Multi-system Flashcards
What spinal issue can be see in duchenne
Scoliosis
Dx and Tx for Duchenne
Dx with either biopsy of muscle or genetic test. Tx with steroids
What can eventually occur in the joints of a DMD patient
Joint contractures
Why does CK drop in the progression of duchenne
As the muscle is replaced by fibrofatty infiltration… the CK will drop a bit
List so,e complications of Prada Willi syndrome
All relates to obesity. Sleep apnoea, DM, choking, gastric rupture. So make sure to limit food for these little chubby kids. Also can give GH, to increase vertical growth
Protruding Metopic suture, seen where
Seen in cris du chat
Name some of the less obvious edwards signs
Low set ears, small jaw, limited hip abduction
Screening recommendations for gon chlam infx
Annual NAAT test, for sexually active under 25 (or has RFs)
What is congenital contractural arachnodactylyl
A fibrilin II defect, causing Mariah features, except no CV or ocular signs
AL Amyloidosis main manifestations
Nephrotic syndrome, Hmeg, periorbital purpurin, waxy skin, restrictive cardiomyopathy
Why is lymphoedema not pitting
Because the protein concentration is high
Two reasons we need estrogen therapy in turners syndrome
For sexual development, but also to decrease risk of osteoporosis
The gene test we have to do for CHARGE syndrome
CHD7
Contrast manifestions of CREST and diffuse SS
CREST:
• Scleroderma on head & distal UE
Prominent vascular manifestations
• Raynaud phenomenon
• Cutaneous telangiectasia
• Pulmonary arterial hypertension
• CREST syndrome
Diffuse SS:
• Scleroderma on trunk & UE
• Prominent internal organ involvement
• Scleroderma renal crisis
• Myocardial ischemia & fibrosis
• Interstitial lung disease
Joint fluid:
> 10,000 wbc
> 75% PMN
culture it… likely septic
WBC numbers in joint fluid to remember for step
<2000 is normal
2,000-10,000 is inflam
> 10,000 is septic
Join fluid with blood and fat droplet
Maybe fracture
Foot puncture wound and osteoM… cover which bac
Pseudomonas
Adults vs kids. Osteomyelitis. Which is more from seeding and which from contiguous spread
Adults from spread, kids more seedinh
If patient had allergic rash on penicillin, can we give ceph? What about anaphylaxis or angioedema
Yes, and No
Are OA patients at higher risk of osteoporosis after Sx
Yes
Viscosity of joint fluid in inflam
Lower!
Retina bulls eyes appearance
Chloroquine tox
Don’t forget carpal tunnel from RA
Other than AR… what other cardiac issue in ank spond
Heart block
Mixed connective tissue disease AB
U1 RNP Ab
Other than our tigger and target zones… what else do we see in myofascial pain and not fibromyalogia
Myofascial pain can be seen in muscle tissue only. Whereas fibro also in other CT
Anti RNA polymerase III in SS a risk for what?
Scle renal crisis
CS can be given for SS flare…. But what is the main risk
Increased risk for renal crisis
CREST mainstay Tx
Methotrexate usually
Is lupus arthritis deforming
No
Aortic complications of GCA
Aneurysm
Most common artery affected in AION in GCA
Posterior ciliary artery. From the ophthalmic. From the ICA
Commonest cause of mortality in Behcets
Thrombosis
Preventing recurrence in Behcets?
Colchicine (sounds Turkish too)
Some other random causes of adhesive capsulitis
DM, hypothyroid, contractures, stroke, shoulder injury
Rotator cuff impingement Dx test
X-ray! Not MRI (if tear)
Compartment syndrome delta pressure cut off
30
Open fractures usually need what intervention (medically)
Abx and Tet prophylx
Within how many hours to prevent long term complications of compartment syndrome
6 hours to do fasciotmy. Main Px factor
Durkan test (carpal compression): positive in what?
Carpal tunnel
Carpal tunnel worse when
At night
Carpal tunnel risks
Preg, DM, hypothyroidism, acromegaly, RA, amyloidosis, overuse
Are ganglion cysts mobile
Not usually
Dupytrens contracture…. High recurrence after Tx?
Yes?
Alarm signs of hand bite and invx to do
Crepitus and skin discolouration. Do X-ray and usual labs
Osteochondritis dissecans Signs
Antalgic gait patient, usually adol boy, how does a lot of activity. Almost OA like signs. Often has history of ankle inversions
Patellofemoral pain syndrome overview of signs
Anterior knee pain. Overuse injury. Worse when walking up and downstairs. Worse when squatting. Squeeze test positive. Just rest and give nsaid, quad training
Morton neuroma signs
Click sensation when palpating area, numbness and pain and paraesthesia. Symptoms worse than squeezing metatarsal
Postmenopausal women is a risk factor for gout.
Salicylates. High-dose or low-dose can cause hyperuricaemia
Low-dose
Acute attacks for gout first line is NSAID. Name me a couple of circumstances where the contra indicated.
Heart failure, chronic kidney disease, peptic ulcer disease, anticoagulant patient
Colchicine is only useful in gout and Sudo gout after how long after disease Flair onset
24 hours
Xanthine oxidase inhibitor is an increase the risk of what in gout
Nephrolithiasis
Uricosuricsh drugs are contraindicated in what circumstances in gout
Toffee, nephrolithiasis, CKD
What’s the issue with giving a. XOI, In patients were taking Azathioprine or six mercaptopurine
Remember these therapeutics require xanthine oxidase as degradation
Hypothyroidism is linked to go out or pseudogout
Pseudogout
A couple of ways to distinguish between L2 to L4, and L5
First one will have lots of hip flexion, need extension, foot dorsi flexion. Patella reflex gone. Anterior thigh and medial aspect of lower leg is gone.
L5 you will lose big toe dorsi flexion and foot aversion. Lateral aspect of the leg and dorsum of the foot tend to go
 Is active ROM, but with limited impact on passive ROM, is characteristic of which specific problem. Could be more than one,
Bursitis
Post op fever timing.
any time:
One to 3 days:
4 to 5 days:
More than a week:
Drug reactions
Atelectasis or pneumonia
UTI
DVT/PE
Surgical site infection
If fever of unknown origin work up is negative, what is the prognosis for the patient
Usually very good
What is the malaria prophylaxis a GP should give
Before patient travels to endemic region give atovaquone proguanil, mefloquine. They should be given two weeks before travel and continued for four weeks after return
CI to give the following:
Primaquine
Mefloquine
Arovaquone
Chloroquine:
G6PD (test prior)
Seizure, psych, cardiac condition issue
Preg or breastfeed, or CKD
Psoriasis
Malaria fever patters
Chikungunya
Join pain (mozzy bite)
We all know Zeca can cause micro carefully. What can I do neurologically to the patient directly
Guillain barré
What is the diagnosis steps for Lymes disease initially
Do no serology. Since usually negative until weeks after. So just clinical
Diagnostic steps for disseminated or late limes
Must do ELIZA. Then if positive to Western blot
If someone has a tick bite, what are the criteria to give prophylactic doxycycline
The Tick is ixodes.
The tick was in for more than 36 hours. Prophylaxis can be started less than 72 hours of removal. They have no contra indications to doxy.
Local rate of infection in the tics for Borrelia is more than 20%
If patient gets limes disease. You usually treat this early disease with doxycycline. How do you treat pregnant patient? How do we treat young patients? How do we treat more advanced disease, CNS involvement, cardiac involvement, arthritic involvement.
Amoxicillin for pregnant patients. Young patients can be given doxy. Advance cases you can give Foxy
Dengue virus
Phone pain, thrombocytopenia, shock, hi LFT. Just give fluids and blood products as needed
Banesiosis
Also by same tick as limes disease. Coinfection common. Causes intravascular homolysis and the Maltese cross in blood Smith. Give oral azithromycin
Rocky mountain spotted fever. How to manage
Clinical diagnosis at 1st to empiric treatment. Give doxycycline. If patient is pregnant in first two trimesters, tried to give chloramphenicol. Confirmed diagnosis with biopsy and immunofluorescence
Name some states that rocky mountain spotted fever can be seen
North Carolina, Virginia, Missouri, Arkansas
Name a few complications of infectious mononucleosis
Nasopharyngeal carcinoma, haemolytic anaemia, hepatic necrosis, bacterial superinfection, upper airway obstruction, spleen rupture, CNS infection
If a patient with infectious mononucleosis gets upper airway obstruction (swollen tonsils), or haemolytic anaemia what do we do
Give corticoster
If a patient has infectious mononucleosis presentation, Monospot is negative. What two steps do you have to do in your head
Test the EBV antibody. As the Monospot can be negative.
If the antibody test is negative then it maybe is CMV, toxo, HIV
What is the caveat with B cells and T cells in EBV infection
The bee cells cause the lymphocytosis, but the T cells are the atypical cells
Why is a concurrent STI a risk for HIV
Because there’s lots of macrophages in the area, and that means that more HIV can infect the macrophages
Recall my three structural genes in HIV
Env (GP120 and GP41) gag (P24 and P17) pol (Reverse transcriptase, integrates, protease
Recall the receptor on macrophages, and the receptor on T cells that allow HIV to enter
CCR five on macrophages, CXCR4 On T cells. CCR five mutations can cause immunity if homozygous, or slower course if heterozygous
HIV patient, cd4 less than 50. Fever, night sweats, focal lymphadenitis
MAC
List the opportunistic infections that can occur at a CD less than 500
Oral thrush, hairy leukoplakia, Kaposia, HPV and TB
List the opportunistic infections that can occur at a CD less than 200
Histoplasmosis, HIV Dementia, junkie cerebrum, pneumocystitis
List the opportunistic infections that can occur at a CD less than 100
Bartonella, candida oesophagitis, the CMV infections, Cryptococcus meningitis, Cryptosporidium, EBV, MAC, toxo
HIV patient with non-enhancing areas of focal demyelination on MRI
Progressive multifocal Luca and kettle apathy
If you are doing HAART for HIV, and after a few months the viral load as above 50, what do you do. Whereas if it’s below 20 what do you do
Above 50 you need to do regime change/check for resistance. If it’s below 20 this is good
General HAART therapy
To reverse transcriptase inhibitors. Plus either and integrate inhibitor, non-nucleoside reverse transcriptase inhibitor, or protease and
Tegravir
Integrase inhibitor
List me all the nuclear side and non-nucleoside reverse transcriptase inhibitors
Abacavir, emteicitabine , lamivudine,, tenofovir, zidovudine, didanozine
Efavirenz, nevirapine
-navir
Protease inhibitor
Before starting abacavir,
What do you need to check
The HLA-B 570 one. Hypersensitivity risk
If patient has a little bit of cryptococcus meningitis, why do we need to be slow giving HAART, and even treat the cryptococcus first
Cryptococcus is famous for causing immune reconstitution syndrome.
So it can actually worse in the infection given HAART without treating cryptococcus first
We know about PCP and toxo prophylaxis in HIV. We also know about histoplasmosis prophylaxis if the patient is in an endemic area and the CD is less than 150. What about if a less than 50 CD
Is this from my son for MAC prophylaxis
If emergency and haven’t ruled out cervicle injury. . Do we intubate
Yes, and immobilise the neck
When is nasotracheal intubation preferred and when CI
Bronchial tree rupture. CI if basilar skull fracture
Aside from our massive radiation 1:1:1. In other emergency transfusion; for every 4 RBC, do what?
1 FFP
alternative to IV access? If many attempts
Interosseous line
To note: blood at the meatus, hematuria, difficulty voiding, high riding prostate, scribal hematoma
Voiding yrethrogralhy
Best imaging of neck, in emergency, if NEXUS. If find fracture, what do we do?
CT! If find fracture, do imaging of whole spine
Why might patient with orbital fracture get bradycardia
Due to trapped interior rectus muscle… causing a oculocardiac reflex. Should do Sx release
If sus of orbital globe laceration,.. what to do
Maybe flourescin test. Avoid eyelid retraction, vom, crying. And do not do tonometry
Otorrhea in face of facial injury/laceration, should be tested for what
B transferrin. To see if CSF leakage. Consider a CT too
Patient with Colliflower ear… how?
Auricular hematoma forms, and isn’t sufficiently drained
Risks of having a septal hematoma
Pressure injury and because the area isn’t well vascularised…. It can perforate
Tension Pneumothorax. Neck veins?
Often distended (pressures are usually high in thorax)
True penetrating neck wound. Mx
Unstable = Sx
Stable = CTA, then consider Sx
New diastolic murmur after chest trauma
Maybe AR and dissec
If patient has neck wound, and significant hypovolemic shock. When you check the neck wound, you see it doesn’t penetrate the platysma…. What next
Check for other bleed. Doesn’t pass through plastysma = not true neck laceration
Penetration to the abdomen reqcuires lap when?
Any peritonitis, unstable signs. If not, then explore yourself (if peritoneal sign, do lap also). Otherwise observe for 24 hours
Gunshot wound to thorax… below 4th IC space
Always lap
Remember can apply hard and soft signs of Clavicular fracture to most things
!!!
Amputation stump painful neuroma can be treated with?
Anaesthetic injection
DVT common in amputation stump
Yes yes yes
If have urethral injury, and it’s so bad we need to do Sx at a later date, how to deal with urine
Urine diverted to suprapubic catheter
Our two urethral injuries: anterior and posterior. Location? Association? Tx?
Anterior:
Distil to membranous urethra. Straddle, penile fracture etc. do catheter, supeapubic if needed. May need Sx
Posterior:
Membranous and prostatic. Seen with hip dislocation. Usually do normal catheter, but may need same as above
Differences between extra and intra peritoneal bladder injury
Extra: rupture of neck or trigone. Pain only in the lower abdomen or pelvis. Causes major hematuria. Do Foley catheter
Intra: dome rupture . Abdomen pain all over with some guarding. Low urine output all together. Do Sx
Carnett sign and forthergill sign, to differentiate rectus sheath hematoma, from abdominal originating issue
Point of max tenderness doesn’t change when supine or upright.
Mass doesn’t cross midline.
Both point toward rectus sheath hematoma
Rectus sheath hematoma Invx
CT. And do CT guided hematoma evacuation. Lugs tree the vessels needed. Transfuse as needed
Why do rectus sheath hematoma more commonly occur below arcuate
There is no posterior sheath below arcuate. So there is huge shearing forces of the rectus abdominus. Causing a rupture
General workup for pelvic fractures
Assess hemodynamic (around 40 % have bleed and need transfusion). Apply pressure to ASIS both sides to
Assess stability. X-ray or CT (if stable). Retrograde cysto in men, proctoscopy, pelvic exam in women.
Unstable patients should have binder over trachanters (this tamponades any bleed). Then do angio embol.
Other than duodenal Hematoma… what else can be damaged with handlebar injuries
Pancreas
After spleen injury from blunt abdo trauma. When give the Vx
2 weeks afte r
After spleen injury from blunt abdo trauma. When give the Vx
2 weeks after
Patient on anticoag and has cardiac catheterisation. Had back pain and flank bruise and hemodynamic instability. At risk for what
Retroperitoneal Hematoma
Note: treat aortic disruption (after blunt chest trauma) invx the same as aortic dissec
General Mx of pulmonary contusion
Intubate if needed or NIPPV. Be conservative with fluid (can worsen it)
Chest injury. Segment of chest moves IN on INspiration
Flail chest
If after blunt chest trauma, there is fractures of either sternum, clavicle, first rib…. Check what
See if aortic disruption. Associated, since such large forces are needed to break these bones
Once done a CXR in suspected unilateral phrenic nerve injury. Do what test
Flourscopic sniff test. Watch patient inspire (sniff), and see paradoxical elevation of hemidiaphragm)
Left sided diaphragm ruptured can be repaired with surgery… what about right
Non op at first (liver tampnades injury)
Any blunt force can cause diaphragm rupture. But what areas of penetration trauma can cause it?
Any penetration between T4-T12
Linear skull fracture Mx
Non op, unless comminuted/displaced
Subdural Hematoma Mx
If major AMS, midline shift on CT, then craniotomy. Otherwise manager ICP and little fluid (edema risk)
Most basilar scull fractures can be left unTx. But if there’s CSF leak for more than a week?
Consider Sx, due to high risk of mengitis
If child had bad head trauma and CT negative..: what to do
MRI. Better to see DAI etc.
After child TBI… why is there risk if secondary hypoxia injury
Decrease perfusion and increase demands
Le Fort fracture
Midface fracture. Generally need fixation and good approximation of dental surfaces. Then do liquid diet
Le fort 1-3
1: mobile maxilla with rocking maneuvre
3: compete instablity of midface (and often send in basilar skull fractures)
If GCS above 14 and patient seems ok. If they had nasty fall or loss of consciousness prior… what to do?
Can discharge, and ask patient to return if Neuro symptoms develops
Angular stomatitis cheiliosis corneal vasc
Vit B2 (riboflavin def)
How can B6 def relate to B3 def.
B6 def can cause B3 def. So INH can also cause B3 def
Dermatitis, enteritis, alopecia, adrenal insufficiency
b5 def
Sideroblastic anemia and peripheral neuropathy after INH
B6 def. Give with INH
Dementia and enteritis. Ears a lot of raw eggs. Or recent ABx
Biotin def (B7)
Vit C def
Swollen gums, bruising, anemi, poor wound healing
b12 like disorder. (Neuro symptoms and anemia). But it’s normocytic with signs of hemolysis
Vit E def
Impaired taste, poor wound healing, alopecia, hypogonadism,, acrodermatitis enterioathica, anosmia
Zinc def
Main risk of acyclovir
Cyrstalluria. Give with fluids
Amantadine SE
Ataxia, livedo retic, antiCh
Amphotericin SE
Fever or rigours. Nephrotox. BM surp
Azoles P450
Inhib
Carabamazepine P450
Inducer. Can induce own degrad, so increase doses for these people in the first few weeks
Clonidine side effects
Dry mouth, severe rebound headache/HTN
Cataracts from CS
Yes
Hemolysis from G6PD Def. I’m INH
Yes
Metformin Vit def?
B12, withold until it improves
Metronidazole SE
Disulfiram, vestibular dysf, metallic taste,
Penicillinamine main SE
DILE
Phenytoin main SES
Nystagmus diplopia ataxia gingival hyperplasia histriism
Prazosin on first dose, issues
Low BP
Quinidine SE
CInchonism, TCP, QT prolongation
Trazadone SE
Priapism (Trazabone), QT prolong, serotonin syndrome
Can tetracyclines cause Fanconi…
Yes
Zidovudine SE
TCP, megalobalstic anemia.
Vincristine can cause neuropathy and paralytic ileus. Vinnlastine causes BM surp
🙌🙌🙌
Vancomycin SE
Nephrotox, ototox, thrombophleb, red man (recall picture)
Gynaecomastia drugs
Spirino, digitalis, cimetidine, alcohol, ketoconazorl,
DILE drugs
Procainamide, hydralazine, INH, pencilliamine,, quinidine, chlorpromazine, methylodopa,
Cyp inducers
Barbi, St. John’s, phenytoin, rifampin, griseofulvin, carabamazepine,
CYP inhibitor
Quinidine, cimetidine, azole, INH, grapefruit, erythromycin, sulfonamide
Meds increasing risk for digoxin tox
Quinidine, cimetidine, Amiodarone, CCB
G6PDH def drugs
Sulfas, INH, ASA, ibuprofen, nitro, primquine, pyrimethamine, chloramphenicol, dapsone
Charcoal good for acetaminophen at what point!
<4hours
Acid alkali ingestion Mx
Endoscopy. ABC and remove clothing. Not charcoal, vom, or neutralising agent. If I’m eyes, irrigate a lot
Anticholinestwease tox Tx (our gardening stuff)
Atropine and pralidoxime
Antimuscarinic tox Tx
Physostigmine
Garlic breath in which toxicity
Arsenic
Child with hematemesis and met acidosis (hemorhafic gastritis). See eadioopaque tablets of X-ray)
Iron tox!!! Five deferxamine
Digitalis tox… give the Fab first or correct electrolytes
Fab first
We use flumazenil for acute benzos tox… but what do we give in chronic
NOT FLUMANEZIL. Causes withdrawal, even in acutely Intox too
Cyanide tox.. Tx or test blood levels first
Tx… slow blood results common
Drugs heavily depend on CYP
benzos, barbi, metoprolol, CCB, warfarin, quinidine, phenytoin, carbamazepine, theophylline,
Overview of Invx for CO tox
Our proper ABG analysis (O2 normal I’m pulse ox). ECG done in most, and preg test in women
100% O2 for CO poisoning, but when to give hyperbaric or intubate
If preg, CNS or cardiac issues or severe CO (<25%) do hyperbaric
If signs of airway burn or smoke inhalation, early intubate
Causes of metHb
Dapsone, nitrate, local aneathsha
Met Hb Tx
Methylene blue
Inhaled burning carpet or textile and has elevated lactate
CN poisoning
Discuss a bit about anticholinergic toxidrome
Usually from somebody taking antimuscarinics. Causes a sympathetic nervous system response (blind as a bat et cetera). Give physostigmine
Discuss a bit about organophosphate poisoning
These are anticholinesterases. so they cause a pro parasympathetic response. Give atropine and pralidoxime
General overview of activated charcoal for toxic things
Only really it’s less than 2 to 4 hours after ingestion. Exceptions is lithium, iron, lead, alcohol, alkalines, acids. These do not require Chaco
Main management for chemical burn
Copious irrigation for 30 minutes before transferring to hospital
Remember electrical burns caused the deep muscle injury and rhabdomyolysis. What’s the general management for electrical burns for this reason
Prophylactic fasciotomies to prevent compartment syndrome. Check kidney function, ECG et cetera
Bikes with sharp teeth and deep punctures do they need to be sutured
No
Rabies prophylaxis. Consider if immunised or never immunised
If immunise just get vaccine. If never immunised the vaccine and Ig
Patient has clean minor wound. Usually you don’t give prophylaxis unless when
If the patient had less than three lifetime vaccines. All the last vaccine was more than 10 years ago
And if patient has a non-clean or major wound. When do we give just the vaccine
If the last Vaccine was more than five years ago
And if patient has a non-clean or major wound. When do we give the vaccine And Ig
If they’ve had less than three lifetime vaccines
Black widow bite signs. Treatment
Causes muscle spasm. Even mimicking abdomen guarding.
Given antivenom
Brown recluse spider bite signs and treatment
Causes necrosis (black Usher) and DIC potentially. Do cold compress, dapsone, debride meant
Quick overview of shell fish bite, infection
Of vibrio valve in a kiss. Causes severe necrotising fasciitis and Paula solutions. Worse in patients with a liver disease. Give Ivy Doxey and foxy. And debridment
Foremost cat and dog in human bites. What’s the main antibiotic to give
Amoxicillin clavulanic acid
General rules about snakebites
Give antivenom. Keep the limb below the heart
What methods to take in hypothermia:
32 to 35
28 to 32
Less than 28
Passive external rewarming. Like remove wet clothing give blanket
Active external warming. Light warm blanket, warm bath
Active internal rewarming. Like warmed IV fluids, warm lavash, warm ECMO
Osborn ECG wave
Seen in hypothermia
Generally, a patient is not dead until they’re warm and dead. What does this mean
Essentially means you can only diagnose death if the body is above 32°C. Don’t stop resus until we rewarm
What’s the presentation difference between tunnelled and non-tunnelled catheter CLABSI
None tunnel usually don’t have any obvious local signs of infection. Where is tunnelled you will see usually signs of discharge in pain at the site of the catheter
Obviously to diagnose ACLABSI, you need blood cultures. And of course of the lambs. But what’s the difference between non-tunnelled and tunnelled diagnosis
Non-tunnelled you do exactly what little micro George said. Isolation of organism from central line and peripheral blood sample, with a greater concentration at the central line. I.e. a shorter time to culture in the Central line in the peripheral vein.
Tunnel catheter you do a similar saying but you can take the bus Alexi date from the subcutaneous track Lane
Blunt cardiac injury general treatment
Largely supportive, but a lot of the time you can give an inotrope
Traumatic haemothorax management
Tube thoracostomy. And then if output more than 1.5 L or more than 300 mL over three consecutive hours. You do thoracotomy. Surgery if you think there’s aortic, diaphragm, oesophagus, tracheobronchial injury causing it. If there is an actual penetrating trauma then you may go straight to thoracotomy
