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?
Bacteria affecting valves in IE + how diagnose
Normal valve - staph A
Abnormal valve - strep viridens
Prosthetic valve - staph epidermis
Investigate with DUKE criteria
2 major (+ve blood culture, evidence of endocardial involvement)
1 major, 3 minor
5 minor
STEMI management
Ix:
Hx, Exam
Serial troponin, CK-MB, myoglobin if recent MI
ECG - look for ST elevation, new LBBB, Q wave
ECHO/ CXR
Bloods - FBC look for anaemia, U+E to check renal function for contrast, BNP
O2 sats
Mx Morphine +metoclopramide O2 if sats <94% Nitrates - GTN infusion Aspirin 300 Relocate to cardiac intensive unit Ticagrelor 180 Unfractionated heparin - give for max of 5 days, stop post PCI
PCI with stent (or CABG if multi vessel disease) within 90 mins, if not possible within 120 give thrombolysis w. alteplase or streptokinase
If low CO consider ionotrope e.g. dobutamine
Post MI discuss lifestyle - smoking, alcohol (<14), exercise (150 mins a week, weight training at least 2days), cardio protective diet (reduced salt and fat, more fruit, seeds and nuts, more fish).
Start on ACEi Beta blocker Antiplatelet - aspirin + ticagrelor - 12m, after this cont aspirin, stop ticagrelor Rehab Statin
Antianginals - give ranolazine if low BP
Presentation and treatment of cardiac tamponade/effusion
Raised JVP, low BP, muffled heart sounds
Lie with feet up
Treat cause (infection, malignancy, aortic dissection, AI), most resolve on own
IV fluids, O2
Ionotropes e.g. dobutamine
Pericardiocentesis, pericardial fenestration
AVNRT - young person who collapses with palpitations
Manage with Vagal manoeuvre. If not work try adenosine to slow heart rate (see cause) then verapamil, then DC cardioversion, then amiodarone
Long term ablation, beta blocker,
Stop driving until sx controlled for 4w
CLD causes and investigations + complications
Alcohol - history
Hep B/C - history and serology
NAFLD - hx, exclusion
Hered haemochromatosis - ferritin, transferrin
Alpha-1-antitrypsin deficiency - A1-AT lvl
Wilsons - caeruloplasmin
AI - Hepatitis, PBC, PSC - AI screen
complications
- anaemia
- clotting issues, low platelets
- encephalopathy
- varices
- HCC
- Low albumin and ascites
- SBP
- altered drug metabolism
When to perform emergency dialysis
Hyperkalaemia
Pulmonary oedema
Uraemic encephalitis or pericarditis
Metabolic acidosis
Pleural effusion - management
Cough, SOB, pleuritic chest pain
On exam looking for stony dullness, reduced breath sounds, reduced chest expansion, reduced vocal resonance
Take detailed history to elucidate cause
Do CXR, bloods to differentiate causes, ABG, CT if suspect malignancy, ECG/echo for HF
Important take a sample of pleural fluid using US to differentiate cause - look at protein, LDH. Not needed if bilateral effusion typical of transudate
if asymptomatic - 50ml, if symptomatic aspirate till sx improve
Send for biochem (pH, protein, LDH, glucose), cytology (blood), microbiology (gram stain and culture)
If >35 = exudate (unilateral) - cancer, infection, PE, AI, pancreatitis
If <25 = transudate (bilateral) - HF, LF, RF, hypo-albumin, peritoneal dialysis
Can also be haemothorax, chylothorax, empyema (pH <7.2)
If between the two use lights criteria - is exudate if
Protein pleural: blood >0.5
LDH pleural:blood >0.6
LDH pleural >2/3 upper limit of normal for serum
Also send aspirate for cytology, pH, glucose, gram stain, culture and sensitivity, acid fast bacilli
Treatment
If transudate - treat underlying failure - diuretics etc
If exudate
- small - observe
- infection - Abx
- Large - therapeutic aspiration (no >1.5L), chest drain
- If recurrent - long term chest drain or pleurodesis
Bronchiectasis - cough and lots of sputum (bloody)
Causes and management
Prev LRTI, TB
Asthma/COPD
CTD - SLE, RA
CF, kartagners
On exam: Clubbing, coarse crackles, rhonchi, high pitch squeaks and pops
Ix
O2 sats, sputum culture
FBC, U+E, LFT, CRP, ANCA, ANA, RF, ant-CCP, genetic for CF, specific IgE for ABPA
Bronchoscopy if single area, suspect aspiration
High resolution CT shows signet ring, dilation without thickening
Tram track on xray
Mx
Stop smoking, annual vaccines, physio for sputum clearance, acapella/flutter devices
Humidification
Mucoactive agent - saline neb, DNAase, carbocisteine
If >3 exacerbations a year azithromycin prophylaxis
Bronchodilators - SABA/LABA
Treat cause e.g. CF
LTOT if sats <88% or PO2 < 7.3
Surgical - lung resection if localised, transplant if <65
Psoriasis - hyper proliferation of keratinocytes
Symmetrical erythematous patches, papules and plaques with overlying silver scale
Differentials - dermatitis, lichen planus, cutaneous lymphoma
Recent alcohol binge -> rash = psoriasis
Ix:
Clinical diagnosis, skin biopsy only if doubt
Auspitz sign - removal of scales causes capillary bleeding
IBD, assess CV risk
Ask about nails (pitting and onycholysis), joints, dactylics (swelling of digit)
Dermatology quality of life index score
Use psoriasis area and severity index (PASI) to assess severity, also assess body surface area affected
Tx:
Educate, is chronic condition, help sx not cure
Identify + avoid precipitants, stop smoking, alcohol, healthy lifestyle diet and exercise
Emollient, salicylic acid for scale/itch
1st line - vit D analogue OD + topical corticosteroid OD
If after 4-8 weeks not gone stop steroid and try vit d analogue BD for 12 w.
If still not better consider corticosteroid BD or coal tar
If ongoing treatment resistant consider referral and dithranol
Dermatology - topical calcineurin inhib, ciclosporin, acitretin, narrow band UVB. If UVB ineffective consider methotrexate, ciclosporin or TNF alpha inhibitors e.g. adalimumab
For joint - do xray (central erosions), bloods, joint aspiration. Treat with NSAID first line, 2nd line corticosteroid injection and if active disease methotrexate, if dactylitis or entheses - adalimumab, NSAID
Guttate psoriasis - rain drop lesions, commonly post strep throat, treat with phototherapy
Pustular psoriasis - acute withdrawal of psoriasis meds - treat with supportive care and systemic management
Eczema mx
Red itchy rash in skin folds
Erythema, scaling, papules, scratching lead to excoriation, lichenification
If round, scaly = discoid eczema
Ask about hx of atopy
Ix
- clinical
- consider allergy testing
- swab if suspect infection
- eczema area and severity index
Mx
- educate patient is a chronic condition that will come and go, requires treatment all the time, can become infected (red, hot swollen) if so see the doctor, usually grow out of it, avoid exacerbating agents
- avoid allergens, tight clothing, soap substitutes, keep house cold, cut finger nails and avoid animals
Mild - emollient + mild topical steroid (put steroid on 30 mins post emollient)
Mod - emollient + moderate topical steroid + non sedating antihistamines if itch (maintain on steroid or calcineurin inhib)
Severe - emollient + potent topical steroid + antihistamine (sedating if itch affecting sleep) or oral steroid. Can also use calcineurin inhib e.g. tacrolimus
Mild - hydrocortisone
Mod - bethametasone - 0.025%
Severe - bethametasone - 0.1%
Refer to derm - phototherapy, immunosuppressants e.g. methotrexate, biologics,
Treat 2ndry infection with fluclox
if develop blisters - think eczema herpeticum
ve Management
Ix:
MRI/CT - look at size of ventricles (normal)
LP - assess pressure
Visual field mapping
Mx: Loose weight, lifestyle Acetazolamide, serial LP can drop ICP Prednisolone for papilloedema Surgery - bariatric, CSF shunt
Extradural/ subdural mx
Ix:
CT head - extradural lemon, subdural banana
If small, no sx watch and wait
If large, causing symptoms then consider surgical decompression with burr hole
Manage fall holistically
MG management
Often first sign is drooping of eyelid and diplopia, then get muscle weakness that is worse with exertion. Worse at end of day.
Myopathy, eye trauma, third nerve palsy, cyst or swelling
- differentials for MG eye symptoms
Ix:
Do a full neuro exam, assess vision and muscle weakness
Crushed ice on eye for 3 mins, improves ptosis
Ask to count to 50 and see if they tire
Anti-Acetylcholine receptor antibodies
Repetitive nerve stimulation test
CT/MRI of thymus to look for thymoma
Tensilon test - rarely done as can cause bradycardia
Mx:
Myasthenic crisis - intubation, mechanical ventilation + immunoglobulins, plasma exchange and steroids
Treat with acetylcholinesterase inhibitor e.g. pyridostigmine, add steroids or azathioprine if not sufficient. Is also rituximab, biologics
TPMT before start azathioprine, not combine with allopurinol
Oral atropine for muscarinic SE
If thymoma present - thymectomy
GB - management
Ix Clinical diagnosis of ascending weakness, parasthesia and hyporeflexia occurring post infection Do NCS, EMG Look for antibodies Do LP - protein in CSF Spirometry if suspect resp involvement Routine bloods
Mx:
Immunoglobulins and plasma exchange
Supportive care - treat resp failure, monitor heart, give analgesics and DVT prophylaxis
Improves over time
MS -Mx
vision problems/ pain on eye movement + weakness, sensory loss, loss of control over bladder/bowel + electric shock on neck flexion
Also get internuclear ophthalmoplegia
Ix sx worse when hot (uhthoffs) Routine bloods, vit B12, HIV MRI LP - oligoclonal bands Antibody testing EDSS to assess disability
Mcdonald criteria
- inflammatory cause
- no other cause
- lesions at different locations at different times (>2)
If just one lesion = clinically isolated syndrome
Differential - neuromyelitis optica
Mx Education and general care Oxybutynin for bladder dysfunction Laxatives for constipation SSRI for depression PT/OT for mobility neuropathic pain killers amantadine for fatigue baclofen for spasticity
acute relapse - steroids +ppi
long term - beta interferon glatiramer
Lung cancer pancoast presentation and overall mx
Present with dry cough, worse at night, haemoptysis, SOB, chest pain, weight loss
Can present with SVC obstrusctuction - facial venous engorgement
Pancoast:
Sympathetic chain, subclavian vein, brachial plexus -> horners (anhidrosis, ptosis and miosis), pain, weakness, atrophy, oedema in upper limb
Also get laryngeal nerve involvement -> hoarse voice
Differential = lung abscess, cervical disc prolapse with concurrent TB, Lung mets
2ww if evidence of cancer on CXR or >40 with haemoptysis
Ix:
Obs, FBC (anaemia), LFT (ALP high in bone mets), U+E, bone profile (Ca may be raised due to PTH or bony mets, Na may be low if SIADH)
CXR, CT TAP, Bronchoscopy with biopsy or percutaneous biopsy
Paraneoplastic
Squamous - PTH
Small cell - ACTH, SIADH, Lambert eaton (antibodies to voltage-gated calcium channels, prox and ocular weakness better with exercise)
Mx:
Stage fitness with ECOG
Early disease consider surgery (lobectomy)
Consider adjuvant or neoadjuvant chemotherapy (platinum based)
Radiotherapy often used in palliative cases
Periop care
Support head and control airway during movements
Warming - prevent coagulopathy, periop cardiac events, reduce risk of postop infection - Anaesthesia cause vasodilation
Fluid balance for perfusion
Positioning – avoid nerve and pressure injury
Prevent awareness, maintain appropriate level of anaesthesia – unplanned recall of events
Muscle relaxants as and when needed by the surgeon
Manage haemorrhage with blood transfusion or fluids
CV manipulation
Increase HR with anti-muscarinic (atropine or glycopyrrolate) or mixed beta-adrenoceptor agonist e.g. ephedrine
Reduce HR with Beta blocker
Increase BP with alpha 1 adrenoceptor agonist e.g. metaraminol
Reduce BP with alpha antagonist e.g. phentolamine
Operative and anaesthetic risks/ complications
Haemorrhage, basal atelectasis, shock, sepsis, DVT/PE
Compression stockings, enoxaparin pre and post op
Obs for shock: Low BP, tachycardia, tachypnoea, low O2 sats, reduced urine output
Sepsis 6
Basal atelectasis - deep breathing exercises and physio
Anaesthesia anaphylaxis: IM adrenaline, chlorphenamine, hydrocortisone, fluid challenge
On intubation or removal of ET tube:
Bronchospasm: IV salbutamol +/- aminophylline Laryngospasm: Check airway clear, 100% oxygen (CPAP), may need suxamethonium to relax muscles or propofol to deepen anaesthesia and re-intubate
Clonidine used to treat shivering as muscle contraction increases O2 consumption
Malignant hyperthermia – Autosomal dominant
Caused by volatile anaesthetic/ suxamethonium
Increased O2 consumption, hypercapnia, raised HR/RR, acidotic, hyperthermia
See rhabdomyolysis – raised myoglobin, creatinine kinase, potassium
Stop current anaesthesia (volatile) and start propofol
Give dantrolene + 100% O2, cool via cold IV saline, NG lavage, give bicarb if acidosis, treat high K+, treat dysrhythmias
Vertigo CBD
Ask: how long for? Tinnitus, hearing loss, what makes better, what makes worse, headaches, visual changes?
If seconds to minutes, comes on when turning head, no tinnitus or hearing loss: BPPV
- diagnose with dicks hall pike manoeuvre (rotary nystagmus)
- treat with epley manoeuvre
- educate, advise against sudden head movements and sit/lie down in stages
If >20 mins to hours, fullness in ear, sensorineural hearing loss, tinnitus, N+V = Menieres
- inform DVLA
- limit salt, alcohol, caffeine as can trigger
- avoid dangerous activities
- prochlorperazine for vertigo and nausea
- beta-histone as prophylaxis, diuretics in 2dry care
- hearing aid for hearing loss
If spont vertigo lasting days = acute labyrinthitis (hearing loss) or vestibular neuritis (no hearing loss). Often post viral infection.
- resolves on own in few weeks
- start moving as soon as possible
- not drive when dizzy
- if severe consider antihistamine/ antiemetic e.g. prochlorperazine
- give antiemetics, hydration, vestibular rehab
If central (also sx of dysphagia, dysarthria, diplopia, dysmetria) - brainstem lesion or acoustic neuroma
Nose fracture management
If suspected septal haematoma – same day
5-7 days for first ENT OPD follow up from date of injury (allows for bruising/swelling to settle)
7-21 days for MUA (manipulation under anaesthetic) – callous formation occurs after this
3-6 months if thinking of operation (rhinoseptoplasty) – await full healing
Sore throat CBD
Examine throat with tongue depressor (not use if stridor due to epiglottitis)
Common causes: cold, influenza, strep, infection mononucleosis, herpetic pharyngitis, smoking, acid reflux, hay fever, leukaemia
Splenomegaly, cervical lymphadenopathy, mono-spot test can be used to identify IM
2 main causes are tonsillitis and infectious mononucleosis
Tonsillitis can be viral or due to strep pyogenes
IM is caused by EBV
To differentiate the two look at LN - if only anterior chain involved most likely strep if widespread lymphadenopathy most likely IM
Use feverPAIN and Centor criteria to identify strep throat
- fever, lymphadenopathy, exudate, no cough
Advise general measures to make more comfortable
- Regular use of ibuprofen and paracetamol
- Adequate fluid intake
- saltwater gargle, local anaesthetic lozenges/ spray
In mild cases usually get better by self, help sx with above
May prescribe back-up prescription - Phenoxymethylpenicillin first line for 10 days
In severe - if dysphagia and high fever consider IV fluids, Abx and steroids. If sx of severe sore throat, dysphagia, trismus or stridor consider epiglottitis (AtoE)
Main complications are quinsy (needle drainage), otitis media, sinusitis, acute rheumatic fever, acute glomerulonephritis
If >7 in one year, 5 per year over 2 or 3 per year over 3 refer for tonsillectomy
- major complication is primary haemorrhage within 48hrs, return to theatre
If IM: Avoid contact sport for 3 weeks Avoid alcohol Paracetamol + NSAID No antivirals Avoid ampicillin/amoxacillin as can cause rash
HAART and AIDS
AIDS = CD4 <200 or HIV + indicator disease
HAART - 2 nucleoside reverse transcriptase inhibitors + one of integrase strand transfer inhibitor, non-nucleoside reverse transcriptase inhibitor, protease inhibitor
E.g. Truvada + Raltegravir (integrase) or Etravirine (NNRTI), Indinavir (PI)
Early stages - seborrheic dermatitis, varicella zoster, herpes reactivation, oral or genital candidiasis
Later on - karposi sarcoma (tumour caused by herpes, presents as purple lesions in mouth or on the skin)
Pneumocystis jirovecii - pneumonia, also TB, Mycobacterium avium
CMV, Cryptosporidiosis -> diarrhoea, CMV also cause retinitis
Toxoplasmosis, cerebral lymphoma -> neuro Sx
Cryptococcal meningitis
Management of chlamydia and gonorrhoea
gonorrhoea - yellow/green discharge
First catch urine/ vulvovaginal swab
NAAT test - 2w window period
Gonorrhoea can also be examined by microscopy and culture - gram-negative diplococci
Transvaginal US, cervical motion tenderness - can be used to identify endometritis and salpingitis of PID
Chlamydia - 7d 100mg doxycycline or 1g azithromycin oral
- also treat partner
- avoid sex until completed course
- partner notification - 1 month or last partner for symptomatic males, 6 months for others
- if under 25 retest in 3-6 months
Gonorrhoea - 1g Ceftriaxone IM
- also treat partner
- abstain from sex until completed treatment
- partner notification - 2w or last partner if symptomatic male, 3m for all else
- Follow up after 1 week to ensure treatment successful, test of cure 2w after
Causes of meningism - stiff neck, Photophobia, Neck stiffness, Nausea, Vomiting
Meningitis, Encephalitis, SAH
NAFLD investigations
Look for steatosis on US
Enhanced liver fibrosis blood test
Fibroscan
Symptoms of total vs partial ant circulation stroke
total: hemiplegia, higher cortical dysfunction, homonymous hemianopia
Partial 2 of 3
Difficulty swallowing CBD
Oesophageal cancer
Achalasia
Pharyngeal pouch
Scleroderma (crest)
Ask about type of food can eat, ask about blood, ask about constitutional sx, ask about swelling in neck, ask about aspiration, lung infection
1st line refer via 2ww for upper GI endoscopy
Do barium swallow
CT TAP
CXR/AXR
Drug treatment of parkinsons
1st line drug is Levodopa - this is a precursor to dopamine that can ended BBB
The decarboxylase inhibitor carbidopa is always given alongside to prevent metabolism
Some of the issues with levodopa are its wearing off effect and propensity to dyskinesia
To prevent dyskinesia can delay use of L-DOPA at first until symptoms progress or to use a dopamine agonist such as apomorphine either alone or alongside
To prevent wearing off effect can use MAOB inhib (selegiline) and COMT inhib (entacapone) which slow degradation of dopamine. Can also give long acting L-dopa, give smaller doses more regularly
SE - dopamine agonists can cause hallucinations and impulse control disorders. The medication can cause daytime sleepiness, should not drive if so. Can also cause orthostatic hypertension (review meds, midodrine), is also a risk of neuroleptic malignant syndrome. Glycopyrronium bromide for drooling
Parkinsons plus syndromes and their features
MSA - hypotension
PSP - Vertical gaze palsy
Lewi body - dementia
Drug induced - antipsychotics
Red eye - conjunctivitis management
Can be viral, bacterial (STI) or allergic
If infectious - gritty, foreign body sensation, watering of eye lead to blurring
Viral - watery discharge
Bacterial - sticky yellow/green discharge crusting and sticking together of eyelids on waking
Allergic - itchy eye with watery discharge and associated nasal congestion, sneezing, eyelid swelling
Wear gloves, examine eye, visual acuity, fundoscopy
Consider swab if cause not clear, red flags (herpes)
Viral - usually resolves within 7 days, advise cleaning eyelids, cool compress, lubricating drops. Avoid contact lenses, hand hygiene, different towels to stop spread, safety net
Bacterial - same as above, if severe can treat with topical chloramphenicol drops or fusidic acid drops. Safety net - reduced visual acuity, photophobia/ headache etc.
Allergic - identify and avoid allergens, avoid eye rubbing, apply cold compress to relieve sx, ocular lubricants
- Topical antihistamine or oral antihistamine
- Mast cell stabiliser (sodium cromoglycate)
- topical steroids if very severe
Types of dementia - key features
How to investigate, treatment of AD
AD: early impairment of memory. Manifests as short-term memory loss and difficulty learning new information.
VD: typically a ‘stepwise’ decline in function. Predominant gait, attention and personality changes. May have focal neurological signs (e.g. previous stroke)
DLB: parkinsonism (tremor, rigidity, bradykinesia, postural instability). Fall, syncope and hallucinations predominant feature
FTD: marked personality change and behavioural disturbances. Memory and perception relatively preserved.
Investigate with cognitive tests - Abbreviated mental test score - Mini mental state exam Refer to memory clinic then: - MOCA (26/30) - Addenbrookes
DSM-V Diagnosis - functional impairment, affect >2 cognitive domains, no other cause (depression, delirium)
Do Brain MRI
Mx:
Advanced planning, capacity, care plan, end of life care
Supportive care
Physical and mental health
Inform DVLA
Exercise, group cognitive stimulation programmes
Mild to moderate - acetylcholinesterase inhibitors e.g. rivastigmine or donepezil
Moderate to severe - NMDA antagonist e.g. memantine
Shoulder pain CBD
Impingement syndrome - pain on raising arm above head, pain lying on arm at night, loss of internal rotation, +ve neers and Hawkins test. Clinical diagnosis may be confirmed with MRI. Analgesia, rest, physio, steroid injection. Surgery to decompress acromium or remove bursa
Rotator cuff tear - Acute weakness and pain, test individual muscles. Xray to exclude fracture, can look for tear using MRI/US. Rest, analgesics, physio, steroids. If complete tear consider surgical repair.
Frozen shoulder - Deep, constant pain, stiffness of all movements. Freezing (pain+stiffness), frozen (stiffness), thawing (improves). Common in diabetics, test. Treat with analgesics, reassurance, steroid injection. May consider hydroxylation, capsular release or manipulation under anaesthesia
Dislocation of ACJ - pinpoint pain over joint following fall onto shoulder. Rest, put in sling for 3w and review. Most improve with conservative treatment for 3m, may need stabilisation
Knee pain CBD
OA - Elderly, chronic stiffness, locking/ instability, prev trauma. Do Xray if unsure. Physio, joint support, walking aids, analgesics, steroid injections. Consider arthroplasty
Meniscal tear - Twisting around a flexed knee. Knee pain (worse on extension), swelling a few hours after injury (if immediate may be ACL or peripheral tear), giving way/catching/locking. Joint line tenderness, mcmurrays +ve. To differentiate from MCL do MRI. RICE, physio. Surgery if large tears or persistent symptoms.
ACL - Hyperextension or change in direction with foot fixed. Acute pain and audible pop, immediate swelling, joint stability and unable to weight bear. +ve anterior draw and lachmans test. Xray to exclude avulsion fracture, MRI to confirm. RICE, if not highly active knee brace and physio. Not heal on own so all others ligament reconstruction with tendon grafting
PCL - dashboard injury, posterior draw and post sag sign. MRI to confirm. Respond well to conservative. Immobilise in extension for few weeks, crutches, physio.
Back pain CBD
Mechanical back pain - spasm of vertebral muscles, soft tissue dmg. Pain worse on movement. START back tool to assess risk, can do CT/MRI if chronic or red flag. Return to normal, lat bending exercises, warm compress, analgesics. If med risk - physio, high risk MDT approach
If chronic lower back pain in a young male with associated stiffness that is worse in the mornings and better throughout the day = ankylosing spondylitis. Do a lumbar spinal Xray. 1st step is NSAIDs and physio. 2nd line biologic e.g. adalimumab
exclude metastasis, AAA
Prolapsed disc - middle aged, sudden onset when heavy lifting, hx of repetitive movements. Have low back pain, radicular pain worse on bending, better on standing, shooting pain into leg and sensation loss. Can have cauda equina if low and large. +ve straight leg raise, Trendelenburg gait. MRI if pain persist >6w or bilateral. Rest, NSAID, neuropathic pain killers, physio. Corticosteroid injection second line, microdiscectomy 3rd line.
Spinal stenosis - Gradual onset of back pain, unilateral or bilateral leg pain and weakness. Neurogenic claudication (pain, tingling in back and leg when walking as pain worse when standing, better when sitting forward). May be bladder or bowel involvement. -ve leg raise, MRI lumbar spine. NSAID, physio, steroid injection, back brace. If persistent pain or neuro sx - decompression laminectomy
Cauda equina - prolapsed disc below L1/L2 - bilateral leg pain, bowel/bladder dysfunction, saddle anaesthesia, sensorimotor changes, poor anal tone on PR. Investigate immediately with MRI and refer for urgent surgical decompression
If old, sudden onset severe pain exacerbated by movement consider osteoporotic fracture. Do xray, rule out cancer. Observe, brace, give calcitonin and bisphosphonate. Vertebroplasty or kyphoplasty
Facial nerve palsy - CBD
UMN - forehead sparing
LMN - non forehead sparing
Assess facial movements against resistance, ask about changes in taste (ant 2/3) and intolerance to load noises
Can grade degree of paralysis by House-Brackmann
LMN causes - Idiopathic bells palsy, parotid tumour, base of skull fracture, cholesteatoma, acoustic neuroma, herpes (Ramsey hunt), GB
UMN causes - brainstem stroke, MS, tumour, HIV, syphilis
Refer if suspected cause or red flag features (cancer, UMN, ENT sx etc)
Mx:
Eye care - Refer to ophthalmology: lubricating eye drops, patches, taping, eye weights, botulinum, surgery
Give steroids if present within 72 hours, cont for 10 days. Most resolve spontaneously. If refractory consider facial nerve decompression surgery or reanimation surgery
BPH - present with LUTS
Storage
- urgency
- nocturia
- incontinence
- Poor flow
- Hesitancy
- Dribbling
- Nocturia
- Frequency
- Urgency
Ix: IPSS PR Dipstick - Diabetes, UTI Blood tests including PSA Flow rate <10mls = obstruction (or neuro/DM) Bladder, kidney US to look for chronic retention (recurrent UTI, CKD, hydronephrosis, stones, overflow incontinence) May do MRI, CT KUB in secondary care
Mx:
If mild - reassure and reduce alcohol/caffeine, incontinence pads, bladder training, follow up
If moderate - Alpha blockers (tamsulosin), 5-alpha reductase inhibs (finasteride), catheters
If severe (recurrent UTI, haematuria, acute retention) - surgery Transurethral resection of prostate
If acute urinary retention catheterise
Bladder cancer Mx
Painless haematuria, recurrent UTI
Transitional cell cancer
Ix:
Urine dipstick + microscopy
Routine bloods (PSA)
2ww to hosp for:
Flexible cystoscopy + biopsy
Upper urinary tract imaging with CT/US
Mx:
If clots - need to catheterise to avoid clot retention
Transurethral resection of bladder tumour - assess grade and staging
If not invade muscle, consider either active surveillance, intravesical BCG or mitomycin or radical cystectomy
If muscle invasive - radical radio or cystectomy + chemo
In bladder removal - ureters plugged into bowel, bowel brought to surface as a stoma
Ureteric colic
Very painful, loin to groin, comes in waves, blood in urine, N+V, storage LUTS
Ix: Ask about previous stones Urine dipstick + culture (blood, infection) Routine bloods Non contrast CT US for hydronephrosis Pregnancy test
Mx:
Analgesia, IV fluids, antiemetics
Nifedipine or tamsulosin can help stone passage
If small (<10mm) - pass within 4w, follow up imaging, get to catch stone for analysis if 1st. Safety net.
If >10mm - extracorporeal shock wave lithotripsy or percutaneous. If obstruction - nephrostomy or stent
Advise to increase fluid, reduce salt, protein, oxalate, rate rich foods
Urinary incontinence management
Ix:
Do urine dip to exclude infection and haematuria
Bladder diary
Explore red flags for cancer, infection, neuro disease
Stress incontinence:
Reduce caffeine, weight loss, stop smoking to reduce cough, pelvic floor muscle training (12w), pads, restrict fluid intake
Surgical - colposuspension
Medical (2nd line) – duloxetine (SNRI)
Urge incontinence
Reduce caffeine, monitor fluid intake, bladder training (6w)
Medical – antimuscarinic e.g. oxybutynin, 2nd line mirabegron.
If fail botulinum toxin injection, sacral nerve stimulation, augmentation cystoplasty (increase size of bladder)
Overflow incontinence:
Refer to urologist or nephrologist
Further investigations of cause, may need catheterisation, nephrostomy
Heel pain CBD
Differentials - DVT, Gastroc/ soleus sprain, claudication, ankle sprain, achilles tendinopathy, achilles tendon rupture, nerve entrapment, fracture
Achilles tendinopathy, plantar fasciitis
- pain in back of heal, base of foot worse in the morning and with movement
- stiffness better on movement, tender, crepitus
- due to overuse, repetitive trauma, inflammation
- obesity is a RF
- tender to touch and painful on dorsiflexion
Usually takes 12w to resolve. Treat with initial rest period, restart exercise as pain allows. NSAID/ paracetamol. Refer to physio if not improving or suspect misalignment or muscle weakness to be contributing
For fasciitis Can give foot orthotics e.g. heel inserts, splints. Shock wave treatment if last >6mo, surgical release with fasciotomy at >9mo
Achilles tendon rupture
- Hx of repetitive strenuous activity
- Forced plantar flexion or violent dorsiflexion
- hear a pop, weakness, pain in heel
- struggle to stand on tip toes
- palpable gap, Simmons test +ve
Do US to locate and stage tear, Xray if suspect fracture. Only do MRI if diagnostic uncertainty
Treat with analgesia, physiotherapy. If complete rupture put in a boot for 6-8w. No steroid injections. If high risk of re-rupture then consider operative management (open end to end or percutaneous)
Tarsal tunnel syndrome
= tibial nerve entrapment under flexor retinaculum
- paraesthesia, pain, and swelling of the feet
- NSAID, rest, orthotics, steroid injection
- surgical decompression if not respond
Coeliac
Weight loss Fatigue Weakness Abdominal pain Bloating Flatulence Loose stools Steatorrhoea
Associated with dermatitis herpetiformis
Ix
confirm individual eaten gluten twice a day over last 6 weeks
- IgA Ttg and Total IgA, (2nd line IgG ttg/ IgA EMA)
- If +ve send to GI for endoscopy and duodenal biopsy
- stool culture, MC+S
- FBC, U+E, LFT, CRP, ESR
- Skin biopsy if rash
Mx
Avoid gluten - dietary counselling, referral to dietician
No wheat, barley, rye
Vit D, Ca supplements if insufficient in diet
Assess and manage osteoporosis risk
Yearly follow up, assess sx, BMI, diet adherence, blood tests
If refractory - refer to dietician, specialist and consider short term prednisolone
Complications are dermatitis herpetiformis and Enteropathy-associated T-cell lymphoma (EATCL)
Carpal tunnel - presentation causes and management
DM, acromegaly, pregnancy, Idiopathic, neoplasm, oedema, trauma, RA
Presents with pain, numbness, parasthesia over the palmar aspect of the lateral 3 1/2 digits. Also have wasting of thenar eminence, difficulty making a fist. Pain worse at night, have to hang hand off of bed or shake.
Differentials = C6 radiculopathy (also have neck pain), pronator teres syndrome, Flexor carpi radialis tenosynovitis (pain at base of thumb)
Supplies LOAF
- Lateral lumbricals
- Opponens pollicis
- Adductor pollicis brevis
- Flexor pollicis brevis
Phalens and tunnels test +ve
If diagnostic uncertainty consider NCS or MRI
Mx:
Analgesia, activity modification, physio, corticosteroid injections.
Splinting at night
If failure of non-operative treatment consider carpal tunnel release
Fall onto outstretched hand - 2 main consequences
Scaphoid fracture
Tenderness in anatomical snuffbox
Pain, swelling in wrist, difficulty gripping
Xray in AP, lateral and R/L oblique views
Scaphoid plaster/splint and place in cast
If complicated fracture do ORIF or percutaneous crew fixation
Colles fracture
Dinnerfork deformity
Closed reduction, splint and cast
If grossly displaced do MUA, put in backslab and sling
Gout
Common causes are hereditary, alcohol, renal impairment, NSAID, Diuretic, purine rich foods
History of acute attack of pain, swelling, redness and warmth. Commonly 1st metatarsophalangeal joint
May have tophi on extensor surfaces of limbs, ears and achilles tendon
Ix:
Hx - ask about prev attacks, diet, alcohol
Often clinical diagnosis
Do joint aspiration to confirm (urate crystals)
Do uric acid lvl 4-6w post attack
Xray to exclude other causes
Screen for CV and renal disease
Mx:
Discuss lifestyle changes - loose weight, reduce purine in diet (red meat, seafood), reduce alcohol consumption
Rest, ice, elevate
1st line: NSAID (naproxen + PPI) or colchicine
2nd line: oral or corticosteroid injections
Prevention - once acute attack resolved
- allopurinol - titrate dose to reduce uric acid <300. Give colchicine alongside for first 6 months. Can cause rash/fever, if renal impairment monitor U+E
- 2nd line febuxostat
Haematuria CBD
Ix:
Hx (recent instrumentation), abdo/PR/genital exam
Urine dipstick
PSA
AI screen if nephritic
FBC (anaemia), U+E, LFT, CRP, Coag (clotting disorder)
Mid stream urine - send for culture, microscopy, cytology
Refer based on 2ww
>45 and haematuria not linked to or post UTI
>60 and non visible + either dysuria or raised WCC
Flexible cystoscopy +/- biopsy
Upper urinary tract imaging - US KUB, CT urogram
Diverticular disease
- Constant abdo pain in hypogastrium then LLQ
- Change in bowel habit, signif bleeding
- N+V
- may have fever
- may have urgency of urination as can irritate bladder
Ix:
Routine obs + bloods
CXR - look for air under diaphragm (perforation)
CT of abdomen
Barium enema
Sigmoid/colonoscopy - not do in diverticulitis due to risk of perforation
Mx:
If asymptomatic diverticulosis - reassure, suggest lifestyle changes and increase fibre in diet
Diverticular disease - 30g fibre a day, bulk forming laxatives 2nd line, give paracetamol and antispasmodics. Avoid NSAIDS and opioids (increase risk of perforation)
Diverticulitis - Co-amoxiclav, if complications admit for IV fluids, Abx, analgesia. Consider surgery if peritonitis or sepsis, percutaneous drainage if abscess.
UTI / pyelonephritis
Ix:
Urine dipstick
Mid stream urine sample - MC&S
Bloods, US/CT if complicated or renal function affected
Mx:
Trimethoprim (not if pregnant)
Nitrofurantoin (not if renal F)
(3 days in women, 7-14 in men)
Pyelonephritis
urine dipstick and culture
Bloods - FBC, U+E, CRP, Lactate
USSKUB, CTKUB (gold standard)
AtoE, sepsis 6, resuscitate
Treat obstruction
Treat hydronephrosis with nephrostomy
Ciprofloxacin 500mg for 14 days
If severe or urosepsis give co-amox or ceftriaxone
Anxiety management
Assess with GAD2, GAD7
Screen for organic causes e.g. hyperthyroid, SVT, anaemia, hypoglycaemia etc.
Step 1 - educate, sleep hygiene, exercise, Beta blocker
Step 2 - Low intensity psychological interventions based on CBT (individual)
Step 3 - CBT or drug therapy with SSRI
Step 4 - Refer for specialist care, medication
OCD
Yale-brown OCD scale
low severity - relaxation techniques, low intensity CBT with exposure and response prevention (exposed to a situation causing anxiety and prevented from performing repetitive actions)
More severe - high intensity CBT or SSRI
PTSD management
Must last longer than 4w
Trauma based CBT first line
Eye movement desensitization and reprocessing
SSRI
If no response consider antipsychotic
Depression
Last at least 2w, no hypo or mania
Core symptoms are low mood, fatigue and reduced energy, loss of interest in activities that are normally pleasurable
Can do routine bloods to screen for organic causes
Mx: Assess suicide risk PHQ-9 >5 – mild >10 – moderate >15 – moderately severe >20 – severe
Sleep hygiene, exercise Crisis team if suicidal
If mild
Discuss concerns, sleep hygiene, regular sleep/wake times
Exercise programmes
Provide information
Active monitoring
Follow up in 2 weeks, make contact if not attend
Mild - mod
low intensity self guided or computerised CBT, second line is group CBT
Mod to severe
High intensity individualised CBT
SSRI first line - continue for 6m post remission
ECT can be considered for fast short term improvement
Hypercalcaemia of malignancy - what cancers, effects and how to manage
a
Hyperkalaemia - causes, presentation and ECG
= >5.5
Increased intake: dietary, IV fluids, blood transfusion,
Decreased excretion: K+ sparing diuretic, ACEi, spironolactone, Addisons, AKI
Extracellular shift: Acidosis, TLS, Rhabdo
Presents with Fatigue Generalised weakness Chest pain Palpitations
Ix: Full set of bloods ABG - see electrolyte levels Urinalysis ECG
Mx: ABCDE Cardiac monitoring Protect myocardium - calcium gluconate Reduce K+ with insulin/dextrose solution Nebulised salbutamol
Management of septic joint
Aspirate joint + send for culture
- Cloudy yellow/green, raised WCC, low viscosity, low glucose, raised neutrophils, gram stain +ve, crystal negative
Do 2x blood cultures, routine bloods + urate and obs
Consider urine dip, STI screen to look for causative infection
Imaging - CT/MRI, US, Xray
Do sepsis 6 - take blood culture, lactate level, measure urine output. Give fluids, IV abx, O2
Treatment
Liaise with microbiology, fluclox often 1st line - IV for 2w, continue for total of 6w, Vanc for MRSA
Aspirate joint to dryness, consider arthroscopic drainage, washout
SLE
Presents with fever, arthralgia, butterfly rash
Rhinosinusitis - diagnostic sx and management
Diagnosed if have facial discomfort/pain, nasal obstruction or purulent discharge, loss of sense of smell
May consider nasal endoscopy to look for polyps, inflammation, oedema, purulent discharge
Mx
Reassure, most resolve within 3 weeks
Anti-pyretic, nasal decongestant max a week, nasal irrigation with saline, fluid + rest, warm face mask
If >10 days consider 14 days of high dose intranasal corticosteroid
If prolonged beyond this or very severe may consider Abx, first line = phenoxymethylpenicillin
SIADH
Can be caused by meningitis, small cell lung cancer, SSRI, carbamazepine
Present with fluid overload, sx of hyponatraemia (N+V, headache, muscle cramp, confusion)
Differential if K+ raised = Addisons
Ix:
U+E
Plasma and urine osmolality (high in urine, low in blood)
TFT, cortisol
Mx: Treat cause Fluid restrict Demeclocycline Vaptans
Cervical cancer
Intermenstrual, post sex, post menopausal bleeding. Malodorous discharge, pelvic pain, pain on sex.
Refer via 2ww for cervical screening if abnormal looking cervix or unexplained symptoms, post or premenopausal bleeding
Cervical screening - first invited at age 25, 25-49 every 3 years and 50-65 every 5 years. Only screen over 65 if not had a test since 50 or if recent abnormal test
Insert speculum, use brush and rotate 5 times against squamocolumnar junction = liquid based cytology
Results are
Negative - return to screening
Inadequate - repeat
Borderline - some changes, very unlikely to progress
Mild dyskaryosis - Cancer very unlikely, most revert to normal smears
For borderline or mild - do HPV test and if +ve do colposcopy
Moderate dyskaryosis - Intermediate probability of developing into cancer
Severe dyskaryosis - high risk of cancer, some may show changes suggestive of cancer
Glandular neoplasia - adenocarcinoma
Microinvasive - large loop excision or cone biopsy
Early stage - radical hysterectomy + lymphadenectomy
In locally advanced/ metastatic consider chemoradiation
Pancreatitis
Acute abdominal pain in epigastric/ LUQ. Radiates to back, better when in foetal position, N+V, fever, peritonitis, flank and periumbilical bruising
Main causes are gallstones, alcohol, steroids
Ix: Serum lipase/amylase (also high Obs Blood sugar, ECG, pregnancy test Routine bloods + bone profile + LDH Do blood gas for grading Do US, if negative MRCP for gallstones
Go Glasgow score in first 48hrs to assess severity >3 = severe PaO2 Age Neutrophils Calcium Renal function Enzymes Albumin Sugar
Mx:
Cut down on alcohol, review meds
IV fluids, analgesia (morphine or buprenorphine), nutritional support
Manage gallstones, Abx if infected
If suspect pancreatic necrosis - aspirate and culture
Essential tremor vs parkinsons
Essential - bilateral, symmetrical, intention tremor. Better with alcohol, beta blocker
Parkinsons - unilateral, asymmetrical, resting tremor. Additional rigidity, bradykinesia, postural instability
Haemorrhagic stroke
Main cause = hypertension
A-E, CV exam Same investigations as ischaemic stroke FAST rapid assessment Assess GCS, blood glucose, nutrition screen (MUST), bloods, CT - haemorrhage = white If suspect SAH do a lumbar puncture
Mx A to E oxygen BP control swallow assessment Early mobilisation Falls risk assessment Decompressive hemicraniectomy
Neutropenic sepsis
Temperature >38 or features of sepsis in a person with a neutrophil level <0.5. Occurs within 6w of chemo
Peak risk at 7-14 days
Ix: Routine obs - rr, hr, sats, bp, bm Infection screen (FBC, U+E, CRP, Lactate, coag) - look at neutrophil lvl Relevant stool, sputum, urine culture
Sepsis 6
Take blood culture, lactate and urine output
Give O2, iV fluids and empirical IV Abx (start immediately)
MASCC index to assess risk
Mx:
Prevention - neutropenic diet (uncooked vegetables and most fruits, raw or rare meat, fish, uncooked or undercooked eggs, soft blue cheeses, food from salad bars), can give prophylactic G-CSF if high risk
IV Abx started immediately
Give G-CSF if prolonged neutropenia or hypovolaemic shock
Consider transfer to ITU
Manage subsequent chemotherapy
Hyperkalaemia management
Causes: DKA, CKD, Addisons, ACEi, spironolactone, Beta blocker, TLS, rhabdomyolysis
Fatigue, chest pain, palpitations
10ml 10% calcium gluconate over 10 mins to stabilise myocardium
10 units of short acting insulin alongside dextrose 50ml 50%
Back to back 5mg salbutamol nebs
If refractory - Dialysis
Do repeated ECGs and check U+Es every 4-6 hours
Do medication review
Can offer calcium resonium
Delirium tremens
Presents with delirium, hallucinations and tremor
24-72 hours post cessation of alcohol
Do ABCDE
Correct dehydration and electrolyte abnormalities
Treat with chlordiazepoxide or diazepam, can add barbiturates if refractory.
Give pabrinex - 2 ampoules 3x day for 3 days
Magnesium can protect against seizures/arrhythmias
Prostate cancer
Adenocarcinoma
Ix: DRE, PSA (>3, abnormal DRE refer for 2ww) Multi-parametric MRI Transrectal ultrasound guided biopsy Bone isotope scan/ CT
PSA, TNM and Gleason score for used for risk stratification and prognosis
Mx:
For localised prostate cancer consider active surveillance, radical prostatectomy and radical radiotherapy.
Add in anti-androgen therapy for 6 months
Can also give docetaxel chemo if metastatic castrate resistance.
Androgen deprivation - orchidectomy or LHRH agonist e.g. Goserelin. Can cause SE if flushes, gynaecomastia, sexual dysfunction, osteoporosis
Test and treatment for Herpes,
Herpes: swab from base of ulcer, NAAT
If 1st episode oral acyclovir within 5 days
Self care e.g. clean, Vaseline, increase fluid, pain relief, avoid tight clothing, urinate in bath, not share towels.
Test and treatment of syphilis
Single, round, painless, indurated lesion
2ndry have rash on palms and soles
Tertiary have neuro, cardiac and gummate
Ix:
Dark ground microscopy - gram -ve motile spiral bacteria
PCR
Treponemal and non treponemal test
Mx:
Benzathine benzylpenicillin - one off IM if early, weekly for 3 weeks if late
If cardio give steroids alongside
Treatment for genital wart
podophyllotoxin, immiquimod, TCA, cryotherapy, excision
PID symptoms and treatment
Uterine, cervical motion tenderness
Lower abdo pain, pain on urination and sex
Uterine bleeding (inter-menstual or post coital)
Abnormal cervical or vaginal discharge
Fever, nausea and vomiting
Ask about recent termination of pregnancy or IUD
Ix: Bimanual + obs Vulvovaginal swab Urinalysis + culture Bloods Pregnancy test Transvaginal US
Tx:
Pain relief
Empirical antibiotics: Ceftriaxone IM, doxy 100mg BD and metro 400 mg BD for 14 days
Consider removing IUD
Contract trace all partners in last 6 months, give 7 days doxycycline to all partners
TV management
Frothy yellow discharge, vulval itching and soreness, cherry red cervix, offensive odour, superficial dysuria/dyspareunia
Ix:
High vaginal swab from post fornix
Motile protozoa on light microscopy
Treat with metronidazole
Screen and treat all partners in last 4 weeks
BV management
Amsels criteria
- clue cells on microscopy
- thin grey discharge
- pH >4.5
- +ve amine test (fishy smell with KOH)
Grade with Hay Ison score
Treat symptomatic with oral or intravaginal metronidazole gel. Avoid vaginal douching, use of shower gel, and use of antiseptic agents or shampoo in the bath.
Inform is often recurrent
Causes of ATN
Pre-renal
Aminoglycosides, chemo
MM
Rhabdomyolysis
How to treat pulmonary oedema
Diamorphine, furosemide and nitrate
Or dialysis
AKI treatment
Prerenal - hypo perfusion due to haemorrhage, low blood pressure, sepsis, renal artery occlusion (embolus, infarct, stenosis), reduced cardiac output (HF, MI, PE
Intrinsic - rhabdomyolysis (+ve blood on dipstick), myeloma, ATN, glomerulonephritis
tubular interstitial nerphritis - abx (penicillin), ppi, chemo, nasi
Post renal - bilateral renal stone, lymphoma, bladder outflow obstruction (tumour, stricture, stone), tumours, BPH, neurogenic bladder
Stage 1 - Creatinine >26.5, 1.5-1.9x baseline, urine <0.5 ml/kg/hr for 6-12 hrs
Stage 2 - Creatinine 2.0-2.9x baseline <0.5ml/kg/h for >12 hours
Stage 3 - Creatinine >3x baseline <0.3ml/kg/h for >24 hours OR anuria for >12 hours
hospital acquired AKI - after 48 hours post admission
Ix:
Observe urine output
Do lying/standing BP
urine dip (looking for raised protein, blood), MSU, PCR, PSA
U+E, bicarb, inflam markers, nephritic/MM screen
ABG (pH)
USS KUB
Correct high K+
If hypovolaemic - fluid challenge and maintenance, stop BP meds
If hypervolaemic - furosemide, diamorphine and nitrate plus fluid restrict
If acidosis - sodium bicarbonate
Relieve obstruction, remove stones etc
If sepsis - sepsis 6
Stop DAAAMN- Aminoglycosides, NSAID, ACEi, Metformin, Amphoteracin, Diuretics, Lithium, Digoxin
Insulin renally cleared - if develop AKI reduce dose by 10-20%
ATN - prerenal or post renal cause to an extreme
TIN - sensitivity reaction to Abx, NSAID - give steroids
nephrotic vs nephritic
Nephritic - Haematuria, HTN and hardly any urine
Nephrotic - Hyperlipidaemia, oedema, proteinuria and hypoalbuminaemia
COVID-19
Presents with fever, SOB, cough, fatigue and loss of smell
Can develop tachypnoea, hypoxia and worsening SOB
Ix
Diagnose with NAAT, also lat flow tests, antibody testing Obs including BP, HR, RR, Sats, temp
Bloods, coag
Sputum culture, ABG
CXR - bilateral patchy infiltrates suggesting acute respiratory distress syndrome, ground glass
Screen for sepsis
D-dimer, trops
Mx: Self isolate for a full 10 days from time of symptoms onset and conservative management Call 111 if worsening symptoms Increase fluid intake Take antipyretics May need to monitor O2 sats
O2, ventilation Dexamethasone (6mg for 7-10 days)/ hydrocortisone for severe or critical (sats <90, RR >30) Remdesivir Tocilizumab Anticoag if hospitalised
AACG treatment
Lie flat - 4% pilocarpine in brown eyes and 2% in blue, give 500mg acetazolamide oral. Refer to 2ndry care. Do laser iridotomy. Treat unaffected eye as prophylaxis
Follow up for 2 years - visual field, pressures
Scleritis management
NSAID
Prednisolone
Methotrexate
Distinction between orbital and periorbital cellulitis
Orbital - posterior to orbital septum (Sinus infection)
- CT orbit, bloods, blood culture
- co-amoxiclav
Peri-orbital - anterior to orbital septum
CRAO
GCA, Embolus, atherosclerosis of carotid artery
- important to ask about headache etc to rule out GCA
Sudden acute painless loss of vision
RAPD, cherry red spot + pale retina
If transient, complete black out that comes back after time = amaurosis fugax - treat as TIA
Occular massage
Acetazolamide, paracentesis to reduce pressure
Hyperbaric O2/ isosorbide dinitrate
Rebreath into a bag
Thrombolysis recombinant tissue plasminogen activator
Laser embolectomy, vitrectomy
Refer to stroke team
Give aspirin to protect against TIA
CV risk factors
Tinnitus what ask in Hx and causes
Ask about location (what ear) onset, freq, what sound like, how often, anything relieve. Ask about hearing loss, dizziness, vertigo, jaw pain, facial weakness. Ask about impact on life (sleep, mental health), current meds. History of noise exposure, ear disease or surgery
Unilateral with sensorineural hearing loss
- menieres and acoustic neuroma
Unilateral/ bilat with conductive hearing loss
- wax, middle ear effusion, cholesteatoma, otosclerosis
Bilateral with sensorineural
- noise induced, presbycusis, drug induced
Treat cause, reassure most improves with time
If refractory consider sound enrichment therapy, tinnitus based CBT, hearing aid
Subjective - only they can hear
Objective - you can hear
Acoustic neuroma
Unilateral tinnitus, hearing loss, facial/trigeminal nerve involvement
Do audiogram and MRI with contrast, consider biopsy
Stereotactic radiotherapy or surgery
Achalasia treatment
Balloon insertion to stretch LOS or surgery to loosen it.
Neck lumps - differentials
Skin infections Lipoma Reactive or malignant lymphadenopathy Salivary, thyroid or parathyroid gland tumour Thyroid lump e.g. thyroglossal cyst (midline near hyoid, moves on swallowing), goitre Parotid lumps Lateral neck, smooth = brachial cyst Laryngocele - more prominent on valsava
Hip fracture
Presents with pain post fall, leg shortened and externally rotated. Not able to weight bear. Stage with garden classification
On xray see loss of continuity of shentons line
Investigate cause of the fall
Do Bloods and CK to rule out rhabdomyolysis
Urine dip, CXR, ECG
AtoE
Give paracetamol, opioid, nerve block as needed
If intracapsular - hemiarthroplasty or can do cannulated hip screw if non displaced
If extra capsular - dynamic hip screw
If subtrochanteric do intramedullary nail
Physiotherapy - mobilise asap
Bipolar
- mania vs hypomania
- depressive episode
Mania - symptoms of increased mood and energy lasting at least 7 days and interfering with social or occupational functioning, requiring hospital admission or causing psychotic symptoms
Hypomania - symptoms lasting >4 days but not severe enough to fit above
Depressive episode - at least 2 weeks of depressed mood, reduced energy, reduced interest
Bipolar I - mania +/- depression
Bipolar II - hypomania + depression
Mixed episode - where occurring together
Rapid cycling - 4 episodes of depression/mania within 12m
Refer to bipolar disorder service, early intervention in psychosis or CAMHS. Urgent if risk to self or others
If manic episode - stop antidepressant, offer antipsychotic e.g. onlanzapine, quetiapine. 2nd line is different antipsychotic and 3rd line add sodium valproate or lithium. Get them to stop driving during manic episode
For depression give quetiapine or lamotrigine or onlanzapine alone
Long term - discuss care plan 4 weeks post resolution of acute episode. Consider Lithium first line for prevention of relapses. Consider psychological therapies. Get lasting power of attorney to control spending.
Yearly review - assess sx, warning signs
Encouraging compliance
Sleep
Avoidance of shift work, night flying and flying across time zones, or routinely working excessively long hours
Regular morning routine
Self-monitoring and coping strategies
Avoiding caffeinated drinks such as tea, coffee, or cola.
Stop smoking, correct alcohol and drug misuse
Monitoring for antipsychotics
Baselines when initiate treatment
BMI weekly for first 6 weeks, then at 3 months, then every 12 months
U&E, eGFR, HbA1c, LFT every 12 months
BP/BMI/lipids/glucose at 3 months
Prolactin– at 6 months then every 12 months if risperidone
ECG at start if cardiovascular risk factors, also when changing doses
Creatinine kinase if neuroleptic malignant syndrome is suspected
FBC for clozapine - agranulocytosis
Testicular lumps CBD
Seminoma or non seminoma
- painless testicular mass that is irregular, firm, fixed, not transilluminate
- Do US, alpha fetoprotein, LDH, beta HCG, CT TAP
- also do urinalysis to exclude other causes
- Marsden staging
- Radical orchidectomy
- chemo with cisplatin or radio if high risk
- Offer sperm storage
Testicular torsion - very painful, sudden, hot, red, swollen testicle. Absent cremasteric, one higher than other, lifting not relieve pain
- US, emergency referral to urology, fix both
Tender, red, hot, swollen - pain relieved on lifting
- epididymis-orchitis
- identify cause with first catch urine (NAAT), MSU, bloods
- Doxy, Cef, Ciprofloxacin
Epididymal cyst
- Upper pole of testes, separate from testes, smooth/ fluctuant nodule that transilluminates
- Do US, aspirate if large or symptomatic
Varicocele
- bag of worms, painless
- dragging sensation, disappear when flat
- red flag if right side
- embolize or ligate if symptomatic or affecting fertility
Hydrocele
- painless, fluctuates, transluminates
- US to rule out trauma, malignancy
- conservative in adults, may fix in babies
Hernia
- cant get above, worse when cough,
Heart block causes
increased vagal tone, inferior MI, myocarditis, cardiac surgery,
Aortic dissection - how present and what type of murmur get
Present with central tearing chest pain radiating to the back
Aortic regurg murmur
Torsades de pointes
If unstable, adverse features - DC cardiovert
If stable - magnesium sulphate
Treatment of 2nd and 3rd degree heart block
atropine and/or temporary pacemaker insertion. Treatment by insertion of a permanent cardiac pacemaker may be required, particularly for Mobitz type II and complete
Dementia vs depression
Dementia
- not aware of memory loss, confusion, mood normal, slow onset and deteriorating, activities of daily living normal initially, suicide and guilt rare
- worse late in day
Depression
- aware and worried about memory loss, poor attention, low mood, more sudden onset, neglect of self care, loss of interest, lots of don’t know answers, can remember if cued.
- worse early in day
Features of valve disease on exam
dizziness, chest pain, SOB, cough
Slow rising - AS
Collapsing - AR
Wernickes
Ataxia, ophthalmoplegia and confusion
Discrete thyroid nodule with normal TFTs
Think thyroid cancer, cyst, adenoma
Do US, FNA
Excise and radioactive iodine
frailty - what is it, how do we assess, management
Frailty - Loss of in built reserves: weakness, weight loss, exhaustion, reduced mobility and reduced walking speed
Sarcopenia - loss of muscle mass and strength as a result of ageing
risk factors for frailty - comorbidities and chronic diseases, physiologic impairment e.g. electrolyte imbalances, anaemia, infection, inflammation, and environment
Diagnose frailty following a cognitive geriatric assessment
- prisma7 - age, male, health conditions that limit activity, need help on regular basis, need to stay at home, have someone can count on, use walking aids.
- electronic frailty index
- edmonton frail score
- rockwood clinical frailty score
- fried frailty index
Do timed get up and go test, grip strength, turn 180 degrees test
Mx comprehensive geriatric assessment Refer to geriatric ward Review meds with Stopp Start Manage Comorbs Personalised care plan exercise, nutrition
Nephritic screen
MM (light chains, plasma electrophoresis), complement, ds-DNA, ANA, ANCA
Ovarian cancer
Abdominal distension, Early satiety, weight loss, change in bowel habit, abnormal bleeding, pelvic pain, urinary symptoms, pelvic mass
Do CA 125, USS - calculate risk of malignancy score
Then do CT
Can do image guided percutaneous biopsy or take sample as part of laparoscopic surgery
Stage 1 - within ovary
Stage 2 - within pelvis, spread to uterus, Fallopian tube
Stage 3 - Spread outside pelvis
Stage 4 - metastasised to liver or lungs
Treatment = surgery, adjuvant chemotherapy
Cellulitis vs erysipelas
Erysipelas is raised, red
Cellulitis is flat to the skin
papilloedema management
Furosemide and acetazolamide to lower intracranial pressure
decompressive craniotomy, CSF shunt
Morphine conversion
Oral -> subcut divide by 2
Oral -> IV divide by 3
Sick sinus syndrome
Causes bradycardia, sinoatrial pauses, blocks, and arrest
Treat acutely with atropine first line, second line pacemaker
Can treat long term with pacemaker but if asymptomatic no need to treat
Medication pre-op
COCP, HRT - stop 4 weeks before Herbal meds - 2 weeks before Clopidogril/aspirin - 7days Warfarin 6 days before, bridge with LMWH DOAC - 48 hours before Metformin - day of surgery ACEi/ARB on the day, all others cont Bisphosphonates - stop on day of surgery Insulin - reduce dose by 20%, stop short acting
Consider stopping TCAs, Lithium
Diabetes drugs
Biguanide - metformin
SU - gliclazide - weight gain, hypo
Thiazolidine - Pioglitazone - weight gain no hypo
SGLT2 - dapagliflozin - weight loss, no hypo
DPP4 - Linagliptin - weight neutral, no hypo
GLP-1 - Exenatide - weight loss, no hypo
Dietary changes in haemodialysis
Types of peritoneal dialysis
AV/DV of each type
Fluid restrict, reduce K+ and PO4 intake
Do HD - 4hours 3x a week
Continuous ambulatory PD - 4x 30 mins a day
Autonomous PD
HD better for those that cannot carry out PD themselves, such as visually impaired, dementia, or in poor state or health
- You have to restrict yourself from certain foods and fluid needs to be restricted
- Fewer restrictions on diet and fluid intake of PD
- One of the main disadvantages of PD is that it needs to be carried out every day, which people can find very disruptive
- People may also find it upsetting to have a catheter left permanently in their abdomen
- Risk of peritonitis with PD
- Another drawback of peritoneal dialysis is that the dialysis fluid used can cause a reduction in protein levels, which can lead to a lack of energy – weight gain is also a possible SE
- For haemodialysis are in hospital for 4 hours, 3 times a week. Generally feel very unwell after treatment so are ill at home t
Psychosis - presentation and early management
Prodrome for 18m before
Symptoms of auditory hallucinations, thought insertion, broadcasting, withdrawal, delusions of control and delusions of perception
First thing do - assess risk, refer to early intervention service
Consider treatment in community or admission to hospital under MHA section 2.
In emergency can do section 4 for 72 hours, needs just one Dr and AMHP.
Start on antipsychotic - typical (EPSE, Cholinergic), atypical (high prolactin, metabolic se, QT, cholinergic, agranulocytosis, sedation)
Initiate a care plan for both primary and secondary care
- crisis plan
- advance statement (how prefer to be treated in future)
- contacts in case of crisis
Need to be stable under secondary care for 3 years before discharge
SJS-TEN
SJS - <10%
TEN - >30%
Due to detachment of epidermis from papillary dermis
Dusky erythematous skin rash with formation of blisters and skin detachment
Nikolsky sign - epidermis sloughs off when pressure applied
Most cases caused by drugs - Abx, anticonvulsants, SLE, HIV
Fever, painful skin rash, mucosal ulceration
Take a skin biopsy
SCORTEN scoring to assess mortality
Stop causative drug
Supportive care, assess resp status
Upper GI referral
Refer 2ww anyone with dysphagia or abdo mass
Refer 2ww if weight loss + dyspepsia, reflux
Refer routinely if haematemesis
Wilsons disease management
Ix:
Caeruloplasmin low
Free copper high
24hr urine copper high
Management
penicillinamine
Monitoring
SLE management
ANA, ds-DNA
Raised ESR, low CRP
hydroxychloroquine 1st line
NSAID/steroid for flares
May require methotrexate long term
Systemic sclerosis
Crest
ANA, Anti-ro/la
Treat raynauds with nifedipine
Treat sclerodactyly with emollients and pain killers
PPI for oesophageal problems
Consider immunosuppressants if organ involvement
Sjogrens
dry eyes and dry mouth
Associated with RA, SLE, Scleroderma
Tear/saliva substitutes
NSAID/paracetamol
DMARD, steroids
Dermatomyositis
Proximal muscle weakness, heliotrope rash, periorbital oedema
Do EMG, biopsy, ANA +ve, CK high
Acute: IV steroids/ Immunoglobulins
In chronic: DMARD and steroids
Haemorrhoid - grades, presentation, ix and mx
Abnormally enlarged vascular mucosal cushions in the anal canal
Grade:
1 – not prolapse
2 – prolapse on straining and reduce spontaneously
3 – prolapse on straining and can be reduced manually
4 – permanently prolapsed
RF: Constipation, prolonged straining, increased abdo pressure (ascites, cough, pregnancy) can cause
Presentation:
- Internal = painless, External = painful and itchy
- Bright red bleeding with + after defecation, rectal fullness, impaired continence, lump at anal verge
- Can become thrombosed, very painful
Ix
- Exam – ask to strain to see if visible
- Proctoscopy
- Flexible sigmoidoscopy/ colonoscopy to exclude malignancy/ diverticular
- FBC for anaemia if high blood loss
Mx
- Prevent constipation with fibre, fluids, methylcellulose/ lactulose
- Analgesia
- Lignocaine gel, topical steroids (up to 7d)
Non surgical – grade 1/2
- Rubber band ligation, infrared coag, injection sclerotherapy, bipolar diathermy
Surgical
- Haemorrhoidectomy (3 or 4) or haemorrhoidal artery ligation (2 or 3)
Anal fisure management
- Anal pain on defecation, bright red blood on paper
Primary (no cause) or secondary (constipation, IBD, STI, malignancy)
Mx
Primary care
- Soften stool – fluid, fibre, laxative (bulk forming e.g. fybogel)
- petroleum jelly
- Analgesia (paracetamol/NSAID), warm bath
- GTN ointment if no improvement over week, topical lignocaine if extreme pain (max 14 days)
- Refer if not resolved within 6-8w
Secondary care
- Topical diltiazem or nifedipine
- Botulinum toxin
- Sphincterotomy
