PACES Flashcards
IBS Mx
Conservative: Trial probiotics, FODMAP
Medical: Loperamide for diarrhoea, antispasmodics (hyoscine bromide) for cramps
GORD Ix
- H pylori (stool antigen)
- Oesophageal pH via manometry
- OGD
H Pylori eradication
PPI plus 2 antibiotics i.e. amoxicillin and clarithromycin) for 7 days
PUD surgical mx
resection if severe
GE mx
Cons: oral rehydr salts (IV fluids if needed), isolate to prevent spread until 48h after syx resolve,
Med: abx in severe cases/ depending on org
Systems r/v to ask for CP
- SOB
- Dizziness
- Palp
- Tingling/numbness
- Reflux
CVD Ix (bloods)
- Glucose
- Lipids
Stable angina mx
Med:
1. GTN
2. BB or CCB
(if both - then must be dihydropiridine CCB e.g., nifedipine) - ! decreasing the heart’s workload and oxygen demand
2ndry prev: Aspirin, ACEi, statin
Surg: PCI or CABG
Dizzy spell px ddx
- Arrhythmia, e.g., AF
- Valve disease, e.g., Aortic stenosis
- HF
- Anxiety/panic attack
Dizzy spell px ix
Bedside: Lying standing BP
Bloods: U&Es, NTproBNP
AF Mx
Cons: cardio ref / hosp admission if tachy++
Med:
- Rate control: B-blocker, CCB, or digoxin (sedentary lifestyle)
all pt rate control unless asyx/new onset within 48h/reversible cause/
- Rhythm control: Fleicanide, or amiodarone (structural heart disease)
- Long term anticoag w DOAC (or warfarin) according to CHADVASC
(For paroxysmal AF: Consider pill in the pocket strategy i.e. flecainide/ amiodarone.)
Surg: ablation trx
How does AF cause stroke?
Normally, blood flows into the heart, and gets fully pumped out every time the heart beats. But in AF, blood can pool inside the heart. A clot can form in the blood and then travel up to the brain, causing a stroke
Why DOAC over warfarin
wider therapeutic window, rapid onset of action, stable and predictable
Testicular torsion ddx
- Epididymoorchitis
- Hydrocoele or haematocoele
- Incarcerated hernia
TT Mx if orchidopexy fails
- Orchidectomy (removing the affected testicle) if surgery is delayed or necrosis occurs
- Follow-up for fertility issues and hormonal consequences, whether viable or non-viable testicle and offer counselling
- Psychotherapy as required
- Consider implantation of a prosthesis if an orchidectomy is performed
TT pathophysiology and RF
Testis rotates around its own axis, causing twisting of the blood vessels that supply it. This leads to ischaemia (lack of blood flow) and subsequent damage to the testicular tissue
RF: trauma, undescended testis, prior intermittent torsion
GRACE score
Estimates admission-6 month mortality for patients with acute coronary syndrome
MI complx
- Death
- Heart failure
- Valve disease
- Embolism
- Recurrence
Raised troponin causes
- MI
- Aortic dissection
- PE
- HF
STEMI (/NSTEMI) mx
- Loading dose antiplatelet: aspirin and clop 300mg
2ndry prevention
- DAPT
- ACEi
- BB (or CCB)
- Statin
- Cardiac rehab programme
- ECHO post MI
Lumps in neck ddx
- Lymphoma
- Lymphadenopathy
- Infx mononucleosis/glandular fever
Lymphoma ix
Bloods
- HIV test
- EBV monospot
Imaging/special
- Excisional lymph node biopsy
- Bone marrow aspirate (if B syx)
- PET (staging)
Classification for lymphoma
Lugano
Limited
Stage I: one node or group of adjacent nodes
stage II: two or more nodal groups, same side of diaphragm
Advanced
stage III: nodes on both sides of the diaphragm
stage IV: diffuse or disseminated involvement
Addison Ix
Bedside: lying standing BP
Bloods: iron studies, glucose, TFTs, renin/aldosterone
TSH/Prolactin /FSH / LH ( assess hypothalamic-pituitary axis)
screening test: 9am cortisol level (usually high, but low in Addisons)
confirmatory dx: short synACTHen test (will see that cortisol still doesn’t rise:()
Imaging/special tests: CT adrenals
steroids SEs
- Cushings
- Weight gain
- Thinning of skin
- Immunosuppression
Drowsy + T1 Diabetes hx Ddx
- DKA
- HHS
- Dehydration
- Rule out infx
Diabetic emergency mx
Cons
- Frequent monitoring
- DVT prophylaxis
- Diabetics team/endo r/v
- Consider HDU if severely unwell
- Consider NG tube for drowsy/vomiting pts
Blood glucose targel levels!
Before meals
4-7mmol/L
2h after meals
5-10mmol/L
HbA1C
1) 48mmol/L for dx of diabetes
2) 48mmol/L target if no trx
3) 53mmol/L target if on trx
DKA dx criteria
Blood glucose >= 11mmol/L
Ketones
pH <7.3
Types of insulin
- Rapid acting (15 mins): humalog
- Short acting (30 mins): humulin R
- Intermediate acting (2-4h): humulin N
- Long acting (several hours): lantus
Acromeglay ddx
Pseudo-acromegaly
(looks like it but w/o incr GH)
Causes: obesity, insulin resistance, hypothyroidism
Acromegaly ix
Bedside: BM/HbA1c, ECG
Bloods: IGF-1 (insulin-like growth factor 1), oral glucose tolerance test, prolactin, triglycerides, GHRH, cortisol/estradiol/testost
Imaging: ECHO, MRI brain/hypothal, CT scan (to check for lung/pancreas/adrenal/ovarian tumours in ectopic production)
Acromegaly mx
Definitive:
- Pit adenoma: trans-sphenoidal pituitary tumour removal
- Ectopic: ca removal
- Familial cause, e.g., MEN 1: genetic counselling
Meds to suppress GH:
- Somatostatin analogue, e.g., octreotide
- Dopamine agonist, e.g., bromocriptine + cabergoline
Pathophys of acromegaly
Pituitary gland releases too much GH -> signals liver to produce insulin-like growth factor I (IGF-I) -> causes bones and body tissue to grow.
Acoustic neuroma (vestibular schwannoma)
benign tumour on vestibular nerve
Acoustic neuroma ix and mx
Ix
- Audiometry to assess hearing loss (sensorineural)
- MRI or CT head to establish dx
Mx
- ENT referral
Conservative: monitor growth if no syx
- Radiotherapy to reduce/stop tumour growth
- Microsurg to remove tumour
Crohn’s mx
(!quit smoking)
Induce: PO pred / IV hydro
Maintain: azathioprine
UC mx
Induce: if mild- mod, PO/PR mesalazine; if severe, IV hydro
Maintain: mesalazine (Aminosalicylates)
Surg: panproctocolectomy
NY HF classification
1 - no syx/ no limitation ADL
2 - mild syx / slight limitation
3 - only comf at rest / sig limitation
4 - syx at rest / severe limitation
Qs for hepatobiliary
- Jaundice
- Pale stool
- Dark urine
- Itchiness
- IVDU
Ix for hepatobiliary
Bloods:
- Iron studies (haemochromatosis)
- Viral hep screen
- Antibodies: Anti-smooth muscle (AI hep), Anti-mitochondiral (PBC), p-ANCA(PSC)
- HIV
- STI
Viral hep (B and C) mx
- Hep ref
- Analgesia: paracetamol
- Itch: chlorphenamine
- minimise transmission - pt education
- consider GUM referral
- contacts for hep vax
Antivirals - hepB:interferon alpha, hepC: ribavirin
AI hep mx
- Steroids
- Azathioprine (immuno suppr)
Child Pugh score
Cirrhosis severity and mortality (BR, albumin, INR, ascites, encephalopathy)
Thyrotoxicosis mx
- Supportive care: O2, fluids, electr repl
- Anti-thyorid meds: PTU
- Steroids: prednisolone (reduce inflamm and lower thyroid levels)
- v severe: plasmapheresis
Cushings Ix
Cushings syndrome
1. 24h urinary cortisol OR overnight (low dose) 1mg dexamethasone suppression test OR salivary cortisol
2. If +ve, perform 2nd test from above -> positive = confirmed
(dexamethasone is basc acting on same Rs as cortisol, so we should get -ve feedback and thus low cortisol)
Cushings disease
Serum midnight ACTH -> normal/high
^High dose dexamethasone suppression test
- If suppressed -> cushing’s disease -> pituitary MRI
- If not suppressed -> ectopic ACTH -> CT TAP
Serum midnight ACTH -> low
^ACTH independent cause -> CT TAP ?adrenal carcinoma
Cushings mx
Syndrome
- Identify + treat underlying cause
- Syx mx: HTN, high blood sugar, osteop
Disease
- First line: transsphenoidal surgery to remove pit tumour ± adjuvant radiation
- Medication: Ketoconazole - lower cortisol // neoadjuvant
Lung ca mx
- SCLC: chemo, e.g., cisplatin
- NSCLC: immunotherapy, e.g., tyrosine-kinase inhib
- SVCO: IV dexameth -> radiotherapy or SVC stenting
Surgical
Lobectomy + adjuvant chemo & radio (more for NSCLC which is more localised)
HF Ix to ask
BNP and ECHO !!
COPD cons mx
- Vaccinations incl pneumococcal, influenza and COVID
- Pulm rehab
- Personalised self-mx plan
- Good inhaler technique
Bronchitis and emphysema
Bronchitis is inflammation of the bronchi in the lungs that causes coughing.
Emphysema is damage to alveoli
Combo inhaler therapy asthma
MART - combo of corticosteroid preventer and long acting bronchodilator
1)ILD caused by asbestosis/silicosis
2) ILD caused by exposure to hay/dust/birds
1) Pneumoconiosis
2) Hypersensitivity pneumonitis
Mx ILD
Cons
- Vacc: pneumococcal, influenza + COVID
- Physio + pulm rehab
- Advanced care planning
Med
- IPF: anti-fibrotics, e.g., pirfenidone
- Hypersens pneumonitis: avoid antigen, PO gluococorticoids
- Advanced: LTOT
Surg
- Lung transpl
1)AS associations
2)AS Mx
1) Uveitis, IBD
2) Regular:NSAIDs
Steroids during flares -> biologics: anti-NF (e.g., infliximab)
Surg: may be required to fix spine deform
Extra articular manifestations RA
- Rheumatoid nodules
- Secondary sjogrens (dry eyes, dry mouth)
- Carpal tunnel
Gout !blood test
Serum urate
PMR v polymyalgia v fibromyalgia
PMR - inflamm disease; bilat pain and stiffness of shoulders, hips, neck; clinical + raised ESR & CRP
PM - inflamm disease; proximal muscle weakness; clinical + CK, lactate dehydrog raised, muscle biopsy
FM - chronic pain disorder widespread MSK pain and tenderness
PMR mx
Cons: NSAIDs, PT+OT, rheum
Med: Steroids + PPI, osteoprophylaxis (bisphos, Ca, vit D), consider steroid-sparing/immunosuppressants (MTX + folate)
SLE mx
1st line (non severe): hydroxychloroquine
(±NSAIDs&Corticosteroids&immunosuppr, e.g., MTX, biologics, e.g., rituximab)
Pathophys SLE
In SLE, the immune system produces antibodies that target and attack various parts of the body, including the skin, joints, kidneys, lungs, and other organs.
SLE Complx + related diseases
- Kidney disease
- CVD
- Pulm disease
- Infx
- Osteopor
Rhabdo and Ix
Occurs when damaged muscle tissue releases its proteins and electrolytes (K+, Na, Ca) into the blood. These substances can damage the heart and kidneys and cause permanent disability or even death.
Ix:
- Urine myoglobin
- CK, ABG (met acidosis)
Rhabdo mx
- IV fluids
- Correct complx, e.g., hyperK or arrhythmia
- Consider withholding nephrotoxic drugs
- Consider IV mannitol (impr eGFR and oedema surrounding muscle and nerves)
- Consider haemodialysis if renal function doesnt improve
Cluster headache mx
High flow O2 + triptans
prophy - verapamil
Stroke mx
! Refer to acute stroke unit
Ischaemic
- 300mg STAT dose PO aspirin
- Thrombectomy (6h) / thrombolysis (4.5h)
Haemorrhagic
- Neurosurgeon referral
- Reverse if on warfarin
- Monitor BP and gradually lower as necessary to prevent further bleed
- TED stockings
(2ndry prevention incl clopidogrel 75mg daily)
Pathophys MG
Autoimmune disease of the neuromuscular junction (NMJ) caused by antibodies that attack components of the postsynaptic membrane, impair neuromuscular transmission, and lead to weakness and fatigue of skeletal muscle.
MG Complx
- Myasthenic crisis (worsening of muscle weakness, resulting in respiratory failure that requires intubation and mechanical ventilation)
- Dysphagia
MG mx
- Pt education and support
- Ref to specialist neuromusc services
- Reg monitoring syx
- Syx mx: AChesterase inhib - pyridostigmine
- Immunomodulatory mx: corticosteroids/azathioprine/rituximab - pt w mod-severe/don’t respond adequately to syx trx
! Thymectomy should be considered for all pts
Seizure meds
Generalised tonic clonic & absence & atonic & myotonic: sodium valproate
focal: carbamaz/lamotr
Triggers for epileptic seizures
- Lack of sleep
- Missed meds
- Stress
- Alcohol
MS ddx and ix
Ddx
- Vit B12 deficiency
- GBS
Ix
- Vit b12
- MRI brain/spinal cord (demyelinating lesions)
- LP (oligoclonal bands in MS, elevated in GBS
- Nerve conduction studies (slow in GBS)
MS mx
- Relapsing-remitting: immunomodulator - interferon beta
- Primary progressive: anti CD20 MAB
- Neuropathic pain: amitryptiline
- Spasticity: baclofen
- Psychotherapy
MS eye condition assoc
Optic neuritis (50%) - inflamm of optic N
- Pain worse w eye movement
- Vision loss one eye
- Loss vision colour
- FLashing lights
Mx hx Qs
- Fatigue
- low mood
- Vertigo
- Vision
- Bowel/bladder
- Speech issues
BCC types
Nodular, superficial spreading, sclerosing, pigmented
BCC and SCC Ix and Mx
1) Dermoscopy, excisional biopsy + histology ± CT/MRI for spread
2) Surgical excision and closure / radiotherapy / 5-fluorouracil / cryotherapy / curettage and ekectodesiccation / Moh’s micrographic surgery!
Acne patho
Combo of: excess sebum production + follicular plugging with sebum and keratinocytes + colonisation of follicles by cutibacterium acnes
Acne mx
Topical:
1. Mild-mod: Retinoids
2. Severe: retinoids + benzoyl peroxide + PO abx
PO (not resp to topical)
3. Mod-sev: PO abx
4. Sev/scarring: isotetrinoin
*referral to derm if severe/scarring or no response to initial treatments
Eczema steroids weak to strong
- Hydrocortisone
- Eumovate
- Betnovate
- Dermovate
Eczema patho
people with eczema suffer from the condition due to a lack of filaggrin. Filaggrin is a protein responsible for building a strong, protective skin barrier
Cellulitis patho
skin is disrupted and microorganisms invade the subcutaneous tissues
Psoriasis mx
Topical steroids / vit D analogue / phototherapy
Psoriasis v eczema
Psoriasis - scalp, elbow, knees, lower back; thick, scaly silver/white patches
Eczema - backs of knees, inside elbows, face; red, itchy, inflamed skin
Types of psoriasis
- Plaque (most common)
- Scalp
- Nail
- Guttate
- Pustular (dangerous)
How does cholecystitis cause shoulder pain?
when GB inflamed and swollen, irritates your phrenic nerve
murphys sign
Acute chole, elicit by asking pt hold deep breath while palpating R subcostal area-> pain
SBO (adhesions) ddx
- Bowel perf
- Bowel isch
- Diverticular disease
Gen surg mx on admission
- NBM
- IV fluids ± NG tube
- electrolyte repl
- Analgesia
- VTE
Paralytic ileus/ pseudo obstr
normal coordinated movements of the muscles of the digestive system become impaired, resulting in a blockage of the intestines
due to surgery, injury, infection
Rovsings sign
Appendicitis - pain referred to RLQ when LLQ palpated
Acute pancreatitis mx
Mild
- Admission + monitor
- NBM
- IV fluids + correct elec disturb
- Analgesia
Mod-severe
as above +
- Nutr support via NG
- Abx if infx susp/confirm
Pancreatitis causes
I - idiopathic
G - gallstones
E - ethanol
(T)
(S)
M - mumps
Peritonitis v guarding
Severe abdo pain that worsens w any motion
voluntary or invol tensing of abdo muscles
Diverticulitis presentation
- Melaena
- Vomiting
- LL abdo pain, worsen by eating
- ±pyrexia/shivering
Diverticulitis mx
Cons:
1) home ± abx if syx + safety net
2) admit if
- Pain not managed w paracetamol
- Poor hydration
- Syx >48h
cons: NBM + IV fluids + analgesia ± NG if vom
medical: PO Co-amox 5 days if uncompl // IV if severe acute
surg: ref + surg if complx (perf, abscess, sepsis)
Most common site diverticulum
sigmoid colon
Tender, swollen testicle ddx
- Epidiymo-orchitis
- Trauma
- Cellulitis
- Test torsion
Chlamydia and gonorrhea testing
NAAT - nucleic acid amplification testing
Epididymo-orchitis / epididymitis mx and complx
Mx
- Admit if acutely unwell
- Abx depending on pathogen: STI - doxy, E coli - cipro
- Bed rest + scrotal elevation + analgesia
- Abstain sex intercourse + reduce physical activity
Complx
- Chronic epididymitis
- Abscess
- Infertility
- Sepsis
Stress incont v urge incont mx
1) lifestyle: avoid caff/excessive fluid + weight loss + pelvic floor exercise
Stress
2) 3/12 pelvic floor exercise if ineffective - surgery: colposuspension, urethral bulking agent, tension free vaginal tape
3) duloxetine
Urge
2) BLadder training
3) meds: oxybutynin (anti musc), or mirabegron
4) surg/procedures: botulinum toxin A inj, sacral nerve stim
Prostate ca ddx and ix
ddx
- Prostatitis
- UTI
- bladder ca (typically haematuria)
ix
- Pt voiding diary
- PSA
- Transrectal US-guided biopsy (confirms dx and Gleason grading)
prostate ca mx
Depending on Gleason score + staging
- Asyx/unsuitable: watchful waiting - annual PSA and mx urinary syx
- Low risk + localised: active surveillance - 6 monthly PSA + annual DRE + yearly MRI
- Intermed/high risk: radical prostatectomy or radiotherapy
- Mets: hormone therapy
BPH ddx & ix
- Prostate ca (less likely w/o FLAWS, but should excl)
- Prostatitis
- UTI
Ix
! clinical dx
IPSS score
International prostate syx score
- Screen/track syx/suggest mx for syx of BPH
What are LUT symptoms?
range of urinary symptoms that can affect the bladder, prostate gland, urethra (LUT)
Obstructive syx
- hesitancy
- weak stream
- straining
- incomplete emptying
Irritative syx
- Urinary urgency
- frequency
- nocturia
- urinary incont
Tamsulosin SE
- Orthostatic HTN
- Sexual dysf - decr libido, ED, ejac disord
BPH mx
Cons: physical acitivity, less fluid before med, mod consump alc and caff + intermit self cath if BPH causing frequent retention, UTI or renal failure
Med: alpha blocker, e.g., tamsulosin or 5-alpha reductase inhib, e.g., finasteride
Surg: transurethral resection of the prostate (TURP)
*TURP syndrome: HTN + brady + mental status change (too much of the fluid used to wash the area around the prostate during the procedure is absorbed into the bloodstream)
1 AAA screening
2 AAA mx
3 ruptured AAA mx
1) M 65 USS screening ± F 70 w/ RFs
<3cm bye bye, 3-4.4 yearly, 4.5-5.4cm 3-monthly
2)
Cons: contact DVLA if >6, stop driving is >6.5cm
Med: mx RFs
Surg: refer to vasc if >3cm; urgent if >5.5cm vie
EVAR (endovascular aneurysm repair) or laporotomy
3) Ruptured AAA
- Emerg surg (not to be delayed by diagnostic imaging)
- Lower BP than usual
DVT mx
DOAC (apixaban)
Provoked: 3 months
Unprovoked: up to 6 months
(LMWH/UFH if low renal function)
signs of aortoiliac involvement in intermittent claudicationt
erectile dysfunction and pain in thighs
Intermittent claudication/ Peripheral vascular disease ddx
- Neurogenic claudication (due to spinal canal stenosis)
- MSK cause
- ?DVT
Ix to look at presence of pulses + ABPI values
1) Doppler US
2) 0.5-0.9 peripheral artery disease, <0.5 critical limb ischaemia
Mx peripheral vascular disease
Lifestyle
- Alc <14 units/week
- Exercise programme
Med (2ndry prev CVD)
- Antiplatelet
- Statin
- Good control DM and HTN
Surg/proced
- Interventional - angioplasty + stenting
- Bypass surg (last resort)
Types of breast ca
- Invasive (most common)
- Invasive lobular
- Paget’s disease of the breast
- DCIS
- LCIS
Breast ca mx
- Surgery: breast-conservative + adjuv radio/chemo, OR mastectomy
- Chemo
- Radio
- Hormonal: if ER+ -> tamoxifen (premen), or aromatase inhib (postmen)
- Targeted: if HER2 +ve -> herceptin
BPPV ddx, Ix and Mx
Ddx
- Acute vestibular labyrinthitis
- Vestibular neuritis
- Meniere’s
Ix
- Dix- hallpike (syx of vertigo and rotational nystagmus when head tilted to opposite side of diseased ear)
Mx
- Consider DVLA/occup risk
- Limit syx by moving head slowly
- Vestibular rehab, e.g., Brandt-Daroff exercises ±physio input
- Epley manoeuvre
1 Acute vestibular labyrinthitis/ viral labyrinthitis v
2 vestibular neuritis v
3 meniere’s disease v
4 osteosclerosis
1 - Inner ear problem usually caused by viral infx -> vertigo/ hearing loss/tinnitus
2 - Inflamm of vestibular nerve -> no hearing loss/tinnitus
3 - Inner ear problem due to accum fluid -> recurrent episodes of vertigo, tinnitus and hearing loss + syx pressure/fullness
4 - Abnormal bone growth in middle ear -> cond hearing loss
BPPV pathophys, cause and RF
BPPV occurs when small crystals of calcium carbonate, shift in the inner ear and/or fall into another area within the balance canals
Cause: inner ear infx (labyrinthitis), fever, head injury, whiplash injury
RF: Concussions, meniere’s, DM, HTN
Neck lump ddx and ix
Ddx
- Tumour
- Goitre
- Skin abscess / cyst
- Lymphadenopathy
Ix
- Blood film
- HIV
- Monospot/EBV test
- TFT
- USS (soft tissue sarcoma)
- CT
Head and neck ca mx
Cons: SALT, dietitician input, psychosocial support
2ndry prev: smoking/alc/fruit/veg/reduce red meat + fried food / reg dentist/ vax against HPV
Types of lympadenopathy
- Reactive
- Infected
- Inflamm
- Malignant
Sore throat ddx
- Tonsillitis (most commonly due to group A strep/strep pyogenes)
- Pharyngitis/laryngitis
- Infx mono/glandular
Tonsillitis mx
Cons: avoid spread, analgesia, safety net
Med:
- ABx: if CENTOR >= 3 or FeverPAIN >=4; if not delayed abx
Surg
- ENT ref if recurrent >7/year or 5/year for 2 years or 3/year for 3 years
FeverPAIN
Fever past 24h
Purulent tonsils
Attend rapidly within3 days
Inflamm tonsils severely
No cough or coryza
TOnsillitis complx
- Otitis media
- Quinsy (peritonsillar abscess)
- OSA
Otitis externa complx
- Abscess
- Stenosis ear canal
- Perf tymp membr
Otitis media ±effusion
Cons
- watch & wait, usually resolves 3-7 days
- Analgesia
- Valsalva manouevre
Med
- Admit if syst unwell
- Immed abx if syst unwell/immunosupp
- Delayed prescr after 3 days if syx dont impr
Surg
- ENT ref if complx -> tympanocentesis or grommet fitting
Common pathogenic causes and complx of otitis media
Pathogens: strep pnum, RSV
- Facial N palsy
- Mastoiditis
- Acute labyrinthitis
Meniere’s Ix and Mx
Ix
- Audiometry (low freq sensorineural hearing loss)
- MRI (excl vestibular schwannoma)
Mx
- Decr salt and caffeine intake
- DVLA
- Vestibular suppressants for acute eps (prochlorperazine)
Achilles tendinopathy mx
- Rest + immobil
- Ice
- Analgesia (NSAIDs)
- Elevation
- 6-12 weeks to heal
- Night splints to hold foot in neutral position
- VTE prophylaxis
- Physio input
If ruptured
- Period of non weight bearing
- Brace or plaster cast
- Surgical r/v
Carpal tunnel, RFs, and mx
Compression of median n in risk
RFs: overweight, preg, activities repeatedly bend wrist, prev wrist injury
Cons
- Rest
- Minimise activities which exacercbate
- Wrist splint
- Trial NSAIDs ± PPI cover
- physio
- ergonomic changes
Med
- Steroid inj (syx relief)
Surg
- Carpal tunnel decompr surgery
- Sonographically guided carpal tunnel release
Shoulder pain Ddx and Ix
- Rotator cuff tear (USS)
- Rotator cuff rupture (USS)
- Adhesive capsulitis (frozen shoulder)
- OA (XR)
- #
Rotator cuff inj mx
Cons
- Rest
- Analgesia
- Ice
- Adapt activities
- Physio
Surg
- Depends on degree of damage lol
Compartment syndrome
ddx, cause and mx
increase in pressure inside a muscle, which restricts blood flow and causes pain
ddx
- #
- Haematoma
- RHabdo
cause
- #
- badly bruised muscle
- constricting bandages
mx
- urgent ortho referral for fasciotomy
(relieve Pa within compartment and restore blood flow -> prevent tissue necrosis) within 6h
- Analgesia
- oral hydr
- remove any external dressings
- elevate leg to heart level
ACL tear ddx, ix, mx
ddx
- #
- Patellar disloc
- meniscal tear
ix
- MRI
- arthroscopy (gold standard to visualise ligaments)
Mx
- ortho ref
Cons
- Rest, ice, compression, elevation, rehab
- analgsia: NSAID
- crutches/knee brace
-physio
Surg
- Ligament reconstruction (arthroscopic surgery) in complete rupture where no local healing detectable
Fall/collapse ix
- Primary survey
- Lying/standing BP
- ECG
- Urine dip
NOF # mx
Cons
- analgesia
- VTE prophylaxis
- PT/OT input
- prophyl abx if open wound
- falls assessment (age, presenting w/ fall, meds or med conditions that incr risk fall, hx falls, etc)
- r/v meds
Surg
Intracapsular
- Displaced: THR or hemiarthroplasty
- Undisplaced: dynamic hip screw
Extracapsular
- Intertrochanter: dynamic hip screw
- Subtrochanter: intramedullary nail
Meds that increase risk of falls in elderly
- HTN meds
- Benzodiazepines
- Antidepressants
- Antipsychotics
- Opioids
- NSAIDs
Garden classification
For subcapital femoral neck #, predicts development of osteonecrosis
HTN dx value and stages + targets
Dx: >140/90 (clinic), or 135/85 (home)
Stage 1: >140/90, or >135/85
Stage 2: >160/100, or >150/95
Stage 3: >180/120
<80 y/o: <140 S, <90 D
>80 y/o: <150 S, <90 D
HTN end organ damage ix
- Kidney: dipstick -> proteinuria, haematuria // Urine albumin:creatinine ratio // U&Es
- Eye: fundoscopy -> hypertensive retinopathy
- Bloods: glucose, lipid profile
Osteoporosis RF
- Incr age
- F
- Low BMI
- Long term steroids
- Alcoh
-Smoking
FRAX assess
Risk of fragility # over next 10 years
CIs of LP
- Local skin ifx
- Spinal cord compr
- Papilloedema/other signs of raised ICP
Adhesive capsulitis (frozen shoulder) and mx
fibrosis and thickening of the joint capsule and adherence to the humeral head
onset to recovery 12-42 months, most pts recover but normal ROM may not return
!diabetes pts at higher risk
Mx
Cons
- Continue using arm but dont exacerbate pain
- Physio -> active/passive exercise and stretching
- Analgesia ± TENS (transcutaneous electr N stim) for pain mx
- Pain clinic/ortho if signif disab + poor pain control
Med
- Intra-articular steroid injections
Surg
- Arthroscopy to remove adhesions
Phases of adhesive capsulitis
Freezing/inflamed -> frozen/stiff -> thawing
Cauda equina ddx, ix and mx
Ddx
- Prolapsed lumbar disc
- Conus medullaris
- Peripheral neurop
Ix
- ER MRI to confirm/exclude
Mx
- Hosp admission
- Neurosurg input -> lumbar decompr surg
- VTE proph
- Abx if infx cause
Conus medullaris v cauda equina
Vertebral level
CM: most distal end of spinal cord - CNS (L1-2)
CE: collection of N roots - PNS (L2-S5)
Impacted n roots
CM: sacral
CE: lumbosacral
Symmetry of signs
CM: symmetrical
CE: asymmetrical
Involvement of lower extr, bowel, urin
CM: less extr, but more bowel + urin
CE: more
Reflexes
CM: Increased
CE: decreased
Spinal stenosis, syx, rf, ix, mx
Narrowing of spinal canal -> compr of spinal n, or sometimes spinal cord.
syx: back pain + leg pain ± numbness, mostly when walking
rf:
- Narrow spinal canal
- F
- >= 50 yo
- Prev inj/spinal surg
ix: MRI
mx:
1. Cons
- Physio: impr spiinal mobility, strength
- Pain mx
- Overal fitness ++, ± weight loss
2. Med
- Spinal injections
- Nerve root block
3. Surg
- Decompression
(*types: lateral, central and foraminal stenosis)
Acute prostatitis presentation and ddx
Most commonly due to ascending urethral infx
- Groin pain, worse on opening bowels
- Dysuria, incr freq, slow stream
- Feverish
(can be caused by STIs huh)
Ddx
- UTI
- Urinary tract stones
- Prostatic abscess
Acute prostatitis mx and complx
Cons
- Analgesia
Med
- Admission if acutely ill/septic
- Abx if <6/12 hx
- Alpha blockers, e.g., tamsulosin, to relax smooth muscle and improve syx
Surg
- Suprapubic cath (if urin reten)
- Transrectal aspiration under US guidance for abscess
Complx
- Abscess
- Epididymitis
- Sepsis
Haemorrhoids
Swollen vein/group of veins around anorectal region
(*Thrombosed -> when blood clots develop -> pain & itch + -> bleed if ulcerated)
Haemorrhoids mx
- Topical trx to reduce swelling/pain - anusol
- Constip: incr fibre + fluid intake
- Non-surg: rubber band ligation (cut off blood supply), bipolar diathermy
- Surg: haemorrhoidectomy, haemorrhoidal artery ligation
Lateral epicondylitis (tennis elbow) ddx, ix, mx
Ddx
- Olecranon bursitis
- Elbow arthritis
Ix
- Clinical dx
- XR if unclear
Mx
- Self limiting (most good progn)
- Rest
- Modify activities that exacerbate syx
- NSAIDs
- Apply heat/ice
- Physio
- Orthotics - elbow braces
Med: ± steroid inj short term relief
Surg: release/repair damaged tendons
MM ddx, ix, mx
Ddx
- Monoclonal gammopathy of undetermined significance (MGUS)
- Bone metastases
- CLL
Ix
- Urine electrophoresis (Bence Jones protein)
- Bone profile (ca)
- Serum protein electrophoresis (shows which type of myeloma proteins raised)
- Blood film (rule out leukaemia)
- XR (lytic bone lesions)
Mx
Cons: analgesia, hydration, emotional/psych support
Med: trx guided by haem and onc specialists
- Non chemo regime: combo of dexamethasone and immunomodulatory agent
- Conven chemo: as above + chemo, e.g., cyclophosphamide
- Cement inj in #/lesions to improve spine stab
- Stem cell transpl
- Treat any complx myeloma
MM complx
- infection
- renal failure
- spinal cord/nerve root compression
- neuropathy
MM v MGUS v smouldering myeloma
MM: malignant cancer of plasma cells that produce abnormal M protein, which can cause bone pain, anaemia, kidney damage, and other symptoms
all related to the abnormal growth of plasma cells in the bone marrow, but differ in terms of severity and risk of progression to multiple myeloma
MGUS: benign condition presence of small amount of abnormal monoclonal protein (M protein) in blood without any symptoms or organ damage. MGUS does not require treatment and does not progress to multiple myeloma in most cases.
SM: higher level of M protein and abnormal plasma cells in the bone marrow than MGUS, but no symptoms or organ damage. Smoldering myeloma has a higher risk of progression
Leukaemia, presentation, ddx, ix
Ca of particular line of stem cells in bone marrow - myeloid v lymphoid
Prx
- Bruising/petechiae
- FLAWS
- pallor
- hepatosplenomgaly
Ddx
- HSP
- ITP
- Meningococcal septicaemia
Ix
- Blood film!
- Bone marrow biopsy
HSP
Henoch-Schönlein purpura (HSP) is an IgA mediated vasculitis, tends to occur post-infection with the most common trigger being group A streptococci (URTI or GI)
purpura on legs, buttocks, arms
(self limiting)
ITP
Purpura + low platelets following viral illness
(self limiting)
AML (acute myeloid leukaemia)
Most common acute adult leukaemia. It can be the result of a transformation from a myeloproliferative disorder (e.g., PCV or myelofibrosis). Associated with Auer rods + blast cells ++.
CML (chronic myeloid leukaemia)
Has three phases: 1) chronic - 5yr and asyx, 2) accelerated and 3) blast. Associated with the Philadelphia chromosome.
CLL (chronic lymphocytic leukaemia)
Most common leukaemia in adults overall. Associated with warm haemolytic anaemia, CLL can undergo Richter’s transformation into high grade lymphoma. Blood film shows smudge / smear cells.
Chemo complx
- Failure
- Infx due to immunodef
- Infertility
- TLS
TLS
Release of uric acid from cells being destroyed by chemo -> forms crystals in interstitial tissue and tubules of kidneys -> AKI
mx: allopurinol
Causes clubbing
Cardiac
- Congenital heart disease
- Infective endocarditis
Respiratory
- Lung ca
- Bronchiectasis
- Pulm fibrosis / ILD
GI
- IBD
- Coeliac
CV exam spiele
Resp exam spiele
ILD -> pulm fibrosis causes by areas of lung
Abdo spiele
Ddx abdo pain
UMN v LMN
Upper limb spiele
LL spiele
Hip exam spiele
Knee exam spiele
Mc Murray’s test
OA Knee XR spiele
OA mx
Knee joint repl
Hands and wrist spiele
Breast spiele
Vascular spiele
I performed a vascular exam on this x year old pt.
The patient appeared comfortable at rest.
On examination, there were no signs associated with vascular disease. CRT was <2s both in upper and lower limbs. All pulses were palpable throughout the body. Buergers test was negative.
Breast signs
Breast path
HL and NHL ix and mx
HIV patho
Once inside the body, HIV gets inside certain types of white blood cell called CD4. These cells are part of the body’s defenses against infection.Without treatment the virus gradually damages the immune system. Eventually people become susceptible to unusual infections that would not normally trouble someone with a healthy immune system.
E.g.s of AIDs defining illnesses
- Bacterial infx - multiple or recurrent
- Kaposi sarcoma
- Pneumocystis jirovecii pneumonia
Mx new HIV dx
General mx new HIV dx
- ART
- START study - better health outcomes when starting early
- Normal life expectancy
- Undetectable = untransmittable
- <50 copies/ml undetectable viral load
- Contact tracing & PEP
- Charities offering support
- Once stable
- Monitor 2x/year: in-depth annual r/v and six-monthly viral load, hepatitis and syphilis test
Febrile neutropenia
Duet to pt’s decreased ability to mount an inflamm response
- most common life-threatening complication of cancer therapy - onc emergency
- Prompt empirical abx trx
IBD + preg mx
-
5 mg of folic acid per day + Ca + vit D supplementation ± nutritional support if not gaining weight early in preg
- Meds such as sulfalazine interfere folic acid metab
- Latter 2 to prevent bone loss
Types of AF
- Paroxysmal: occurs intermittently and stops on its own within 7 days
- Persistent: lasts longer than 7 days
- Long-standing: lasts longer than a year
*Fluttering chest syx w no pain (±tachy, SOB, dizziness/lightheadedness) ddx
- AFib
- SVT
- Premature ventricular contractions
How is acromegaly linked to heart problems?
Acromegaly is a condition that results from excess growth hormone (GH) secretion by the pituitary gland. This excess GH can cause abnormal growth of body tissue, including the heart.
One of the most common cardiac problems associated with acromegaly is hypertrophic cardiomyopathy, which is a thickening of the heart muscle. This occurs most commonly at the septum, which can cause reduced, or even obstruction, of blood flow out of heart.
You can also get stiffness of the ventricle due to cellular changes that happen in cardiac muscle when it thickens - ventricle can’t relax normally and fill with blood → less blood at end of filling → less blood pumpled to rest of body
Causes of end stage renal disease
- Diabetes
- HTN
- PKD
- SLE
- Kidney stone
- Chronic pyelonephritis
ADPKD (autosomal dominant polycystic kidney disease) and cause
Fluid filled cysts develop → gradually enlarge + damage kidney → reduced kidney function over time
Cause: mutation of PKD1 or PKD2 gene which produce proteins that are important for kidney function.
ADPKD syx and mx
Syx
- Abdo pain
- Back pain
- Haematuria
- HTN
Mx
- Refer to nephrology
- Monitor kidney function
- Creatinine
- eGFR
- urine dip for protein
- Mx HTN
- ACEi/ARBs
- Mx pain
- Genetic counselling
(Charcot triad) - dx features of cholangitis
- Jaundice
- RUQ
- Fever
Peripheral arterial disease subtypes
1) Intermittent claudication ->
2) critical limb ischaemia
3) acute limb ischaemia
Intermittent claudication
syx of ischaemia during exertion
- crampy/achy pain which resolves on rest
Acute limb ischaemia
rapid onset limb ischaemia due to thrombus (/clot) blocking supply to distal limb!
- 6Ps!
- emergency trx needed
Critical limb ischaemia
end stage disease (chronic) - inadequate blood supply at rest
- Pain at rest
- Muscle wasting
- Hair loss
- Non-healing ulcers
- small, deep, well-defined borders
- More peripherally, e.g., toes
- painful
- Gangrene
Atherosclerosis
Lipid deposits in artery walls → atheromatous plaques → stiffening (which causes HTN and increased strain on heart) + stenosis (reduced blood flow) + plaque rupture (thrombus)
End results atherosclerosis
- Angina
- MI
- TIA / stroke
- Peripheral artery disease
- Chronic mesenteric ischaemia
Intermittent claudication mx
Lifestyle changes
- stop smoking
- exercise training programme
- treatment of medical conditions
Medical:
- Atorvastatin 80mg
- clopidrogel 75mg
- naftidrofuryl oxalate (peripheral vaso-dilator)
Surgical
- Angioplasty and stenting
- Inserting catheter through arterial system under xray guidance → balloon inflated at area of stenosis to create space in the lumen → stent to keep artery open
- Endarterectomy
- cutting vessel open and removing atheromatous plaque
- Bypass surgery
- Using graft to bypass blockage
Mx critical limb ischaemia
- Urgent referral to vasc team
- Analgesia to manage pain
- Urgent revascularisation
- Endovascular angioplasty and stenting
- Endardectomy
- Bypass surgery
- Amputation
- If unable to restore blood supply
Mx acute limb ischaemia
- Urgent referral to oncall vasc team
- Endovascular thrombolysis
- Inserting catheter and applying thrombolysis directly to clot
- Endovascular thrombectomy
- Inserting catheter and removing thrombus via aspiration/mechanical device
- Surgical thrombectomy
- Cutting open vessel and removing thrombus
- Endarterectomy
- Bypass surgery
- Amputation
How do you unblock an artery? - Fogarty catheter
Venous disease and classification
Veins bring blood back to the heart, in venous disease veins become diseased or abnormal so we essentially have a drainage issue.
Venous disease can be classified via CEAP classes (Clinical manifestation, etiology, anatomic distr, and pathophysiology), the following is the C bit:
C0 - no signs of venous disease
C1- telangiectasia/spider vei
C2 - varicose veins
C3 - oedema
C4 - skin changes, e.g., pigmentation
C5 - healed venous leg ulcer
C6 - active venous leg ulcer
Venous ulcers
- Larger, more superficial
- Irregular border
- Affect midcalf down to ankle
- Less pain
- ±Haemosiderin staining
- ±venous eczema
Venous disease ix and mx
Investigations: duplex USS (look at the speed of blood flow, and structure of the leg veins)
Management (venous ulcer)
- Conservative: ulcer clinic for compression banding, analgesia, patient education - self-care, including regular exercise, maintaining a healthy weight, keeping limb raised where poss
- Medical: corticosteroids for itching, abx for infx
ILD v PF
ILD are a group of lung conditions which cause inflamm and scarring
PF is what the scarring itself is called
Parkinson plus syndromes and some features
- Multisystem atrophy
(LSBP -> shy drager syndrome) - Progressive supranuclear palsy
(eye movements -> nystagmus) - Corticobasal degeneration
Causes aortic stenosis
-Degenerative: age-related calcific
- Infx: Rhfever, IE
-Structural: HOCM
Aortic stenosis: Signs of severity
-Narrow pulse pressure / slow-rising pulse
-Delayed closure of A2 or reversed splitting of 2nd HS
-Absent 2nd HS
-Heaving apex beat
-Features of congestive cardiac failure
-Symptomatic
Aortic stenosis: Indications for surgery
-Symptomatic
-CCF
-Mean transvalvular pressure grdient -> Pa before and after valve
>40mmHg; valve area <1cm^2; or jet velocity
>4m/s
-Concomitant CABG
Surg options for aortic stenosis
-Open surg
-TAVI
:) No bypass / large scars
:( ^ risk stroke vs open
-Balloon valvuloplasty
Metallic v bio valve
TAVI usually inserted via temporal artery and up into aorta
Metallic:
-Lasts >20-30 yrs
- ☑ Warfarian life long -> younger pt
- ☑ hyperpanothyr
Bio:
- Lasts 10-15 yrs -> More likely replacement
- Not typically needing warfarin -> older pt
- ☑ Kidney disease
Warfarin targets (examples)
Aortic bioprosthetic -> Nil (aspirin) -> n/a
}Much lower rates thromboembolic events
Mitral bioprosthetic -> 2.5 (2-3) -> 3 months (then aspirin)
Aortic mechanical -> 3 (2.5-3.5) -> Life-long !Mech. valve ALWAYS warfarin
Mitral mechanical -> 3.5 (3-4) -> Life-long
INR target mitral > aortic as mitral valve at greater risk thromboemb. event
CABh most commonly used
Internal thoracic (mammary) ARTERY currently most commonly used
Coronary artery bypass grafting: Medication post-CABG
1:-Dual anti-platelets (aspirin + -c-l-o-p-i-d-o-g-r-e-l-) -> ticagrelor -> more common
- For 12 months
- Then aspirin alone
- +/- Specialist opinion [NICE]
2:-Cardio-selective beta-blocker (e.g. bisoprolol)
3:-ACE-inhibitor (or angiotensin receptor blocker) -e.g. ramipril
Causes of mitral regurg:
-Degen: M1
-Infx: RhF, IE
-Autoimm: SLE
-Structural: conn. tiss dis, e.g. Marfans
