October #3 Flashcards
In patients who are critically ill (anaphylaxis, shock etc) oxygen should initially be given via a — mask at – l/min. Hypoxia kills. The BTS guidelines specifically exclude certain conditions where the patient is acutely unwell (e.g. —) but stable. Oxygen saturation targets acutely ill patients: —% patients at risk of hypercapnia (e.g. COPD patients): — (see below) oxygen should be reduced in stable patients with satisfactory oxygen saturation Management of COPD patients prior to availability of blood gases, use a –% – mask at 4 l/min and aim for an oxygen saturation of –% for patients with risk factors for hypercapnia but no prior history of respiratory acidosis adjust target range to –% if the pCO2 is normal
In patients who are critically ill (anaphylaxis, shock etc) oxygen should initially be given via a reservoir mask at 15 l/min. Hypoxia kills. The BTS guidelines specifically exclude certain conditions where the patient is acutely unwell (e.g. myocardial infarction) but stable. Oxygen saturation targets acutely ill patients: 94-98% patients at risk of hypercapnia (e.g. COPD patients): 88-92% (see below) oxygen should be reduced in stable patients with satisfactory oxygen saturation Management of COPD patients prior to availability of blood gases, use a 28% Venturi mask at 4 l/min and aim for an oxygen saturation of 88-92% for patients with risk factors for hypercapnia but no prior history of respiratory acidosis adjust target range to 94-98% if the pCO2 is normal
Severe depression can mimic dementia but gives a pattern of – memory loss rather than short-term memory loss - this is called —
Severe depression can mimic dementia but gives a pattern of global memory loss rather than short-term memory loss - this is called pseudodementia
Skin manifestations of systemic lupus erythematosus 1.photosensitive ‘— rash 2.-lupus 3. al- 4. livedo reticularis: —like rash
Skin manifestations of systemic lupus erythematosus (SLE) photosensitive ‘butterfly’ rash discoid lupus alopecia livedo reticularis: net-like rash
Neuroleptic malignant syndrome is a rare but dangerous condition seen in patients taking –medication. . It may also occur with — drugs (such as —) for Parkinson’s disease, usually when the drug is suddenly stopped or the dose reduced the typical features are: p- m— autonomic lability: typical features include h-, tachy–and tachy— agitated delirium with confusion A raised – is present in most cases. Acute – (secondary to —) may develop in severe cases. A — may also be seen
Neuroleptic malignant syndrome is a rare but dangerous condition seen in patients taking antipsychotic medication. It carries a mortality of up to 10% and can also occur with atypical antipsychotics. It may also occur with dopaminergic drugs (such as levodopa) for Parkinson’s disease, usually when the drug is suddenly stopped or the dose reduced It occurs within hours to days of starting an antipsychotic (antipsychotics are also known as neuroleptics, hence the name) and the typical features are: pyrexia muscle rigidity autonomic lability: typical features include hypertension, tachycardia and tachypnoea agitated delirium with confusion A raised creatine kinase is present in most cases. Acute kidney injury (secondary to rhabdomyolysis) may develop in severe cases. A leukocytosis may also be seen
Hoffman’s sign: is a reflex test to assess for – It is performed by gently flicking one finger on a patient’s hand. A positive test results in reflex twitching of the —on the same hand in response to the flick.
Hoffman’s sign: is a reflex test to assess for cervical myelopathy. It is performed by gently flicking one finger on a patient’s hand. A positive test results in reflex twitching of the other fingers on the same hand in response to the flick.
CTS is a disease of the peripheral nervous system, resulting from – nerve compression at the — inside the carpal tunnel. It therefore affects only the aspects of the hand innervated by the — nerve: Sensation; — / — / — Finger. This typically manifests as intermittent — or —- Motor; LOAF : Motor signs are less commonly seen with presentations of CTS, but wasting of the — may be present.
CTS is a disease of the peripheral nervous system, resulting from median nerve compression at the wrist inside the carpal tunnel. It therefore affects only the aspects of the hand innervated by the median nerve: Sensation; Thumb / Index / Middle Finger. This typically manifests as intermittent pain or parasthesiae. Motor; LOAF Muscles(lateral lumbricals, opponens pollicis, abductor pollicis brevis and flexor policis brevis). Motor signs are less commonly seen with presentations of CTS, but wasting of the thenar eminence may be present.
Otitis externa Causes: infection: bacterial x2 or fungal seborrhoeic — contact — (allergic and irritant) Features ear pain, itch, – otoscopy: x3 canal The recommended initial management of otitis externa is: topical— or a combined topical – with a — if the tympanic membrane is perforated — are traditionally not used* if there is canal debris then consider — if the canal is extensively swollen then an ear wick is sometimes inserted
Otitis externa is a common reason for primary care attendance in the UK. Causes of otitis externa include: infection: bacterial (Staphylococcus aureus, Pseudomonas aeruginosa) or fungal seborrhoeic dermatitis contact dermatitis (allergic and irritant) Features ear pain, itch, discharge otoscopy: red, swollen, or eczematous canal The recommended initial management of otitis externa is: topical antibiotic or a combined topical antibiotic with a steroid if the tympanic membrane is perforated aminoglycosides are traditionally not used* if there is canal debris then consider removal if the canal is extensively swollen then an ear wick is sometimes inserted
Pregnancy: DVT/PE Pathophysiology increase in factors V–, V–, X and – decrease in protein - uterus presses on — causing venous stasis in legs Management – contraindicated S/C — preferred to IV – (less bleeding and thrombocytopenia)
Pregnancy: DVT/PE Overview pregnancy is a hypercoagulable state majority occur in last trimester Pathophysiology increase in factors VII, VIII, X and fibrinogen decrease in protein S uterus presses on IVC causing venous stasis in legs Management warfarin contraindicated S/C low-molecular weight heparin preferred to IV heparin (less bleeding and thrombocytopenia)
As a first line investigation, all people with iron deficiency anaemia should be screened for —
As a first line investigation, all people with iron deficiency anaemia should be screened for coeliac disease
Irradiated blood products are used to avoid transfusion-associated —
Irradiated blood products are used to avoid transfusion-associated graft versus host disease
Situation CMV negative Irradiated Granulocyte transfusions Intra-uterine transfusions Neonates up to 28 days post expected date of delivery Pregnancy: Elective transfusions during pregnancy (not during labour or delivery) Bone marrow / stem cell transplants Immunocompromised (e.g. chemotherapy or congenital) Patients with/previous Hodgkins Disease HIV
Situation CMV negative Irradiated Granulocyte transfusions ✓ ✓ Intra-uterine transfusions ✓ ✓ Neonates up to 28 days post expected date of delivery ✓ ✓ Pregnancy: Elective transfusions during pregnancy (not during labour or delivery) ✓ CMV negative Bone marrow / stem cell transplants✓Irradiated Immunocompromised (e.g. chemotherapy or congenital) ✓Irradiated Patients with/previous Hodgkins Disease✓Irradiated HIV
A sudden anemia and a low reticulocute count indicates – Acute — and — causes a high reticulocyte count.
A sudden anemia and a low reticulocute count indicates parvovirus. Acute sequestration and haemolysis causes a high reticulocyte count.
Following Wells’ scoring, if a DVT is ‘likely’ (> 2 points) then arrange a proximal leg vein —within— hours
Following Wells’ scoring, if a DVT is ‘likely’ (> 2 points) then arrange a proximal leg vein ultrasound scan within 4 hours
The universal donor of fresh frozen plasma is – RhD – blood
AB negative
This patient is blood group B RhD negative, meaning her red cells possess – antigens only from the ABO grouping, and she naturally produces anti– antigens in her plasma. Therefore, she needs to receive red cells with only - antigen or no antigens at all (i.e. Groups - or -) but needs to receive FFP that does not have anti– in it. Group - donors naturally produce anti-A and anti-B, Group - donors naturally produce only anti-B, so she can only receive FFP from groups - or –. Group – is the universal donor for FFP because they produce neither anti– or anti– and is therefore compatible with all ABO groups. In many cases the RhD status would not matter for blood transfusion, however as this is a woman of childbearing age who is RhD negative, she should receive RhD negative blood in order to avoid problems with future pregnancies in which the foetus is RhD positive.
This patient is blood group B RhD negative, meaning her red cells possess B antigens only from the ABO grouping, and she naturally produces anti-A antigens in her plasma. Therefore, she needs to receive red cells with only B antigen or no antigens at all (i.e. Groups B or O) but needs to receive FFP that does not have anti-B in it. Group O donors naturally produce anti-A and anti-B, Group A donors naturally produce only anti-B, so she can only receive FFP from groups B or AB. Group AB is the universal donor for FFP because they produce neither anti-A or anti-B and is therefore compatible with all ABO groups. In many cases the RhD status would not matter for blood transfusion, however as this is a woman of childbearing age who is RhD negative, she should receive RhD negative blood in order to avoid problems with future pregnancies in which the foetus is RhD positive.
Fresh frozen plasma (FFP) most suited for ‘clinically significant’ but without ‘major haemorrhage’ in patients with a prothrombin time (PT) ratio or activated partial thromboplastin time (APTT) ratio > — typically 150— mL can be used prophylactically in patients undergoing — where there is a risk of significant bleeding In contrast to red cells, the universal donor of FFP is – blood because it lacks any - or – antibodies Cryoprecipitate contains concentrated Factor –:-, — factor, f–, Factor – and f–, produced by further processing of . Clinically it is most commonly used to replace — much smaller volume than FFP, typically 15—mL most suited for patients for ‘clinically significant’ but without ‘major haemorrhage’ who have a fibrinogen concentration < – g/L example use cases include —coagulation, – failure and hypo– secondary to massive transfusion. It may also be used in an emergency situation for – (when specific factors not available) and in — disease can be used prophylactically in patients undergoing invasive surgery where there is a risk of significant bleeding where the — concentration < 1.0 g/L Prothrombin complex concentrate used for the emergency reversal of — in patients with either severe — or a head injury with suspected intracerebral — can be used prophylactically in patients undergoing emergency surgery depending on the particular circumstance
Fresh frozen plasma (FFP) most suited for ‘clinically significant’ but without ‘major haemorrhage’ in patients with a prothrombin time (PT) ratio or activated partial thromboplastin time (APTT) ratio > 1.5 typically 150-220 mL can be used prophylactically in patients undergoing invasive surgery where there is a risk of significant bleeding In contrast to red cells, the universal donor of FFP is AB blood because it lacks any anti-A or anti-B antibodies Cryoprecipitate contains concentrated Factor VIII:C, von Willebrand factor, fibrinogen, Factor XIII and fibronectin, produced by further processing of Fresh Frozen Plasma (FFP). Clinically it is most commonly used to replace fibrinogen much smaller volume than FFP, typically 15-20mL most suited for patients for ‘clinically significant’ but without ‘major haemorrhage’ who have a fibrinogen concentration < 1.5 g/L example use cases include disseminated intravascular coagulation, liver failure and hypofibrinogenaemia secondary to massive transfusion. It may also be used in an emergency situation for haemophiliacs (when specific factors not available) and in von Willebrand disease can be used prophylactically in patients undergoing invasive surgery where there is a risk of significant bleeding where the fibrinogen concentration < 1.0 g/L Prothrombin complex concentrate used for the emergency reversal of anticoagulation in patients with either severe bleeding or a head injury with suspected intracerebral haemorrhage can be used prophylactically in patients undergoing emergency surgery depending on the particular circumstance
Venous thromoboembolism - length of warfarin treatment provoked (e.g. recent surgery): – unprovoked: –
Venous thromoboembolism - length of warfarin treatment provoked (e.g. recent surgery): 3 months unprovoked: 6 months
G6PD deficiency vs Hereditary spherocytosis
Gender Ethnicity Typical history Blood film Diagnostic test
G6PD deficiency
Gender Male (X-linked recessive)
Ethnicity African + Mediterranean descent
Typical history • Neonatal jaundice • Infection/drugs precipitate haemolysis • Gallstones
Blood film Heinz bodies Spherocytes
Diagnostic test Measure enzyme activity of G6PD
Hereditary spherocytosis
Gender- Male + female (autosomal dominant)
Ethnicity-Northern European descent
Typical history
- Neonatal jaundice
- Chronic symptoms although haemolytic crises may be precipitated by infection
- Gallstones
- Splenomegaly is common
Blood film- Spherocytes (round, lack of central pallor)
Diagnostic test -EMA binding test
Venous thromboembolism: risk factors
General
increased risk with advancing –
o–
– history of VTE
p– (especially puerperium)
i–
h–
a–
central venous catheter: – >> subclavian
Underlying conditions
m–
thrombophilia: e.g. Activated protein - resistance, protein -and - deficiency
— failure
anti– syndrome
B-
poly–
— syndrome
s— disease
paroxysmal nocturnal haemoglobinuria
hyper– syndrome
homo–
Medication
– pill: 3rd generation more than 2nd generation
hormone replacement therapy: the risk of VTE is higher in women taking – + – preparations compared to those taking – only preparations
r– and t–
antipsychotics (especially —) have recently been shown to be a risk factor
Venous thromboembolism: risk factors
Common predisposing factors include malignancy, pregnancy and the period following an operation. The comprehensive list below is partly based on the 2010 SIGN venous thromboembolism (VTE) guidelines:
General
increased risk with advancing age
obesity
family history of VTE
pregnancy (especially puerperium)
immobility
hospitalisation
anaesthesia
central venous catheter: femoral >> subclavian
Underlying conditions
malignancy
thrombophilia: e.g. Activated protein C resistance, protein C and S deficiency
heart failure
antiphospholipid syndrome
Behcet’s
polycythaemia
nephrotic syndrome
sickle cell disease
paroxysmal nocturnal haemoglobinuria
hyperviscosity syndrome
homocystinuria
Medication
combined oral contraceptive pill: 3rd generation more than 2nd generation
hormone replacement therapy: the risk of VTE is higher in women taking oestrogen + progestogen preparations compared to those taking oestrogen only preparations
raloxifene and tamoxifen
antipsychotics (especially olanzapine) have recently been shown to be a risk factor
In chronic myeloid leukaemia there is an increase in – at different stages of maturation +/- —
Acute myeloid leukaemia - blood tests will reveal —
Acute lymphocytic leukaemia - far more common in —and blood tests will reveal –
Chronic lymphocytic leukaemia - a malignancy of the lymphoid lineage so there will be a raised – count.
Essential thrombocytosis - although patients with essential thrombocytosis can have a raised white cell count, these patients tend to have much higher – counts (typically >450 * 109/l).
In chronic myeloid leukaemia there is an increase in granulocytes at different stages of maturation +/- thrombocytosis
Acute myeloid leukaemia - blood tests will reveal immature blood cells (blasts).
Acute lymphocytic leukaemia - far more common in children and blood tests will reveal immature blasts.
Chronic lymphocytic leukaemia - a malignancy of the lymphoid lineage so there will be a raised lymphocyte count.
Essential thrombocytosis - although patients with essential thrombocytosis can have a raised white cell count, these patients tend to have much higher platelet counts (typically >450 * 109/l).
The Philadelphia chromosome is present in more than 95% of patients with –.
It is due to a translocation between the long arm of chromosome – and –
– is now considered first-line treatment
The Philadelphia chromosome is present in more than 95% of patients with chronic myeloid leukaemia (CML). It is due to a translocation between the long arm of chromosome 9 and 22
imatinib is now considered first-line treatment
The transfusion threshold for patients with ACS is — g/L
The transfusion threshold for patients with ACS is 80 g/L
Practical points
red blood cells should be stored at -°C prior to infusion
in a non-urgent scenario, a unit of RBC is usually transfused over – minutes
Practical points
red blood cells should be stored at 4°C prior to infusion
in a non-urgent scenario, a unit of RBC is usually transfused over 90-120 minutes
Polycythaemia
Polycythaemia may be relative, primary (polycythaemia rubra vera) or secondary
Relative causes
d–
stress: — syndrome
* *Primary**
polycythaemia –
Secondary causes
C–
a–
o–
excessive –: cerebellar haemangioma, hypernephroma, hepatoma, uterine fibroids*
Polycythaemia
Polycythaemia may be relative, primary (polycythaemia rubra vera) or secondary
Relative causes
dehydration
stress: Gaisbock syndrome
Primary
polycythaemia rubra vera
Secondary causes
COPD
altitude
obstructive sleep apnoea
excessive erythropoietin: cerebellar haemangioma, hypernephroma, hepatoma, uterine fibroids*
Hyposplenism e.g. post-splenectomy
— cells
— bodies
—r bodies
— granules
acanthocytes
Iron-deficiency anaemia
— cells
‘pencil’ —
if combined with B12/folate deficiency a ‘—’ film occurs with mixed microcytic and macrocytic cells
Myelofibrosis
’—’ poikilocytes
— haemolysis
schistocytes
Megaloblastic anaemia
hypersegmented neutrophils
Hyposplenism e.g. post-splenectomy
target cells
Howell-Jolly bodies
Pappenheimer bodies
siderotic granules
acanthocytes
Iron-deficiency anaemia
target cells
‘pencil’ poikilocytes
if combined with B12/folate deficiency a ‘dimorphic’ film occurs with mixed microcytic and macrocytic cells
Myelofibrosis
‘tear-drop’ poikilocytes
Intravascular haemolysis
schistocytes
Megaloblastic anaemia
hypersegmented neutrophils
The most common cause of an isolated thrombocytopenia is ITP
ITP-Immune thrombocytopenia (ITP)
Hodgkin’s lymphoma - best prognosis = —predominant
Hodgkin’s lymphoma - best prognosis = lymphocyte predominant
Bite and blister cells are typical of the blood film in — –
Bite and blister cells are typical of the blood film in G6PD deficiency
— is the preferred NOAC for patients with renal impairment due to minimal renal drug clearance
Apixaban
In VWD, bleeding time is — but platelet levels are —
In addition, APTT is–
In VWD, bleeding time is increased but platelet levels are normal. In addition, APTT is prolonged
Ileocaecal resection may result in —deficiency
vitamin B12
A — anaemia with – serum iron, – TIBC but – ferritin in a patient with a chronic illness is typical of anaemia of chronic disease
A normocytic anaemia with low serum iron, low TIBC but raised ferritin in a patient with a chronic illness is typical of anaemia of chronic disease
Causes of normocytic anaemia include
anaemia of —
—- disease
— anaemia
— anaemia
acute –
Causes of normocytic anaemia include
anaemia of chronic disease
chronic kidney disease
aplastic anaemia
haemolytic anaemia
acute blood loss
Platelet transfusion is appropriate for patients with a platelet count < – x 109 and clinically significant bleeding
30
If no active bleeding or planned invasive procedure
A threshold of 10 x 109 except where platelet transfusion is contradindicated or there are alternative treatments for their condition
For example, do not perform platelet transfusion for any of the following conditions:
Chronic — failure
Autoimmune —
Heparin-induced —, or
Thrombotic—
If no active bleeding or planned invasive procedure
A threshold of 10 x 109 except where platelet transfusion is contradindicated or there are alternative treatments for their condition
For example, do not perform platelet transfusion for any of the following conditions:
Chronic bone marrow failure
Autoimmune thrombocytopenia
Heparin-induced thrombocytopenia, or
Thrombotic thrombocytopenic purpura.
Acute haemolytic transfusion reaction should be treated with generous — and – of the transfusion.
Acute haemolytic transfusion reaction should be treated with generous fluid resuscitation and termination of the transfusion.
Sickle cell disease causes a — anaemia with raised – count – due to haemolysis
Sickle cell disease causes a normocytic anaemia with raised reticulocyte count – due to haemolysis
— should form part of the diagnostic work-up in a woman found to have an abdominal malignancy of unknown primary
CA 125
Recurrent infections (due to hypogammaglobulinaemia) are a complication of –
CLL
In chronic myeloid leukaemia there is an increase in — at different stages of maturation +/- —
In chronic myeloid leukaemia there is an increase in granulocytes at different stages of maturation +/- thrombocytosis
Acute myeloid leukaemia - blood tests will reveal immature blood cells (blasts).
Acute lymphocytic leukaemia - far more common in children and blood tests will reveal immature blasts.
Chronic lymphocytic leukaemia - a malignancy of the lymphoid lineage so there will be a raised lymphocyte count.
