OSCE Flashcards
Management of AF
Ix: Pulse, ECG, Bloods, ECHO, TFT
Tx:
If present with collapse - O2, fluid, airway adjunct, emergency cardioversion
If new, young, reversible, HF - Cardiovert with DC or amiodarone
If paroxysmal - pill in pocket or catheter ablation
Long term:
Rate - BB, CCB or digoxin
Rhythm - BB, flecainide, amiodarone
CHADVAS vs HASBLED
Chadvas >1 in m or >2 in female - need anticoag
Hasbled >3 - at risk of bleeding
- DOAC or warfarin
Management of Aortic stenosis
If radiates to carotids, narrow pulse pressure, slow rising, symptoms = stenosis not sclerosis
Displaced apex = LVH
Differential for aortic stenosis - hypertrophic cardiomyopathy (also presents with syncope, dyspnoea, angina)
Ix: Cardio exam, obs, ECG, transthoracic ECHO, CXR
Tx:
Conservative
HF: Diuretic, ACEi
Angina: BB or CCB
TAVI or AVR, or balloon valvuloplasty
- if severe sx, LVEF <50, already undergoing cardiac surgery, pressure gradient on echo
Assess QRISK - Statins, BP etc
Management of UC
Ask if eye, skin, MSK, hepatobilliary
Admit if systemically unwell Ix: FBC (blood loss), U+E (dehydration), ESR, CRP Stool sample to exclude infection, do calprotectin Colonoscopy + Biopsy pANCA +ve, ASCA -ve CT to stage, look for complications Abdo xray- lead pipe
Assess severity with true love and Witts
Tx:
Induce remission with 5ASA either topical or oral, if resistant can use corticosteroids
Maintenance use ASA topical or oral, if >2 relapses in last 12mo add azathioprine
Protocolectomy - 1st line surgery
Subtotal colectomy with end ileostomy, preservation of rectum - if malignancy, toxic megacolon, failure of medical mx
Don’t give loperamide - risk of toxic megacolon
Avoid NSAIDs
UC associated with increased risk of colorectal cancer and PSC
Epididymo-orchitis management
Ix: Testicular and external genital exam NAAT - chlamydia and gonorrhoea Urinalysis, microscopy and culture for E coli Doppler US to exclude torsion Gram stain TB - AFB HIV test
Tx: Chlamydia - doxy for 14 days Gonnorhea - Cef IV, single dose Ecoli - Ciprofloxacin Torsion -> urology NSAID for pain
Asthma management
Ix:
FeNO - eosinophil inflammation (>40)
Spirometry w. bronchodilator - FVC increase by 200ml, FEV1 by 12%
Peak flow - >50-75% mod, 33-50% severe, <33% life threatening - 20% diurnal variation is indicative
Bronchial challenge test
Tx:
Educate - lifestyle
ABCDE Oxygen Salbutamol neb Hydrocortisone Ipratropium bromide neb Magnesium sulfate Theophylline Escalate if pH <7.3, Intubate
Long term:
SABA
SABA+ICS
SABA+ICS+LTRA
TB management
Ix:
CXR - apical opacification, effusion, millet seed
Early morning sputum sample for AFB, culture
NAAT
Antibiotic sensitivity
HIV test
Tx Notify infection control body, place in ventilated side room Isoniazid (pyridoxine) Ethambutol Rifampicin Pyrazinamide
All for 2m then I+R for 4m (10m if CNS)
Contact trace, screen others with Mantoux and IGRA
What to ask in STI Hx
Why come in? Discharge? - smell, colour, consistency Soreness? - where, when Pain on sex or in general? - where, when Changes in period? Bleeding? - when does it happen? is it linked to sex? Lumps or bumps? - how many, where, painful Pain when passing urine? Fever
Obstetric and gynae Hx
When last time had sex, consensual How many partners in last 3 months Any history of STIS What kind of sex Contraception use high risk country, population, been in contact with HIV
Upper GI bleed management
Ix:
Routine observations - BP, pulse
Do FBC (microcytic anaemia if chronic), U+E (urea high due to blood breakdown), LFT (varies), CRP, INR, coag, G+s crossmatch
Do PR (rule our malaria), ECG, CXR to rule out perforation
If suspect peptic ulcer do carbon breath test or H pylori stool test
Do Glasgow blatchford score to determine need for GI endoscopy - high within 24 hours, low high as outpatient
Do upper GI endoscopy
Treatment AtoE, protect airway, give O2 IV access, monitor urine output as proxy for organ perfusion Fluids, transfuse as needed Omeprazole infusion if high risk
Oesophageal varicose - Beta blockers, terlipressin, oesophageal band ligation, prophylactic cipro or cef, give vit K if PT prolonged
Peptic ulcer - stop NSAID - thermal, adrenaline, clip on endoscopy, loose weight, small regular meals, stop smoking/ alcohol, Hpylori +ve: 2x daily of all: Amoxacillin, PPI, Clarithro
Rockall post endoscopy - predicts mortality and risk of new bleed
ACNE Management
PCOS, normal hormones in adolescence, CAH, steroids, exogenous testosterone, EGFR inhibitors can cause
Has follicular distribution
Ix:
Examine, assess the severity based on number and type of lesions
just closed/open comedones, <20 total = mild
Papules/pustules, 20-125 = moderate
Scarring, causing MH problem, hyperpigmentation, >125 = severe
Tx
Advise - Don’t pick or squeeze, not over wash, use fragrance free face wash, wash when sweaty, loose weight, diet, SPF in sun.
Say ACNE not due to poor hygiene
Diet, skincare, makeup
1st retinoid +/- benzoyl peroxide, azelaic acid
2nd benzoyl peroxide + clindamycin 1%
3rd contraceptive pill/spironolactone in women or oral doxycycline + retinoid or benzoyl
4th refer to derm for isotretinoin
Follow up 8-12 week after starting treatment
Rule out acne rosacea by asking about eye involvement, nose changes, flushing of face. No comedones, older age onset, hot fluid/alcohol/stress trigger
MSCC
Ix: MRI whole spine PR for anal tone Bloods - Ca 15-3 for breast cancer, PSA for prostate Neuro exam
Tx Lie flat Dexamethasone Catheterise if urinary incontinence Bisphosphonates DVT Analgesics Laminectomy/ radiotherapy
Hyperthyroid / thyrotoxic storm
Ix: TFT: TSH low, T3/T4 high TSH receptor antibodies US of goitre Biopsy ECG for AF CRP Radio-iodine scan
Tx: Carbimazone, propylthiouracil - titration block or block replace Beta blocker for tremor Radioactive iodine treatment Surgical removal
Thyrotoxic storm Cool Hydrocortisone Carbimazole or propylthiouracil Beta blocker Iodine after 4 days
Hypothyroid
Ix:
TFTs - TSH high, T3/T4 low
Anti thyroid peroxidase, antithyroglobulin antibodies, US if goitre
MRI if suspect secondary cause
Tx:
Levothyroxine - titrate until TSH normalises
Myxoedema - IV levo, IV steroids, warming
HF
Ix:
Routine obs, cardiovascular examination
Bloods - FBC (anaemia can exacerbate), LFT, U+E, CRP
BNP - >400 do ECHO (look for dilated CM)
CXR - batwing, kerley B line, Bilat effusion, increased heart size
ECG - LVH, HF
NYHA score
Tx:
Manage Comoros, lifestyle
Ejection fraction maintained - observe
Ejection fraction reduced give ACEi, BB, spironolactone if fluid overloaded. If need more give ivabradine, ARB, digoxin or hydralazine
ICD or cardiac resynch
COPD managment
Ix: Respiratory exam Peak flow Spirometry with bronchodilator - restrictive picture CXR for cor pulmonale If acute exacerbation do sputum culture, ABG MRC dyspnoea score - activity limitation BODE index - prognosis GOLD staging
Tx
Lifestyle modification and patient education
Acute: NIV, Theophylline, Abx, pred, O2, Salbutamol, physio
Start on SAMA or SABA
Add either LABA + LAMA or LABA +ICS
LAMA + LABA + ICS
COPD rescue pack
- prednisolone
- Salbutamol
- Amoxicillin
Long term oxygen therapy
if PO2 <7.3 or between 7.3-8 and have secondary polycythaemia, peripheral oedema or pulmonary HTN
Hypoglycaemia
Causes -Insulin/SU, Addisons, Insulinoma, Factitious (C-peptide low), post prandial
Ix:
Do BMs = fasting glucose <3
Do neurological assessment and calculate GCS
Do serum insulin - see if due to insulin
C-peptide - see if endogenous cause (insulinoma)
ECG
SU level
Cortisol level to look for adrenal insufficiency
Management:
Get the hypo box
If conscious and able to swallow - 20g carbs, retest in 15 mins
If confused give 2 tubes of glucogel, IM glucagon
If cant swallow, low GCS give IM glucagon, IV dextrose Cant give glucagon if alcoholic, SU, liver disease, malnourished
If due to SU give ocreotide
Important to alert DVLA, refrain from driving until BMs under control
- test BM before driving and then 2hrly throughout the journey
After stable assess hypo awareness with GOLD score
Crohns management
- mouth ulcers
- Diarrhoea
- Blood in stool
- B12 deficiency (malabsorption in terminal ileum), tingling in fingers
Ix: GI exam, PR and Oral examination FBC (anaemia), U+E, LFT, CRP, ferritin, B12, folate Stool sample - culture and calprotectin ASCA +ve, pANCA -ve Colonoscopy + biopsy Bowel CT/ MRI to look for fistula
Mx:
Induce remission with corticosteroid e.g. prednisolone or 5-ASA
Maintain remission with azathioprine/mercaptopurine, second line methotrexate
Loperamide, analgesia, mebeverine, Abx, topical steroids as needed
Widen strictures, colectomy, fistula repair, segmental resection
Stoma if failure of medical, strictures (obstruction), fistulae
Strictures, fistuae, obstruction are complications
PE management
Ix: Calculate the wells score - >4 -> CTPA - <4 -> Ddimer, if +ve do CTPA If allergic to contrast, GFR <30 or pregnant do V/Q SPECT Do FBC, U+E, CRP, LFT, Coag ABG Screen for cancer if >40, unprovoked
Mx:
Give O2, analgesia, iv access, assess circulation (BP)
If low risk, outpatient anticoagulant
If high risk, admit to hosp
1st line: rivaroxaban or apixaban
Or LWMH for 5 days then dabigatran or edoxaban
Or LMWH for 5 days with warfarin until INR normal then warfarin alone
If renal failure - LMWH or warfarin
3 months for provoked, 3-6 months provoked with cancer, 6 months for unprovoked
haemodynamically unstable - continuous UFH infusion and consider thrombolytic with streptokinase
If repeated: IVC filter or pulmonary embolectomy
BCC/SCC management
Refer on 2ww for SCC
Routine referral for BCC
Ix:
Biopsy, dematoscopy, CT if suspect spread, FNA of local nodes
RF - UV exposure, fair skin, weakened immune system, personal or family history
SCC looks wet, sloughy, ulcer, from keratinocytes. Comes on more quickly, tender, more common on back of hand, may be nearby actinic keratitis
BCC from hair follicles - pearly, nodular, depression in middle, telengectasia, non tender
Superficial BCC - patch/plaque, pale ping, Clear rolled edge
High risk
Diameter >2 cm
Location on the ear, vermilion of the lip, central face, hands, feet, genitalia
Elderly or immune suppressed patient
Histological thickness greater than 2 mm, poorly differentiated histology, or with the invasion of the subcutaneous tissue, nerves and blood vessels
Tx:
Excision with 4mm margins
If complex, deep or unclear boarders do MOHs
Radiotherapy alternative if not want surgery (increased scarring),
For superficial BCC or actinic keratitis or Bowens disease - cryotherapy, photo-dynamic therapy , curettage, 5-FU, immiquimod
Actinic Keratosis - Diclofenac
Pericarditis management
Ix:
Look for triad of pleuritic chest pain, pericardial rub, serial ECG changes
Do cardiovascular exam, ECG looking for widespread saddle shaped ST elevation
Do FBC, LFT, U+E (creatinine, uraemia), CRP, Troponin (high if myocardium involvement), INR
Do CXR, echo to look for fluid
Do blood culture, pericardial fluid culture if unclear cause
Tx:
restrict physical activity until symptoms resolve or CRP, ECG resolve
NSAID for 4 weeks + PPI (aspirin over nsaid if recent MI)
Colchicine for 3 months
steroids if refractory pain
majority as an outpatient unless fever, large effusion, cardiac tamponade, immunosuppressed, due to trauma, on anticoagulation, poor response to treatment
and treat cause - anti-tb for tb, antibiotics if bacterial
pericardiocentesis for symptomatic effusion
DKA management
Present with dehydration, vomiting, abdo pain, polyuria, confusion, hyperventilation
Ix: AtoE assessment Urine ketones 2+ or blood ketones >3 Blood glucose >11 ABG: Bicarb <15 or pH <7.3 CXR to exclude pneumonia as cause
Routine bloods, TFT, CK, amylase, cultures, trops
Mx:
Obs, cannula, catheterise to assess urine output
If BP<90 - fluid challenge (500ml over 15 mins) otherwise long term fluid replacement
Give fixed rate 0.1 unit/kg/hr act rapid insulin
- aim for ketone drop of 0.5 per hour
- when glucose <14 then start on dextrose
Continue long acting insulin
K+ replacement - in second bag of fluid
Treat underlying cause (infection, MI etc), monitor BM, Ketones, K+, urine output hourly
(resolved when ketones <0.3 and pH >7.3)
PBC
Ix:
AMA +ve, ALP/GGT raised and no other explanation
Do liver biopsy to confirm
UDCA (obeticholic acid is 2nd option) Sedating antihistamine or cholestryamine for itching Rituximab for fatigue Avoid the pill, HRT Supportive treatment liver transplant
PSC more common in men, younger
Ischaemic stroke
Always do BMs
general - oxygen, blood glucose, swallow assessment, nutrition screen, consider for carotid endartectomy - >50% on US
<4.5 hours - alteplase infusion, 300mg aspirin after 24 hrs for 2 weeks then clopidogrel long term
> 4.5 hours - aspirin 300mg for 2 weeks then clopidogrel long term
MR dipyridamole
indications for thrombectomy (mechanical thrombectomy via catheter +/- stent) - <6 hours confirmed occlusion of proximal anterior circulation demonstrated by CTA or MRA - AND later than this if potential to salvage brain tissue
manage comorbidites such as lipids etc
Confirm size of infarct, check for any complications of thrombolysis with CT at 24hrs
If haemorrhage = poor prognosis, supportive care, manage BP, contact neurosurgery
Meningitis
Ix:
Assess GCS
If suspect raised intracranial pressure do CT before LP
LP within an hour - WCC, gram stain, glucose, protein, lactate, culture, PCR, Ziehl-Neelson
If cant LP do: FBC, CRP, coag, culture, PCR, BM, ABG
Kernigs and brudzinski signs
differential if altered mental status - encephalitis, usually herpes, treat with acyclovir
Mx:
Raised ICP -> ITU -> fluids, analgesics, antiemetics
Viral - often self limiting, may give acyclovir
Bacterial - IM or IV benzylpenicillin immediately (only if meningococcal rash). When in hosp start ceftriaxone if >3mo old, add ampicillin or amoxicillin if >60 yo. Give dexamethasone asap, continue for 4 days if pneumococcal
Length of treatment depends on cause
Cryptococcal - fluconazole, amphoteracin B
Consider prophylaxis of contacts - ciprofloxacin
SAH management
Ix: Assess consciousness Baseline bloods + coag Do fundoscopy and neuro exam Do Ct without contrast - if -ve do LP for xanthochromia ECG
Mx:
Analgesics, antiemetics, supportive care
nimodipine 60mg every 4 hours for 21 days - prevent vasospasm and ischaemia
CT angiogram to locate aneurysm
Neurosurgical clipping or coiling
Treat hydrocephalus with drain
Pressure sores Management
Ix:
Assess cause, location, grade, size, infection, odor, exudate
Waterlow risk assessment
Grade based on appearance and depth
Tx:
Pressure redistribution, nutrition, analgesia, dressing (-ve pressure)
Rotate position, address incontinence, malnutrition, regular skin assessment
Debridement
6w fluclox if osteomyelitis
Plastic surgery
POAG managment
Can present with gradual onset of fluctuating pain, headaches, blurred vision and halos appearing around lights, particularly at nighttime
Ix:
Fundoscopy - cupping of optic disc (>0.4), notching, retinal haemorrhage
Vision assessment - scotoma, loss of peripheral vision (Humphrey visual field)
Tonometry (>21mmhg)
Goniometry - exclude AACG
Slit lamp
MRI scan of orbit if suspect graves or orbital cellulitis
Tx:
1st line - latanoprost (prostaglandin analogue) or timolol (beta blocker)
2nd line - switch, combine or add pilocarpine, acetazolamide, bimonidine
Laser trabeculoplasty, trabeculotomy, aqueous shunt
Monitor yearly for rest of life -
Pneumothorax managment
If >50 and smoke or evidence of lung disease -> secondary
Primary <2cm AND no breathlessness = discharge with outpatient x-ray
Primary, >2cm OR breathless = percutaneous aspiration and oxygen then 2nd x ray to confirm gone
Secondary <1cm = oxygen and admit for 24 hours
Secondary 1-2cm = aspiration (if fails then chest drain)
Secondary >2cm OR breathless = chest drain (if fails then discuss with thoracic surgeon)
Tension = needle decompression in 2nd IC space MC line, oxygen then chest drain in triangle of safety
Refer for pleurodesis if recurrence or surgery for open thoracotomy and pleurectomy or video-assisted thoracoscopic surgery with pleurectomy and pleural abrasion (better tolerated than open surgery)
Falls management
Ix
Investigate cause of fall - syncope, CV, neuro, mechanical
Assess for risk factors: vision impairment, cognitive impairment, fear, arthritis, alcohol, urinary incontinence, tinnitus, vertigo etc
fragility fracture - fracture from standing height
Assess mobility with timed get up and go test - (>12-15s = high risk) or turn 180 test (>4 steps high risk)
QFracture - risk of fragility fracture
DEXA scan if fracture ( -1to-2.5 = osteopenia, >-2.5 = osteoporosis)
If >2 falls in past 12 mo or needed medical attention post fall do multifactorial falls risk assessment
Mx Lifestyle - exercise, stop smoking/alcohol, increased vit D and calcium Exercise - weight bearing, muscle strengthening, balance exercises, back care Adjust medication PT, OT Walking aids Home adjustment and support Treat osteoporosis Vision correction Footwear
Causes and management of delirium
Causes: Pain Infection Nutrition Constipation Head injury, hypoxia Endocrine + electrolyte - altered pH, hypo/hyper Na+ Ca++, acute liver or renal failure, hypoglycaemia Stroke Medication and alcohol Environment
Ix:
Take a Hx from person and third party
Baseline
Cognitive assessment based on DSM-V criteria or a 4AT or CAM, AMT10
Admit for further investigations and treatment
U+E, ABG, HbA1c/BM, Infection screen (CXR, urinalysis, FBC), LFT (encephalopathy), neuro exam, medication review, home hazard review
confusion screen: FBC, LFT, CRP, U+E, ABG, Coag, TFT, Bone profile, Mg, b12, folate, ferritin
Mx:
Treat cause
Optimise treatment of Comorbs, medications
Reorientation strategies
Quiet side room, normalise sleep/wake cycle
Home comforts
PT/OT assessment
Home hazard assessment
Give haloperidol or benzodiazepines as sedation may be used if very agitated
Explain diagnosis to carers
Melanoma Mx
Ix:
Do a dermatological exam - ABCDE, determine classification (superficial, nodular)
Use Glasgow 7 point checklist
Dematoscopy
Biopsy - excisional with 2mm margins
Breslow, Clarkes (not part of staging), ulceration, mitotic index give indicator of prognosis
Do CT if suspect metastatic spread, assess for BRAF mutation
Mx: Wide local excision with margin based on breslow thickness insitu - 5mm <1mm - 10mm 1-2 - 10-20 2-4 - 20-30 >4 - 30mm \+/- lymphadenectomy/ sentinel LN biopsy Can also do electrochemotherapy
If metastatic - BRAF inhib, immunotherapy e.g. ipilimumab, chemo, interferon alpha
TIA management
Ix:
Do neurological examination
Do routine obs, perform a GCS, listen to carotids for bruit
Can use FAST screening tool in primary care
Refer to specialist centre for appointment within a day
FBC, ESR, U+E, LFTs (including PT, INR), TFT, ECG
Do CT head if suspect haemorrhage
Carotid doppler to look for stenosis
Assess risk of stroke using ABCD2 score
Mx:
300mg aspirin loading dose immediately
Discuss lifestyle: diet, exercise, smoking, alcohol
Treat CV risk factors e.g. BP, cholesterol
Give 300mg clopidogrel loading dose then continue on 75mg a day long term
If >70% stenosis - carotid endarterectomy
Stable/ Unstable angina management
Ix:
Take history and perform cardiac examination
Do an ECG to look for ST elevation or LBBB
Take serial troponins
Do routine bloods: FBC, U+E, LFT, CRP, CK, myoglobin, lipids, TSH
CXR, echo
Consider exercise stress test, CT angiogram or Coronary angiogram to investigate angina Sx and degree of CAD
Mx: O2 if sats less than 94% Morphine, metoclopramide 10mg of each Nitrates Aspirin 300mg Ticagrelor according to Chadvas/hasbled Heparin if going for PCI Resuscitate Glycoprotein inhibs if PCI
Use grace score to decide the risk of MI and need for PCI
Discuss lifestyle risk factors e.g. diet, exercise, smoking, alcohol
Evaluate CV risk factors and start on statins, Acei, Beta blockers
12m Ticagrelor and aspirin
For stable angina:
1st line - rest +GTN
2nd line - Beta blocker or CCB (verapamil/diltiazem)
3rd line - Beta blocker + CCB (bisoprolol and nifedipine)
4th line - Add in long acting nitrate (isosorbide mononitrate), nicorandil, ivabradine, ranolazine
+
Secondary prevention: 3A’s: aspirin (75mg OD), atorvastatin (80mg OD), ACEi (e.g. ramipril, titrated up to max dose)
HTN management
Ix:
Do surgery reading, if raised then do ambulatory home blood pressure monitoring for 7 days
If >140/90 - stage 1
If >160/100 - stage 2
If >180/110 - stage 3
Tx:
Lifestyle advice and education:
- exercise, low salt diet, weight loss, smoking, alcohol, reduce caffeine
- educate about the risks of hypertension including renal disease, eye disease, CV disease and metabolic disease
If <55 or diabetes- ACEi
If >55 or black - CCB e.g. amlodipine
Step 2 - add each other or thiazide diuretic
Step 3 - all 3
Pneumonia management
Ix: Respiratory exam Blood + sputum culture CXR FBC, U+E, LFT, CRP, ABG Lung function test Sepsis 6 is suspect systemic infection, dropping vitals Procalcitonin to monitor
Do CURB 65 - who needs admission
Confusion, Urea >7, RR >30, BP <90/60, >65
home: 0-1, hosp >2, ITU >3
Tx: Educate, stop smoking Fluids Oxygen if hypoxic Analgesics for pleuritic pain Start on antibiotics - low severity: amoxicillin - Mod: amoxicillin +/- clarithro - severe: co-amox + clarithro
If suspect aspiration -> metronidazole
Acute cholecystitis/ cholangitis management
Ix:
Do a GI exam - look for jaundice
FBC, U+E, CRP, LFT (ALP/GGT/billirubin), amylase/lipase (pancreatitis)
ABG, culture if suspect sepsis
US gallbladder
ECRP, MRCP or HIDA cholescintigraphy if US -ve
Contrast CT for cholangitis or if suspect complication e.g. perforation
Mx:
Acute cholecystitis:
Monitor BP, pulse urine output
Analgesics - diclofenac or opioid
IV abx - trust guideline (cefuroxime and metro)
Laparoscopic cholecystectomy - Nil by mouth, IV fluid, analgesia, ondasteron
Cholangitis
Monitor BP, pulse urine output
Analgesics - diclofenac or opioid
IV abx - trust guideline (cefuroxime and metro)
ERCP to remove stone or can stent/lithotripsy
Cholecystectomy
Migraine management
Unilateral, throbbing 4-72hrs
have to lie down in dark room
Associated N+V, aura, photophobia and photophobia
Ask about prodrome and postdrome
Cant carry out normal daily life
For diagnosis
- without aura need 5 characteristic headaches
- with aura need 2 headaches with associated visual, sensory or speech/language aura
Ix:
Comprehensive history
Visual assessment, fundoscopy if eye signs
Neuro exam/CN exam if neurological symptoms
Take drug history to identify if medication overuse
Mx:
Educate, do headache diary to understand triggers and avoid them.
Limit standard analgesics
Optimise Comorbs e.g. OSA, insomnia, depression
Take off oral contraceptive pill
1st - Ibuprofen, aspirin, paracetamol
+ metoclopramide
+ sumatriptan - take at start of headache not aura
Prevention: Propanalol (1st line in women of childbearing age), Topiramate, amytriptalline
- start if 2 or more attacks a month that last 3 or more days
Consider mindfulness, acupuncture, riboflavin
Trigeminal neuralgia management
- vascular compression of trigeminal nerve, also: MS, tumours, abnormalities of the skull base, AVM
Ix:
CN exam
Examine face and dental cavity
MRI if diagnostic uncertainty, young, suspect malignancy or MS, not improve with treatment
Tx:
Educate patient, get to understand their triggers e.g. shaving, cold air to face etc
Carbamazepine 1st line - titrate up to effective dose, explain not work immediately
alternatives - baclofen, lamotrigine
Can give botulinum, perform decompression
Cluster headache treatment
Tx:
Avoid triggers such as alcohol and smoking
Acute: 100% O2 via non rebreathe and sumatriptan, metoclopramide if nausea
Prevention: verapamil, lithium or prednisolone
Epistaxis management
Ix:
Routine observations
Medication history - blood thinners
FBC, U+E, LFT, CRP, Coagulation profile (INR, PT), Group and save
Mx:
Immediate management includes pinching the soft cartilage at the base of the nose for 15 mins, leaning forward and placing a cold compress on bridge of nose or back of neck
In hosp:
AtoE
Wide bore cannula - blood/fluid
Stop warfarin, reverse with vit K, reverse doac
If stop with pinching give naseptin
If not stop visualise with thidicum to locate a bleeding point
If present cauterise with silver nitrate
If not present then pack nose - rapid rhino
Admit to hosp for review and remove after 24 hours, then reattempt cauterisation
If still bleeding - ligate artery under GA
Avoid blowing or picking the nose, heavy lifting, strenuous exercise, lying flat, drinking alcohol or hot drinks, avoid hot showers, 2w naceptin
Causes of ear discharge - CBD
Otitis media
Sx: Earache, fullness, hearing loss, fever
Ix: Otoscopy to look for bulging, redness of TM, fluid level or perforation, impedance audiometry to measure pressure in middle ear, do nasal endoscopy to check the openings of eustachian tubes, audiometry if hearing loss
Mx: Analgesics, warm compress, most self limiting. If severe, <2yo, bilateral: oral amoxicillin
Consequences include mastoiditis, facial nerve palsy, meningitis, cerebral abscess.
If mastoiditis - IV abx, consider CT (if consider surgery or abscess, have headache, lethargy etc) and mastoid air cell clearance.
Otitis media with effusion - due to closure of Eustachian tube. Get negative pressure in middle ear, draws fluid in from middle ear. hearing loss, poor speech development, ear popping, imbalance
If effusion - fullness, hearing loss persists after infection treated. Observe for 6-12 weeks for spont resolution, if ongoing, limiting development, bilateral consider grommets, adenoidectomy
If perforation persists (Chronic otitis media) - antibiotics and surgery to fix eardrum
Otitis externa
Sx: Ear pain, itch, discharge often post water based activity. If unrelenting pain that interferes with sleep, hearing loss, FN involvement, fever think necrotising otitis externa (do CT, CRP, ESR)
Ix: otoscopy - red swollen external auditory canal, ear swab if recurrent, if necrotising do CT/ MRI
Mx: Clean ear, analgesic, often self limiting - if severe: ear wick, acetic acid or topical antibiotic (aminoglycoside e.g. gent or ciprofloxacin) +/- hydrocortisone drops, keep ears dry. For necrotising, same day referral to ENT, 6w oral ciprofloxacin
Cholesteatoma
Sx: Non resolving unilateral offensive discharge thats unresponsive to antibiotics
Ix: Retraction of pars flaccida on otoscopy, if facial nerve involvement or planned surgery do an MRI
Tx: Surgical removal often required - canal wall up mastoidectomy
Also want to rule out CSF if base of skull fracture - test for glucose and beta 2 - transferrin
Colorectal cancer
L side: bleeding, altered bowel habit
R side: anaemia, weight loss, abdo pain
Ix:
Abdominal and PR exam looking specifically form mass
Routine observations
FBC (anaemia), U+E, LFT (mets), CRP, CEA, CA19-9, BRAF
2ww: 1st line: Colonoscopy with biopsy 2nd line: Barium enema CT TAP - staging and metastatic identification Liver Ultrasound PET scan
Screening: Faecal immunochemical testing - every 2 years from age of 60-74. If +ve have colonoscopy
2ww:
Aged 40 and over with unexplained weight loss and abdominal pain
Or if they are aged over 50 with unexplained rectal bleeding
Or if they are over 60 with IDA or changes in their bowel habit
Mx:
Remove polyp on colonoscopy and send for histology
Segmental resections with anastomosis or stoma
Radiotherapy
Chemo: FOLFOX, anti-VEGF
Causes and management of peripheral oedema
Causes: HF, CKD, Cirrhosis, Cellulitis, venous insufficiency, DVT, obesity, immobility, protein loss in IBD/ coeliac, pregnancy, lymphedema, hypothyroid
Ix: Urinalysis to look for high protein in nephrotic syndrome FBC, U+E, LFT, CRP, BNP, TFT Abdo/pelvic US look for ascites, tumour, liver mets CXR for HF, lung malignancy ECG D-Dimer/ Doppler for DVT Pregnancy test
Mx:
Dependant on cause
Epirical management with diuretics not appropriate without clear cause
Child presents with hip pain and limp following upper respiratory tract infection - cause and how to differentiate
Ix
Blood, pressure, pulse, saturations
FBC (WCC), ESR/CRP (Inflammatory markers for septic arthritis), blood cultures
Xray to exclude fracture and tumour
US to see if there is an effusion within the hip
Aspirate hip for microscopy and culture
Tx if septic arthritis:
Sepsis 6
Escalate
Surgery: incision and drainage - perform a washout
- need to do asap as otherwise can get avascular necrosis
Infection in joint replacement is grumbling, low grade, aspirate, ESR/CRP, take to theatre, remove metalwork, insert antibiotic spacer, give IV abx then replace metalwork
Osteoarthritis management
Ix
Assess level of pain and limitations of activity
Assess psychological impact
Do examination of joint and one above/below
Calculate BMI
Bloods: FBC (WCC), U+E (before starting on NSAID), LFT as baseline, CRP/ESR (identify inflammation)
Do Xray of the joint
Consider joint aspiration to rule out gout, septic arthritis
Mx
Educate, weight loss, physio, hot/cold compress, stop smoking, foot wear, psych, TENS
WHO pain ladder
Surgical opinion of refractory to conservative
Rheumatoid arthritis management
Ix
Examination and history - systems review
FBC, U+E, LFT, CRP/ESR, RF, Anti-CCP, ANA
Xray - bony erosions, joint space narrowing, soft tissue swelling, juxta-articular osteoporosis
US - look for effusion and thickening/blood flow in synovial membrane
Joint aspiration if suspect septic
Assess disease activity with DAS28
Mx
Educate, lifestyle, psych
Assess psych wellbeing
NSAID for pain relief
Corticosteroid if flare - up to 3x a year
1st Line: cDMARD e.g. methotrexate, if palindromic hydroxychloroquine. Bridge with glucocorticoid.
2nd Line: bDMARD (if 2x above ineffective) e.g. TNF inhibit adalimumab, Anti CD20 rituximab
3rd line: surgery
Drug SE
Steroids - Infection, osteoporosis, DM, cushings
Methotrexate – liver toxicity, pneumonitis, oral ulcers
Osteoporosis Mx
Ix:
Qfracture risk assessment tool: if >10% in 10 years then perform a DEXA scan
DEXA of -2.5 or more is diagnostic
Investigate for vit D, calcium deficiency, do U+E, LFT
(high ALP, low Ca, PO4 in osteomalacia, all normal in osteoporosis)
Do xray if suspect fracture
Do a falls risk assessment and assess fragility with a timed get up and go test (comprehensive geriatric assessment)
Investigate cause (steroids, DM, hypogonadism, hyperthyroid, GI, RA)
Mx:
Education, fall prevention programmed, exercise, balance training, diet, smoking, alcohol
1st line bisphosphonate e.g. alendronate
2nd line: raloxifene, strontium ranalate, zoledronic acid
Replace vit D, calcium as needed
HRT if premature menopause
Antipsychotic SE, how to treat, dopamine pathways and Neuroleptic malignant syndrome
Schizophrenia = overactivity of dopamine in mesolimbic pathway
Decreased dopamine in mesocortical leads to negative sx
d2 blockage in nigrostriatal pathway leads to parkinsonian, dystonia, akathisia sx
Tuberoinfundibular pathway blockade leads to hyperprolactinaemia
2 types:
Typical = D2 antagonist
Atypical = D2 + 5HT2a
SE:
typical - extrapyramidal (Parkinsonism, acute dystonia, akathisia, tardive dyskinesia), sedation (histamine), anticholinergic (constipation, dry mouth, urinary retention, confusion), postural hypotension, impotence
Atypical - Weight gain, hyperprolactinaemia, sedation, QTC prolongation, postural hypotension, anticholinergic, reduce seizure threshold, agranulocytosis
To reduce:
Reduce qqt of drug, switch to atypical or procyclidine can be used EPS (anticholinergic) Parkinsonism, akathisia, acute dystonia
To improve compliance - depot
NMS:
- fever, tachy, fluctuating BP - due to muscle contraction
- Raised CK/Myoglobin, MI
- muscle rigidity, tremor
- altered mental status
- autonomic dysfunction
Protect airways, stop antipsychotic, cool, dialysis for AKI/rhabdo, benzo if agitated, Bromocriptine, amantadine, dantrolene in sever cases
Alcohol dependance
- criteria for dependance
- alcohol limits
- how would discuss with patient
- management
> 3 or more of
- withdrawal, lack of control over qqt, impulse, difficulty controlling when start/stop, tolerance, affecting other activities, persisting despite negative effects
Alcohol limit is <14 units a week spread over 3 days
CAGE (>2)/AUDIT (>16) score - screen for heavy alcohol use
SADQ score - measure dependence & tolerance
Brief intervention: FRAMES F - feedback (risks) Dependance can lead to: - Alcoholic liver disease, cirrhosis, liver failure - pancreatitis - cause high blood pressure - Cancer incl head/neck, bowel - Wernickes, Korsakoff - Peripheral neuropathy - Sexual dysfunction
R - responsibility to change A- advise the need to cut down M - menu of alternative options - (non drinking days, different alcohol, low alcohol drinks, alternative activities E - empathetic interviewing S - self efficacy
Mx:
- CBT
- Alcoholics Anonymous
- Family, social behaviour therapy
- Rehabilitation
- Advice of social drinking, keeping an alcohol diary
Meds - Antabuse (drinking brings on nasty SE), Naltrexone/Nalmefene (reduce pleasurable effects), Acamprosate (reduces cravings)
For withdrawal (delirium tremens) - reducing dose of chlordiazepoxide over 5-7 days and thiamine (pabrinex)
4 features of nephrotic syndrome
Hyperlipidaemia, proteinuria, hypoalbuminuria, peripheral oedema
Paracetamol overdose - specific Ix and Mx
Ix: Take plasma paracetamol lvl 4 hours post ingestion U+E, LFT as baseline Regular BM for hypoglycaemia Clotting screen, INR ABG for Acidosis
Mx:
If within an hour give activated charcoal
If >4 hrs but <10-12 hours, >100mg/L then give 3 bags of IV N-acetylcysteine infusion over 21 hours
If doubt about timing or staggered give irrespective
If >150mg/kg give prior to bloods
Stop when level <10, bloods normalise
If pH <7.3, Lactate or INR high, high grade encephalopathy consider transplant
Acute liver failure management
Fulminant if no known prev liver disease and altered clotting
Ix:
Hx - ask about onset of jaundice and encephalitis
Asses consciousness/ mental state and do abdo exam for asterixis/ ascites
Raised PT, low Albumin
Do routine bloods (FBC, LFT, U+E, glucose, INR, ammonia) and liver screen (hep b/c AI etc)
High ammonia -> encephalopathy
Do G+S, blood culture if suspect infection
ABG for lactate
Liver US + doppler for Budd chiari
CT - Assess for cerebral oedema, raised ICP, EMG
Investigate for cause
- caeruloplasmin (low), alpha 1 antitrypsin, ferritin (haemochomatosis), ANCA, AI screen, Alcohol, viral
Mx:
Treat cause
Fluid resus - fix distributive shock with: Fluids, monitoring urine output, BP
Encephalopathy -Lactulose with neomyciny, mannitol can reduce ICP
IV glucose
Coagulopathy - clotting factors, plasma, platelets, PPI to stop bleeding
AKI - Correct electrolytes, dialysis
Abx prophylaxis
Consider transplant based on kings college criteria if high INR, quick onset encephalopathy, high bilirubin
PEPSE - what drugs, how work, how manage
Truvada OD + Raltegravir BD for 28 days
Works by inhibiting viral replication stopping the virus from entering the blood and reaching the LN
Can do if present within 72 hours of event
Screen for STI, do HIV, check baseline U+E, LFT prior to starting
Give emergency contraception if needed, ensure woman avoids getting pregnant whilst on treatment
Consider Hep B vaccine
Side effects include: tiredness, diarrhoea, nausea, vomiting, feeling generally unwell
HIV test at 8-12 weeks post exposure
Advise to attend future regular sexual health checks
Pre-exposure prophylaxis is just Truvada OD
SE of bisphosphonate + how to take
- Oesophagitis and oesophageal ulcers
- Osteonecrosis of the jaw
- Atypical fractures of the proximal femoral shaft
- Acute phase reaction: arthralgia, myalgia and fever
- Hypocalcaemia
- Alopecia
- Allopecia
Take 30 mins before a meal and sit upright for 30 mins after
Medication review/ history
WIPE Ask about any recent symptoms, anything they want to discuss about their medication Take a brief PMHx, Social Hx, allergies Ask about prescribed medication - indication, when start, dose, dose regimen, when do you take, how do you take OTC meds Extras - inhalers, creams ICE Summary, advice, med changes, plan
Dyspepsia CBD - differentials and mx
GORD:
Heartburn - worse post meal when lying flat or leaning forwards
Peptic ulcer:
Present with Abdominal fullness, heartburn, nausea, belching or upper abdominal pain, heartburn, malaena
Eating worsens gastric, improved duodenal
GORD Peptic ulcer Hiatus hernia Gastroparesis - DM Malignancy Drugs lactose intolerance Coeliac
Lifestyle - smaller more regular meals, lift head in bed, eat meals earlier, weight loss, avoid trigger foods, smoking, stress/anxiety
GORD:
Ix - PPI trial, OGD if any alarm symptoms (anorexia, anaemia, loss of weight, IDA, melaena)
Mx
Consider a month trial of PPI to help the oesophagus heal, if severe 2months. If recurrent put on lowest effective dose long term
If ineffective consider laparoscopic fundoplication
Peptic ulcer:
Ix - Hpylori breath test or stool antigen test (not have taken PPI for 2w or Abx for 4), OGD with biopsy, FBC for anaemia due to blood loss,
Mx
Review meds (aspirin, bisphosphonates, corticosteroids, potassium supplements, SSRIs, cocaine)
Ask about prev Abx that could affect H pylori tx
7d - Omeprazole, clarithro and amoxicillin
Retest breath or stool test as TOC
Hiatus hernia/ malignancy - Barium swallow or endoscopy
Diabetes management and Annual review
Diabetes is diagnosed as a HbA1c > 48, Fasting >7 or random glucose >11.1
1 +ve result with sx, 2x if no symptoms
First line management is lifestyle, education (DESMOND, X-pert programmes)
- exercise, reduce intake of sugar, low GI foods, reduce alcohol, stop smoking, weight loss, screening
If HbA1c > 48 start metformin 500mg OD, each week increase by 500 to max of 2g
If HbA1c >53 then start then add DPP4, SGLT2, pioglitazone, SU
If still >53 - triple therapy
SU - hypo, gain weight
SGLT2 - (gliclazide) Improve weight, cardio and renal protective (not work if eGFR <60
TZT - contraindicated with haematuria
DPP4 - (-gliptin) not improve weight, use in liver or renal failure
GLP-1 - (-tide) third line, only use if already on triple therapy
If insulin/ SU - aim 53
If others aim 48
Consequences
Microvascular - neuro, nephropathy (peripheral, autonomic e.g. gastroparesis, erectile dysfunction), retinopathy
Microvascular - ischaemic heart disease, stroke, PVD
Annual review
Take a hx, ask about how managing, sx, SE of tablets
Depression and anxiety
Qrisk to look for CV disease - cholesterol, BP, BMI
Do a blood glucose measurement - HbA1c
Diabetic retinopathy screen
Foot exam - check sensation, for ulcers, do ABPI
Ask about autonomic SE including erectile dysfunction, gastroparesis
Nephropathy - early morning first pass urine specimen for ACR, also do creatinine level for eGFR
Differentials for swollen foot and mx of charcots
Localised: DVT, cellulitis, rheumatoid arthritis, lymphedema, malignancy
Systemic: Heart failure, liver failure, nephrotic syndrome calcium antagonists, NSAIDS, hypothyroid
Have neuropathy, greater than 2 degrees difference in temp between two feet
Charcot Mx:
Xray and screen for infection and ulcers: involves MDT, nurses, podiatry, diabetes drs, orthopaedics
Immobilisation of the joint in a cast (or with orthopaedic stabilisation), which will usually remain in place for 3 – 6 months (monthly X-Rays are used to assess progress) - takes weight off of foot to allow healing
Surgery is required if foot deformity puts the patient at risk of ulcers or protective footwear (custom braces and orthotic footwear) is not effective. Also if is unstable fractures or dislocations.
Longer term management is with optimisation of diabetic control, including BP and lipids, as well as specialised footwear and education
Important to regularly check the feet for ulcers
May require amputation if not healing and infection
The total process of healing usually takes 1 – 2 years
Give antibiotics as needed,
Cataract management - phacoemulsification procedure and complications
Caused by normal ageing, trauma, steroids, DM
Clouding, loss of vision, washed out colours, glare, defect in red reflex
Ix: Check visual acuity with snellen, colour vision and peripheral vision with Humphrey's Dilated fundoscopy Slit lamp exam Tonometry - assess IOP Wild field fundoscope images OCT for macula degen and oedema
Mx
Conservative - watchful waiting, optimisation of glasses
If visual impairment refer for phacoemulsification +/- intra-ocular lens implant
To drive: need to be able to read a number plate from 20m away and need to see at least 6/12 on snellen
Phacoemulsification - LA - Incise into cornea - remove anterior lense capsule - Using US break up and aspirate lens - remove cortex - Insert post chamber IOL into capsule (decide lens using biometry which includes measurement of the eye) - postop given topical steroids and antibiotics
Complications - rupture of posterior capsule leading to a dropped nucleus. Post operative can get infection called endopthalmitis (staph epidermidis). Can also get post op raised IOP, macular oedema, retinal detachment
AMD
CP leads to death of retinal pigment epithelium
geographic atrophy and neovascularisation
Loss of central vision and distortion of vision (straight lines appear crooked, fluctuates from day to day
Ix: Slit lamp Dilated fundoscopy Visual acuity Retinal wide field imaging OCT can identify drusen Amsler grid Fluorescein angiography
Mx:
Educate, stop smoking, exercise, diet rich in leafy green veg and fruit, antioxidant and mineral supplements e.g. AREDS2, register as sight impaired
Dry
- give an amsler grid, say to self monitor at home
In early stages observe, visual rehab, safety net
If neovascularisation
- anti-VEGF (bevacizumab), injection monthly for 3m
- other options - laser photocoag, photodynamic therapy with verteprofin and implantable miniature telescope (focuses central visual field onto healthy portion of retina)
What type of drug typically causes a cough?
ACEi
Acute viral hepatitis management
LFT, U+E, FBC, CRP, coag
Viral serology including hep B/C antibody antigen tests
HCV RNA, HBV DNA
Hep B - acute
Hep C - more chronic
Treat with:
Avoid unprotected sexual intercourse
Contract tracing, inform local health protection team
Regular monitoring of INR, PT and LFTs
Avoid alcohol and stop non essential meds
Supportive treatment with fluids, antiemetics, rest
Treat itching with chlorphenamine
Consider antiviral agents if fulminant hepatitis or chronic
GCA management
Ask about joints (polymyalgia rheumatica), scalp, vision, jaw, resp tract sx
Ix: Exam, bloods: FBC (normochromic normocytic anaemia and an elevated platelet count) , U+E, LFT (raised ALP), ESR, CRP Fundoscopy (CRAO), RAPD Biopsy Duplex US PET
Mx: If strong clinical suspicion start high dose corticosteroids immediately prior to confirmation with biopsy - IV Methylpred if eye - 60mg pred if jaw, 40mg if no jaw - Assess response after 48 hrs - Taper and continue for 1-2 years Start aspirin 75mg daily unless contraindications \+ PPI If recurrent tocilizumab
Epilepsy Hx and management
> 2 unprovoked seizures occurring more than 24 hours apart – within a year of each other
Ix: CV, neuro, MSE - identify injuries Routine obs FBC, U+E, LFT, CRP, BM (hypoglycaemia), Raised prolactin and CK ECG MRI - look for structural cause EEG
Mx:
Advise on water safety (shower not bath, buddy system), leave bathroom door unlocked, fire safety and cooking, environment and work safety. Care with heights, high risk activities and consider contraception for certain meds. Advise family and carers.
1st seizure - 6months for car 5 years for HGV
epileptic seizure 1 year for car
>1 seizure - 10 years for HGV
Focal - carbamazepine
Tonic-clonic seizures: sodium valproate or lamotrigine.
Absence seizures: ethosuximide or sodium valproate
Myoclonic seizures: sodium valproate or topiramate.
Status epilepticus = seizure >30 mins or recurrent without regaining consciousness (treat at >5mins)
AtoE
Lorazepam 4 mg IV, if unavailable;
Diazepam 10 mg PR, if unavailable;
Midazolam 10 mg buccal
if 2 doses of above 10 mins apart, if not work give phenytoin
If phenytoin not work transfer to ITU for GA
Ureteric stones mx
Ix: Bedside - urinalysis and culture Bloods - urate and calcium levels, FBC, U+E, LFT, CRP, Ca, PTH (exclude high ca as cause), uric acid Imaging - US for hydronephrosis, CT KUB Stone analysis
Struvite stones - stag horn calculi
Mx:
Advice to increase fluids, loose weight, reduce salt/urate/oxalate/protein in diet
At home, (<5mm) - fluids, pain relief (PR diclofenac), antiemetic - most pass within 3w. Refer all to urology within 7 days. can help passage with CCB (nifedipine) or alpha blocker (tamsulosin)
In hosp - AtoE give IV fluids If hydronephrosis - stent, nephrostomy, catheterise Treat infection Shock wave lithotripsy Percutaneous removal Uretero-renoscopy
Prevention - potassium citrate, thiazide diuretics
Ascites mx
Ix:
Regular bloods, Clotting, albumin, ascitic tap, liver screen, US, MRI/CT
Perform ascitic tap if suspect SBP - raised WCC and neutrophils. Treat with abx (cefotaxime/ ceftriaxone) and human albumin solution
Put on a low salt diet - in some this will be enough to resolve
1st line fluid restrict and spironolactone
2nd line furosemide
Aim for no more than 1kg loss a day
If large, refractory or causing resp compromise paracentesis followed by plasma expansion
If persistent - TIPS
Cholestyramine for pruritis
Diabetic retinopathy CBD
1 yearly checkups - 2 x digital fundus photographs
Ix: Presence of micro aneurysms, haemorrhages, cotton wool spots, hard exudates on fundoscopy OCT can show macula oedema Fleuroscein angiography B scan US to look for detachment Examine cranial nerves Check red reflex for cataracts
R0 - no changes R1 - just haemorrhage or microaneurysm R2 - extensive above or cotton wool spot R3 - neovascularisation M0 - no maculopathy M1 - maculopathy present
Tx:
Optimise glucose, BP, lipids
Stop smoking, healthy diet, observe
Macular oedema - focal laser, intravitreal steroids
proliferative retinopathy - pan retinal photocoag, anti-VEGF (bevacizumab)
Vitrectomy if virtual bleed
Features + Management of graves eye disease
Periorbital oedema, intraocular muscle swelling, redness, photophobia, eyelid retraction, proptosis
Ix: TFTs and MRI of orbits, anti-TSH receptor antibodies
Management:
Conservative first line - lubricating/ NSAID eye drops, stop smoking, avoid dmg to eyes with sunglasses when out, taping shut at night. Prism glasses.
To reduce inflammation use corticosteroids
Surgery if raised IOP (decompression), if scar tissue pulls eye out of alignment
Red painful eye CBD
Ix:
Visual acuity, slit lamp exam, gonioscopy
Acute angle closure - acetazolamide and pilocarpine + laser iridotomy
Keratitis - corneal ulcer, red, painful, photophobia, corneal infiltrate (staph a, pseudomonas, herpes). Diagnose by presence of lesion on slit lamp. Manage with corneal scraping, intensive topical antibiotics (broad spectrum at first e.g. gentamicin), cyclopentolate for pain relief
See acanthamoeba in contact lense wearers
Avoid steroids in keratitis, herpes keratitis as would dampen immune system
Uveitis - pain, photophobia, flashers, floaters, blurring
Aqueous flare, synechiae, HLA B27
Treat cause: non infectious - corticosteroid eye drops, cyclopentolate for pain and systemic immunosuppressants e.g. methotrexate
Eating disorder Hx + Mx
Defined as BMI below 17.5 kg/m2
Ask about binge eating, purging, vomiting, perceptions towards appearance, typical food consumption in a day, how often weigh self or look in mirror, make excuses not to eat. Ask about excessive exercise, any tablets used to loose weight. Lack of insight into own weight loss. Ask about menstrual irregularities, sexual dysfunction, weakness, fainting, fatigue, constipation, changes in skin or hair, seizures?
SCOFF questionnaire
do you make yourself Sick
have you lost Control over how much you ear
lost > One stone in last 3m
Do you believe you are Fat when others say you are thin
would you say Food dominates your life
Routine obs + blood glucose
Sit-up, Squat–stand test - rank difficulty
BMI, FBC, U+E, LFT, CRP, ESR, TFT, Bone profile, Mg
ECG
Pregnancy test
Consider DEXA if <18, >1year
Assess risk with marsipan document
Immediate referral to CAHMs, community mental health team or eating disorder specialist
If high risk, risk of referring syndrome admit
<18 - anorexia focussed family therapy or individual CBT/ psychotherapy second line
> 18 - eating disorder based CBT, group therapy
If refuse to eat - NG tube and TPN, consider sedation if refusing, emergency crash team
General
monitor food consumption + U+Es
Avoid QT prolonging drugs e.g. citalopram
If vomiting - dental checkup, rinse mouth with mouthwash after rather than cleaning
Stop excessive exercise/laxatives
Dexa scan, refer to diabetes if insulin misuse
Advise against conception until weight improves, give contraception even if amenorrhoea
Refeeding syndrome electrolyte changes
Low potassium, magnesium, phosphate and thiamine
Fluid retention leads to peripheral oedema
Can get fluid overload, HF and arrhythmias
Adrenal insufficiency (Addisons) management
Hypotension, fatigue, weight loss, GI/MSK sx, hyperpigmentation, hair loss in women, salt craving
Ix:
Early morning serum cortisol
Synacthen test
Test ACTH level to differentiate primary and secondary
Electrolytes - low sodium, high potassium
Mx:
Educate that it is a chronic condition, will need to take medication for the rest of their life. Is important they take the medication every day, not suddenly stop. Ensure they know how to recognise an adrenal crisis (hypotension, hypovolaemic shock, low blood glucose, N+V, abdo pain, low grade fever)
Treatment involves a combination of hydrocortisone taken 3x daily 10mg on waking, 5mg at noon and 5mg in the evening and fludrocortisone
Can get all their medications for free
Wear a medic alert bracelet
Educate on sick rules
- mild to mod (fever, Abx) - 2x dose for 2 days
- severe - 2x dose, cont until better
- vomit - if vomit within 30 mins, double dose again immediately, if again then 100mg hydrocortisone inject
- maj surgery - cont infusion
If go abroad take enough for double doses + injection kit
Addisonian crisis - hypotension, high K, low NA, vomiting, weight loss
AtoE
Identify cause, screen for infection
Iv hydrocortisone 100mg-200mg
IV fluid rehydration
Cushings management
Central obesity, HTN, insulin resistance, facial redness, purple striae, easy bruising, premature osteoporosis, facial rounding, menstrual abnormality, acne, mood changes
Ix:
1st 24hr urine free cortisol or 1mg overnight dex suppression test
- 3.5-4.5 norm for urine, <2 norm for suppression test
2nd - repeat (2mg instead) to confirm +ve
3rd - ACTH lvl (differentiate if primary or secondary)
4th - High dose (8mg) dex suppression test (differentiate between secondary causes of pituitary or ectopic small cell lung cancer
CT adrenals, MRI pituitary, CT chest if ectopic
Mx:
Surgical removal of adrenal tumour, pituitary adenoma or cause of ectopic ACTH
Transsphenoidal pituitary adenomectomy
Radio or bilateral adrenal removal second line
Metyrapone, ketoconazole - can block production or function of cortisol
CKD management
Causes - HTN, DM, Nephrotoxins, Nephrotic/Nephritic, PKD
Diagnose if eGFR <60 or ACR >3 for at least 3 months
Ix:
CKD is defined by albumin:creatinine ratio (taken early morning) and the creatinine (GFR)
Other investigations need to do include U+E, BP, BM, ca, PO4, Hb, PTH
(high ca, high PTH, low PO4)
Also CT KUB, US kidneys, ANCA/ANA, urinalysis, culture, biopsy if glomerulonephritis
Mx:
Treat cause - immunosuppressants for glomerulonephritis, diabetic drugs, antiHTN
Stop nephrotoxics, monitor, lifestyle changes
Give statins, aspirin (if high risk CVD)
Keep blood pressure below 130/80 - ACEi
Correct any fluid overload with diuretics
Correct any electrolyte imbalances (K+ high)
Replace EPO if anaemia
Vit D, Ca supplements, PO4 binder
If acidosis give bicarb
End stage - renal replacement therapy or transplant (5-7 or <10 w. sx)
Tumour lysis syndrome
Changes
- High K+
- High PO4
- High uric acid
- Low Ca
Lab TLS - if 2 or more of above are abnormal or change by >25% within 3d before, 7d after chemo
Do ECG
Clinical TLS = Lab + symptoms (raised creatinine, seizure, dysrhythmia)
Large tumour burden haematological malignancies with recent chemo most common cause
Management: General - prechemo fluids Low risk - just fluid Mod risk - allopurinol 7 days High risk - 1 dose rasburicase 3mg
Acute:
Uric acid - Rasburicase
PO4 - give phosphate binders e.g. aluminium hydroxide
K+ - calcium gluconate, insulin/dextrose solution
Ca - calcium gluconate
Renal failure - fluids and haemodialysis if needed
Breast cancer
Screening - every 3 years from 50-70
earlier if gene mutation, have MRI
Investigations:
breast exam, US, cancer markers (CEA, CA 15-3)
2ww:
> 30 + unexplained breast lump or >50 + nipple discharge, retraction.
Triple assessment: Hx and exam, imaging, Biopsy/FNA Hormone receptor status CXR, routine bloods US of LN CT if suspect mets
Nottingham prognostic index predicts survival/ relapse
Treatment
- wide local excision - breast conserving
- Mastectomy with reconstruction
- +/- LN biopsy/clearance
- +/- chemo with anthrocycline
- alternative is radiotherapy
Hormone therapy - cause infertility
If ER positive - Tamoxifen if premenopausal or Anastrozole if post menopausal
If HER2 positive - Herceptin
Depression Hx
Open consultation - Acknowledge difficult topic say if want to stop and have a break at any time please say
How long been going on for, any triggers?
How much been affecting life - appetite, sleep, exercise, social life, hobbies, mood, libido
How changed over time
Anything your worrying about
Anything pre-occupying your mind
When is it at its worst
What do you feel is getting you through
Hows your concentration, how feel about self, how feel about future
Have you ever thought about harming yourself or others
Have you ever felt the opposite to how you are now, particularly high?
What do you think is causing this, anything you’re worried about?
Have you ever felt like this before?
Have you ever suffered with mental health conditions before or been on any medication
How are you otherwise, fit and healthy
Any family history of mental health conditions?
Do you drink, smoke, take drugs? Live alone, with family? Able to look after self? Relationships? Support network?
