My common mistakes Flashcards
MDMA (ecstasy) poisoning is associated with…
Hyponatraemia
N-Acetylcysteine commonly causes what type of reaction?
Anaphylactoid reaction (non-IgE mediated mast cell release)
For DMT2 when is metformin contraindicated?
eGFR <30
What is the most highly negatively inotropic CCB? (weakens heart contractions- slows HR)
Verapamil
Key investigation for suspected CO poisoning?
ABG- carboxyhaemoglobin
Liver transplantation criteria in paracetamol overdose?
pH <7.3 more than 24hrs after ingestion
Patient on amiodarone (eg for AF) develops hypothyroidism?
Continue amiodarone and add levothyroxine
Double duct sign?
Pancreatic cancer
Haemochromatosis iron study profile?
Raised transferrin and ferritin, low TIBC
Upper GI bleed or lower GI bleed if high urea?
Upper- blood digested (contains protein) so increase in urea
Acute hypophosphataemia management- severe or symptomatic
IV phosphate polyfusor
Visual hallucinations with dementia
Lewy body dementia
Blood tests that form part of the confusion screen
TSH, B12, Folate & Glucose
Memantine drug class
NMDA receptor antagonist
Complications of thyroid surgery
- Recurrent laryngeal nerve damage
- Bleeding- laryngeal oedema.
- Damage to the parathyroid glands resulting in hypocalcaemia.
Ways to remember causes of nystagmus?
Horizontal nystagmus = peripheral cause (goes in direction of ears)
Vertical nystagmus = central cause (goes in direction of brain)
Difference between neuronitis and labrynthitis?
Neuronitis = No loss
Labrynthitis = Loss
Vestibular neuronitis = inflammation of the vestibular nerve, which deals with balance but not hearing
Labyrinthitis = inflammation of labyrinth, which deals with both balance AND hearing
FLUID THERAPY IN CHILDREN
FLUID THERAPY IN ADULTS
Atropine increase or decrease HR?
Increase, if fails then external pacing
Amiodarone increase or decrease HR?
Decreases HR (treats fast irregular HR)
Cause of infective endocarditis <2m post valve surgery
Staph epidermidis
Is a child is choking, why is the foreign object most likely found in right main bronchus?
Shorter, wider and more vertical
Severe anaemia is a cause of
high-output heart failure
RBBB +left anterior or posterior hemiblock + 1st-degree heart block
trifasicular block
Acute heart failure not responding to treatment
consider CPAP
Hypothermia is a cause of
Torsades de pointes
ACS: Nitrates are contraindicated in patients with
hypotension (< 90 mmHg)
‘Global’ T wave inversion (not fitting a coronary artery territory) - think
non-cardiac cause of abnormal ECG
Hypothermia causes what on ECG
J waves
Mx if V tachy leads to haemodynamic instability?
synchronised electrical cardioversion; may be followed by an amiodarone infusion when more stable to enhance the probability of achieving sinus rhythm
Lichen planus vs scleorsus?
planus: purple, pruritic, papular, polygonal rash on flexor surfaces. Wickham’s striae over surface. Oral involvement common
sclerosus: itchy white spots typically seen on the vulva of elderly women
Toxic epidermal necrolysis (TEN) vs Stevens-Johnson syndrome (SJS)?
Both severe skin reactions, TEN more severe end of spectrum.
SJS: Affects less than 10% of the body’s surface area
TEN: Affects more than 30% of the body’s surface area
erythema nodosum vs erythema multiforme?
Erythema multiforme is typically target shaped and only slightly raised. It’s not typically painful but can be itchy. They can also be on various sites of the body
Erythema nodosum is more like a raised nodule that mainly presents on the shins. It looks a bit like a bruise and it is painful.
most accurate way to asses the burns area
Lund and Browder chart
Wallace’s Rule of Nine
Each of the following is 9% of the body when calculating surface area % if a burn:
Head + neck, each arm, each anterior part of leg, each posterior part of leg, anterior chest, posterior chest, anterior abdomen, posterior abdomen
Psoriasis commonly exhibits what pgenomenon
Koebner phenomenon
What clotting factors and other components does the liver make?
1) Clotting factors= I (fibrinogen); II (prothrombin); V; VII; IX; XII; XIII (all for blood coag)
2) Albumin (transport and maintain BP)
3) Transport proteins= ceruloplasmin (transports copper) and transferrin (iron)
4) Bile salts (fat digestion)
5) Bilirubin (from RBC breakdown)
6) Glucose (through gluconeogenesis and glycogen storage/release)
7) Lipids (cholesterol, trigly and lipoproteins)
8) Detoxification products (ammonia to urea & drug metabolism)
9) Hormones= angiotensinogen and thrombopoietin
Role of angiotensinogen and thrombopoietin?
A= BP regulation
T= platelet production
What blood tests would you do to investigate the liver?
1) LFTs (enzymes & proteins):
- ALT & AST
- ALP
- GGT
- Bilirubin (total & direct)= direct is conjug and indirect is unconjug
- Albumin
- Total protein
2) Clotting screen= INR or PT
3) Viral serology= hep A, B, C, E
4) Autoantibodies= AMA, ANA, Anti-SMA
5) Ceruloplasmin
6) Ferritin and transferrin
7) Paracetamol levels
8) Alpha-1 antitrypsin
9) Tissue Transglutaminase antibody
10) Ammonia levels
Overall tests to measure kidney function?
1) Bloods= serum creatinine; blood urea nitrogen (BUN); eGFR; serum uric acid
2) Urine= eg. urinalysis; protein, albumin, glucose, blood, bacteria
3) Imaging= USS, CT or MRI
What does high serum creatinine indicate about kidney function?
impaired.
Creatinine= waste product from muscle metabolism in blood
What does elevated uric acid levels indicate about kidney function?
kidney disease or gout
What does proteinuria indicate about kidney function?
damage or disease
What does high urine albumin indicate about kidney function?
Damage eg. in diabetes or HTN
Budd-Chiari Ix- way to remember?
(pt presents with abdo pain, tender hepatomegaly and ascites- basically a painful swollen liver)
USS with doppler.
basically a ‘liver DVT’ , being a hepatic vein thrombosis.
The ‘painful, swollen calf’ is essentially just a painful swollen liver (abdo pain, tender hepatomegaly) + ascites due to venous obstruction.
They also have exactly the same gold standard investigation in Doppler Ultrasound!
Hepatocellular disease LFTs?
ALT= raised at least 2 fold
ALP= normal
ALT/ALP= 5+
Cholestatic disease LFTs?
ALT= normal
ALP= raised at least 2-fold
ALT/ALP= <2
LFTs in mixed disease (hepatocellular + cholestatic)?
ALT= raised at least 2-fold
ALP= raised at least 2-fold
ALT/ALP= 2-5
ALP, AST and ALT produced by what?
AST & ALT produced by hepatocytes; in hepatocellular disease, hepatocytes release these enzymes into blood so get raised ALT.
ALP produced by cells lining bile duct so in obstructive disease ALP rises.
Summary of liver enzymes in LFTs?
ALT = correspond to hepatocytes
AST = correspond to hepatocytes, cardiac cells, and muscle cells
ALP = correspond to biliary system (bile ducts) & various tissues in the body eg. bones
GGT= more specific version of ALP in terms of biliary system; also indicates pt drinks alcohol
deranged LFTs combined with secondary amenorrhoea in a young female
autoimmune hepatitis
C.diff Mx
1st: oral vancomycin
2nd: if doesn’t work then oral fidazomicin
OR IF SEVERE (eg. hypotension, shock) or doesn’t respond to above= oral vanc + IV metronidazole
Maintain remission in UC if have had a severe relapse or >=2 exacerbations in past yr?
oral azathioprine or oral mercaptopurine
Metoclopramide MOA?
antagonism of D2 dopamine receptors
Electrolyte disturbances in refeeding syndrome?
hypophosphataemia, hypokalaemia and hypomagnesaemia
Receding bleeding gums
think scurvy
What electrolyte disturbance can PPIs cause?
hyponatraemia
Primary biliary cholangitis- M rule?
IgM
anti-Mitochondrial antibodies, M2 subtype
Middle aged females
How long should pts not eat gluten for before they get endoscopic intestinal biopsy to diagnose coeliac?
6w
Most common site affected in Crohn’s
ileum
How to stop uncontrolled variceal haemorrhage?
Sengstaken-Blakemore tube
1st line Ix for acute mesenteric ischaemia?
Lactate= raised
Liver + neuro disease?
think Wilson’s
Mneumonic to remember causes of erythema nodosum?
NO - idiopathic
D - drugs (penicillin sulphonamides)
O - oral contraceptive/pregnancy
S - sarcoidosis/TB
U - ulcerative colitis/Crohn’s disease/Behçet’s disease
M - microbiology (streptococcus, mycoplasma, EBV and more)
Reversible causes for cardiac arrest?
H.ypothermia
H.ypovolaemia
H.ypoxia
H.yperkalaemia
T.hrombus
T.oxins
T.ension pneumothorax
T.amponade
ALS for VF/pulseless VT?
single shock followed by CPR
ALS if cardiac arrest is witnessed in monitored pt eg. coronary care unit and is in VF/pulseless VT?
Up to 3 quick successive shocks rather than 1, then CPR
What is first line drug administration route and should always be attempted in ALS?
IV access
if can’t achieve then give drugs IO
Role of adrenaline in ALS?
1mg given as soon as possible for non-shockable rhythms
shockable rhythms= 1mg once restart chest compressions after the third shock
repeat adrenaline 1mg every 3-5mins whilst ALS continues
Role of amiodarone in ALS?
300mg given to pt in VF/pulseless VT after 3 shocks have been given.
then further 150mg given after 5 shocks, then 7 ect.
lidocaine can be an alternative
When should thrombolytic drugs be given in ALS and how long should CPR continue for?
is PE suspected.
continue CPR for extended period of 60-90mins
A to E vs DRABC?
DRABC for immediate, on-scene assessments, and A to E for systematic evaluation in a clinical setting.
What is a heart attack?
- must have troponin RISE AND FALL
- must also have typical CP, ECG changes or new scar (eg. ST depression or elevation; T wave inversion-new; CLINICAL CONTEXT)
Standard bloods for chest pain?
FBC, U+E, LFT, Clotting screen, Troponin +/- D dimer, Cholesterol, Glucose/HbA1c
Ix for chest pain?
- vital signs
- ECG
- CXR
- Bloods
- ABG if hypoxic/PE suspected
Criteria for PPCI in STEMI?
- ST elevation >2mm in 2 contiguous chest leads or >1mm in 2 contiguous limb leads (i.e. territorial not randomly distributed)
~Chest pain or other evidence of ischaemia
- New or presumed new LBBB was an indication for thrombolysis and is often considered an indication for PPCI in the right clinical context
If morphine is given in acute Mx of STEMI, what needs to be given with it?
Metoclopramide as morphine can make pt feel sick (delays absorption of anti platelet drugs)
What if pt is already on aspirin but you need to give 300mg stat for STEMI acute Mx?
in theory don’t need to give but best to just give anyway as shouldn’t do any harm
When to measure troponin?
- Depends on assay
STH assay – hsTnT: - Measure ASAP
- If raised, measure again in 3h – significant rise or fall suggests MI
- If not raised, can r/o MI, unless pain was <6 hrs ago, in which case obtain further measurement at that point – significant rise suggests MI
- Does NOT rule out ACS (could still be unstable angina)
- MI is NOT always due to ACS
Follow up post MI?
Clinic 1 month – can consider device therapy if significant LVSD
Transthoracic echocardiogram if not had as inpatient
Cardiac rehabilitation programme
Smoking cessation
GP – uptitrate secondary prevention e.g. ramipril and bisoprolol towards 10 mg OD
Advise for pt post MI?
Don’t drive for 1 week if PCI, 4 weeks if no PCI (we advise all pts 4 weeks)
Gradual return to usual activity levels
Typically 6 weeks off work
Stop smoking
MI- what to write on the TTO?
Big 5
1) Aspirin 75 mg OD
2) Potent P2Y12 inhibitor – ticagrelor 90 mg BD or prasugrel 5-10 mg OD for >=1 year. Can consider a PPI alongside.
3) Cardioselective beta blocker (caution if asthmatic, bradycardic, conduction disease) e.g. bisoprolol 2.5 mg OD
4) ACE inhibitor (ARB if intolerant due to cough) (caution if hypotensive, severe CKD) e.g. ramipril 2.5 mg OD
5) High intensity statin e.g. Atorvastatin 80 mg OD
(PRN GTN)
Pretty much most pts will go home on these if tolerated
What drugs to consider writing on the TTO for MI?
- Consider if poor LV function
MRA – eplerenone or spironolactone 12.5 – 25 mg OD - Consider if pericarditic pain
Colchicine 500 mcg BD - Consider if clinical heart failure
Loop diuretic e.g. Furosemide 40 mg OD
SGLT2 inhibitor e.g. Dapagliflozin or Empagliflozin - Consider if non-revascularized significant coronary artery disease
Anti-anginals - beta blocker, nitrates, amlodipine etc.
Cardiac Resynchronisation Therapy (CRT)
Patients with LVSD + LBBB or needing a PPM or very wide
RBBB
Dual chamber PPM
- RA lead
- RV lead
- PLUS LV lead (in the CS)
- Bi-ventricular PPM
- Biventricular PPM = ‘CRT-P’
Groups of patients with at significant risk of VT/VF
Severe LVSD
Previous VT/VF (but not if assoc with an acute infarct)
Inherited cardiac conditions
HCM, Brugada etc.
Implantable Cardioverter Defibrillator (ICD)
Adds a generator and shock coils to pacing function
If added to a single lead or dual chamber PPM = ‘ICD’
If added to a CRT device = ‘CRT-D’
What is the tumour marker for pancreatic ca?
CA 19-9
What lung ca has the strongest association with smoking?
squamous cell lung ca
What drug is used to suppress N&V with intracranial tumours?
dexamethasone
What chemo drug is associated with hypomagnesaemia?
cisplatin
What chemo drug may cause pulmonary fibrosis?
bleomycin
What should be part of the diagnostic work up in a women found to have abdo malignancy of unknown primary?
CA 125
What HPV subtypes are carcinogenic and increase risk of cervical ca?
16,18,33
What HPV subtypes are NOT carcinogenic and are associated with genital warts?
6, 11
Tumour marker in colorectal ca and has a role in monitoring disease activity?
CEA
Most common cause of SVCO?
small cell lung ca
What chemo drug may cause peripheral neuropathy?
vincristine
Tumour marker for breast ca?
CA 15-3
Women with bone mets, likely to originate where?
breast ca
Tumour marker in medullary thyroid ca?
calcitonin
PBC vs PSC?
PBC is middle-aged women, anti-mitochondrial antibodies, assoc with keratoconjunctivitis sicca.
PSC is young men, often with Ulcerative colitis, assoc with pruritus and fatigue, anti-mitochondrial antibodies negative.
Primary Sclerosing Cholangitis is associated with Ulcerative Colitis (i.e. both ‘itis’), which occurs in younger people.
Way to remember PBC?
PBC - M Disease - Increased IgM, AMA associated, Middle Aged Women!
Melanosis coli is most commonly caused by
prolonged laxative use
The oral contraceptive pill and co-amoxiclav is associated with
drug-induced cholestasis
Budd-Chiari syndrome presents with the triad of
sudden onset abdominal pain, ascites, and tender hepatomegaly
High urea levels can indicate
upper GI bleed versus lower GI bleed
Bile-acid malabsorption may be treated with
cholestyramine
Antinuclear antibodies, anti-smooth muscle antibodies and raised IgG levels are characteristic of
autoimmune hepatitis
Odynophagia is a concerning symptom that may be present in patients with
oesophageal ca
first line test for diagnosis of small bowel overgrowth syndrome
hydrogen breath testing
All patients with suspected upper GI bleed require
endoscopy within 24 hours of admission
key investigation for a suspected perforated peptic ulcer
erect CXR
PPIs can increase the risk of
osteoporosis and fractures
used in the management of severe alcoholic hepatitis
corticosteroids
should be given before endoscopy in patients with suspected variceal haemorrhage
Both terlipressin and antibiotics
Autoimmune hepatitis is more likely to show predominantly raised
raised ALT / AST on LFTs than ALP
cause of hypogonadotrophic hypogonadism
haemochromatosis
generally used to induce remission of Crohn’s disease
Glucocorticoids (corticosteroids) (oral, topical or intravenous)
used to monitor treatment in haemochromatosis
Ferritin and transferrin saturation
first-line in maintain remission in ulcerative colitis patients with proctitis and proctosigmoiditis
A topical (rectal) aminosalicylate +/- an oral aminosalicylate
HBsAg negative, anti-HBs positive, IgG anti-HBc positive
previous infection, not a carrier
Diarrhoea, fatigue, osteomalacia →
?coeliac
diagnostic investigation of choice for pancreatic cancer
High-resolution CT scanning
Always examine the what in a young man with RIF pain
testicles
In an acute upper GI bleed, what can identify low risk patients who may be discharged
Blatchford score
A transjugular intrahepatic portosystemic shunt (TIPS) procedure connects the
hepatic vein to portal vein
may be useful for diagnosing and monitoring the severity of liver cirrhosis
Transient elastography
characteristic iron study profile in haemochromatosis
Raised transferrin saturation and ferritin, with low TIBC
Jaundice following abdominal pain and pruritus during pregnancy think
acute fatty liver of pregnancy
somatostatin analogue used to treat the symptoms of carcinoid syndrome
Octreotide
develops in around 10% of primary sclerosing cholangitis patients
Cholangiocarcinoma
Obesity with abnormal LFTs
? non-alcoholic fatty liver disease
Iron defiency anaemia vs. anaemia of chronic disease
TIBC is high in IDA, and low/normal in anaemia of chronic disease
C. difficile antigen positivity only shows what?
exposure to the bacteria, rather than current infection
toxin=current
If a patient with ulcerative colitis has had a severe relapse or >=2 exacerbations in the past year they should be given what to maintain remission?
oral azathioprine or oral mercaptopurine
Small bowel obstruction (often due to intussusception) is a common presenting complaint in what syndrome?
Peutz-Jegher’s syndrome
Ongoing diarrhoea in Crohn’s patient post-resection with normal CRP
cholestyramine
Large-volume paracentesis for the treatment of ascites requires albumin ‘cover’. Evidence suggests this reduces
paracentesis-induced circulatory dysfunction and mortality
best first line management for NAFLD
weight loss
prophylaxis of oesophageal bleeding
non-cardioselective B-blocker (NSBB) eg. propanolol
Acute mesenteric ischaemia first line Ix?
raised lactate (causes this and is the 1st line Ix)
Acute hypoperfusion (e.g. low BP secondary to blood loss) may result in
ischaemic hepatitis
Most likely area to be affected by ischaemic colitis
splenic flexure
Increased goblet cells
Crohn’s
Constipation - if symptoms don’t respond to a bulk-forming laxative such as isphagula husk, try what?
osmotic laxative such as a macrogol
Bile-acid malabsorption may be treated with
cholestyramine
The definition of an Upper GI Bleed is a haemorrhage with an origin proximal to the…
ligament of Treitz
HBsAg negative, anti-HBs positive, IgG anti-HBc negative
previous immunisation
In patients with severe colitis, colonoscopy should be avoided due to the risk of perforation, so what should be used?
flexible sigmoidoscopy
Coeliac disease increases the risk of developing what ca?
enteropathy-associated T cell lymphoma
Long term proton pump inhibitor therapy can cause what electrolyte disturbances?
hypomagnesaemia
hyponatraemia
Dermatitis, diarrhoea, dementia/delusions, leading to death
Pellagra
First-line pharmacological management of acute constipation
bulk-forming laxative such as isphagula husk
mobility, increasing fluid intake and high fibre diet also v important
Induce remission in crohn’s
glucocorticoids (oral, topical or intravenous)
Budesonide is alternative in certain pts
metronidazole is often used for isolated peri-anal disease
Maintaining remission in crohn’s?
azathioprine or mercaptopurine
and stop smoking
methotrexate is used second-line
Useful in refractory disease and fistulating Crohn’s to induce remission?
infliximab
Patients typically continue on azathioprine or methotrexate.
Induce remission in ulcerative colitis?
topical (rectal) aminosalicylate
if not achieved in 4w= add an oral aminosalicylate
still not achieved= add topical or oral corticosteroid
Induce remission in ulcerative colitis in extensive disease?
topical (rectal) aminosalicylate and a high-dose oral aminosalicylate
if remission is not achieved within 4w= stop topical treatments and offer a high-dose oral aminosalicylate and an oral corticosteroid
Induce remission in ulcerative colitis in severe colitis?
should be treated in hospital
IV steroids first-line
IV ciclosporin may be used if steroids are contraindicated
if after 72 hours there has been no improvement, consider adding IV ciclosporin to IV corticosteroids or consider surgery
Maintaining remission in UC if mild or moderate eg. proctitis and proctosigmoiditis?
topical (rectal) aminosalicylate alone (daily or intermittent) or
an oral aminosalicylate plus a topical (rectal) aminosalicylate (daily or intermittent) or
an oral aminosalicylate by itself: this may not be effective as the other two options
Maintaining remission in UC if left-sided and extensive ulcerative colitis?
low maintenance dose of an oral aminosalicylate
Maintaining remission in UC following a severe relapse or >=2 exacerbations in the past year?
oral azathioprine or oral mercaptopurine
UC flare severity?
Mild= <4 stools a day, with or without blood
Moderate= 4-6; minimal systemic distrubance eg. slight raise in CRP
Severe= >6 a day, containing blood; systemic disturbance eg. fever, anaemia, hypoalbuminaemia, tachy, abdo tenderness
first line test for diagnosis of small bowel overgrowth syndrome
Hydrogen breath testing
You cannot interpret TTG level in coeliac disease without looking at
IgA level (so test this when u test TTG)
Patients must eat gluten for at least how long before they are tested for coeliac?
6w
What is used for complex perianal fistulae in patients with Crohn’s disease?
A draining seton
crypt abscesses
UC
Dyspepsia: there is no need to check for H. pylori eradication with urea breath test if
symptoms have resolved following test and treat
treatment for achalasia
1st= Pneumatic dilatation (less invasive)
2nd if failed= Heller cardiomyotomy (surgery)
If a severe flare of UC has not responded to IV steroids after 72 hours, consider adding
IV ciclosporin or surgery
In a mild-moderate flare of ulcerative colitis extending past the left-sided colon, how to Mx?
oral aminosalicylates should be added to rectal aminosalicylates, as enemas only reach so far
Coeliac disease is associated with what deficiencys?
iron, folate and vitamin B12 deficiency
What should be assessed before offering azathioprine or mercaptopurine therapy in Crohn’s disease?
TPMT activity
Ascites: a high SAAG gradient (> 11g/L) indicates
portal hypertension
A combination of liver and neurological disease points towards
Wilson’s
During infection, ferritin is an unreliable indicator of iron stored in the body as it is an acute phase protein. What should be used instead?
Transferrin saturation
Autosomal recessive vs dominant conditions typically….
Autosomal recessive conditions are ‘metabolic’ - exceptions: inherited ataxias
Autosomal dominant conditions are ‘structural’ - exceptions: Gilbert’s, hyperlipidaemia type II
Cerebellar disease signs?
D - Dysdiadochokinesia, Dysmetria (past-pointing), patients may appear ‘Drunk’
A - Ataxia (limb, truncal)
N - Nystamus (horizontal = ipsilateral hemisphere)
I - Intention tremour
S - Slurred staccato speech, Scanning dysarthria
H - Hypotonia
Unilateral cerebellar lesions cause…
ipsilateral cerebellar signs
Ptosis + dilated pupil = ?
Ptosis + constricted pupil = ?
Ptosis + dilated pupil = third nerve palsy
Ptosis + constricted pupil = Horner’s
Total anterior circulation infarcts - all 3 of the following:
unilateral hemiparesis and/or hemisensory loss of the face, arm & leg
homonymous hemianopia
higher cognitive dysfunction e.g. dysphasia
left homonymous hemianopia means
visual field defect to the left, i.e. lesion of right optic tract
homonymous quadrantanopias
PITS (Parietal-Inferior, Temporal-Superior)
Lambert-Eaton Syndrome is a paraneoplastic myasthenic syndrome most commonly associated with
small cell lung cancer.
It may precede the cancer diagnosis by a number of years
Lateral medullary syndrome - PICA lesion?
cerebellar signs, contralateral sensory loss & ipsilateral Horner’s
Fever, headache, psychiatric symptoms, seizures, focal features e.g. aphasia
?herpes simplex encephalitis
The radial nerve is at risk in a shaft fracture of the
humerus
Raised ICP can cause what nerve palsy?
third nerve palsy due to herniation
Contralateral hemiparesis and sensory loss with the upper extremity being more affected than the lower, contralateral homonymous hemianopia and aphasia
middle cerebral artery
Patients who present 4.5-9 hours after symptom onset, or with ‘wake-up stroke’ should still be considered for thrombolysis if
they have imaging evidence of potential to salvage brain tissue
Progressively worsening headache with higher cognitive function impaired
urgent imaging
Contraindication to triptan use
Cardiovascular disease
Hoover’s sign
differentiates between organic and non-organic lower leg weakness
Headache linked to Valsalva manoeuvres =
raised ICP until proven otherwise so LP is contraindicated
Partial anterior circulation infarcts - 2 of the following:
unilateral hemiparesis and/or hemisensory loss of the face, arm & leg
homonymous hemianopia
higher cognitive dysfunction e.g. dysphasia
rapid onset dementia and myoclonus
Creutzfeldt-Jakob disease
Intubate if the GCS is less than
8
Common peroneal nerve lesion can cause
weakness of foot dorsiflexion and foot eversion
Pt presents with a fall following a recent diagnosis of Parkinson’s, think what?
may be Parkinson’s Plus syndrome eg. Progressive supranuclear palsy- so test CN III, IV and VI (common CP of PSP is vertical supranuclear gaze palsy
anyone with a fall test CN III, IV and VI
Progressive supranuclear palsy
postural instability, impairment of vertical gaze, parkinsonism, frontal lobe dysfunction
Progressive supranuclear palsy vs multiple system atrophy?
PSP= vertical gaze impairment
MSA= autonomic dysfunction is a more significant feature such as tachycardia, fainting, erectile dysfunction
both may present like Parkinsons
Pulmonary function test results for obstructive lung disease eg. asthma, COPD, Bronchiectasis,
Bronchiolitis obliterans?
FEV1 - significantly reduced
FVC - reduced or normal
FEV1% (FEV1/FVC) - reduced
transfer factor reduced or normal
Pulmonary function test results for restrictive lung disease eg:
Pulmonary fibrosis
Asbestosis
Sarcoidosis
Acute respiratory distress syndrome
Infant respiratory distress syndrome
Kyphoscoliosis e.g. ankylosing spondylitis
Neuromuscular disorders
Severe obesity
FEV1 - reduced
FVC - significantly reduced
FEV1% (FEV1/FVC) - normal or increased
transfer factor reduced or normal
Normal FEV1, FVC and FEV1/FVC ratio?
FEV1= >80% predicted
FVC= >80% predicted
FEV1/FVC= >70% predicted
Clubbing may be seen in what?
bronchiectasis
What is helpful in ventilated pts with ARDS?
prone positioning
Pneumothorax Mx- what are the high-risk characteristics that determine the need for a chest drain?
- Haemodynamic compromise (suggesting a tension pneumothorax)
- Significant hypoxia
- Bilateral pneumothorax
- Underlying lung disease
- ≥ 50 years of age with significant smoking history
- Haemothorax
Over rapid aspiration/drainage of pnuemothorax can result in what?
re-expansion pulmonary oedema
When should oral Abx only be given in acute exacerbation of COPD?
presence of purulent sputum or clinical signs of pneumonia
Neuromuscular disorders result in what pattern on pulmonary function tests?
restrictive pattern
patient get admitted and you don’t know their full PMH. If someone is put on 15L of high flow O2 and suddenly go into respiratory acidosis and T2RF
think COPD
Causes of upper lobe pulmonary fibrosis?
C - Coal worker’s pneumoconiosis
H - Histiocytosis/ hypersensitivity pneumonitis
A - Ankylosing spondylitis
R - Radiation
T - Tuberculosis
S - Silicosis/sarcoidosis
Examples of SABA, SAMA, LABA, LAMA, ICS
SABA - Salbutamol or Terbutaline
SAMA - Ipratropium Bromide
LABA - Salmeterol or Formoterol
LAMA - Tiotropium
ICS - Budesonide or Fluticasone
Characterising fractures: way to remember the Salter-Harris criteria (type of fracture)?
SALTEr
1 S-Straight
2 A-Above
3 L-Lower
4 T-Through (above and below)
5 Er-Everything (Crush)
General Abx for pregnant pt allergic to penicillin?
erythromycin
CO2 in asthma exacerbation?
pt hyperventilates so should be high O2 and low CO2
in severe= CO2 normal
near-fatal= CO2 >6 (should be low as breathing fast in exacerbations but as it is raised this is really bad)
Pregnant women, severe asthma attack and improve with medical Tx?
still need hospital admission if pregnant
What causes lower zone pulmonary fibrosis?
A - asbestos.
C - connective tissue diseases.
I - idiopathic pulmonary fibrosis.
D - drugs e.g. methotrexate, nitrofurantoin.
Acute asthma Mx?
- Oxygen
- Salbutamol nebulisers
- Ipratropium bromide nebulisers
- Hydrocortisone IV OR Oral Prednisolone
- Magnesium Sulfate IV
- Aminophylline/ IV salbutamol
- ITU (intubation)
Oh
Shit,
I
Hate
My
Asthma
initially salbutamol + ipra together if severe or life-threatening
COPD exacerbation, what to do when medical Mx fails?
BiPAP
if this fails then intubation and ventillation
Target O2 sats in COPD?
if a known type 2 resp failure i.e hypercapnic on blood gas= 88-92%
Normal CO2 (not hypercapnic)= 94-98%
COPD symptoms in a young person/non-smoker?
think alpha-1 antitrypsin (A1AT) deficiency
Painful shin rash + cough
?sarcoidosis
Persistent productive cough +/- haemoptysis in a young person with a history of respiratory problems →
?bronchiectasis
Bronchiectasis vs pulmonary fibrosis
Bronchiectasis:
Primary Problem= Airway damage and dilation
Cough= Productive (mucus) Onset= Chronic but not necessarily progressive
Main Tx Focus= Infection control, airway clearance
Pulmonary Fibrosis:
Primary Problem= Lung tissue scarring
Cough= Dry
Onset= Progressive and worsening
Main Tx Focus= Slowing fibrosis, symptom management
Sudden deterioration with ventilation suggests
tension pneumothorax
Patients diagnosed with pneumonia who have COPD should be given what even if no evidence of the COPD being exacerbated
corticosteroids
Although diagnosis is often confirmed on CT imaging, WHAT is raised in approximately 60% of sarcoid patients at diagnosis and is the most specific autoantibody used in diagnosis.
serum ACE raised in sarcoidosis (also hypercalcaemia)
Mining occupation, upper zone fibrosis, egg-shell calcification of hilar nodes
silicosis
Hypercalcaemia + bilateral hilar lymphadenopathy
?sarcoidosis
Light’s criteria state that a pleural effusion is an exudate if:
- Effusion lactate dehydrogenase (LDH) level greater than 2/3 the upper limit of serum LDH
- Pleural fluid LDH divided by serum LDH >0.6
- Pleural fluid protein divided by serum protein >0.5
If a pleural effusion is drained too quickly, a rare but important complication that can develop is
re-expansion pulmonary oedema
Gynaecomastia - associated with what lung ca
adenocarcinoma
most commonly causes a cavitating pneumonia in the upper lobes, mainly in diabetics and alcoholics
Klebsiella
A chest infection failing to improve with antibiotics followed by a deterioration in symptoms with a cough productive of foul, purulent sputum, and rigours suggests
an empyema or abscess
CT findings of a smooth-walled fluid collection with air-fluid levels and pleural enhancement, alongside pleural fluid analysis showing a low pH, high LDH, and low glucose, confirm this diagnosis
chest tube drainage combined with antibiotics
Indications for corticosteroid treatment for sarcoidosis are:
parenchymal lung disease, uveitis, hypercalcaemia and neurological or cardiac involvement
treatment of choice for allergic bronchopulmonary aspergillosis
oral glucocorticoids eg. pred
Which of the following options confirms that the chest drain is located in the pleural cavity?
The water seal rises on inspiration and falls on expiration
COPD - still breathless despite using SABA/SAMA and no asthma/steroid responsive features →
add a LABA + LAMA
COPD - still breathless despite using SABA/SAMA and asthma/steroid responsive features →
add a LABA + ICS
contraindication for chest drain insertion
INR >1.3
The treatment of extrinsic allergic alveolitis is
mainly avoidance of triggers
Acute respiratory distress syndrome can only be diagnosed in the absence of
a cardiac cause for pulmonary oedema (i.e. the pulmonary capillary wedge pressure must not be raised)
Decrease in pO2/FiO2 in poorly patient with non-cardiorespiratory presentation eg. acute pancreatitis →
?ARDS
Obstructive sleep apnoea can cause
HTN
first-line for acute bronchitis (unless pregnant/child)
oral doxycycline
Fine end-inspiratory crepitations are seen in
idiopathic pulmonary fibrosis
Coal workers’ pneumoconiosis typically causes
upper zone fibrosis
What is recommended in COPD pts who have frequent exacerbations?
Azithromycin prophylaxis
Large bullae in COPD can mimic a
pneumothorax
Squamous cell carcinoma is associated with
hypertrophic pulmonary osteoarthropathy (HPOA)
Asthmatic features/features suggesting steroid responsiveness in COPD:
previous diagnosis of asthma or atopy
a higher blood eosinophil count
substantial variation in FEV1 over time (at least 400 ml)
substantial diurnal variation in peak expiratory flow (at least 20%)
Causes of hypoglycaemia
EXPLAIN
Exogenous drugs (typically sulfonylureas or insulin)
Pituitary insufficiency
Liver failure
Addison’s disease
Islet cell tumours (insulinomas)
Non-pancreatic neoplasms
DKA resolution is defined as:
pH >7.3 and
blood ketones < 0.6 mmol/L and
bicarbonate > 15.0mmol/L
What should happen to patients regular insulin if DMT1 in DKA?
continue long acting insulin and stop short acting
Hyponatraemia, hyperkalaemia and weight loss
?Addison’s disease. Presentation of adrenal insufficiency can be very non-specific.
Cushing’s syndrome electrolyte abnormality
hypokalaemic metabolic alkalosis
Primary hyperaldosteronism can present with
hypertension, hypernatraemia, and hypokalemia
High-dose dexamethasone suppression test with an ectopic source of ACTH
Cortisol: not suppressed
ACTH: not suppressed
High-dose dexamethasone suppression test with Cushing’s syndrome due to other causes (e.g. adrenal adenomas)
Cortisol: not suppressed
ACTH: suppressed
High-dose dexamethasone suppression test with Cushing’s disease (i.e. pituitary adenoma → ACTH secretion)
Cortisol: suppressed
ACTH: suppressed
‘unrecordable’ blood sugar measurement with confusion and abdominal pain
DKA
‘unrecordable’ means it is too high
High insulin, High C-peptide = Endogenous insulin production →
Insulinoma or sulfonylurea use/abuse
Congenital adrenal hyperplasia has the following biochemical abnormalities
Increased plasma 17-hydroxyprogesterone levels
Increased plasma 21-deoxycortisol levels
Increased urinary adrenocorticosteroid metabolites
PHaeochromocytoma - give what to manage HTN prior to surgical removal
PHenoxybenzamine (non-selective alpha-blocker) before beta-blockers
Water deprivation test: primary polydipsia
urine osmolality after fluid deprivation: high
urine osmolality after desmopressin: high
Endocrine parameters reduced in stress response: eg. following major surgery
Insulin
Testosterone
Oestrogen
SGLT-2 inhibitors examples
canagliflozin, dapagliflozin and empagliflozin.
TFTs in critically ill pt eg. ITU with pneumonia?
TSH normal, T3 & T4 low (Sick euthyroid syndrome)
How to distinguish between DMT1 and DMT2?
C-peptide levels and diabetes-specific autoantibodies (anti-GAD)
normally in type 1= c-peptide low and antibodies present
normal stroke - Mx
normal TIA - Mx
AF causing stroke - Mx
AF causing TIA - Mx
normal stroke - aspirin first, then lifelong clopi
normal TIA - aspirin first, then lifelong clopi
AF causing stroke - aspirin first, then DOAC
AF causing TIA - immediate DOAC
1st line Mx for HTN?
Do they have diabetes? Yes = ACEi or ARB if Afro-Carribean
Are they Afro-Carribean or over 55? Yes = CCB
Are they non-Afro-Carribean and under 55? Yes = ACEi
Patients with bradycardia and signs of shock require what
500micrograms of atropine (repeated up to max 3mg)
New onset AF is considered for electrical cardioversion if it presents within
48 hours of presentation
A patient develops acute heart failure 5 days after a myocardial infarction. A new pan-systolic murmur is noted on examination -
ventricular septal defect
Mx of aortic dissection?
type A - ascending aorta - control BP (IV labetalol) + surgery
type B - descending aorta - control BP(IV labetalol)
ACE inhibitor or ARB in pt who is afro-caribbean (after CCB or 1st line if diabetic)?
ARB preferred
A right coronary infarct supplies the AV node so can cause what after MI (infarction)?
arrhythmias
Poorly controlled hypertension, already taking an ACE inhibitor, calcium channel blocker and a standard-dose thiazide diuretic. K+ > 4.5mmol/l - what should you add?
specialist review
add an alpha- eg. carvedilol
58% or beta-blocker
Tx if pharmacological cardioversion of AF agreed on?
amiodarone
A posterior MI causes what on a 12-lead ECG
ST depression not elevation
What drug class is contraindicated in V Tach?
CCB eg. verapamil
PR interval over 200ms with an otherwise normal ECG (regular sinus rhythm, no missing QRS complexes) is consistent with
1st-degree atrioventricular block.
Isolated 1st degree atrioventricular block is common rarely problematic and a normal variant in athletes
Mx of alcohol withdrawl if pt has liver cirrhosis?
long acting benzodiazepines eg. lorazepam
chlordiazepoxide C/I in cirrhosis
Acute dystonia secondary to antipsychotics is usually managed with
procyclidine
After starting an ACE inhibitor, significant renal impairment may occur if the patient has
undiagnosed bilateral renal artery stenosis
Beta-blockers combined with verapamil can potentially cause profound
bradycardia and asystole
Patients with bradycardia and signs of shock require
500micrograms of atropine (repeated up to max 3mg)
Bleeding on dabigatran? Can use what to reverse
idarucizumab
What drug might cause cold peripheries?
beta blockers
Diabetic ketoacidosis: the IV insulin infusion should be started at what rate?
0.1 unit/kg/hour
What is suggested by the tender goitre, hyperthyroidism and raised ESR. The globally reduced uptake on technetium thyroid scan is also typical?
Subacute thyroiditis
hypothyroidism + goitre + anti-TPO
Hashimoto’s thyroiditis
Symptomatic bradycardia is treated with
Atropine (500mcg IV)
Hormones in Klinefelter’s vs Kallmans vs Turner’s?
Klinefelter’s syndrome= high LH & FSH and low testosterone (CLIMB felters- can’t feel testes too small)
Kallman= low LH & FSH and low testosterone (ALL low/FALL)
Tuners= high FSH & LH (TURNED UP) and low oestrogen
Depression, nausea, constipation, bone pain →
?primary hyperparathyroidism
medication of choice in suppressing lactation when breastfeeding cessation is indicated
Cabergoline (dopamine receptor agonist)
After 20 weeks, symphysis-fundal height in cm =
gestation in weeks +/- 2cm
eg/ 24w= 22-26cm
AFP - raised with
fetal abdominal wall defects (e.g. omphalocele)
The investigation of choice for ectopic pregnancy is
transvaginal ultrasound
HRT: unopposed oestrogen increases risk of
endometrial cancer
COCP: If 2 pills are missed in week 1…
consider emergency contraception if she had unprotected sex during the pill-free interval or week 1
SSRIs of choice in breastfeeding women
Sertraline or paroxetine
The combined oral contraceptive pill CAN be given if requested 6 weeks postpartum even if breastfeeding. BUT they can get pregnant from day
21 postpartum so if they have had unprotected intercourse from day 21 postpartum, a pregnancy test should be performed first
The combined oral contraceptive pill CAN be given if requested … w postpartum even if breastfeeding
6w
The most common cause of PPH by far is
uterine atony
In patients with urinary incontinence, make sure to rule out
UTI and diabetes mellitus
HNPCC/Lynch syndrome is a strong risk factor for
C.olon
E.ndometrial
O.varian
Suspected PE in pregnant women with a confirmed DVT:
treat with LMWH first then investigate to rule in/out
most common cause of postmenopausal bleeding
vaginal atrophy
Red eye - glaucoma or uveitis?
glaucoma: severe pain, haloes, ‘semi-dilated’ pupil
uveitis: small, fixed oval pupil, ciliary flush
Proliferative diabetic retinopathy is the most common underlying cause of a
vitreous haemorrhage
scleritis vs episcleritis
scleritis painful
episcleritis painless
sudden painless loss of vision in diabetic
? Vitreous haemorrhage
Anterior uveitis is most likely to be treated with
steroid + cycloplegic (mydriatic) drops
red eye, dilated pupil, and a hazy cornea due to increased intraocular pressure
Acute angle closure glaucoma
In diabetic retinopathy, cotton wool spots represent areas of
retinal infarction
A patient is noted to have persistent ST elevation 4 weeks after sustaining a myocardial infarction. Examination reveals bibasal crackles and the presence of a third and fourth heart sound. No chest pain ???
left ventricular aneurysm
AV block can occur following an …. MI
inferior
ECG findings of sinus tachycardia and right axis deviation are characteristic features of
PE
A third heart sound is one of the possible features of
left-sided HF
Complete heart block following a MI? -
right coronary artery lesion
Offer a ……. in addition to an ACE inhibitor (or ARB) and beta-blocker, to people who have heart failure with reduced ejection fraction if they continue to have symptoms of heart failure
mineralcorticoid receptor antagonist eg. spirinolactone
Way to remember systolic vs diastolic murmur?
MS ARD = Mitral Stenosis (late), Aortic Regurg (early)- Diastolic
MR ASS = Mitral regurg (pan), Aortic Stenosis (ejection) - Systolic
What electrolyte disturbances could lead to long QT syndrome?
hypocalcaemia, hypokalaemia, hypomagnesaemia
For cardioversion of AF: patients must either be
anticoagulated (for 3w) or have had symptoms for < 48 hours to reduce the risk of stroke.
eg.
Bisoprolol and oral anticoagulant therapy for 3 weeks and then electrical cardioversion
What is contraindicated in aortic stenosis?
nitrates eg. GTN spray due to risk of profound hypotension
ECG is reported as showing no visible P waves and an irregularly irregular narrow QRS complex?
AF
not SVT as AF is irregulary irregular but SVT is regular
Narrow complex tachy (<0.12s) vs broad complex tachy (>=0.12s)?
Narrow= AF, SVT, atrial flutter
Broad= v tach, v fib (v tach can go into v fib), BBB
early diastolic murmur, pulse is collapsing (water-hammer) and has wide pulse pressure
aortic regurg
The ECG shows monomorphic ventricular tachycardia. The patient still no pulse.
What should be the next step in management?
defib
If VF/pVT persists, only after a third shock should adrenaline 1 mg IV and amiodarone 300 mg IV be administered.
Aortic dissection can present with
neuro complaints
Focal neurological deficits occur due to propagation of the intimal tear to branch arteries, or due to mass effects as the expanding aorta compresses surrounding structures. Eg. man presents with chest pain & with symptoms of Horner’s syndrome (classically ptosis, miosis and anhidrosis) due to compression of the sympathetic trunk by the expanding aortic dissection.
Tricuspid regurg type of murmur?
pan-systolic murmur
as, during systole, the blood is ejected from the ventricles which are contracting. If the tricuspid valve is ‘leaky’ as in tricuspid regurgitation, the blood will backflow to the right atrium during this process, causing a pansystolic murmur.
Expert help should be sought for stable patients with what heart rhythm?
IRREGULAR broad complex tachycardia (rare)
What heart condition is most associated with S3?
dilated cardiomyopathy
Mx of cardiac tamponade?
Pericardiocentesis
if cancer then Percutaneous balloon pericardiotomy (Pericardiocentesis is good for one off drainage, but these patients need intervention to manage recurrence)
when are nitrates contraindicated?
hypotension or aortic stenosis
Hypertrophic obstructive cardiomyopathy - is classically associated with an
S4
S3 vs S4?
An S3 heart sound occurs early in diastole, signifying rapid ventricular filling, while an S4 heart sound happens late in diastole, just before the S1, and indicates the atria forcefully pushing blood into a stiff ventricle
S3 (threeee) - hard to breeeeeath (LVF and MR can lead to pulmonary oedema)
S4 - hit the floor (HOCM and AS can cause collapse/sudden death)
Also if you noticed
S3 is normal in under 30 (3 is the number to remember)
S4 is normal in over 40 (4 is the number to remember)
DCM = S3 (3 letters)
HOCM = S4 (4 letters)
Most common cause of primary adrenal insufficiency?
autoimmune so test for 21-hydroxylase antibodies (Addisons)
3 types of hyponatraemia?
hypervolaemic, hypovolaemic and euvolaemic
Causes of hypervolaemic hyponatraemia?
secondary hyperaldosteronism= heart failure, liver cirrhosis
nephrotic syndrome
IV dextrose
psychogenic polydipsia
Causes of hypovolaemic hyponatraemia?
Diarrhoea & vomiting
Medications eg. thiazides, loop diuretics
Addison’s disease
Diuretic stage of renal failure
Burns
Causes of euvolaemic hyponatraemia?
SIADH
Hypothyroidism
How to determine hyponatraemia Mx?
1) Acute (<48hrs) or chronic (>48hrs)= look at the trend
2) Severity= mild (130-134), moderate (120-129) or severe (<120)
3) Fluid status:
- hypovolaemic= clinically dehydrated, diuretics, Addisonian crisis, diuretic stage of renal failure
- euvolaemic= SIADH, hypothyroidism
- hypervolaemic= HF, liver failure, nephrotic syndrome
4) Symptomatic?
- early symptoms= headache, lethargy, nausea, vomiting, dizziness, confusion, muscle cramps
- late= seizures, coma, resp arrest
Ix for hyponatraemia?
serum osmolality; urine osmolality; urine sodium; 9 am cortisol (exclude adrenal insuf- low sodium, high potassium), TSH (?hypothyroidism)
Hyponatraemia- check Na how often?
every 2hrs (VBG not very accurate); don’t be too aggressive with fluids- just 1L slow then reassess
How may hypovolaemic hyponatraemia present?
subtle, may just have low urea and low urine output
SIADH?
high urine osmolality and urine sodium >40
causes= ca (esp lung); meds (SSRI, antipsychotics); chest infections (pnuemonia)
Mx= fluid restrict (to 1L or 750ml); talk to endo, tolvaptan
Mx if hypovolaemic hyponatraemia suspected?
normal, i.e. isotonic, saline (0.9% NaCl)
this may sometimes be given as a trial
if the serum sodium rises this supports a diagnosis of hypovolemic hyponatraemia
if the serum sodium falls an alternative diagnosis such as SIADH is likely
Mx if euvolaemic hyponatraemia suspected?
fluid restrict to 500-1000 mL/day
consider medications:
demeclocycline
vaptans
Mx if hypovolaemic hyponatraemia suspected?
fluid restrict to 500-1000 mL/day
consider loop diuretics
consider vaptans
Patients with acute, severe (<120 mmol/L) or symptomatic hyponatraemia?
require close monitoring, preferably in an HDU or above setting.
Hypertonic saline (typically 3% NaCl) is used to correct the sodium level more quickly than would be done in patients with chronic hyponatraemia.
For type 2 diabetics requiring treatment, metformin is contraindicated in those with
eGFR < 30
IgA deficiency increases the risk of
anaphylactic blood transfusion reactions
The main ECG abnormality seen with hypercalcaemia is
short QT
Hypothermia ECG changes?
Jesus Quist It’s Bloody Freezing
J-Waves
QT interval - prolonged
Irregular Rhythm
Bradycardia
First Degree Heart Block
Examples of a a long-acting nitrate?
ivabradine
nicorandil
ranolazine
What is characterised by a positive direct antiglobulin test (Coombs’ test)?
Autoimmune haemolytic anaemia
Warfarin drug interactions?
Inducers: (INR decreases)
“SCARS”
* S → Smoking
* C → Chronic alcohol intake
* A → Anti- epileptics: Phenytoin, Carbamazepine, Phenobarbitone (all barbiturates)
* R → Rifampicin
* S → St John’s Wort
Inhibitors: (INR increases)
“ASS-ZOLES”
* A → Antibiotics: Ciprofloxacin, Erythromycin, Isoniazid
* S → SSRIs: Fluoxetine, Sertraline
* S → Sodium Valproate
* - Zoles → Omeprazole, Ketoconazole, Fluconazole
Rhabdomyolysis can cause AKI by causing what damage in kidney?
Tubular cell necrosis
Myeloma without metastasis is characterised by what electrolyte levels?
high calcium, normal/high phosphate and normal alkaline phosphate
How to identify bundle branch block on ECG?
If QRS is broad look at V1:
If QRS predominantly negative then its a LBBB
If QRS predominantly positive then its a RBBB
So much more reliable than William marrow as it doesn’t rely on you looking at the shape of the QRS
Bifascicular block vs
Trifascicular bloc
Bifascicular block= RBBB + Left axis deviation
Trifascicular block= RBBB+ Left axis deviation + 1st degree heart block
Stokes–Adams syndrome?
episodes of syncope due to intermittent complete heart block or other high-grade arrhythmia which compromise cerebral circulation
Half life of adenosine?
Adenosine has a very short half-life of about 8-10 seconds
Patients who are given adenosine will experience unpleasant, but short-lived, side-effects.
chest pain + neurology, always rule out
aortic dissection
Narrow complex tachy?
Regular= SVT but if Mx fails consider flutter
Irregular= AF
Broad complex tachy?
Regular= V tach or SVT with BBB (if previously diagnosed)
Irregular= torsades de pointes or if stable then AF with BBB
Mx of SVT?
vagal manoeuvres -> IV adenosine
if fails then ?flutter -> beta blocker
MX of AF?
BB for rate control
or
onset <48hrs consider rhythm control -> cardioversion
Mx of V tach?
IV amiodarone
Mx of torsades de pointes?
IV magnesium sulphate
Mx of severe bradycardia (signs of haemodynamic compromise)?
1) IV atropine (500mcg)
if no response…
2) atropine, up to a maximum of 3mg
3) transcutaneous pacing
4)isoprenaline/adrenaline infusion titrated to response
Mx of narrow or broad complex tachy if unstable?
synchronised DC shock
A patient develops acute heart failure 5 days after a myocardial infarction. A new pan-systolic murmur is noted on examination -
ventricular septal defect
What does it mean if patient’s cardiac arrest was witnessed?
it was seen in a patient already receiving cardiac monitoring, such as in a coronary care unit
Recent sore throat, rash, arthritis, murmur →
?rheumatic fever
causes aortic regurg
Overview of Mx after having stroke/TIA (after CT ect)?
TIA due to AF: DOAC immediately and continue for life
TIA not due to AF: Aspirin 300mg immediately for 2 weeks and then clopidogrel lifelong
Stroke due to AF: Aspirin 300mg for 2 weeks and then DOAC lifelong
Stroke not due to AF: Aspirin 300mg for 2 weeks and then clopidogrel lifelong
Ludwigs angina?
NOT CARDIO RELATED, it is a
rare, life-threatening bacterial infection that affects the floor of the mouth and neck.
What drug class can cause hyponatraemia, hypokalaemia and hypercalcaemia?
thiazide diuretic eg. Bendroflumethiazide
…..should be suspected in patients with continuous dribbling incontinence after prolonged labour and from an area with limited obstetric services.
Vesicovaginal fistulae
U waves?
hypokalaemia
J waves?
hypothermia or hypercalcaemia
Intermittent limb claudication, absent or weak peripheral pulses in a young woman, →
?Takayasu’s arteritis
A transjugular intrahepatic portosystemic shunt (TIPS) procedure connects
the hepatic vein to the portal vein
Hormones in premature ovarian failure vs PCOS?
POF= high FSH
PCOS= high LH and testosterone
important differential for sudden visual loss in diabetics
Vitreous haemorrhage
hyphema
blood collecting in the front (anterior) chamber of your eye
usually caused by trauma to the eye, but can also occur after surgery
Raised IOP number?
> 21 mmHg
Beta blockers such as timolol work in primary open-angle glaucoma by
reducing aqueous production
Mx of dry AMD?
There is no curative medical treatment for dry AMD. High dose of beta-carotene, vitamins C and E, and zinc can be given to slow deterioration of visual loss
Corneal abrasion Mx?
topical antibiotics should be given to prevent secondary bacterial infection
Red eye - glaucoma or uveitis?
glaucoma: severe pain, haloes, ‘semi-dilated’ pupil
uveitis: small, fixed oval pupil, ciliary flush
Common eye disorders affecting vision? (2)
Macular degeneration is associated with central field loss
Primary open-angle glaucoma is associated with peripheral field loss
In diabetic retinopathy, cotton wool spots represent…
areas of retinal infarction
Primary open-angle glaucoma Tx?
360° selective laser trabeculoplasty (SLT) is first-line if the IOP is ≥ 24 mmHg
If patients treated with PCI for MI are experiencing pain or haemodynamic instability post PCI, what should be done?
urgent coronary artery bypass graft (CABG) is recommended as suggests PCI failed
investigation of choice for suspected aortic dissection (depending on stability of patient)
CT aortic angiography of the chest, abdomen and pelvis=
a false lumen (NOT a coronary angiogram)
Transoesophageal echocardiography (TOE) if unstable (NOT transthoracic)
how would you know a type A vs type B aortic dissection?
The presence of the murmur. As the tear in the aorta grows in type A, it can affect the aortic root, where the aortic valve is, leading to acute aortic regurg= new early diastolic murmur
Provoked PE?
surgery or immobilisation for 3 days in the last month
Or recent long haul flight
being started on COCP
Following an ACS, all patients should be offered:
dual antiplatelet therapy (aspirin plus a second antiplatelet agent eg. ticagrelor)
ACE inhibitor
beta-blocker
statin
Way to remember hypokalaemia ECG findings?
U got no Pot and no T, but a long PR and a long QT.
antihypertensive treatment should be offered only if the person is…
aged less than 80 years with stage 1 hypertension with one or more of, target organ damage, established cardiovascular disease, renal disease, diabetes, and/or a 10 year cardiovascular risk of 10% or more.
If stage 2 hypertension is diagnosed then antihypertensive medication should be started regardless of age.
systolic murmur, loudest in the second intercostal space, along the left sternal border; what sided heart failure would this be?
Right sided as the murmur is in the pulmonary region (pulmonary stenosis)
Way to remember where the valves are and which side of the heart they are?
All Prostitutes Take Money
A= aortic (R of sternum); left side of heart (heard in the right as loudest as goes towards upper right sternal border)
P= pulmonary (L of sternum); right side of heart
T= tricuspid (L of sternum); right side of heart
M= mitral (L of sternum); left side of heart
large, broad R waves in several leads are consistent with …
posterior MI
Which finding on ECG is most likely to prompt investigation for an acute coronary syndrome?
ECG shows new widening QRS complexes and a notched morphology of the QRS complexes in the lateral leads
(new LBBB)
Pt has renal impairment but needs a CT with contrast?
give IV saline (1mL/kg) before to reduce risk of contrast nephropathy
Urge incontinence Mx?
1) Bladder retraining min 6w
2) Oxybutynin immediate release (or tolterodine (immediate release) or darifenacin (once daily preparation))
3) If elderly give mirabegron (a beta-3 agonist) eg. if concern about anticholinergic side-effects in frail elderly patients
Stress incontinence Mx?
1) Pelvic floor exercises min 3m
2) Surgery= retropubic mid-urethral tape procedures
3) Decline surgery= duloxetine (combined noradrenaline and serotonin reuptake inhibitor)
HTN but renal impairment eg. CKD?
can still use ACE inhibitor (helps with CKD) but avoid if severe eg. GFR <30 or severe and hyperkalaemia (>5)
SOB, sudden right chest pain radiating to right shoulder?
may be pneumothorax
Normal JVP?
<=4cm above from sternal angle when at 45 degrees
Mx of AF is BB is not an option?
BB, CCB or digoxin
Haematuria after tonsillitis?
?IgA nephropathy
What to do before deciding whether to prescribe an anticoag (DOAC) in pt with AF?
calculate CHADsVASc (don’t just always prescribe to everyone with AF)
Parkinson’s pt agitated?
give lorazepam
Serum osmolality vs urine osmolality?
Conc of solutes in blood vs urine
Measurement of serum osmolality is used to evaluate the body’s regulation of water and sodium balance, while urine osmolality evaluates the kidney’s ability to concentrate urine.
Causes of resistant hypertension?
primary aldosteronism (Conns)
renal artery stenosis
pheochromocytoma
cushings
hyper/hypothyroidism
Carcinoma histology?
nuclei enlarged, hyperchromic and pleomorphic
Inflam back pain improves with…
activity and is NOT relieved by rest
(mechanical pain is opposite)
Septic shock- what if give fluids and BP is still low and signs of hydration or even overload?
give noradrenaline as need vasoconstriction
Premature ovarian failure vs PCOS bloods?
premature ovarian failure= raised FSH
PCOS= raised LH and testosterone
Young pt with intermittent palpitations and ECG showing sinus rhythym?
? supraventricular premature beats
Summarise primary sclerosing cholangitis (PSC)?
may have history of UC; bilirubin and albumin at presentation typically normal; cholestatic pattern on LFTs; USS shows bile duct wall thickening an dilation; GOLD Ix= MRCP (cholangiopancreatography) showing beaded appearance of bile duct
What is it important to check in a pt on lithium?
serum correctd Ca as risk of developing hyperparathyroidism
What could be differentials for kidney injury in elderly pt who had a fall and long lie on floor?
If creatinine in the thousands think rhabdomyolysis
If not then ?hypovolaemia eg. due to dehydration
GOLD Ix for suspected c-spine fracture?
CT neck (not x-ray)
eg. suspected, what is next most appropriate Ix- CT as best detected
Analgesia following major abdo surgery with background of resp disease eg. COPD?
AVOID OPIOIDS
Give epidural anaesthesia as this can be topped up and titrated but spinal anaesthesia cannot
Mx of gout?
NSAIDs or colchicine first line
if contraindicated eg. CKD or asthma then oral pred 15mg od
MRCP vs ERCP vs liver biopsy indications?
- Magnetic Resonance Cholangiopancreatography (MRCP)= Non-invasive imaging of the biliary and pancreatic ducts using MRI.
Indications:
- Suspected biliary obstruction (e.g., gallstones, strictures, tumors).
- Evaluation of primary sclerosing cholangitis (PSC).
- Ix of congenital biliary anomalies (e.g., choledochal cysts).
- Suspected pancreatic ductal abnormalities (e.g., chronic pancreatitis).
- Preoperative assessment of biliary anatomy before surgery. - Endoscopic Retrograde Cholangiopancreatography (ERCP)=
Invasive procedure combining endoscopy and fluoroscopy to examine & treat biliary/pancreatic ducts.
Indications:
- Therapeutic purposes:
Removal of choledocholithiasis (CBD stones).
- Stent placement for strictures or malignancies.
- Sphincterotomy for sphincter of Oddi dysfunction.
- Drainage of bile leaks or pancreatic pseudocysts.
- Diagnostic use (less common due to MRCP availability):
- When tissue sampling (biopsy, brush cytology) is needed.
- Unclear biliary strictures after MRCP. - Liver Biopsy= Histopathological assessment of liver tissue.
Indications:
- Unexplained liver disease (chronic hepatitis, fibrosis staging).
- Autoimmune liver disease (e.g., autoimmune hepatitis, PBC, PSC).
- Metabolic liver disease (e.g., Wilson’s, hemochromatosis, NAFLD/NASH).
- Suspected malignancy (hepatocellular carcinoma, metastases).
- Post-transplant rejection monitoring.
Ix palpitations?
1) ECG, FBC, U&E, TFTs
2) Holter monitor
3) If no abnormality is found on the Holter monitor, and symptoms continue, other options include:
external loop recorder or implantable loop recorder
Antihypertensive drugs max doses?
Ramipril= 10mg
Amlodipine= 10mg
Indapamide= 5mg (normally 2.5)
Candesartan= 32mg
Spironolactone= 25mg
Losartan= 100mg
Acute heart failure not responding to treatment consider-
CPAP
BiPAP usually in T2RF eg COPD exacerbation
Posterior MI ECG?
ST depression and tall R waves
Serum osmolality can be estimated using what equation…
2 * Na+ + glucose + urea
Anion gap =
(sodium + potassium) - (bicarbonate + chloride)
How to help identify cause of meningitis from CSF blood results?
1) Is CSF glucose less than half of serum glucose? Yes = Bacteria No = Viral
2) Are lymphocytes or polymorphs main present? Lymp = TB Poly= Non-TB
Rinnes and webers test= what does negative and positive result mean?
unlike other tests, if the result is negative it is abnormal and if it is positive it is normal
Affect of cocaine on the heart?
causes coronary artery spasm that induces ACS
1st line Mx for bradycardia?
atropine (not fluids)
as it DIRECTLY increases heart rate by blocking the parasympathetic (vagal) influence on the sinoatrial (SA) node.
Ix if pt has recurrent candidiasis (4 or more in 1yr)?
test for diabetes with glycated haemoglobin (HbA1c)
What type of airway Mx is used to prevent reflux of stomach contents into lungs?
tracheal tube (intubation) and NOT igel
SVCO Mx?
dexamethasone
Live size?
8cm palpable edge
if 6cm or less then small
10cm or more then hepatomegaly
Test to monitor resp function in myasethenic crisis?
FVC
Ureteric stones with severe hydronephrosis?
nephrostomy to decompress renal pelvis
1st line Mx for micro & macroprolactinomas?
cabergoline or bromocriptine (dopamine agonists)
Mx of asytstole?
adrenaline/epinephrine only Tx alongside chest compressions (NOT FLUIDS)
Ix in pt who was in house fire?
carboxyhaemoglobin as CO inhalation likely
PE order of most appropriate Ix?
CXR to rule out other causes; Wells score; then either CTPA or V/Q scan
Nephrotic syndrome in adults= what is needed to diagnose before starting Tx?
renal biopsy
Ovarian ca- 1st lymph node will spread to?
para-aortic nodes
Most common cause of cellulitis (incl in diabetics)?
Streptococcus pyogenes
then less commonly Staphylcoccus aureus
Pathophysiology of SIADH?
Syndrome of inappropriate ADH secretion with hyponatraemia and
inappropriately concentrated urine. ADH stimulates synthesis of aquaporin-2 in the apical
membrane of the collecting duct which promotes water absorption. This leads to a
dilutional hyponatraemia.
(Increased water absorption in the collecting duct)
Causes of high plasma aldosterone:renin ratio?
primary hyperaldosteronism
causes of primary hyperaldosteronism= bilateral idiopathic adrenal hyperplasia (most common) and adrenal adenoma- CONNS
Cause of subcutaneous emphysema on side of pts neck?
usually due to an underlying injury to the airway or oesophagus eg. oesophageal rupture
where air gets trapped under the skin of the neck, causing a noticeable swelling and a crackling sensation when touched
Do all pneumothoraces cause tracheal deviation?
No
primary (Simple/spontaneous) pneumothorax: Usually doesn’t shift the mediastinum or trachea.
tension pneumothorax does
Mx of superficial thrombophelbitis?
NSAIDs and compression stockings
Fibrocystic breast changes vs fibroadenoma?
fibroadenoma solid but fibrocystic are fluid filled
What is the extensor plantar response?
also known as the Babinski reflex, is a reflex that causes the big toe to extend upwards when the sole of the foot is stimulated
Does pt with primary sclerosing cholangitis always have fever and jaundice?
No, may be asymptomatic or subtle symptoms like fatigue, abdominal discomfort, or itchy skin (pruritus) and is picked up by abnormal LFTs.
Common to present like this in EARLY stages of disease or if pt has ulcerative colitis.
ECG in aortic dissection
non-specific changes
usually do:
- CXR= widened mediastinum
- CT angiography chest, abdo and pelvis (GOLD)= false lumen
- TOEcho if unstable
Rheumatoid arthritis usually affects multiple joints so it pt presents with swelling, pain and stiffness in 1 joint think what?
gout or OA
When are compression stockings contraindicated?
PAD
Mx of venous ulcers?
compression bandaging, usually four layer= inital Tx, open ulcers, until healed
then
compression stockings= after healed to prevent recurrence
Suspected diabetes insipidus, exclude what before water deprivation test?
exclude hypercalacaemia (with serum corrected calcium) due to hyperparathyroidism before Ix for diabetes insipidus
Mx of acute gout in CKD4?
oral pred NOT NSAIDs
CK in rhabadomyolysis?
> 10,000
What artery may be the source of major haemorrhage in peptic ulcer disease?
gastroduodenal artery (runs posterior to 1st and 2nd parts of duodenum)
Cord compression Mx?
if elderly, frail and/or multiple lesions then radiotherapy not surgical spinal cord decompression
Boerhaave syndrome?
Transmural distal oesophageal rupture caused by sudden increase in intraoesophageal pressure
Ix:
- CXR= left-sided effusion or pneumomediastinum
- Barium swallow= GOLD
Tx= surgery
Awaiting surgery, fluid to run alongside VR insulin infusion in diabetics?
Sodium chloride 0.45% / glucose 5% / potassium chloride 0.15%
1000mL in 8h
Rivaroxaban and apixaban can be reversed by
andexanet alfa
Screening for an abdominal aortic aneurysm consists of
single abdominal ultrasound for males aged 65
Mining occupation, upper zone fibrosis, egg-shell calcification of hilar nodes → ?
silicosis
What test is consistent with successfully treated syphilis?
Negative non-treponemal test + positive treponemal test
Hep… is spread by the faecal-oral route and is most commonly spread by undercooked pork
E
Organisms causing post splenectomy sepsis: (eg. pt with resp infection with history of splenectomy)?
Streptococcus pneumoniae
Haemophilus influenzae
Meningococci
Stroke initial Mx?
Within 4.5 hours: Thrombolysis with Alteplase, followed 24 hours later by aspirin 300mg
After 4.5 hours: No thrombolysis; just give Aspirin 300mg
Fever on alternating days, think?
malaria
When using an inhaler, for a second dose you should wait for approximately how long before repeating?
30 secs
The differentiation between delirium and dementia?
impairment of consciousness eg. lower GCS; fluctuation in symptoms and hallucinations.
Men who have sex with men should be offered immunisation against
hep A
Examination of the right eye reveals a painful, red eye, with a small and irregularly-shaped pupil- diagnosis and Mx?
Anterior uveitis
steroid + cycloplegic (mydriatic) drop
All men presenting with erectile dysfunction should have what checked?
morning testosterone
HbA1c and lipids
What electrolyte abnormalities does vomiting and diarrhoea cause?
Diarrhoea can cause a normal anion gap acidosis because the gastrointestinal loss of bicarbonate causes a reciprocal increase in serum chloride.
Vomiting causes alkalosis as gastric secretions (which are very acidic) are lost.
management of severe alcoholic hepatitis
1st= corticosteroids to limit inflammation.
then also= Lactulose is indicated if hepatic encephalopathy is suspected to avoid constipation, a common precipitant. Do not consider liver transplant if pt is still consuming alcohol.
catheterised patient has developed an asymptomatic bacteriuria- what do you do?
No Tx needed.
Very common amongst catheterised patients. As this very rarely leads to serious sequelae, it should not be treated with antimicrobials.
Any critically ill patient (including CO2 retainers) should initially be treated with? Eg. with COPD presents with suspected CO poisoning and O2 sats 78%, how do you treat the low sats?
Reservoir mask at 15 litres/min
high flow oxygen which is then titrated to achieve target sats. Hypoxia kills
If was COPD exacerbation- 28% Venturi mask at 4 litres/min is used prior to the results of blood gases in patients with risk factors for hypercapnia aiming for oxygen saturation of 88-92%.
BiPAP vs CPAP indications?
BIPAP - COPD / weaning off ventilation
CPAP - most T1RF causes (pneumonia, heart failure etc…) + OSA
URTI symptoms + amoxicillin → rash ? diagnosis and diagnostic Ix?
Glandular fever
Monospot test (blood test that detects the presence of heterophil antibodies made following infection with Ebstein-Barr virus)
The ward doctor is asked to prescribe maintenance fluids for a pt. Her body weight is 60kg and her height is 157cm. What following fluid regimes replaces the potassium correctly for this patient?
30mmol K+ per 12 hours
as gives a total of 60/24hrs
…. is used to prevent vasospasm in aneurysmal subarachnoid haemorrhages?
Nimodipine
(NOT nifedipine)
Human bites, like animal bites, should be treated with what?
co-amoxiclav
High-risk areas include the hands, feet, face, genitals, skin overlying cartilaginous structures or an area of poor circulation. If a bite has broken the skin but not drawn blood, antibiotics should be considered if it is in a high-risk area or if the person is at high risk (immunosuppression, diabetes, asplenia or decompensated liver disease)
What drugs may exacerbate psoriasis?
beta blockers, lithium, antimalarials (chloroquine and hydroxychloroquine), NSAIDs and ACE inhibitors, infliximab
Areas affected in Wernickes and Brocas dysphasia?
Wernickes (dont understand but normal speech)= Temporal
Brocas (broken speech but understand)= Frontal
Spoken word is heard at the ear. This passes to Wernicke’s area in the temporal lobe (near the ear) to comprehend what was said. Once understood, the signal passes along the arcuate fasciculus, before reaching Broca’s area. The Broca’s area in the frontal lobe (near the mouth) then generates a signal to coordinate the mouth to speak what is thought (fluent speech).
severe headache, left retro-orbital pain, left loss in visual acuity, conjunctiva are red and the cornea looks hazy. Pupillary light reflexes on the right are normal; however, the left pupil is non-reactive?
acute angle-closure glaucoma
Initial Mx= Direct parasympathomimetic e.g. pilocarpine and beta-blocker eye drops.
Definitive Mx= laser peripheral iridotomy
The following drugs may exacerbate myasthenia?
penicillamine
quinidine, procainamide
beta-blockers
lithium
phenytoin
antibiotics: gentamicin, macrolides, quinolones, tetracyclines
Mx should be used in euvolemic and hypervolemic hyponatraemic patients who don’t have severe symptoms?
fluid restrict
Summarise hyponatraemia Mx simply?
- Euvolaemic or hypervolaemic and >120 = fluid restrict
- Hypovolaemic and >120 = IV 0.9 NaCl
- <120 or symtomatic= Hypertonic saline (either 1.8% or 3% NaCl)
NIV should be considered in all patients with an acute exacerbation of COPD in?
whom a respiratory acidosis (PaCO2>6kPa, pH <7.35 ≥7.26) persists despite immediate maximum standard medical treatment
When to consider mirabegron instead of oxybutynin in overactive bladder eg. male?
if 1st line fail (oxybutynin), if antimuscarinics are not tolerated or not effective or if there is concern about anticholinergic side-effects in frail elderly patients (>65yrs)
Patients with chronic kidney disease should be started on what?
ACE inhibitor if they have an ACR > 30 mg/mmol
CKD: only diagnose stages 1 & 2 if what?
supporting evidence to accompany eGFR
eg. patient has an eGFR between 60-90 ml/minute. This would be classified as CKD stage II if there were accompanying evidence of kidney damage e.g. abnormal U&Es or proteinuria. If these are absent we do not classify this as having chronic kidney disease.
most common cause of peritonitis secondary to peritoneal dialysis?
Coagulase-negative Staphylococcus eg. staph epidermis
Secondary prevention following ACS?
- dual antiplatelet therapy (aspirin plus a second antiplatelet agent eg. )
- ACE inhibitor
- beta-blocker
- statin
GIVE ALL
DAPT= Ticagrelor/prasugrel/(clopi less common now) + aspirin
Alzheimer’s disease causes widespread cerebral atrophy mainly involving what areas of brain?
cortex and hippocampus (in temporal lobe)
IgM vs IgG in hep B?
IgM = IMmediate infection (acute)
IgG = aGed infection (chronic)
What foods to avoid in coeliac disease and what can you eat?
AVOID= barley, wheat, couscous, bread, rye bread (rye-gluten), pasta, cereals
Can eat= rice, potatoes, corn (maize), quinoa
If a patient has a urine output of < 0.5ml/kg/hr postoperatively the first step is…
consider a fluid challenge, if there are no contraindications or signs of haemorrhage etc
do not need to remove catheter
Patient with acute asthma who do not respond to full medical treatment and are becoming acidotic should be…
intubated and ventilated,
do NOT do BiPAP/CPAP
What is the most accurate marker for assessing the function of the liver in acute liver failure vs chronic liver failure?
Acute= Prothrombin time
- Prothrombin has a shorter half-life than albumin, making it a better measure of acute liver failure
Chronic= Albumin
When may you order a DaTscan?
?parkinsons or lewy body dementia
MRI for vasulcular, alzheimers ect dementia
Finasteride treatment of BPH may take how long before results are seen
6m
What should be suspected in the presentation of dyspnoea and hypoxaemia around 72 hours postoperatively?
Atelectasis
A common postoperative complication in which basal alveolar collapse can lead to respiratory difficulty. It is caused when airways become obstructed by bronchial secretions.
Management
positioning the patient upright
chest physiotherapy: breathing exercises
1st line Mx in any trauma pt?
immobilise c-spine!!!
patients will present following trauma within the previous 24-72 hours. The most common presenting features is worsening shortness of breath, however other symptoms include confusion, drowsiness, or the development of a petechial rash (Fig. 2, classically seen in the axilla and conjunctivae).
On examination, patients will be tachypnoeic, tachycardic, and hypoxic. Often neurological signs that develop are non-specific, including acute confusion or seizures. A low grade pyrexia can also occur. In late stages of the disease, features of organ dysfunction will develop.
what is the diagnosis?
fat embolism
RFs= young age, long bone fractures, closed fractures or multiple fractures, and conservative management for long bone fractures
What is atelectasis?
the collapse of part or all of a lung, is caused by a blockage of the air passages (bronchus or bronchioles) or by pressure on the lung.
Risk factors for atelectasis include anesthesia, prolonged bed rest with few changes in position, shallow breathing and underlying lung disease. Mucus that plugs the airway, foreign objects in the airway (common in children) and tumors that obstruct the airway may lead to atelectasis. Large-scale atelectasis may be life threatening, especially in someone who has another lung disease or illness.
Sjogrens?
autoimmune disorder affecting exocrine glands resulting in dry mucosal surfaces. It may be primary (PSS) or secondary to rheumatoid arthritis or other connective tissue disorders, where it usually develops around 10 years after the initial onset
F>M
marked increased risk of lymphoid malignancy
dry eyes: keratoconjunctivitis sicca
dry mouth
vaginal dryness
arthralgia
Raynaud’s, myalgia
sensory polyneuropathy
recurrent episodes of parotitis
renal tubular acidosis (usually subclinical)
Sjogrens
Ix for Sjogrens?
rheumatoid factor (RF) positive in nearly 50% of patients
ANA positive in 70%
anti-Ro (SSA) antibodies in 70% of patients with PSS
anti-La (SSB) antibodies in 30% of patients with PSS
Schirmer’s test: filter paper near conjunctival sac to measure tear formation
histology: focal lymphocytic infiltration
also: hypergammaglobulinaemia, low C4
Mx for Sjogrens?
artificial saliva and tears
pilocarpine may be helpful to stimulate saliva production
How to know if type 2 resp failure is acute or chronic based on ABG?
Acute= pH low, bicarb normal or slightly increased, base excess may be normal
Chronic= pH near normal (due to compensation); bicarb elevated (eg. >28); base excess markedly increased (> +4)
Acute: The rise in PaCO₂ happens suddenly, and the kidneys haven’t had time to compensate by increasing HCO₃⁻. So, pH is low, and HCO₃⁻ is normal or slightly elevated.
Chronic: The kidneys have compensated by retaining HCO₃⁻ over time, which normalizes pH despite persistently high PaCO₂.
Elderly patient dizzy on extending neck
??vertebrobasilar ischaemia
BPPV does causes vertigo upon head movement, but the characteristic production of symptoms on neck extension makes this a less likely diagnosis than vertebrobasilar ischaemia.
Mnemonic to remember Salter Harris classification:
(for fractures)
SALTER
S: Type 1; Slipped, # through growth plate only
A: Type 2; Above, # ‘above’ growth plate (metaphysis) and in growth plate
L: Type 3; Lower, # below growth plate (epiphysis) and in growth plate
TE: Type 4; Through Everything, # through all 3 elements
R: Type 5; Rammed, crush # of growth plate
I: horizontal line
II: backwards L
III: upside down L
IV: vertical line
Use of 0.9% Sodium Chloride for fluid therapy in patients requiring large volumes eg. 6L = risk of…
Hyperchloraemic metabolic acidosis
