Mosler investigations and management Flashcards
Hypertension Symptoms and investigations
Symptoms: palpitation, chest pain, SOB, N+V, headache, muscle cramos, fatigue, heat intolerance, polyuria/polydipsia
- Bedside: BP, obs, fundoscopy, urine dip, ECG, 24 hour ambulatory blood pressure
- Bloods: FBC, U&E, LFT, glucose, lipids
Investigations: renal US - Secondary: Dexamethasone suppression test (crushings), Metanephrenes (phaemochromatoma), Urine albumine:creatinine ratio (addisons)
Hypertension management
- Conservative: lifestyle, DASH diet, avoid caffeine stress, QRISK2
- Medical: ACEi )<55, diabetic), CCB (>55, afro-carribean), statins, regular monitory. A+C. then A+C+T
Diabetes symptoms and investigations
Symptoms: polyuria/polydipsia, fatigue, weight loss, dizziness, leg ulcer, slow wound healing, loss of sensation, eyes (flashers, floateers, visual loss), thrush, erectile dysfunction, darkening skin in armpits
- Bedside: urine dip, ECG, fundoscopy, peripheral pulses
- Bloods: glucose, HBA1c, FBC, U&E, LFT, lipid
- Investigations: OCT
Diabetes management and complications:
- Conservative: pneumococcal, flue vaccine, lifestyle
- Medication: metformin + SGLT2 (of cardiovascular risk). Titrate metformin first. Then add DDP4, sitagliptan or sulfonylurea
Complications: infections (thrush), diabetic retinopathy, peripheral neuropathy, autonomic neuropathy CKD, diabetic foot, gastroparesis
Heart failure symptoms and investigations
Symptoms: SOB (rest, orthopnoea, walking distance, pillows), chest pain, palpitations, ankle swelling, pink frithy sputum, cough, wheeze, fatigue, weight loss
- Bedside: ECG, urine dip, glucose, sputum culture
- Bloods: FBC, U&E, LFT pro-BNP, TFT, lipid screen
-Imaging: CXR, echocardiogram
Management of Heart failure
- Conservative: encourage to sleep lying up, smoking, diet, exercise, alcohol, vaccines (pneumococcal, flu), cardiac rehabilitation
- Medication: ACEi, SGLT2, Beta blocker, MRA, Furosemide
- Surgery: pacemaker + defib, Cardiac resynchronisation therapy (severe heart failure, EF <35%), heart transplant- severe disease
Myasthenia gravis investigations
- Bedside: obs, BM, ECG, Ice test, FVC
- Blood: ABG, anti-AChR, anti-MuSK, TFT, FBC, UE, LFT, CRP
- Imaging: MRI brain, thymus CT/MRI
- Special: Nerve stimulation, edrophonium test
Myasthenia-gravis management
Urgent admission
Assessment and management of crisis: respiratory support (NIV- BiPAP/intubation), IVIg, Plasma exchange
Long term:
· AChI- pyridostigmine/neostigmine
· Immunosuppression- prednisolone/azathioprine
· Thymectomy
· Mab: rituximab
Sickle cell disease investigations
Bedside: peak flow – essential in chest crises
· Bloods: FBC, U+Es, LFTs, coag, iron studies, b12 and folate
· Imaging: blood film (sickle cells, target cells, reticulocytosis with polychromasia. Also may show features of hyposplenism – Howell-Jolly bodies, nucleated RBCs)
· Special: haemoglobin electrophoresis +/- genetic testing, newborn heel pric
Sickle cell disease management
Conservative:
o Good hydration to try and prevent crises
o Avoid triggers – cold weather, intense exercise, dehydration, high altitudes, alcohol, smoking
o Discussion around family planning e.g. is husband a carrier if planning on pregnancy
· Medical
o High flow oxygen
o IV fluids and analgesia
o Blood transfusions, especially if also anaemic
o Hydroxycarbamide if frequent crises
o Vaccinations including pneumococcal
o Antibiotic prophylaxis – typically penV
- Surgical: Bone marrow transplant further down the line
Causes of nephritic syndrome
- IgA nephropathy
- Post streptocococal nephropathy
- Ant GBM disease
- Small vessel vasculitis
- Granulomatosis with polyangitis
Causes of nephrotic syndrome
- Minimal change disease
- Focal segmental glomerulosclerosis
- Membraneous glomerulonephropathy
- Amyloidosis
- Lupus nephritis
Angina symptoms and investigations
Symptoms: chest pain (exertion, rest, after eating), SOB, palpitation, syncope, ankle swelling, fever, weight loss, cough, wheeze
-Bedside: ECG, BP, obs
- Bloods: FBC, U&E, LFT, TFTL HBA1C, fasting glucose
- Imaging: CT angiogram, cardiac stress test
Angina management
- Conservative: lifestyle, vaccines, QRISK score
- Medical: BB, CCB, GTN spray- take with symptoms then every 5 minutes. Asprin, statin
- Surgery: PCI, coronary artery bypass graft (CABG)
PAD symptoms and investigations
Symptoms: pins and needles, tingling, numbness, pain (with heat, movement), diarrhoea, incontinence, skin changes, heat, swelling, feels cold, paraysis
- Bedside: peripheral pulses, BP, obs, ABPI, ECG, culture, lipids, Buergers test
- Bloods: FBC, U&E, LFT, HBA1C, fasting glucose
- Investigations: duplex ultrasound for pulses, angiography (CT or MRI)
PAD management
- Conservative: lifestyle, foot care (keep foot dry, have well fitting shoes), exercise training
- Medical: give gabapentin/amitriptyline for pain. Statin, clopidogrel, Naftidroforyl oxilate
- Surgery: emergency amputation, bypass surgery, endovascular angioplasty and stenting
CKD symptoms and investigations
CKD: fatigue, N+V, muscle cramps, bony pain, urine (oligouria/haematuria), oedema, SOB, confusion, itch, weight loss, loss of appetite
-Bedside: urine dip, albumin:creatinine ratio,, fluid balance chart, 24 hour urine collection, obs
- Bloods: FBC, U&E, LFT, calcium, phosphate, bone profile, ABG
- Investigations: renal US, CT KUB, post void residual volume, renal biopsy
CKD management
- Conservative: flu and pneumococcal vaccine, low phosphate and sodium diet, maintain fluid intake
- Medical: optimise comorbidities. Statin and antiplatelet. ACEi if ACR >3 with diabetes, >30 with hypertension or just above >70.
For complications: phosphate binders, EPO + iron, bicarbonate in metabolic acidosis, calcitonin
RRT: peritoneal dialysis, Haemodialysis, kidney transplant
Liver failure symptoms
Increased bruising, N+V, abdo swelling, vomiting blood, weight loss, pale stool, dark urine, itch, colour change to skin or eyes, confusion, blood in stools
Liver failure investigations
- Bedside: BP, obs, FIB4 score (NAFLD), AUDIT score, Child-pugh score
- Bloods: FBC, U&E, LFT, CRP, HBA1C, fasting glucose, AFP, ELF (NAFLD)
- Investigations: Fibro scan, abdo US, Paracentesis (in ascites), endoscopy (varices), liver biopsy
Liver failure management
- Conservative: lifestyle (stop drinking, improve diet), flu and pneumococcal vaccine, regular meals to avoid malnutrition
- Meds: Vitamin E (if not diabetic), Liraglutide and Pioglutide (if diabetic), Spironolactone (ascites), B12, folate, stop hepatotoxic drugs
- Surgery: TIPS (ascites), liver transplant (if decompensated)
MELD/UKELD score: if cirrhosis
HE: lactulose, rifaximine
Maddrey score: alcoholic hepatitis
Refer to specialist
COPD symptoms and investigations
Symptoms: SOB, wheeze, haemoptysis, weight loss, cough, sputum, chest pain, oedema, skin changes. Ask about work, pets, smoking
- Bedside: BP, spirometry, sputum culture, ECG (heart failure), TLCO, calculate MRC breathlessness scale
- Bloods: FBC, U&E, CRP, alpha 1-antitrypsinogen
- Investigations: CXR
COPD: Management
- Conservative: stop smoking, lifestyle, pulmonary rehab, flu and pneumococcal vaccine
- Medicine: SABA or SAMA -> add LABA and LAMA. If asthmatic LABA + ICS
- Surgery: lung transplant
A-fib symptoms and investigations
Symptoms: palpitation (coffee and alcohol), chest pain, SOB (on exertion at night), ankle swelling, haemoptysis, syncope, dizziness, heat intolerance, muscle pains, cramping, anxiety
- Bedside: ECG, BP, obs
- Bloods: FBC, U&E, LFT, coag, TFT, Pro-BNP, calcium, magnesium , glucose
- Special: CXR, 24 hour ECG, exercise stress ECG
A-fib management
- Conservative: lifestyle (recreational drugs, smoking), refer to cardiology
- Medical: CCB, BB, Digoxin. If present within 48 hours can electrically cardiovert them. Do CHAD-VISK score for anticoagulation
- Surgery: ICD, pacemaker, Left atrial ablation, atrioventricular node ablation with permanent pacemaker
Pharmacological cardioversion: Flecainide, Amiodarone
Long term rhythm control: Beta blockers, Dronedarone, Amiodarone
Investigations for breast cancer
bedside: full set of obs
bloods:
- FBC to look for anaemia
- U+Es for baseline
- LFTs to look for liver mets
- calcium to look for hypercalcaemia of malignancy
imaging:
- mammogram (ultrasound if under 35)
- ultrasound of axilla to look for lymph node spread
special tests:
- fine needle aspiration
- ultrasound guided biopsy of abnormal lymph nodes
Management of breast cancer
conservative: MDT involvement from surgeon, oncologist and breast care nurse
medical:
- chemo
- radiotherapy
- hormonal therapy with tamoxifen (pre-menopausal) or aromatase inhibitors (post-menopausal)
surgical:
- breast conserving surgery
- mastectomy with breast reconstruction
- axillary clearance
Investigations of Osteoarthritis
bloods: CRP/ ESR to rule out inflammatory cause
imaging: joint XR
Management of osteoarthritis
conservative:
- weight loss
- exercise and physio
- walking aids
medical:
- regular paracetamol and topical NSAID gel (move up pain ladder as needed)
- intra-articular steroid injections
surgical: joint replacement
Investigations for RA
bedside: urinalysis as baseline and to exclude other differentials
bloods:
- FBC to look for anaemia
- ESR/ CRP to look for inflammation
- rheumatoid factor and anti CCP
- LFTs and U+Es for baseline before DMARDs
- TFTs to rule out hypothyroidism
imaging:
- joint ultrasound (sensitive for synovitis)
- joint XR
- CXR to exclude lung disease before DMARDs
special tests: joint aspiration if uncertainty
Management of RA
conservative:
- physio
- patient education
- lifestyle change to reduce CVD risk
- vaccines to decrease risk of infection on immunosuppressive drugs
medical:
- paracetamol and weak opioids
- steroid injections
- DMARDs
- biologics
- treat osteoporosis
surgical: joint replacement
Investigations for back pain
bedside:
- digital rectal examination to assess for reduced peri anal sensation and loss of anal tone
- urinalysis if associated urinary symptoms
bloods:
- FBC to look for normocytic anaemia seen in AS
- CRP/ ESR raised in AS
- LFTs to look for raised ALP seen in AS
imaging:
- XR if suspected spinal fracture or AS
- urgent MRI if suspected caudal equine syndrome
- post void bladder scan to assess urinary retention if associated urinary symptoms
Management of back pain
conservative:
- physio
- consider CBT if functional
- spinal brace if fracture
medical:
- NSAIDs are 1st line analgesia
surgical:
- urgent decompression for cauda equine syndrome
- consider surgery for fracture
- vertebral osteotomy to correct deformities due to AS
Investigations for osteoporosis
bedside: FRAX to assess fracture risk
bloods:
- FBC, ESR/ CRP to rule out inflammatory causes
- bone profile to look for calcium deficiency which can contribute to osteoporosis
- U+Es and LFTs to look for renal or liver failure which can cause osteoporosis
- TFTs to look for hyperthyroidism which can cause osteoporosis
imaging:
- DEXA scan at vertebrae and femoral neck
- XR
Management of osteoporosis
conservative:
- stop smoking and reduce alcohol
- physio
- OT
medical:
- bisphosphonates
- calcium and vitamin D
- HRT
surgical: management of NOF fracture
Asthma investigations
bedside: PEFR
imaging: CXR to rule out other causes
special tests:
- spirometry with reversibility testing
- fractional exhaled nitric oxide
Management of asthma
conservative:
- avoid triggers (consider symptom diary)
- teach inhaler technique
- annual flu vaccine
- smoking cessation
medical:
- SABA reliever -> ICS -> montelukast -> LABA
Epilepsy investigations
bedside:
- capillary blood glucose to rule out non-epileptic seizure
- ECG to rule out cardiac cause
bloods:
- U+Es to rule out non-epileptic seizure
- serum drug levels if appropriate to rule out non-epileptic seizure
- FBC and LFTs for baseline before commencing anti epileptics
imaging:
- MRI or CT lead to localise cause of focal seizure and rule out other causes e.g. tumour/ stroke
special tests: EEG
Management of epilepsy
conservative:
- in acute seizure: remove obstacles, call ambulance, place in recovery position after
- review annually
- counsel about driving (can’t drive until seizure free for 1 year)
- avoid triggers e.g. alcohol and poor sleep
- discuss drug side effects esp relating to contraception and pregnancy
medical:
- in acute seizure: buccal midazolam, PR diazepam or IV lorazepam
- long term anti epileptics
Stroke investigations
bedside:
- capillary blood glucose to rule out hypoglycaemia as a cause
- ROSIER to distinguish stroke and TIA
bloods:
- FBC, U+Es and LFTs as baseline
imaging:
- non-contrast CT head
- contrast CT angiography if considering thrombectomy
- carotid doppler to assess for stenosis
Management of stroke
conservative:
- secondary prevention with lifestyle advice
medical:
- 300mg aspirin
- consider thrombolysis with alteplase if within 4.5hrs
- secondary prevention with ACEi, statin and clopidogrel
surgical:
- carotid endarterectomy if stenosis above 70%
- thrombectomy if within 6hrs and confirmed proximal anterior circulation occlusion
Management of migraines
conservative:
- avoid triggers
- ensure good sleep, hydration, regular meals and reduce stress
medical:
- acute treatment with paracetamol/ NSAID and triptan
- consider anti emetic even in absence of nausea
- prophylaxis with propanolol or topiramate
Management of Parkinsons
conservative:
- physio
- OT
- SALT
- contact DVLA
medical:
- levodopa, dopamine agonists, MAO-B inhibitors, COMT inhibitors
- symptomatic management: midodrine (postural hypotension), melatonin (REM sleep), modanafil (daytime sleepiness), glycopyronium bromide (drooling), quetiapine (hallucinations)
- best medical therapy is intermittent apomorphine injections or continuous infusion
surgical: deep brain stimulation
Investigations for macular degeneration
bedside:
- visual acuity and visual field testing
- slit lamp examination
imaging:
- optical coherence tomography
- fluorescein angiography
Management of macular degeneration
conservative:
- stop smoking to slow progression
- inform DVLA
- help with access to aids
- advise to officially register as visually impaired to access benefits
- correct refractive errors at optician
medical:
- anti VEGF agents for wet AMD
- vitamin supplementation for dry AMD to slow progression
Investigations for glaucoma
bedside:
- visual acuity and visual field testing
- slit lamp examination
imaging: optical coherence tomography
special tests:
- tonometry (measure IOP)
- gonioscopy (measure drainage angle)
- pachymetry (measure corneal thickness)
Management for glaucoma
conservative:
- inform DVLA
- help with access to aids
- advise to officially register as visually impaired to access benefits
- correct refractive errors at optician
medical:
- topical eye drops: prostaglandin analogues, beta blockers, a2 agonists, carbonic anhydrase inhibitors
surgical: laser or surgical trabeculoplasty
Cataracts investigations
bedside:
- visual acuity and visual field testing
- slit lamp examination
Cataracts management
conservative:
- inform DVLA
- help with access to aids
- advise to officially register as visually impaired to access benefits
- correct refractive errors at optician
surgical: cataract surgery
MS investigations
Bedside– consider BP, slit lamp, fundoscopy,
Bloods- consider FBCs, U+Es, LFTs
Lumbar puncture- Oligoclonal bands
I – MRI head and spine (T2 and gadolinium contrast)
McDonald- must show dissemination in time and space
Management of MS
Conservative – physiotherapy, support groups, home adaptations, patient and carer education, when appropriate DNACPR/EHCP M
Medical– acute flare; steroids long-term remission maintenance; pegylated interferons, natalizumab/other specialist mabs symptom management; baclofen (spasticity), SSRIs, pregabalin/gabapentin (pain), oxybutynin (urge incontinence)
Controlled medication and which you use brand names
- Controlled: Methadone, ketamine, Morphine, Codeine, Fentanyl, Oxycodone, Anabolic steroids, Lorazepam
- Brand names: Insulin, antiepileptics, inhalers, Lithium, Opioids, Mesalazine, Diltazem, Tacrolimus, Contraception + HRT, Nifedipine
Heart attack symptoms and investigations
Symptoms= Event (chest pain, palpitations, sense of dread, N+V, sweating), N+V
After event: recovery, weight loss, mood, chest pain, SOB, palpitations, oedema, syncope
- Bedside: ECG, urine dip, BMI, BP, obs, grace score
- Bloods: FBC, U&E, LFT, Troponin, pro-BNP, lipid, glucose
- Imaging: CXR, echocardiogram
Heart attack management
- Conservative: lifestyle, flu and pneumococcal vaccine, cardiac counselling, counselling
- Medicine: Dual antiplatelet (Asprin + Tricregalor (low bleed risk) or Clopidogrel (high bleed risk)), ACEi/ARB, BB, statin, GTN
Cardiomyopathy symptoms and investigations
Symptoms: chest pain, SOB (rest, exertion, night), palpitations, oedema, syncope, reduced exercise tolerance, fatigue, weight loss, dizziness
- Bedside: ECG
- Bloods: FBC, U&E, LFT, pro-BNP, lipid
- Investigations: CXR, echocardiogram, genetic testing, Cardiac MRI, exercise stress test
Cardiomyopathy management
- Conservative: flu and pneumococcal vaccine, lifestyle (less important as genetic). If Hypertrophic dont take part in competitive sports
- Medicine: BB, CCB, Disoporamide, diuretics
- Surgery: Heart transplant if severe heart failure, IDF
Hypertrophic: Surgical myectomy, alcohol septal ablation. Avoid nitrates and ACEi
IPF symptoms and investigations
Symptoms: cough (type, sputum), wheeze, SOB (rest, on exertion, how far can you walk), reduced exercise tolerance, weight loss, fever, work, pets
- Bedside: BP, obs ,spirometry, sputum, culture, TLCO
- Bloods: FBC, U&E, LFT, CRP, ANA, RHF
- Imaging: CXR (granulomatosis), CT thorax (HRCT)- ground glass, Lung biopsy, Broncheoalveolar lavage
IPF management
- Conservative: avoid triggers (keep trigger diary), lifestyle (stop smoking), flu and pneumococcal vaccine, pulmonary rehab, home oxygen
- Medicine: Ani-fibrotics (Pirferidone, Nintedanib)
- Surgery: Lung transplant
