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AS / OS Paces RT > OSCE Stop Emergencies > Flashcards

OSCE Stop Emergencies Flashcards

1
Q

airway assessment ABCDE

A

if talking = patent airway

look inside the mouth
assess for secretions

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2
Q

airway management ABCDE

A 
suction
jaw thrust
head tilt, chin lift
OP, NPA
intubation if GCS <8

TREAT ANY CAUSE
i.e. anaphylaxisis (adrenaline)
foreign body (remove)

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3
Q

breathing assessment ABCDE

including tests

A

pulse ox
resp rate
chest exam
calves

ABG, CXR

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4
Q

breathing management ABCDE

A

15L oxygen non rebreathe mask (care if COPD)
consider NIV or intubation
bag mask if effort poor

TREAT CAUSE
pnuemothorax
asthma
COPD exacerbation 
acute pulmonary oedema
opiate OD
PE
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5
Q

circulation assessment ABCDE

incl tests x4

A 
cap refill central
pulse
BP
temp
ausc

wide bore IV cannulae
3 lead monitor
ECG
catheter + fluid balance

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6
Q

circulation management ABCDE

A

hypotensive:
elevate legs, lie back
500ml sodium chloride stat, monitor response (HF beware)

shock:
1 L sodium chloride stat
replace blood with blood + activate major haemorrhage protocol

if hypotensive and overloaded, need inotropes and ITU

TREAT CAUSE
e.g. arrhythmia

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7
Q

disability assessment ABCDE

A

glucose
GCS/AVPU
pupils
pain

CT brain consider

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8
Q

disability management ABCDE

A

correct glucose
give morhpine

TREAT CAUSE

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9
Q

exposure assessment ABCDE

A

look all over including underneath for bleed, rash, injury

examine abdo
further exams if relevant

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10
Q

investigations to find causes overview ABCDE assessment

A

bloods (ABG, G+S, FBC, UE, CRP, LFT +/- amylase)

urine dip, sputum culture, bHCG

CXR, CT

3 lead monitor, ECG

special tests consider

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11
Q

who to ask for help in acute context

A 
med reg - medical probs
on call endoscopy - upper GI bleed
surgical reg - surgical prob or bleeding
cardio reg - MI, arrhythmia
gynae reg - ruptured ectopic
ITU reg - if likely to need ITU
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12
Q

documenting critically ill pt

A

ABCDE headings
brief summary
findings and mangement
review results + refer

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13
Q

basic stages in acute presentation assessment

A

intro

focused history

check obs

focused examination (ABCDE if very unwell)

investigations to exclude DDx

management (consider: 1.oxygen 2.fluids 3.analgesia 4. disease-specific treatment)

inform patient of progress
document
chase results
discuss with seniors / refer

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14
Q

6 key differentials for life-threatening shortness of breath

A
  1. PE
  2. pneumothorax
  3. ashtma/COPD
  4. pneumonia
  5. acute pulmonary oedema (LVF)
  6. acute coronary syndrome
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15
Q

focused Hx for acute SOB

A

EXPLORE
use SOCRATES components as relevant
exercise tolerance / baseline
orthopnea/PND

SYSTEMS REVIEW

general: how do they feel, fever
cardioresp: chest pain, wheeze, cough, sputum, leg swelling

PMH:
happened before? medical conditions
baseline any chronic condition +treatment / admissions (ITU)
recent surgery

DH+allergies
check treatment compliance

SH:
smoking, alcohol, risk factors for the 6 key acute causes

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16
Q

focused examination for acute shortness of breath

A 
tracheal deviation, JVP
exapansion, apex, heaves
percuss chestzones
auscultate heart and lungs
legs (pain and swelling)
perform peak flow if relev
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17
Q

investigations in a patient with acute shortness of breath

A 
bloods: FBC, CRP, U+E
D-dimer if Well's low
ABG
BNP (if HF suspected)
troponin (if ACS suspected)
blood cultures (if pyrexial)

orifice: sputum culture

xray/imaging: CXR, CTPA if PE suspected

ECG always!

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18
Q

5 key differentials for life-threatening chest pain

A
  1. acute coronary syndrome
  2. PE
  3. aortic dissection
  4. pneumothorax
  5. pneumonia

(less acute: pericarditis, myocarditis, pleurisy, MSK, GORD, anxiety attack, oesophageal spasm)

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19
Q

focused history for acute chest pain

A

SOCRATES

SYSTEMS REVIEW:
general - how feel, fevers, clammy/sweaty
cardioresp: SOB, wheeze, cough, sputum, leg swell

PMH
happened before? other medical conditions? cardioresp risk factors

DH + allergies
cardio meds etc
FH
cardio family events
SH
smoking, relevant DDx risk factors
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20
Q

focused examination acute chest pain

A

cardioresp focused:

tracheal deviation, JVP
exapansion, apex, heaves
percuss chestzones
auscultate heart and lungs
legs (pain and swelling)
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21
Q

investigations in acute chest pain

A

bloods - FBC CRP U+Es, trop stat+ @12 hrs

xray/imaging - CXR, CTPA if indicated (PE), CT angio if indicated (dissection)

ECG always

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22
Q

4 key DDx in life-threatening abdominal pain

A
  1. peritonitis
  2. AAA
  3. ischaemic bowel (blockage, volvulus etc)
  4. medical causes (DKA, pneumonia, MI, Addisionian crisis)
    (5. consider upper and lower abdomen causes of pain)
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23
Q

upper and lower abdo causes of pain

A

UPPER
hepatitis, cholecystitis, peptic ulcer, pancreatitis

LOWER
appendicitis, IBD, diverticulitis, UTI, pyelnonephritis, renal stones, gynae (torsion, ectopic, PID)

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24
Q

focused history in acute abdo pain

A

SOCRATES

SYSTEMS REVIEW:
- general feeling, fevers
-gastro: N+V, bowel habit, bleeding/melaena, weight loss
-gynae: LMP, PV d/c, contraception, pregnancy
PMH
happened before?med conditions
DH+allergies
any relevant meds
SH
smoking alcohol
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25
Q

focused exam in abdo pain

A 
inspect movements
Grey Turner (flank bruising)
Cullen sign (umb bruising)
guarding, rebound tenderness
Murphy's sign (deep breath, GB touches hand, catches)
Rosvig's sign (LLQ pain from RLQ palpation)
organomegaly+AAA screen
palpate for hernias
percussion tenderness
bowel sounds

consider DRE + examining external genitalia if indicated

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26
Q

investigations for acute abdo pain

A

bloods: FBC, CRP, U+Es, LFTs, amylase, INR, G+S, capillary glucose, VBG for lactate
orifice: urine dip, urine bHCG

xray/images: erect CXR, FAST scan for AAA, USS/CT abdo, AXR if ischaemic bowel suspected

ECG always

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27
Q

5 key DDx in life-threatening headache

A
  1. subarachnoid bleed
  2. meningitis
  3. space-occupying lesion
  4. temporal arteritis
  5. pre-eclampsia
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28
Q

common + rarer but important causes of headache (non life threatening)

A

migraine, tension headache, sinusitis

acute glaucoma, venous sinus thrombosis, dissection, hypertensive encephalopathy, CO poisoning,

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29
Q

focused Hx with acute headache

A

SOCRATES
meningism: rash, fever, neck stiffness, photophobia
temporal arteritis: visual problems, jaw claudication, scalp tenderness
glaucoma: visual problems, red eyes, halos around lights

SYSTEMS REVIEW
general: how pt feels, fever, rash
neuro: fits/falls/LOC, limb weakness, altered sensation, vision changes
PMH
happened before, conditions
DH+allergies
anticoag, steroids, analgesia
FH
berry aneurysms
SH
smoking, alcohol, DDx risk factors
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30
Q

focused examination acute headache

A

GCS, signs of photophobia + rash
eyes, pupils, redness, vision
feel sinuses+temporal arteries for tenderness
neck stiffness on passive turning
Brudzinski’s sign (passive flexion of neck cause leg flexion)
Kernig’s sign (pain on passive knee extension with hip fully flexed)
motor neuro: tone, power, reflexes
CN exam
fundoscopy for papilloedema or haemorrhages (subarac)

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31
Q

investigations in acute headache

A

bloods: FBC, CRP, U+Es, ESR, blood cultures if fever, meningococcal PCR

xrays/imaging: CT head

special: lumbar puncture

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32
Q

classic PE history

A

pleuritic chest pain
haemoptysis + SOB
risk factors present

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33
Q

classic pneumonia history

A

fever, SOB
productive cough
pleuritic chest pain
confusion

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34
Q

classic pneumothorax history

A

sudden onset pleuritic chest pain
SOB if large one
risk factors present (esp asthma/COPD)

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35
Q

classic asthma exacerbation history

A

dyspnoea
wheeze
known history of asthma

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36
Q

classic ieCOPD history

A

dyspnoea
wheeze
change in sputum
known COPD or lifelong smoker

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37
Q

classic PE exam findings

A

tachycardia, raised JVP, loud P2, split S2
tachypnoea, chest clear, pleural rub
look for DVT in calves

massive PE = systolic BP<90, persistent bradycardia

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38
Q

classic pneumonia exam findings

A 
tachypnoea, cyanosis
coarse crepitations
bronchial breathing
dullness to percussion
increased vocal resonance
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39
Q

classic pneumothorax exam findings

A

reduced expansion of chest
absent breath sounds one side
hyper-resonant

if TENSION:
raised JVP, hypotensive, resp distress, tracheal deviation away from affected side

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40
Q

classic exam findings asthma exacerbation

A

tachypnoea, accessory muscle use, polyphonic wheeze, reduced air entry, reduced peak flow

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41
Q

classic COPD exacerbation findings o/e

A

tachypnoea
use of accessory muscles
polyphonic wheeze
reduced air entry

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42
Q

classic PE investigation findings

A

D dimer raised (only do it if low Wells score)
CTPA diagnostic
ECG tachycardic, RV strain (T inversion in right and inferior leads, RBBB)
ABG hypoxaemic, hypocapnic, resp alkal)
CXR - wedge opacity, regional oligaemia, enlarged pulmonary artery, effusion

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43
Q

classic investigation findings pneumonia

A 
CXR consolidation and air bronchogram
inflammatory markers raised
sputum culture
urinary pneumococcal and legionella antigens
blood cultures
mycoplasma serology
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44
Q

classic pneumothorax investigation

A

air in pleural space on CXR

clinical diagnosis with follow up confirmation often

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45
Q

classic asthma investigations

A

clinical diagnosis!
ABG - normal oxygen, low CO2 (very bad if oxygen falling as getting tired)
inv to exclude causes

CXR - infection, pneumothorax exclude
blood/sputum cultures - exclude septic trigger

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46
Q

classic COPD investigation findings

A

clinical diagnosis

CXR to exclude x2
ABG low oxygen high co2 raised bicarb

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47
Q

summary PE treatment

A

treatment dose enoxaparin

if massive, thrombolysis

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48
Q

summary pneumonia treatment

A

sepsis six if bad

otherwise just Abx

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49
Q

summary pneumothorax treatment

A

Primary >2cm or have symptoms, aspirate

Secodary > 1cm observe 24 hrs and high flow oxygen
1-2cm aspirate
2cm+ chest drain

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50
Q

summary asthma exacerbation treatment

A 
salbutamol nebs
ipratropium nebs
steroids
IV magnesium 
Abx if indicated
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51
Q

summary COPD exacerbation treatment

A 
salbutamol nebs
ipratropium nebs
steroids
Abx
bipap if needed
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52
Q

classic ACS history

A

crushing central chest pain
radiates to neck/left arm/jaw
associated nausea/SOB/sweatiness
cardiovascular risk factors

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53
Q

classic ACS exam findings

A

may be normal
sweaty, SOB, in pain
+/- signs of HF, brady / tachycardia

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54
Q

classic investigation findings in ACS

A

ECG - ST elevation / depression, new LBBB, inverted T waves, Q waves

troponin - increased (unless unstable angina)

CXR - normal or signs of HF

coronary angio

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55
Q

classic treatment ACS

A 
morphine
oxygen
nitrate
aspirin 
clopidogrel

(anticoagulation, beta blocker)

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56
Q

classic acute LVF history

A

SOB, orthopnoea, PND, pink frothy sputum, peripheral oedema, cardiac Hx

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57
Q

classic acute LVF exam findings

A 
tachycardia, tachypnoea
raised JVP
fine bibasal crepitations
S3 gallop rhythm
peripheral oedema
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58
Q

classic acute LVF investigation findings

A

CXR - Alveolar shadowing, B lines, Cardiomegaly, Diversion of upper lobe, Effusion
Echo
BNP
ECG - exclude MI

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59
Q

classic LVF treatment

A 
position sitting up
oxygen
diuretics
morphine
anti-emetic 
nitrate infusion 
CPAP if needed

treat any cause

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60
Q

classic hyperventilation history

A

tight chest pain SOB, sweating, dizzy, palpitations, doom
anxious / psych Hx
recurrent episodes
clear stimulus

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61
Q

investigation findings in hyperventilation history

A

diagnosis of exclusion!

ECG  - exclude MI
trop - exclude MI
D-dimer - exclude PE
CXR - exclude infection 
ABG will show resp alkalosis

normal obs

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62
Q

classic aortic dissection history

A

tearing chest pain of VERY sudden onset
radiating to the back
pain in other sites depending on circulation

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63
Q

classic aortic dissection exam findings

A

unequal arm pulses or blood pressures
may develop acute AR
may develop acute neurology

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64
Q

classic aortic dissection investigation findings

A

CXR - widened mediastinum
ECG signs of MI
CT angiogram crucial and must be QUICK!!

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65
Q

definitive aortic dissection management

A

type A - surgical repair immediately

type B - blood pressure control

A for ascending aorta

B is descending aorta

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66
Q

classic pericarditis history

A

retrosternal / precordial pleuritic chest pain
relieved by sitting forwards
may radiate to trapezius / shoulder / neck
viral prodrome

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67
Q

classic pericarditis exam findings

+/- tamponade

A

pericardial rub
tachycardia

tamponade:
JVP distension
pulsus paradoxus (BP drop significantly on inspiration)

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68
Q

classic pericarditis investigation findings

A

clinical diagnosis!

ECG - PR depression, widespread saddle-shaped ST elevation
CXR - globular heart IF effusion present
echo - done if suspect effusion around pericardium

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69
Q

managing pericarditis

A

NSAIDs

treat cause if known

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70
Q

classic myocarditis history

A 
chest pain 
palpitations
fever
fatigue
dyspnoea

? viral prodrome

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71
Q

classic myocarditis exam

A 
signs of heart failure 
S3 gallop
fever 
tachypnoea 
tachycardia
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72
Q

classic investigation findings myocarditis

A

ECG - diffuse T wave inversions, ST depressions/elevations
raised inflammatory markers
raised troponin
serology to identify cause

myocardial biopsy if required

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73
Q

treatment myocarditis

A

treat cause
treat complications
bed rest

usually recover

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74
Q

pleurisy history

A

pleuritic chest pain
may have dry cough, fever, dyspnoea

pleural rub heard

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75
Q

diagnosing pleurisy

A

must exclude pneumothorax, effusion or pneumonia first

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76
Q

treating pleurisy

A

NSAIDs, treat cause

treat complications

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77
Q

less severe causes of acute chest pain to be considered

A 
musculoskeletal 
costochondritis
GORD
anxiety attack
oesophageal spasm (corkscrew oesophagous on barium swallow)
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78
Q

classic peritonitis examination findings

A 
shock
no abdo movement with respiration 
guarding 
firm abdo
rebound tenderness 
severe pain to light palpation
percussion tenderness
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79
Q

classic investigations for peritonism

A

erect CXR - air under diaphragm
CT abdo/pelvis - find perforation site

(may not have perforated yet)

urgent surgery

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80
Q

classic ruptured AAA summary

A

elderly
severe generalised abdo pain
back pain
low GCS and collapse

expansile mass

bedside USS and CTangio

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81
Q

treating ruptured AAA

A

permissive hypotension of 100
active massive bleed protocol
urgent open repair

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82
Q

classic appendicitis history

A

young
periumbilical pain moving to right iliac fossa
anorexia, nausea
fever

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83
Q

classic appendicitis exam findings

A

tender RIF
worse at McBurney’s point
guarding
Rovsing sign positive

McBurney is 2/3 from umbilicus to ASIS

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84
Q

classic investigations appendiciits

A

ultrasound abdo / pelvis to exclude gynae
CRP etc raised
bHCG to exclude ectopic

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85
Q

classic biliary colic history

A

severe intermittent RUQ / epigastric pain

worse with fatty food

86
Q

classic cholecystitis history

A

continuous RUQ/epigastric pain
Murphy’s sign positive
tenderness
guarding

87
Q

classic gallstones history

A

jaundice

RUQ pain

88
Q

classic cholangitis history

A

jaundice
fever/rigours
RUQ pain

89
Q

differentiate biliary colic vs cholecystitis vs CBD stones vs cholangitis

A

biliary colic - intermittent pain

cholecystitis - constant pain, peritonism

gallstones - pain + jaundice

cholangitis - pain + jaundice + fever

90
Q

classic investigation findings gallstones

A

obstructive LFT picture if CBD stones or cholangitis

inflamm markers raised if cholangitis / cholecystitis

abdo USS

91
Q

management for gallstones

A

biliary colic - pain relief, fat free diet, elective op

cholecystitis (blocked, accumulated bile) - Abx, elective op

CBD stones - cont IV fluids, ERCP

cholangitis - IV abx, treat cause

92
Q

classic acute pancreatitis history

A

severe epigastric, central pain
radiates to back
vomiting
risk factors seen - alc, gallstones, high fat, trauma, surg, meds

93
Q

classic pancreatitis exam

A 
epigastric tenderness
tachycarida
fever
shock 
jaundice
Grey Turner
Cullen signs (rare)
94
Q

classic inv findings pancreatitis

A

raised amylase / lipase
deranged LFTs
CT abdo if unsure

Glasgow score
USS abdo to exclude gallstones
triglycerides + Ig panel to find cause

95
Q

treating acute pancraes

A 
aggressive fluid resus 
e.g.1L 4 hourly (titrate UO)
NBM until nausea and pain improve
consider NG
only abx if proven infection
treat cause

ITU may be needed

96
Q

classic diverticulitis history

A

old, LIF pain
fever
diarrhoea

97
Q

diverticulitis on examinaton

A

tender LIF
guarding

need PR to exclude cancers or abscesses

98
Q

inv findings and management diverticulitis

A

raised CRP etc
CT abdo pelvis confirms

clear fluids
Abx

99
Q

classic renal colic histry

A

spasms of excruciating loin to groin pain
nausea and vom
never comfortable on bed

100
Q

renal colic inv

A

renal angle tenderness and abdo soft ussually

urine dip - micro blood
US KUB
CT KUB

101
Q

treatment renal colic

A

strong pain relief
IV fluids
abx if infection signs

if <1cm tamsulosin to aid excretion of stone

if >2cm need nephrolithotomy

102
Q

classic bowel obstruction history and exam

A

vomiting (feculent possibly)
colicky abdopain
no bowel motions or flatus

distended, tender
tinkling bowel sounds

103
Q

inv and management bowel obstruction

A

AXR - distended loops
CT abd pelvis
gastrograffin study if small bowel obstruction

NBM + IV fluids
wide bore NG free drainage
laparsocopy if unresolved

104
Q

classic acute mesenteric ischaemia history andexam

A

over 50years
severeabdo pain
dirrhoea
cardiac risk factors (esp AF)

hypovol / shocked
soft abdo with out of proportion pain to exam findings

105
Q

inv and management acute mesenteric ischaemic

A

VBG raised lactate
CT shows ischaemic bowel

mesenteric angiography if required

aggressive IV fluids, NBM, NG decompression
abx
resect infarcted bowel
blood thinners post op

revasc if no infarct

106
Q

big summary of abdo pain considerations

A

surgical -

peritonitis

ruptured AAA, appendicitis, gallstones, acute pancreatitis, diverticulitis, renal colic, bowel obstruction, acute mesenteric ischaemia, gonad torsion, volvulus, strangulated hernia, abscesses, mesenteric adenitis (app mimic), Meckel’s diverticulum

medical - peptic ulcer, pyelonephritis, gastroenteritis, IBD, DKA, Addisonian crisis, hypercalc etc etc

gynae - ectopic, ovarian cyst rupture, ovarian torsion, PID, preg, fibroids

107
Q

summarise history, inv, management peptic ulcer

A

epigastric pain
related to meals
risk factors present

tender but soft abdo

FBC microcytic anaemia
erect CXR to exclude perf
OGF if severe
investiate H pylori

treat - PPI and eradication therapy

108
Q

classic pyelonephritis history and exam

A

fever, rigours
loin pain
frequency and dysuria

loin tenderness
renal angle tenderness

109
Q

pyelonephritis investigations and management

A

urine dip and culture +ve for white cells +nitrites
inflamm markers up
USS to screen structural abnormalities or abscess

(nephronia is intermediate phase)

give abx

110
Q

classic ectopic pregnancy history

A 
severe unilateral pelvic pain 
6-8 weeks, missed period
contraception lacking 
shoulder tip pain
spotting
111
Q

classic ectopic examination

A

tenderness RIF/LIF
guarding
adnexal tenderness +/- mass palpated
cervical exciation

112
Q

investigation findings and management ectopic preg

A

urinary bHCG +ve
serum bHCG number size suggests management
transvaginal USS

methotrexate or
lap salpingectomy or
lapartomy

anti D prophylaxis if needed

113
Q

classic ovarian cyst rupture / torsion history and exam

A

sudden unilateral pelvic pain(very severe if torted)
light vaginal bleeding
fever / vomiting

tenderness RIF/LIF
guarding
adnexal tenderness +/- mass

114
Q

investigation and management ovarian cyst rupture or torsion

A

TVUSS
bHCG to exclude ectopic

laparoscopy for torsion

cyst conservative management

115
Q

pelvic inflammatory disease classic history

A 
bilateral pelvic pain of gradual onset
vaginal discharge
DPU and dysmen 
PCB, IMB
discharge may be purulent
116
Q

classic PID examination

A 
suprapubic tenderness
vaginal discharge 
cervicitis 
bilateral adnexal tenderness
cervical excitation 
fever
117
Q

PID inv and management

A

inflamm markers raised
triple vaginal swabs (tests chlam, gonorrhoea + other bact/fungal)

broad spectrum abx, check local guidelines
usually triple therapy

118
Q

classic tension headache story and treatment

A 
bilateral tight band sensation
recurrent 
late in day
stressed 
muscular tenderness

simple pain relief
destress

119
Q

classic cluster headache story and exam

A

short painful attacks around one eye
30 mins to 3 hrs
1-8x daily for 1-3 months then remits
lacrimation, flushing

conjunctival redness, swollen eye lid
can get Horner’s assoc

120
Q

treating cluster headaches

A

100% oxygen
triptan
verapamil prophylaxis

121
Q

classic migraine history

A 
unilateral pulsating 
trigeminal nerve distribution
hoursto days 
aura 
photophobia

exam usually normal

122
Q

migraine treatments split into two categories

A

abortive
NSAID, aspirin, triptan

preventative
propanolol, amitriptyline, antiepileptics

123
Q

classic trigeminal neuralgia history

A

2 second paroxysms of stabbing pain in UNIlateral trigeminal distribution
face screws up in pain
triggers - shaving, etc
symptoms of underlying cause(can be MS, tumours)

normal onexam

124
Q

trigeminal neuralgia workup and treatment

A

MRI to find cause if any

antiepileptics
treat cause if found

125
Q

group the DDx of headache into 3 categories

A

primary headache
secondary - intracranial
secondary - extracranial

126
Q

classic meningitis hx and exam

A

photophobia
neck stiffness
systemic symptoms e.g. fever, non blanch rash (late sign)

Kernig +ve
Brudzinski +ve
focal neurology
may be NB rash

127
Q

investigation findings and management in meningits

A 
blood culture
meningococcal PCR 
lumbar puncture 
throat swab 
CXR - pneumonia causing pneumococcal meningitis

IV acyclovir+ cef (+ amox if v old / young)
dexamethasone
cipro prophylaxis close contacts

IM benpen in community f

128
Q

classic temporal arteritis history and exam

A 
unilateral throbbing pain 
scalp tenderness 
jaw claudication 
55 years +
visual issues

ipsilateral blindness
tender temporal arteries
optic nerve oedema

129
Q

investigation findings and mnagement temporal arterits

A

raised ESR
+ve temporal artery biopsy
doppler of temp artery shows reduced flow

high dose pred

130
Q

classic subarachnoid history and exam

A 
very sudden
very severe
smacked on the back of the head doctor 
meningism 
thunderclap!

reduced GCS
meningism

131
Q

subarac inv and manage

A

CT head - blood in circle of Willis
LP if normal CT - shows xanthochromia (yellow CSF)

nimodipine
coiling, clipping

132
Q

classic raised intracranial pressure hx + exam

A 
worse in morning 
worse on coughing, bending 
vomiting, reduced GCS
visual disturbance 
neurology +/- seizures if tumour causing 
reduced GCS
papilloedema
CN6 palsy
ipsilateral mydriasis (pupil dilation)
Cushing response in obs
Cheyne-Stokes breathing
133
Q

inv findings and manage high ICP

A

CT head to find cause
monitoring of ICP

mannitol +/-hyperventilate them if severe
drain CSF
treat cause

134
Q

classic venous sinus thrombosis history and exam

A

history of high coag state e.g. pregnant
gradual or sudden onset
nausea, vom
seizures

papilloedema
visual field defect
CN palsies
focal neurology

135
Q

venous sinus thrombosis inv findings and manage

A

CT head
MR venography

treatment dose LMWH

if in cavernous sinus need abx and any treatment for hypopituitarism

136
Q

classic intracerebral bleed hx and exam

A

symptoms of stroke + headache

neuro deficits

CT head
catheter angiography if suspect malformation in young
CT at 6 weeks, MRI at 3 months to screen tumour as trigger

control BP
correct coag
treat cause

137
Q

raised ICP from bleed with midline shift on CT

A

craniotomy and clot evac

endoscopic evac

138
Q

classic acute closed angle glaucoma history and exam

A

pain around one eye
swollen red eye
visual blurring
halos

reduced acuity
conjunctival bleeds
cloudy cornea
pupil mid-dilated and irreg

139
Q

acute closed angle glaucoma inv and manage

A

tonometry >24mmHg IOP

acetazolamide
timolol
laser peripheral iridectomy

140
Q

classic sinusitis history and exa

A

facial pain exacerb by leaning face forward, coughing
rhinorrhoea, nasal congestion

sinus tenderness
pain on percussion of frontal / temporal sinuses

141
Q

inv findings and treatment sinusitis

A

clinical diagnosis

abx
warm face packs
saline nasal drops
analgesia

142
Q

classic hx and exam hypertensive encephalopathy

A

headache
visual blurring
vomiting

severe HTN measured
bilateral retinal bleeds
papilloedema

143
Q

inv findings and management classic hx and exam hypertensive encephalopathy

A

urine dip - micro haemat
CT brain to exclude bleed in brain

controlled BP reduction with IV labetalol

144
Q

classic pre eclampsia hx and exam

A 
3rd trimester
headache
visual disturbance
epigastric pain
vomiting

HTN
brisk reflexes
oedema

145
Q

inv findings and treatment pre eclapsia

A 
urine dip - protein !
Haemolysis 
Elevated liver enzymes
Low platelets
CTG and fetal USS

deliver if 34 weeks +
labetalol, methyldopa
mag sulphate to stop seizures
aspirin to prevent

146
Q

classic carotid / vertebral artery dissection hx and exm

A

most common stroke cause in young adult

dull pressure occip headache
neck and facial pain
stroke signs (transient)
risk factors = trauma, neck manipulation, conn tissue disease

stroke signs

147
Q

inv findings and management carotid / vertebral artery dissectin

A

CT or MR angiography
duplex carotids

thrombolyse or antiplatelets depending on timing and CT clear of bleed
antiplatelets/coag for 6 months
endovasc stent

148
Q

group the differentials for collapse / fall

A

neurological
vascular
metabolic / drugs
infection

149
Q

classic history for the following generalised seizures:

tonic clonic 
absence
atonic
tonic
myoclonic
A

tonic clonic - sudden LOC, limbs stiffen then jerk, incontinence, tongue-biting, myalgia+confusion post-ictal

absence - unresponsive, staring in to space for few seconds, typically a child

atonic - all muscles relax, drops to floor

tonic - all muscles become rigid

myoclonic - involuntary flexion

150
Q

investigate seizures

A

EEG if needed

find trigger:
CT head - intracranial
electrolytes
cap glucose
drug levels
151
Q

management seizures

A

IV lorazepam or PR diazepam to terminate acutely

treat cause
start on anti-epileptics if 2+ instances of seizures

don’t drive!

152
Q

classic Parkinson’s histoyr

A

rigidity+
tremor+
bradykinesia+
postural instability

153
Q

classic Parkinson’s o/e

A

resting tremor,
shuffling festinant gate with lack of arm swing
cogwhell rigidity
bradykinesia

154
Q

Parkinson’s diagnosis

A

clinical

if uncertain, neuroimaging DaTscan

155
Q

brief Parkinson’s treatment summary

A

levodopa
dopamine agonists
monoamine oxidase inhibitors
physio + OT

156
Q

classic TIA/stroke history and exam

A

sudden onset neuro signs (limb/face weakness, slurring, vision change)
risk factors present

neuro deficits seen o/e

157
Q

TIA / stroke inv and management

A

CT head
ECG for AF
coag screen
carotid dopplers

acute: antiplatelet or thrombolysis if confirmed ischaemic stroke (+/- clot retrieval)

long term: clopidogrel, statin, blood pressure

carotid endartectomy if >50% on same side as brain side affected

158
Q

classic vasovagal history and exam

A

stimulus - emotion, pain, prolonged standing
preceding nausea, pallor, sweat, tunnel vision
transient LOC

normal o;e

159
Q

classic situational syncope history and exam and inv

A

transient syncope in specific circumstance e.g. cough, micturition, defecation

normal exam

tilt table if unclear
exclude other causes
ECG to exclude

160
Q

summarise neuro causes of collapse

A 
seizure
Parkinson's 
stroke
vasovagal
situational syncope
neuropathy (MS)
intracranial bleed
raised ICP
161
Q

classic postural hypotension history and exam

A

dizziness +/- LOC on sudden standing
+/- recent start on antiHTN drugs

postural drop of 20+ on standing after 3 mins

162
Q

inv and management postural drop

A

find cause!

U+Es - dehydrated?
inflamm markers - infection?
FBC - anaemic?
synacthen test - Addison's?
fasting glucose - diabetic autonomic dysfunction?

treat cause
BP stockings
take care

163
Q

classic aortic stenosis history and exm

A

collapse on exertion
exertional dyspnoea

ejection systolic murmur 
slow rising pulse
narrow pulse pressure
heaving apex
lung crackles
164
Q

inv and treat aortic stenosis

A

echo

surgical open replacement
TAVI
echo follow up

165
Q

classic arrhythmic syncope history and exam

A

sudden LOC following palpitations / feeling strange
cardiac history
FH sudden death/cardio

exam may be normal

166
Q

arrhythmic syncope inv and manage

A

ECG
telemetry
echo

depends on cause - beta block, antiarrhythmics, ablation, pacemaker

167
Q

carotid sinus hypersensitivity

A

precipitated by head-turning/shaving

diagnosed by carotid sinus massage triggering

168
Q

vertebrobasilar insufficiency

A

vertigo precipitated by head extension in elderly with cervical osteoarthritis

169
Q

subclavian steal syndrome

A

proximal subclavian artery stenosis = retrograde flow into one of vertebral arteries

170
Q

summarise cardiovascular causes of collapse

A 
postural drop
arrhythmia
aortic stenosis 
structural heart disease
carotid sinus hypersensitivity 
subclavian steal 
vertebrobasilar  insufficiency
171
Q

summarise non cardio or neuro causes of collapse

A 
drugs
alcohol
tripping
bleeding out
vertigo 
anaemia
low sugar 
sepsis 
sight problems 
arthritis 
leg weakness
172
Q

define acute asthma attack in words

A

type 1 IgE mediated hypersensitivity reaction causing airway constriction

173
Q

key aspects of history in an acute asthma / COPD exacerbation

A 
baseline + severity
history of exacerbations
ITU admissions
PEFR baseline
inhaler compliance
any home oxygen / nebs
infective symptoms / trigger
174
Q

summarise how to assess an acute asthma or COPD exarcerbation

A 
focused history (as described elsewhere)
regular peak flow measurements (asthma)
ABG
CXR
core bloods
175
Q

summarise the 7 aspects of acute life-threatening asthma

A

33, 92, CHEST

PEFR 33% of predicted
92% saturations 
Cyanosed
Hypotensive
Exhausted
Silent chest
Tachycardic

(severe 50, mod 75, mild more)

176
Q

treating asthma exarcerbation

A 
oxygen 
salbutamol 2.5-5mg neb back to back 
hydrocortisone 100mg IV 
ipratropium 500mcg neb 
mag sulphate 2g IV over 20 minutes if poor resonse
escalate care - tube/ventilate
aminophylline infusion in ITU
177
Q

treating COPD exacerbation

A 
controlled Venturi oxygen titrated to sats 88-92% if chronic retainer 
salbutmol, steroid, ipratrop
Abx if septic signs 
chest physio 
bipap if needed for sats
178
Q

indications for ITU in acute asthma /COPD

A 
require ventilation (duh)
worsening hypoxaemia / hypercapnia / acidosis 
exhausted
delirious
179
Q

someone presents with PE - what do you do initially?

A

ABCDE approach to assess and manage any acute issues

calculate Wells score

180
Q

investigations for PE and their consequences for management (confirmatory and severity assessment)

A

low Wells score <4 - D dimer (if negative, reassure)

high Wells score - treatment dose LMWH and CTPA

CTPA confirms - 6 months anticoag

severity -> ECG, CXR, echo

181
Q

severity of PE - signs on ECG, CXR and echo

A

ECG - tachycardia, RV strain (T wave inversion in RHS leads, RBBB, right axis)

CXR - wedge infarcts, regional oligaemia, enlarged pulm artery, effusion

Echo - right heart strain

182
Q

PE therapeutic anticoagulant options

A

DOACs - rivaroxaban or apixiban -> most people

warfarin -> if renal impairment or need for quick reversal likely

daily LMWH -> only option for cancer patients

183
Q

indications for thrombolysis in PE

A

massive PE - systolic < 90 for 15+ mins, lack of pulse, persistently low HR
-> immediate alteplase

sub-massive PE - myocardial necrosis or large clot burden, sig RV dysfunction
-> 72hrs unfract heparin

184
Q

ACS initial assessment

A

12 lead ECG and continuous cardiac monitor
normal bloods + 2 x troponins, Mag, phosphate, lipids
CXR

185
Q

types of ACS

A

STEMI - ST elevation or new LBBB

NSTEMI - no ST elevation but raised trop at 12 hours

untable angina - no trop or ST rise

186
Q

short term management of ACS

A

morphine
oxygen to maintain sats
nitrates
aspirin + clopi loading dose

187
Q

managing ACS after initial medical management

A

thrombolysis is rarely used nowadays and is only used if PCI not available within 2 hours (as many contraindications and not as good)

PCI gold standard for all STEMIs, done otherwise with high Grace score or if unstable

188
Q

other medications started after loading doses with ACS

A

statin
beta blocker
ACEx
anticoag if NSTEMI (?)

189
Q

general points on managing ACS after PCI

A

on ward

regular electrolytes and keep on telemetry / monitor
order echo to assess LVF

190
Q

long term ACS managemetn

A 
beta blocker 12 months
ACEx
GTN spray PRN
eplerenone if poor LVF
aspirin + clopi 12 months
statin
control BP
alter lifestyle factors
191
Q

key aspects of assessment in acute pulmonary oedema

A

ABCDE approach at first

then ECG - screen trigger of ACS or arrythmia
CXR
echo
catheter + fluid balance chart
serial weights
BNP bloods 
troponin if necessary
ABG
192
Q

initial treatment protocol with acute pulmonary oedema

A

position SAT UP
high flow oxygen
IV furosemide

morphine
anti-emetic (metaclop 10mg IV)
nitrates infusion if severe i.e. hypotensive

193
Q

further interventions that may be needed following initial management with acute PO

A

look for and treat trigger - valve surgery, PCI for ACS, drugs for dodgy rhythm, BP management, drain tamponade

CPAP if still hypoxic in spite of treatment
ICU if cardiogenic shock

194
Q

core long term heart failure treatments

A 
ACEx
beta block
diuretic 
aldosterone antag
ivabradine in HR remains 7-+ with blockers

implantable defib

195
Q

arrhythmia + adverse signs

A

ABCDE assess

adverse signs = SBP low, syncope, MI, heart failure

tachyarrhythmia = synchronised DC cardioversion

bradycardia = atropine + pacing

196
Q

first steps with ALL arrhythmias

A

cardiac monitoring
treat reversible causes
review ECG + determine type

197
Q

narrow complex tachycardia

A

sinus tachy - treat cause

SVT - vagal then adenosine then beta blocker
(in asthma use verapamil)

AF / flutter - rate control (beta blocker, diltiazem, digoxin) and treat cause + assess for anticoag

(only do rhythm control in case of acute new episode or refractory to rate control after weeks)

rhythm control = DC cardiovert or flecanide/amiodarone

198
Q

broad complex tachycardia management

A

monomorphic VT - amiodarone

polymorphic VT - mag sulphate

SV origin broad complex tachy - DC cardiovert

199
Q

broad complex tachycardia of supraventricular origin

A

looks like VT

but caused by conduction of pre-existing conditions like bundle branch block

not supravent if very broad complexes, Left axis deviation or AV dissociation

200
Q

differentials of bradycardias

A

sinus brady

SA node dysfunction (‘sick sinus syndrome’)

AV node dysfunction i.e. heart block

201
Q

sinus bradycardia causes

A

-> drugs, carotid sinus hypersensitivity, vasovagal syncope, hypothermia, hypothyroidism, SA node dysfunction

202
Q

SA node dysfunction / sick sinus syndrome

A

sinus brady or sinus pauses or sinoatrial arrest
+ escape rhythm

either 1. junctional rhythm initiated from AVN (no p waves but normal QRS) or 2. from ventricles (no p waves but abnormal broad QRS v slow)

can be caused by fibrosis (surg,MI), drugs

203
Q

bradycardias at risk of asystole

A

Mobitz 2 type 2 heart blok
complete heart block with broad complexes
ventricular pauses >3 secs

204
Q

management overview of bradycardias

A
  1. treat cause
    2a. if adverse signs -> atropine
    2b. if still bad, transcutaneous pacing + adrenaline until pacemaker can be fitted

if no adverse signs, observe and treat cause

205
Q

indications for permanent pacing

A

MObitz type 2 heart block, complte block, sympto bradys,

206
Q

key cardiac drug doses to know

adenosine
amiodarone
atropine
mag sulphate

A

addnosine 6mg IV then 12mg then 12mg wide bore proximal cannula

amiodarone 300mg IV over 20-60 mins then 900mg over 24 hours

atropine 500mcg IV repeat up to 3mg every 5mins

mag sulphate 2g IV over 10-15mins

207
Q

placement of cardiac monitor

A

red lead - anterior right shoulder
yellow - anterior left shoulder
green - left ASIS
(black would go on right ASIS if present)

208
Q

placement of defib pads

A

right pad - along left sternal edge

left pad - left paraspinal muscles (align through body)

209
Q

synchronised DC cardioversion

A

need defib on synchronised mode + anaesthist present

start 150J if braod complex tachy or AF

start 70J if narrow complex or flutter

proceed once patient sedated
remove oxygen

reassess ABCDE

if go unstable, give 300mg amiodarone quikcly

give 4 weeks anticoag

210
Q

transcutaneous pacing

A

some sedation needed

set to pacing setting

monitor the QRS to see if follow each pacing spike - inc energy if not
check pulse corresponds to QRS generated

then seek definitive management

211
Q

summarise bradycardia algorithm

A

ABCDE approach and asessement
treat reversible causes
assess for adverse features (shock, syncope, MI, HF)

if adverse do atropine 500mcg x6 or t/c pacing or adrenaline

also do atropione on any high risk astystole pts

seek expert input for pacemaker

212
Q

summarise tachycardia algorithm

A

ABCDE assess
if adverse features - synchro DC shock + expert help + amiodarone

if not, assess broad/narrow

broad regular
VT amiodarone
SVT+BBB vagal + adenosine

broad irregular
AF+BBB vagal + adenosine
pre-excited AF amiodarone

narrow regular
vagal, adenosine
(if resolves quickly, likley re-entry paroxysmal SVT)
(if not, possible atrial flutter,, give beta blocker)

narrow irregular
probable AF
beta block + diltiazem
treat other aspects

AS / OS Paces RT (11 decks)

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