
ECT
Mentally incapacitated ?
Vs
Voluntary for Rx and capable mentally?
✓Refer mental health tribunal
Vs
✓2 doctor: 1 of them psychiatrist agree for ECT
Patient on long term hypnotic for insomnia.
When suitable to continue further?
✓aware he/she dependent on it
✓No adverse events to the medicine
✓Reduction program unsuccessful
✓Reduction program was against the patient’s wish
Break off relationship
Lonely
> 3mths of exposure to stressor
Lasts upto 6 mth
Adjustment Disorder
Grief
Usually LOSS of someone or property
USG findings of chronic pancreatitis
Remember calcification*
pancreatic duct calcifications, ductal dilation, enlargement of the pancreas and fluid collection.
Fetal alcohol syndrome features
Small teeth and faulty enamel
Transient synovitis
Rx
First rest and then analgesia
Hypoglycemia in child
glucose is with a bolus of intravenous dextrose 10%, 2.5 to 5 mL/Kg followed by 0.03 to 0.05 mL/Kg/minute until the patient is stable.
IV Dextrose 50% not given to child
High serum osmolarity and death
Fat embolism
24 to 72 hours after the insult, and involve lungs, brain and skin,
1° spontaneous pneumothorax
<15% : observe r/V in 24 hrs
> 15% : needle aspiration
If > 3L\symptomatic/distance chest wall and pleura > 2cm : chest tube+ underwater seal
2° spontaneous pneumothorax
Need admit
<15° : needle aspiration
> 15° : chest tube+ underwater seal
Traumatic pneumothorax
<15°: observe
> 15° : chest tube+ underwater seal
UTI in male less than 35 sexually active
Organism
Chlamydia
UTI in children/male > 35
E.coli other coliform organism
Cushing
Causes?
Test?
✓Pituitary ACTH 70%, adrenal 15%, ACTH peptide from lung10%,
1mg dexamethasone suppression
24hr urinary cortisol
Serum ACTH
High dose suppression
MRI, petrous venous sampling
Cushing
SX?
Rx?
Psychosis,poor concentration
HPT
ED in male, irregular menses
Moon facies, buffalo hump
Hyperglycemia, polyuria
Osteoporosis
Most important test for azoospermia
Hormone tested?
Level ?
FSH
2.5 times or more increase in serum FSH level indicates irreversible testicular failure. FSH is the most important endocrine test inassessment of male infertility.
Occult GI bleeding
Active, hemodynamic stable: CTA
Inactive, minimal bleeding: capsular endoscopy
Life threatening GI bleeding
Interventional angiography
CKD patients with pulmonary embolism
Rx
Unfractioned heparin
Cervical motion tenderness +
Ectopic pregnancy or PID
Ectopic pregnancy: transvaginal ultrasound
PID: cervical swab
Jaundice, wt loss, abd mass
Initial ix
USG
Abd pain, wt loss, no jaundice
Initial ix?
CT scan
Oral bisphosphonates
✓< -2.5 dexa scan
✓< -1.5 with minimal
traumafracture
✓Age> 70 yrs old
✓On daily steroid > 7.5mg/day
Sickle cell disease
Autosomal recessive
Bone infarction main symptom
HbS mutated
Vaso occlusive crisis or hemolysis under stress i.e hypoxia, dehydration, acidosis
Renal
Spleen
Gall bladder
Femoral head AVN
Rx: IV fluid, oxygen, pain relief
Exchange transfusion, blood transfusion, BM transplant
Hydroxyurea
INR
Bleeding 🩸
> 1.5 life threatening: vit K+ prothrombinex+ FFP
2 significant bleed but not life threatening: vitamin K+ prothrombinex/ FFP ( if prothrombinex NA)
Any INR with minimal bleeding: omit Warfarin, observe for 1 day and see INR is within therapeutic range
If high risk of bleeding , vitamin K to be given esp INR> 4.5
INR above therapeutic range
No bleeding
Stop Warfarin
INR < 4.5: omit Warfarin, observe INR into therapeutic range, give reduced dose
INR > 4.5-10: omit Warfarin, vitamin K, observe INR into therapeutic range,
INR > 10:
Fibroadenoma> 3 cm
Remove
Fibroadenoma
Age> 40
Remove biopsy
Polycythemia vera 4P
Pruritic, plethora, pressure, phlebotomy
Mutations Jak 2
RBC excessive amount
Hyperviscosity
Plethoric
Pruritus after shower
Budd Chiari
Normal albumin
Elevated liver enzymes
Obstruction at hepatic vein
Abd pain ascites
COVID
Asymptomatic
Mild
Mod: viral pneumonia
Severe: spo2 < 94 lung > 50%
Critical : resp failure,,mods
