PACES 2 Flashcards
key management points to remember
MDT
conservative
medical surgical
key investigation points
bedside
bloods
imaging
special tests
what to remember in resp stations?
ABG
mx of AF
- acute (48hr) and unstable = cardioversion
- rhythm control (BB or CCB)
- anticoag using CHA2DS2VASc (apixaban)
NSTEMI vs UA
NSTEMI = +ve trop
UA = -ve trop
(measure trop twice)
STEMI management
A-E
oxygen if needed
morphine and metoclopramide
aspirin 300 and clopi 300
GTN
if <12 hours = PCI (give heparin)
if not thrombolysis
NSTEMI management
A-E
oxygen if needed
morphine and metoclopramide
aspirin 300 and clopi 300
GTN
Fondaparinux
Calculate GRACE score
ongoing therapy in IHD
ACEi
BB
Cardiac rehab
statin
DAPT (aspirin lifelong and clopi for 1 year)
angina management
GTN + BB/CCB + statin
consider ACEi if DM/HTN and angina
HF investigation to remember
BNP
management of HF
ACEi
BB
Spironolactone
SGLT-2
add ons: hydralazine, entresto, CRT
weights, manage RFs
Severe pulmonary oedema management
A-E
Sit up and give oxygen
Morphine
Furosemide
GTN
CPAP
Management of AS
Optimise RFs (statins, anti-HTN, DM)
Regular F/U with echo
BB if angina
Valve replacement (severe symptoms, dec EF, undergoing CABG)
Unfit = valvuloplasty, TAVI
Management of AR
Optimise RFs
Regular F/U
Dec afterload = ACEi / CCB
Replace (if HF or reduced EF)
Management of MR
Optimise RFs
Monitor
Control AF and anticoagulants
Dec afterload (ACEi)
Diuretics if HF
Replace valve (symptoms, dec EF)
Pneumonia management
CURB-65
Antibiotics
Oxygen
Fluids
Analgesia
Chest physio
X-ray
Bronchiectasis investigations
CXR (tramlines)
Spirometry
HRCT chest (dilated airways)
Management of bronchiectasis
Chest physio
Antibiotics for exacerbation
Bronchodilators
Treat underlying cause
Surgery if localised disease
Management of CF
MDT
Chest: physio, antibiotics (acute and prophylaxis), mucolytics, bronchodilators, vaccinate
GI: Creon, ADEK supplements, insulin, ursodeoxychokic acid
Lung cancer management
MDT
Assess risk of operative mortality
Smoking cessation
NSCLC: surgery, radio, chemo
SCLC: palliative mostly, radiotherapy
Asthma investigations
FBC (eosinophillia)
Inc IgE
Aspergillosis serology
CXR
Spirometry
PEFR monitoring
Management of asthma
TAME
Drugs:
1. SABA
2. SABA +ICS
3. LABA + ICS
4. + LTRA
specialist help
Investigations for COPD
Bloods (inc FBC)
ABG
CXR
ECG
Spirometry
Echo (PHT)
Assess severity by FEV1
Management of COPD
General: stop smoking, pulmonary rehab, vaccinate (influenza, pneumococcal)
Optimise treatment for co-morbidities
Meds:
Non-asthmatic features: LABA+LAMA, add ICS if lots of exacerbations
Asthmatic features: LABA+ICS, LABA+LAMA+ICS
LTOT
Pulmonary fibrosis investigations
CXR and HRCT: reticulonodular shadowing, honeycombing
Pulmonary fibrosis management
Supportive
Stop smoking, rehab, oxygen therapy, palliative
Treatment of hyderaldosteroism
Bilateral adrenal hyperplasia = spironolactone
Adrenal adenoma (Conn’s) = lap adrenelectomy
Dyspepsia what to check
ALARMS
Anaemia
Loss of weight
Anorexia
Recent onset progressive symptoms
Melaena or haematemesis
Swallowing difficulties
Dyspepsia management
Stop smoking
Stop NSAIDs
Avoid hot drinks and spicy food
OTC (antacids)
Lose weight
Upper GI bleeding
- Resus (fluids, oxygen, check coagulopathy)
- Terlipressin if variceal, prophylactic antibiotics
- Urgent endoscopy
- After endoscopy = IV omeprazole, NBM, daily bloods
Scoring systems for UGI bleed
Glasgow blatchford
Rockall
Cirrhosis investigations
Bloods (FBC: dec WCC, dec platelet, inc LFTs, inc INR, dec albumin)
Find cause
Cirrhosis management
General: good nutrition, ETOH absence, colesytramine
Screening: HCC= US +AFP, Varices = endoscopy
Treat specific cause
Treat decompensation (acute, coag, encephalopathy, SBP)
Child Pugh Grading
Alcoholic Hepatitis
Check CAGE
Stop ETOH, withdrawal, Pabrinex, optimise nutrition
Check LFT/U&E/INR, manage complications
NAFLD investigations
BMI, glucose, fasting lipids, LFTs, biopsy
NAFLD management
Lose weight,
Control HTN, DM, lipids
PBC/PSC
Symptomatic: priorities (colestramine), diarrhoea (codeine)
Specific: ADEK vitamins, ursodexoycholic acid
IBD extra-articular
Skin: clubbing, erythema nodosum
Eyes: arthritis
Joints: arthritis
HPB: PSC, gallstones
Chron’s pathology
Skip lesions
Rose thorn ulcers
Cobblestoning
String sign of kantor
Chronic pancreatitis management
Drugs: analgesia, CREON, ADEK vits, DM
Diet: no ETOH, dec fat, inc carb
Surgery: pancreatectomy
Criteria for AKI
RIFLE criteria
chronic renal failure management
general: reverse reversible causes, stop nephrotoxic drugs
lifestyle: exercise, healthy weight, stop smoking, fluid/phosphate retention
CV risk: statins, treat DM
HTN: target <140/90 (give ACEi)
Anaemia: EPO
Bone disease: phosphate binders
renal transplant complications
post-op: bleeding, graft thrombosis, infection
hyderacute rejection: ABO incompatibility
acute rejection (<6mo)
chronic rejection (>6mo): interstitial fibrosis
SEs of immunosuppression
CVD (HTN, atherosclerosis)
PCKD management
General: inc water, dec Na
monitor U&Es, BP
genetic counselling, MRA for berry aneurysms
medical: treat HTN and infections aggressively
surgical: cyst removal, nephrectomy
stroke management
urgent CT
aspirin 300mg
consider thrombolysis <4.5 hrs
consider thrombectomy
primary prevention of strokes
- control RFs (HTN, inc lipids, DM, smokers)
- consider lifelong and anti-coag in AF
- carotid endarterectomy if symptoms 70% stenosis
- exercise
secondary prevention of strokes
- RF control = start statin after 48 hours
- aspirin/clopi 300mg for 2 weeks, then clopi for 75mg
- carotid endarterectomy if good recovery and ipsilateral stenosis >70%
stroke rehab
- MDT (OT, physio, SALT, dietacian, neurologist)
- eating (consider swallow)
- neurorehan
- DVT prophylaxis
- sores
TIA management
- anti-plt therapy (300mg for 2 weeks, then 75mg/d)
- cardiac RF control
- specialist referral to TIA clinic (MRI)
subdural management
irrigation/evacuation via burr hole craniostomy
extradural management
neuroprotective ventilation
consider mannitol
craniectomy for clot evacuation
GCS verbal
1: none
2: sounds
3: words
4: confused
5: orientated
Parkinson’s management
MDT
Assess disability
Physio
Depression screening
Medical: L-DOPA, MOA-B inhibitors, Da agonists
+ COMT (lessen end of dose)
+ Quietapine (disease-induced psychosis)
+ Citalopram (depression)
MS management
MDT
acute attack: methylpred
preventing relapse: IFN-beta, natalizumab
symptomatic management
poor prognostic features of MS
- older
- male
- motor signs at onset
- many relapses
- many MRI lesions
Charcot-Marie Tooth investigations
PMP22 gene mutation
nerve conduction speed
CMT management
supportive
physio, podiatry, orthoses
MND management
MDT
Riluzole
Supportive: drooling (amitriptyline), dysphagia (NG feed), resp failure (NIV), spasticity (baclofen)
OA management
cons: wt loss, alter activites, physio, walking aids
med: analgesia, joint injection
surg: replacement
RA management
cons: rheum, regular exercise, PT, OT
med: monitor with DAS28, DMARDs, steroids, NSAID
manage CV risk
conservative management of gout
lose weight
avoid prolonged fasting and ETOH excess
osteoporosis investigations
DEXA scan
FRAX score
management of osteoporosis
cons: stop smoking, dec ETOH, weight bearing, Ca/Vit D, falls prevention
med: bisphosphonates, supplements
Pre-op checks
OP CHECS
Operative fitness (cardio resp co-morbidities)
Pills
Consent
History (conditions, complications of anaesthesia)
Ease of intubation
Clexane (DVT prophylaxis)
Site
oesophageal Ca management
MDT
Surgical (25%): oesophagectomy (2 or 3 stage approach)
Palliative: stenting, analgesia, radiotherapy
perforated peptic ulcer management
- Resus –> fluid
- NBM
- Analgesia
- Abx: cef and met
- NGT
consider laparotomy if defect needs repairing
biliary colic management
cons: hydrate, NBM, opioid analgesia
surg: lap chole (try for same admission)
ascending cholangitis management
Cef + Met
ERCP
pancreatitis management
cons: fluid resus, NBM, NGT, analgesia (opioid)
interventional: ERCP if dilated ducts secondary to gallstones
chronic pancreatitis management
- lifestyle: no ETOH, dec fat, increase carb
- drugs: analgesia, CREON, ADEK, DM Rx
appendicitis management
fluids, NBM
abx (cef and met)
analgesia
operation
acute severe UC management
resus: IV hydration, NBM
hydrocortisone
LMWH
monitoring
improvement = switch to oral therapy
what additional thing would you add to management in Chron’s?
dietician review
mesenteric ischaemia management
fluids
Abx
LMWH
laparotomy
anal cancer management
- most chemoradiation
- surgery reserved for tumours that fail to respond to radiotherapy/ GI obstruction/ small anal margin tumours
definition of hernia
protrusion of a viscus through walls of its containing cavity into abdominal position
inguinal hernia management
non-surgical: control RFs of cough, constipation, lose weight, truss
surgical: tension free mesh
complications of hernia repair
early = haematoma, infection, intra-abdo injury
late = recurrence, chronic groin pain
general aspects of breast Ca management
MDT
1-2 = surgical
3-4 = chemo, palliation
surgical management of breast Ca
WLE + radiotherapy or mastectomy
sentinal node biopsy +/- axillary clearance
breast cancer surgical complications
haemotoma
frozen shoulder
long thoracic nerve palsy
lymphodema
systemic breast cancer management
radio
chemo
endocrine therapy
biological therapy
main sx and management of duct papilloma
bloody discharge
excise
management of phyllodes
WLE
claudication values of ABPI
0.6-0.8
fontaine classification
asymp
intermittent claudication
ischaemic rest pain
ulceration/gangrene
chronic limb ischaemia management
cons: inc exercise, stop smoking, wt loss, foot care
med: RFs (BP, lipids, DM), anti-plt, analgesia
surg: bypass, endarterectomy
acute limb ischaemia management
NBM
rehydration
analgesia
unfractionated heparin
complete occlusion: yes (embolectomy/bypass), no (angiogram and observe)
venous ulcer management
- refer to leg ulcer communtiy clinic
- optimise RFs (nutrition, smoking)
- analgesia
- 4 layer graded bandaging (if ABPI >0.8)
4 R’s of fracture management
- Resus (ATLS, neurovasc, X-rays)
- Reduce (closed vs open reduction)
- Restrict (non-rigid, plaster, ex-fix, internal fixation)
- Rehab (OT, PT)
fracture complications
Imm: NV damage, visceral damage
Early: compartment syndrome, infection, fat embolism
Late: AVN, problems with union, complex regional pain syndrome
Hip fracture appearance
short, externally rotated
Garden classification of intracapsular fractures
- incomplete, undisplaced
- complete, undisplaced
- complete, partially displaced
- complete, completely displaced
management of 1 and 2
ORIF with cannulated screws
management of 3 and 4
young = ORIF with screws
55-75 = THR
>75 = hemi
OA management
MDT
cons: lifestyle, dec wt, inc exercise
physio for muscle strengthening and OT
med: analgesia, joint injection
surg: arthroscopic washout, replacement
L5 nerve root compression
foot drop
weak inversion
dec sensation on inner dorsum
S1 root compression
weak plantarflexion and eversion
loss of ankle jerk
dec sensation over sole of foot and back of calf
management of Dupuytren’s
cons: physical exercises
fasciectomy
stoma exam findings
exam standing up
patient = well, no acute abdo
abdomen = scar from stoma formation operation
stoma = site, surrounding skin, opening, contents, pt coughs
palpate = abdo around stoma
definition of a stoma
artificial conduit between internal viscera and outside of skin
indications of end colostomy
AP resection
Hartmann’s
indications of loop colostomy
- divert faecal load from newly formed distal anastomosis
- palliative in Ca patient with distal obstruction
- bowel decompression
indications of loop ileostomy
- anterior resection (bowel rest before reversed)
- following panprotocolectomy who have ileo-anal pouch formed
indications of end ileostomy
following panprotocolectomy when can’t anastomose
complications of stoma
early: surg complication, ischaemia, high output, stomal retraction
late: parastomal hernias, prolapse, obstruction due to adhesion
indications for stoma
- exteriorisation
- diversion
- decompression
- feeding
- lavage
any acute station
A-E approach
acute abdo key investigation
amylase
important questions in endo history
- menstrual cycle
- headache and vision
- muscle weakness
- weight changes
- urinary symptoms
- sweaty/hypoglycaemia symptoms
- blood pressure
- libido
important screening questions
- headache
- changes to vision
- SOB
- nausea/vomiting
- chest pain
- palpitations
- abdo pain
- change in bowel habit
- change in urinary symptoms
- back pain
- leg swelling
- leg weakness
- any change in sensation
- FLAWS
( rashes)
what to give in any chronic lung condition
- vaccinations
- chest physio
c spine exam
- look
- feel (trapezius, C7 up to C2) - put hand on pt forehead
- move (left to right, up and down, side to side)
- special test (Spurling = extend neck, tilt to one side, push down)
- neuro (power, tone, sensation, reflexes)
breast screening
50-71 every 3 years
common breast mets
liver
lung
brain
bones
bowel screening
60-74 every 2 years
what to do in vascular ?
radial femoral delay
views of CT scan
axial
coronal
extra bits of hand exam
hands on table - Duputyrens
Finklestein test
appearance of blood and oedema in CT scan
- blood is high attenuation
- associated oedema is low attenuation
- check mass effect
location of descending aorta on scan?
more towards the back
look part of spinal exam
- gait
- inspect from behind and side
feel part of spinal exam
- spinous processes and sacroiliac joints
- paraspinal muscles
- also schober’s test
move part of spinal exam
- lateral flexion (arm down leg)
- lumbar flexion and extension
- cervical spine movements
- thoracic rotation
special tests in spine
- Schober’s test
- femoral nerve stretch test (pt prone, passively flex knee and extend hip)
- straight leg raise (pt supine, lift leg to full flexion then passively dorsiflex foot)
