MLA Paper 2 A Flashcards
first-line to manage secretions in a palliative care setting
Hyoscine hydrobromide
2nd line: glycopyrronium bromide
Conservative
–> avoid fluid overload
–> educate family patient not troubled by secretions
The typical presentation can include reduced conscious level, slow respiratory rate, myoclonic jerks, and pinpoint pupils.
What toxicity does this relate to:
MORPHINE
Mild-moderate renal impairment: oxycodone
Severe renal impairment: alfentanil, buprenorphine and fentanyl patch
Breast cancer: management
1. Pre-operative axillary USS
–> (-) then sentinel node biopsy
–> palpable then axillary node clearance
NOTE consequences
*lymphoedema
*functional arm impairment
**Mastectomy **
–> multifocal tumour
–> central tumour
–> large lesion in small breast
–> DCIS > 4cm
Radiotherapy
1. T3-T4 tumours
2. with 4 or more positive axillary nodes
Wide local excision
–> solitary lesion
–> peripheral tumour
–> small lesion in large breast
–> DCIS < 4cm
Radiotherapy
1. whole breast recommended!
2. reduce recurrence 2/3rd
Hormonal therapy: if tumour (+) for hormone receptors
1. PRE-menopausual –> TAMOXIFEN
2. POST-menopausal –> ANASTROZOLE
Biological therapy
1. Trastuzumab (Herceptin) (HER2 positive)
NOTE
–> cannot use if pmhx heart disorders!
Chemotherapy
–> downstage primary lesion or post surgery
–> FEC-D used
Tamoxifen: oestrogen receptor selective antagonism
Infantile spasms in a child are part of what syndrome
WEST SYNDROME
Low molecular weight heparin (LMWH) exerts its anticoagulant effect primarily through inhibition of
Factor Xa
enoXAparin, dalteparin
Bind to antithrombin III –> cause conformational change allowing it to bind to inhibit factor Xa
Prevents conversion of prothrombin to thrombin –> reducing blood clotting
Heparin overdose may be reversed by
protamine sulphate
only partially reverses the effect of LMWH
Peri-arrest rhythms - bradycardia management
- Atrophine (500mcg IV) up to 3mg MAX
- Transcutaneous pacing
- Isoprenaline / adrenaline infusion titrated to response
If risk of asystole then Transvenous pacing!
–> complete heart block w/ broad complex QRS
–> recent asystole
–> mobitz type II AV BLOCK
–> ventricular pause > 3 seconds
Adverse signs
–> SHOCK
–> syncope
–> myocardial ischaemia
–> heart failure
What criteria is used in consideration of liver transplantation for paracetamol overdose:
KINGS COLLEGE HOSPITAL critiera
- pH <7.3 (24hrs post ingestion)
or ALL of the following: - prothrombin time > 100 seconds
- creatinine > 300 umol/L
- Grade III or IV encephalopathy
HE
Grade 1: Irritability
Grade 2: Confusion, inappropriate behaviour
Grade 3: Incoherent, restless
Grade 4: Coma
WHAT can occur after acute mitral valve regurgitation due to myocardial infarction
Flash pulmonary oedema: frothy sputum, breathlessness and coarse bilateral lung crackles
Acute mitral regurgitation
–> systolic murmur
–> jets of blood directed back towards pulmonary veins
–> causes fluid congestion in lungs and flash oedeam
Metabolic acidosis w/ raised anion gap
CAUSES
MUDPILES
NOTES
–> diarrhoea = normal ion gap metabolic acidosis
M - Methanol (think moonshine)
U - Uraemia
D - DKA (or any cause of ketoacidosis e.g. alcohol, starvation)
P - Paraldehyde (if I remember correctly it’s a rectal anticonvulsant we give to babies, but I could be wrong)
I - Isoniazid (used in TB) or Iron (classically wee kids that get into their parents pills)
L - Lactic acidosis (e.g. from ischaemia)
E - Ethylene glycol (think antifreeze)
S - Salicylates (e.g. aspirin overdose, this causes a bit of a weird picture, they make you hyperventilate so you get respiratory alkalosis, but they separately increase
Causes of respiratory alkalosis
HYPERVENTILATION
–> CO2 lost
Note: COPD patients may chronically retain CO2 so metabolism will compensate –> therefore respiratory acidosis with metabolic compensation
The anion gap is calculated by:
(sodium + potassium) - (bicarbonate + chloride)
A normal anion gap is 8-14 mmol/L
Causes of a normal anion gap or hyperchloraemic metabolic acidosis
- gastrointestinal bicarbonate loss: diarrhoea, ureterosigmoidostomy, fistula
- renal tubular acidosis
- drugs: e.g. acetazolamide
- ammonium chloride injection
- Addison’s disease
Which diabetic medication has been linked to Fournier’s gangrene:
SGLT-2 inhibitors
Mx = Early surgical debridement and ABx
Other adverse effects of SGLT-2 inhibitors
1. Normogylcaemic ketoacidosis
2. increased risk of lower limb amputation
Benefits
–> patients often lose weight
Examples: canaglifozin!
SGLT2 enhances the urinary excretion of glucose -> bacteria love the sugar you are peeing out
paediatric fluid requirements for non-neonates
100mL/24 hours for every kilogram from 0-10 kg
50 mL/24 hours for every kilogram from11-20kg
20 mL per every kilo there after
WHAT is recommended as empirical therapy for adults > 50 years with suspected bacterial meningitis
IV cefotaxime (or ceftriaxone) + amoxicillin (or ampicillin)
IM benzylpenecillin in interchange (GP land)
Signs
–> headache, neck stiffness
–> positive brudzinski sign
–> (erythematous maculopapular rash OE)
Menginitis: management
- ABCDE (GCS, seizures, papilloedema)
- IV-ACCESS
- IV ABx
* (3months-50 years) –> CEFOTAXIME (or ceftriaxone)
* (>50 years) –> CEFOTAXIME (cefotriaxone) + AMOXICILLIN (or ampicillin) - IV dexamethasone (before or w/i first dose of Abx but no later than 12 hours !) avoid dex in septic shock
SIGMOID VOLVULUS mx
What is the most appropriate first line management for this condition?
If unruptured:
Decompression via rigid sigmoidoscopy and flatus tube insertion
Investigation: usually diagnosed on the abdominal film
* sigmoid volvulus: large bowel obstruction (large, dilated loop of colon, often with air-fluid levels) + coffee bean sign
* caecal volvulus: small bowel obstruction may be seen
Frontotemporal lobar degeneration: common features and types
and other causes of memory loss!
- Behavioural-variant frontotemporal dementia
–> social disinhibition
–> FHx - Alzheimers
–> more severe memory loss - Dementia w/ Lewy bodies (2/4 of the following)
–> hallucinations
–> fluctuating consciousness
–> REM sleep behaviour disorder
–> Parkinsonism
Semantic dementia
–> fluent progressive aphasia (speech fluent but conveys little meaning)
Diagnosis and management
LYME DISEASE : spirochaete Borrelia Burgdorferi
Management of asymptomatic:
1. remove tick w/ tweezers , wash area after
Suspected / confirmed lyme disease
1. DOXYCYCLINE
a) Amoxicillin if allergic or pregnant
2. Disseminated disease –> CEFTRIAXONE
Note: Jarish-Herxheimer reaction post tx
–> fever, rash, tachycardia after first dose
Features: Early w/i 30 days
1. Erythema migrans (bulls eye rash)
2. Systemic: headache, lethargy, fever, arthralgia
Late features (after 30 days)
1. CVD –> 3rd degree heart block, peri-myocarditis
2. Neurological –> facial nerve palsy, radicular pain, meningitis
IX –> ELISA
Disseminated gonococcal infection triad
- tenosynovitis
- migratory polyarthritis
- dermatitis
TenDer Pol
gram negative diplococci Neisseria gonorrhoeae
Mx of Gonorrhoea
1. 1g of IM CEFTRIAXONE
2. after sensitivities then single dose oral ciprofloxacin 500mg should be given
OR
- oral cefixime 400mg (single dose) and oral azithromycin 2g (single dose)
Bacterial vaginosis vs Trichomonas
COPD management
Oral ABX prophylaxis –> Azithromycin (bewate long QT)
SABA –> salbutamol
LABA –> salmetoral or formoterol
SAMA –> ipatropium
LAMA –> tiotropium
When would long term oxygen therapy be offered to a patient with COPD
Offer LTOT to patients with a pO2 of < 7.3 kPa or to those with a pO2 of 7.3 - 8 kPa and one of the following:
* secondary polycythaemia
* peripheral oedema
* pulmonary hypertension
Diagnosis and managment
IMPETIGO
Caused: staph aureus or strep pyrogenes –> VERY CONTAGIOUS
Management
1. Hydrogen peroxide 1% (low risk)
2. Topical ABx
–> Fusidic acid
–> OR topical mupirocin if resistant or MRSA
Extensive disease
1. Oral Flucloxacillin
or oral erythromycin if pen allergic
School Exclusion
–> until all lesions are crusted and healed
–> OR 48hrs post Abx tx starting
Raised intracranial pressure management
1. Head elevation to 30 degrees
2. IV Mannitol
3. Controlled hyperventilation
a) reduce pCO2 –> v.constriction of cerebral arteries –> reduced ICP
4. CSF removal
a) repeated LP
b) ventriculoperitoneal shunt (hydrocephalus)
c) drain from intraventricular monitor
normal ICP = (7-15mmHg suprine)
CCP = MAP - ICP
Features
- headache
- vomiting
- reduced consciousness
- papilloedema
- CUSHINGS TRIAD
Ulcerative colitis management
Maintaining remission
1. Proctitis and proctosigmoiditis
–> topical aminosalicylate (daily or intermittent)
–> oral aminosalicyclate plus rectal aminosalicylate
–> oral aminosalicylate by itself
- Left sided and extensive ulcerative colitis
–> low maintenance dose of oral aminosalicylate - Severe relapse or > = 2 exacerbations
–> oral azathioprine or oral mercaptopurine
Hashimoto’s thyroiditis
hypothyroidism + goitre + anti-TPO
associated w/ development of MALT lymphoma
anticoagulation for a patient with a mechanical heart valve
Warfarin
AF = DOACs
Anti-phospholipid syndrome = Warfarin
Prosthetic valces = Warfarin
Minimal change disease: mx
75% cases are children!
Management:
1. oral corticosteroids
2. Cyclophosphamide: steroid resistant cases
Indications for prescribing prednisolone in sarcoidosis:
P- Parenchymal lung disease
U- Uveitis
N- Neurological involvement
C- Cardiac involvement
H- Hypercalcaemia
Patients with chronic kidney disease and an ACR > 30 mg/mmol should be started on
ACE inhibitor
worsening flu-like symptoms and a dry cough. Erythema multiforme is noted on examination
Stereotypical history of:
mycoplasma pneumonia
Ix:
mycoplasma serology
positive cold agglutination test –> peripheral blood smear may show RBC agglutination
Management:
–> doxycycline or macrolide (e.g. erythromycin / clarithromycin)
Hypertension in diabetics management
ACE inhibitors/A2RBs are first-line regardless of age
Legionella pneumophilia is best diagnosed by the
urinary antigen test
Legionella pneumophilia
- severe pneumonia
- hyponatraemia
- deranged LFTs
- recent travel hx turkey
The tremor seen in Parkinson’s disease is
unilateral tremor that improves with voluntary movement
I
cogwheel rigidity, bradykinesia, and tremor
causes of torsades de pointes
METHCATS
○ M - Methadone ○ C - Chloroquine/Citalopram
○ E - Erythromycin ○ A - amiodarone
○ T - Terfenadine ○ T - tricyclics
○ H - Haloperidol ○ S - Sotalol
Patients can present with symptoms such as palpitations, tachycardia, chest pain, shortness of breath, hypotension and syncope.
Acute angle closure glaucoma:
associated with hypermetropia or myopia?
Hypermetropia
Farsighted people prepare well and can only be hit by surprises, like an acute closed angle glaucoma.
Shortsighted people never plan and can be slowly hurt over time, like with open angle glaucoma
Decreasing vision over months with metamorphopsia and central scotoma should cause high suspicion of
wet age-related macular degeneration
Metamorphopsia is a syndrome in which the shape of objects appears distorted.
The initial management of acute limb ischaemia includes
- analgesia (IV opioids)
- IV heparin
- vascular review
Features - 1 or more of the 6 P’s
* pale
* pulseless
* painful
* paralysed
* paraesthetic
* ‘perishing with cold’
Peripheral arterial disease:
- intermittent claudication
- critical limb ischaemia
- acute limb-threatening ischaemia
Most common cause of endocarditis:
- Staphylococcus aureus
- Staphylococcus epidermidis if < 2 months post valve surgery
- Strep viridans (poor dental hygiene)
- Strep bovis (colorectal cancer)
Tuberculosis: drug side-effects
Rifampicin
–> hepatitis, orange secretions
–> flu like symptoms
Isoniazid
–> peripheral neuropathy (prevent with vitamin b6, pyridoxine)
–> hepatitis, agranulocytosis
Pyrazinamide
–> hyperuricaemia causing gout
–> arthralgia, myalgia
–> hepatitis
Ethambutol
–> optic neuritis: check visual acuity before and during tx
–> dose adjust in renal impairment
man presenting with dyspnoea, peripheral oedema and a positive Kussmaul’s sign
Features
- SOB
- R heart failure
- pericardial knock: loud s3
- kussmaul sign positive
constrictive pericarditis
Kussmaul’s sign (the raised JVP that doesn’t fall with inspiration)
Management of spontaneous bacterial peritonitis
Features
- fever
- abdominal pain
- ascites
Diagnosis
- paracentesis
- e.coli !
Management
- IV CEFOTAXIME
Antibiotic prophylaxis is needed in patients who have had an episode of SBP –> ciprofloxacin
What is the most appropriate blood test monitoring for a patient started on statins:
LFTs at baseline, 3 months and 12 months
45 Male
pc: 2 day hx retrosternal sharp chest pain, constant, worse on inspiration.
Diagnosis and mx
ECG: widespread ST elevation and marked PR depression
Causes: viral (coxsackie), TB, post MI, radiotherapy, malignancy, trauma, thyroid etc
IX
- ECG
- Transthroacic echo
- Bloods: inflammatory markers, troponin
Mx
1. avoid strenuous activity until symptom resolution
2. combination NSAIDs and colcicine (taper dose)
Poorly controlled hypertension, already taking an ACE inhibitor
add a calcium channel blocker or a thiazide-like diuretic
Amlodipine is the only CCB licensed for HR. Nifedipine should be avoided to risk of exacerbation.
Thiazide like diuretic = indapamide
Pneumocystis jiroveci penumonia is treated with
co-trimoxazole, which is a mix of trimethoprim and sulfamethoxazole
THIS medication should be considered for the prevention of calcium stones
Potassium citrate
Prevent kidney stones
–> drink 3L of water
–> add lemon juice to drinking water
–> less than 6g salt intake
–> potassium citrate
first-line treatments for painful diabetic neuropathy
Duloxetine
first-line treatment: amitriptyline, duloxetine, gabapentin or pregabalin
THIS presents with flu-like symptoms, RUQ pain, tender hepatomegaly and deranged LFTs
Hepatitis A
vaccine available
High-dose dexamethasone suppression test with an ectopic source of ACTH
Cortisol: not suppressed
ACTH: not suppressed
can be used to treat symptomatic itch in PBC
Cholestyramine
Diagnosis, cause and management
Monomorphic punched out erosions (circular, depressed and ulcerated)
ECZEMA HERPETICUM
Herpes simplex virus 1 or 2
LIFE THREATENING
Admission for IV aciclovir
A patient is started on finasteride for the treatment of benign prostatic hyperplasia. How long should the patient be told that treatment may take to be effective?
Up to 6 months
Finasteride works by inhibiting the conversion of testosterone into dihydrotestosterone which contributes prostate enlargement
NICE recognise any of the following criteria to diagnose AKI in adults:
- ↑ creatinine > 26µmol/L in 48 hours
- ↑ creatinine > 50% in 7 days
- ↓ urine output < 0.5ml/kg/hr for more than 6 hours
may be used in patients with stress incontinence who don’t respond to pelvic floor muscle exercises and decline surgical intervention
Duloxetine
Inducing remission in Crohns
- Glucocorticoids (oral, topical or IV)
- alternatively budesonide
Second line
–> 5-ASA drugs (mesalazine)
–> azathioprine (or methotrexate) or mercaptopurine may be added on (not as monotherapy)
Refractory disease and fistulating Crohn’s –> infliximab
Isolated peri-anal disease - metronisazole
Maintaining remission in Crohn’s
- STOP SMOKING
- Azathioprine or mercaptopurine (1st line)
Vitamin B12 replacement should always occur prior to folate replacement as folate replacement prior to B12, why?
can precipitate subacute combined degeneration of the spinal cord.
Diabetic ketoacidosis: once blood glucose is < 14 mmol/l an infusion of what should be started
10% dextrose should be started at 125 mls/hr in addition to the saline regime
DKA resolution is defined as:
* pH >7.3 and
* blood ketones < 0.6 mmol/L and
* bicarbonate > 15.0mmol/L
