PASS MED Flashcards
A 27-year-old female presents with weakness of both hands. On examination you note wasting and weakness of the small muscles of the hands and loss of pain and temperature sensation over the trunk and arms. Vibration sense is intact.
What is the most likely diagnosis?
Syringomyelia - yringomyelia is a condition whereby fluid filled cavities develop within the spinal cord. Pressure can increase resulting in compression of the spinal cord tracts. The syrinx can extend to and damage the anterior horn cells, thereby resulting in lower motor neurone features. The spinothalamic tract axons decussate to the other side of the spinal cord via the anterior white commissure, and they are particularly susceptible to damage from the syrinx. Pain and temperature sensation are lost due to spinothalamic tract damage, and one side may be affected more than the other. Classically, the sensation loss is experienced in a shawl-like distribution over the arms, shoulders and upper body. Light touch, vibration and proprioception may also be affected as the syrinx enlarges into the dorsal columns.
Complications of aneurysmal SAH:
Re-bleeding
happens in around 10% of cases and most common in the first 12 hours
if rebleeding is suspected (e.g. sudden worsening of neurological symptoms) then a repeat CT should be arranged
associated with a high mortality (up to 70%)
Vasospasm (also termed delayed cerebral ischaemia), typically 7-14 days after onset
Hyponatraemia (most typically due to syndrome inappropriate anti-diuretic hormone (SIADH))
Seizures
Hydrocephalus
Death
window for thrombolysis stroke
A combination of thrombolysis AND thrombectomy is recommend for patients with an acute ischaemic stroke who present within 4.5 hours
NICE have also made recommendations to use a modified Rankin score of less than 3 and a National Institutes of Health Stroke Scale (NIHSS) score of more than 5 when considering the selection of patients for mechanical thrombectomy.
Contraindications to thrombolysis:
Absolute
- Previous intracranial haemorrhage
- Seizure at onset of stroke
- Intracranial neoplasm
- Suspected subarachnoid haemorrhage
- Stroke or traumatic brain injury in preceding 3 months
- Lumbar puncture in preceding 7 days
- Gastrointestinal haemorrhage in preceding 3 weeks
- Active bleeding
- Pregnancy
- Oesophageal varices
- Uncontrolled hypertension >200/120mmHg
relative
Concurrent anticoagulation (INR >1.7)
- Haemorrhagic diathesis
- Active diabetic haemorrhagic retinopathy
- Suspected intracardiac thrombus
- Major surgery / trauma in the preceding 2 weeks
A 68-year-old gentleman was diagnosed with glaucoma and commenced on treatment. He returned in one month for review, his eye pressures had improved but he complains his eyelashes have increased in length. What medicine is likely to have caused his eyelashes to grow in length?
Lantanprost - treatment for glaucoma
preferred antiplatelet for secondary prevention following stroke
Clopidogrel is the preferred antiplatelet for secondary prevention following stroke
In baby (neonate) feeding intolerance, abdominal distension and bloody stools, which can quickly progress to abdominal discolouration, perforation and peritonitis. Xray - pneumatosis intestinalis (intramural gas)
Necrotising enterocolitis
Bone protection for patients who are going to take long-term steroids
should start immediately= start vitamin D and calcium supplements
tetanus vaccination - unsure history - management?
Patients with an uncertain tetanus vaccination history should be given a booster vaccine + immunoglobulin, unless the wound is very minor and < 6 hours old
Infective exacerbation of COPD antibiotics
Infective exacerbation of COPD: first-line antibiotics are amoxicillin or clarithromycin or doxycycline
Laryngomalacia
Congenital abnormality of the larynx.
Infants typical present at 4 weeks of age with:
stridor
Bacterial endocarditis - causative organism
he vast majority of cases of bacterial endocarditis are caused by gram positive cocci.
Common causes:
Streptococcus viridans
Staphylococcus aureus (in intravenous drugs uses or prosthetic valves)
Staphylococcus epidermidis (in prosthetic valves)
HBA1c diagnostic of diabetes.
A HbA1c of 48mmol/mol is diagnostic of diabetes.
Over 58 = 2nd medication
A 17-year-old male presents to the Ear Nose and Throat clinic to discuss the results from the fine needle aspirate taken from a smooth, fluctuant, non-tender, non-translucent mass located anterior to his left sternocleidomastoid muscle. It does not move on tongue protrusion. The aspirate reveals an acellular fluid with cholesterol crystals.
A branchial cyst is typically a benign, lateral, unilateral neck mass
VTE post warfarin length
Venous thromoboembolism - length of warfarin treatment
provoked (e.g. recent surgery): 3 months
unprovoked: 6 months
Pyloric stenosis
Pyloric stenosis typically presents in the second to fourth weeks of life with vomiting, although rarely may present later at up to four months. It is caused by hypertrophy of the circular muscles of the pylorus.
Epidemiology incidence of 4 per 1,000 live births 4 times more common in males 10-15% of infants have a positive family history first-borns are more commonly affected
Features
‘projectile’ vomiting, typically 30 minutes after a feed
constipation and dehydration may also be present
a palpable mass may be present in the upper abdomen
hypochloraemic, hypokalaemic alkalosis due to persistent vomiting
Diagnosis is most commonly made by ultrasound.
Management is with Ramstedt pyloromyotomy.
Myocardial infarction: secondary prevention
NICE produced guidelines on the management of patients following a myocardial infarction (MI) in 2013. Some key points are listed below
All patients should be offered the following drugs:
dual antiplatelet therapy (aspirin plus a second antiplatelet agent)
ACE inhibitor
beta-blocker
statin
Parotid gland mass - Benign pleomorphic adenoma or benign mixed tumor
Most common parotid neoplasm (80%)
Proliferation of epithelial and myoepithelial cells of the ducts and an increase in stromal components
Slow growing, lobular, and not well encapsulated
Recurrence rate of 1-5% with appropriate excision (parotidectomy)
Recurrence possibly secondary to capsular disruption during surgery
Malignant degeneration occurring in 2-10% of adenomas observed for long periods, with carcinoma ex-pleomorphic adenoma occurring most frequently as adenocarcinoma
Paranoid gland mass
Second most common benign parotid tumor (5%)
Most common bilateral benign neoplasm of the parotid
Marked male as compared to female predominance
Occurs later in life (sixth and seventh decades)
Presents as a lymphocytic infiltrate and cystic epithelial proliferation
May represent heterotopic salivary gland epithelial tissue trapped within intraparotid lymph nodes
Incidence of bilaterality and multicentricity of 10%
Malignant transformation rare (almost unheard of)
COPD management
General management
>smoking cessation advice: including offering nicotine replacement therapy, varenicline or bupropion
annual influenza vaccination
one-off pneumococcal vaccination
pulmonary rehabilitation to all people who view themselves as functionally disabled by COPD (usually Medical Research Council [MRC] grade 3 and above)
synchronised DC cardioversion indications
Unstable atrial fibrillation, atrial flutter, atrial tachycardia, and supraventricular tachycardias
Klebsiella pneumonia
Features of Klebsiella pneumonia more common in alcoholic and diabetics may occur following aspiration 'red-currant jelly' sputum often affects upper lobes
Progressive multifocal leukoencephalopathy
Caused by JC or BK virus
superior vena cava obstruction presentation?
Features dyspnoea is the most common symptom swelling of the face, neck and arms - conjunctival and periorbital oedema may be seen headache: often worse in the mornings visual disturbance pulseless jugular venous distension
superior vena Cava obstruction causes and management
Causes
common malignancies: small cell lung cancer, lymphoma
other malignancies: metastatic seminoma, Kaposi’s sarcoma, breast cancer
aortic aneurysm
mediastinal fibrosis
goitre
SVC thrombosis
Management
general: dexamethasone, balloon venoplasty, stenting
small cell: chemotherapy + radiotherapy
non-small cell: radiotherapy
ECG: hypokalaemia
ECG features of hypokalaemia U waves small or absent T waves (occasionally inversion) prolong PR interval ST depression long QT
Palliative care prescribing: pain
when starting treatment, offer patients with advanced and progressive disease regular oral modified-release (MR) or oral immediate-release morphine (depending on patient preference), with oral immediate-release morphine for breakthrough pain
oral modified-release morphine should be used in preference to transdermal patches
laxatives should be prescribed for all patients initiating strong opioids
patients should be advised that nausea is often transient. If it persists then an antiemetic should be offered
drowsiness is usually transient - if it does not settle then adjustment of the dose should be considered
Palliative care prescribing: pain SIGN
the breakthrough dose of morphine is one-sixth the daily dose of morphine
all patients who receive opioids should be prescribed a laxative
opioids should be used with caution in patients with chronic kidney disease
oxycodone is preferred to morphine in palliative patients with mild-moderate renal impairment
if renal impairment is more severe, alfentanil, buprenorphine and fentanyl are preferred
Palliative care prescribing: pain - increasing dose
When increasing the dose of opioids the next dose should be increased by 30-50%.
Conversion between opioids Codine -> morphine = tramadol -> morphine Morphine -> oxy Oral morphine -> Subcutaneous morphine Oral morphine -> Subcutaneous dimorphine Oral oxycodone ->Subcutaneous dimorphine
Codine -> morphine = Divide by 10
tramadol -> morphne = Divide by 10
Morphine -> oxy = Divide by 1.5-2
Oral morphine -> Subcutaneous morphine = divide by 2
Oral morphine -> Subcutaneous dimorphine = divide by 3
Oral oxycodone ->Subcutaneous dimorphine = divide by 1.5
Small bowel bacterial overgrowth syndrome
Diagnosis
Management
Diagnosis
hydrogen breath test
small bowel aspiration and culture: this is used less often as invasive and results are often difficult to reproduce
clinicians may sometimes give a course of antibiotics as a diagnostic trial
Management
correction of underlying disorder
antibiotic therapy: rifaximin is now the treatment of choice due to relatively low resistance. Co-amoxiclav or metronidazole are also effective in the majority of patients.
Undescended testes
A congenital undescended testis is one that has failed to reach the bottom of the scrotum by 3 months of age
consider age - may watch and wait
Treatment
Orchidopexy at 6- 18 months of age. The operation usually consists of inguinal exploration, mobilisation of the testis and implantation into a dartos pouch.
Intra-abdominal testis should be evaluated laparoscopically and mobilised. Whether this is a single stage or two stage procedure depends upon the exact location.
After the age of 2 years in untreated individuals the Sertoli cells will degrade and those presenting late in teenage years may be better served by orchidectomy than to try and salvage a non functioning testis with an increased risk of malignancy.
epigastric ulcers
Features
epigastric pain
nausea
duodenal ulcers -more common than gastric ulcers
epigastric pain when hungry, relieved by eating
gastric ulcers- epigastric pain worsened by eating
non-invasive ventilation indications
Non-invasive ventilation - key indications
COPD with respiratory acidosis pH 7.25-7.35*
type II respiratory failure secondary to chest wall deformity, neuromuscular disease or obstructive sleep apnoea
cardiogenic pulmonary oedema unresponsive to CPAP
weaning from tracheal intubation
Keratoacanthoma
Features - said to look like a volcano or crater
initially a smooth dome-shaped papule
rapidly grows to become a crater centrally-filled with keratin
Spontaneous regression of keratoacanthoma within 3 months is common, often resulting in a scar. Such lesions should however be urgently excised as it is difficult clinically to exclude squamous cell carcinoma. Removal also may prevent scarring.
Osteoporosis: assessing risk
They advise that all women aged >= 65 years and all men aged >= 75 years should be assessed. Younger patients should be assessed in the presence of risk factors, such as:
previous fragility fracture
current use or frequent recent use of oral or systemic glucocorticoid
history of falls
family history of hip fracture
other causes of secondary osteoporosis
low body mass index (BMI) (less than 18.5 kg/m²)
smoking
alcohol intake of more than 14 units per week for women and more than 14 units per week for men.
Use FRAX
neuroleptic malignant syndrome management
Management
stop antipsychotic
patients should be transferred to a medical ward if they are on a psychiatric ward and often they are nursed in intensive care units
IV fluids to prevent renal failure
dantrolene may be useful in selected cases
thought to work by decreasing excitation-contraction coupling in skeletal muscle by binding to the ryanodine receptor, and decreasing the release of calcium from the sarcoplasmic reticulum
bromocriptine, dopamine agonist, may also be used
Gastro-oesophageal reflux disease presentation
oesophagitis secondary to refluxed gastric contents
Gastro-oesophageal reflux disease: management
Endoscopically proven oesophagitis
full dose proton pump inhibitor (PPI) for 1-2 months
if response then low dose treatment as required
if no response then double-dose PPI for 1 month
Endoscopically negative reflux disease
full dose PPI for 1 month
if response then offer low dose treatment, possibly on an as-required basis, with a limited number of repeat prescriptions
if no response then H2RA or prokinetic for one month
otitis externa Features and management
Features
ear pain, itch, discharge
otoscopy: red, swollen, or eczematous canal
Give Topical combination steroid and antibiotic drops s
Swab
may need referral for micro-suction.
If a patient fails to respond to topical antibiotics then the patient should be referred to ENT.
Anterior uveitis presentation
Features
acute onset
ocular discomfort & pain (may increase with use)
pupil may be irregular and small
photophobia (often intense)
blurred vision
red eye
lacrimation
ciliary flush
hypopyon; describes pus and inflammatory cells in the anterior chamber, often resulting in a visible fluid level
visual acuity initially normal → impaired
Associated conditions ankylosing spondylitis reactive arthritis ulcerative colitis, Crohn's disease Behcet's disease sarcoidosis: bilateral disease may be seen
Anterior uveitis management
Management
urgent review by ophthalmology
cycloplegics (dilates the pupil which helps to relieve pain and photophobia) e.g. Atropine, cyclopentolate
steroid eye drops
Subacute thyroiditis
occur following viral infection and typically presents with hyperthyroidism.
There are typically 4 phases; phase 1 (lasts 3-6 weeks): hyperthyroidism, painful goitre, raised ESR phase 2 (1-3 weeks): euthyroid phase 3 (weeks - months): hypothyroidism phase 4: thyroid structure and function goes back to normal
Investigations
thyroid scintigraphy: globally reduced uptake of iodine-131
Management
usually self-limiting - most patients do not require treatment
thyroid pain may respond to aspirin or other NSAIDs
in more severe cases steroids are used, particularly if hypothyroidism develops
Pulsus paradoxus
greater than the normal (10 mmHg) fall in systolic blood pressure during inspiration → faint or absent pulse in inspiration
- severe asthma, cardiac tamponade
Slow-rising/plateau
aortic stenosis
Pulsus alternans
regular alternation of the force of the arterial pulse
severe LVF
Bisferiens pulse
‘double pulse’ - two systolic peaks
mixed aortic valve disease
‘Jerky’ pulse
hypertrophic obstructive cardiomyopathy*
Legionnaire’s disease
Legionella pneumophilia. It typically colonizes water tanks and hence questions may hint at air-conditioning systems or foreign holidays. Person-to-person transmission is not seen
Features flu-like symptoms including fever (present in > 95% of patients) dry cough relative bradycardia confusion lymphopaenia hyponatraemia deranged liver function tests pleural effusion: seen in around 30% of patients
iagnosis
urinary antigen
Management
treat with erythromycin/clarithromycin
Superficial spreading melanoma
70% of cases
Arms, legs, back and chest, young people
A growing moles
flat patch of pigmented skin which grows slowly, often taking months or years to be recognised. It can be recognised by an ABCDE approach (asymmetry, border irregularity, colour variation, diameter >6mm and evolving)
routine manintance fluids adult
NICE guidelines from 2013 state for routine maintenance fluids the water requirement is approximately 25-30 ml/kg/day.
Osteogenesis imperfecta
Features
Investigations
Overview
autosomal dominant
abnormality in type 1 collagen due to decreased synthesis of pro-alpha 1 or pro-alpha 2 collagen polypeptides
Features presents in childhood fractures following minor trauma blue sclera deafness secondary to otosclerosis dental imperfections are common
Investigations
adjusted calcium, phosphate, parathyroid hormone and ALP results are usually normal in osteogenesis imperfecta
Smudge or smear cells
CLL
Reed-Sternberg cells
Hodgkin’s lymphoma.
Rouleaux formation
multiple myeloma.
Auer rods
a feature of AML.
Pseudo Pelger-Huet cells
CML
Hypothermia on ECG
J Wave
reverse tick sign ECG
dioxin
PE management
the use of direct oral anticoagulants (DOACs) as first-line treatment for most people with VTE
the use of DOACs in patients with active cancer, as opposed to low-molecular weight heparin as was the previous recommendation
outpatient treatment in low-risk pulmonary embolism (PE) patients
routine cancer screening is no longer recommended following a VTE diagnosis
if neither apixaban or rivaroxaban are suitable then either LMWH followed by dabigatran or edoxaban OR LMWH followed by a vitamin K antagonist (VKA, i.e. warfarin)
if the patient has active cancer
previously LMWH was recommended
the new guidelines now recommend using a DOAC, unless this is contraindicated
Anticoag for at least three months if provoked
Thrombolysis
thrombolysis is now recommended as the first-line treatment for massive PE where there is circulatory failure (e.g. hypotension)
other invasive approaches should be considered where appropriate facilities exist
Toxic epidermal necrolysis
Drugs known to induce TEN phenytoin sulphonamides allopurinol penicillins carbamazepine NSAIDs
Pericarditis Features
Features
chest pain: may be pleuritic. Is often relieved by sitting forwards
other symptoms include non-productive cough, dyspnoea and flu-like symptoms
pericardial rub
tachypnoea
tachycardia
Pericarditis causes
Causes viral infections (Coxsackie) tuberculosis uraemia (causes 'fibrinous' pericarditis) trauma post-myocardial infarction, Dressler's syndrome connective tissue disease hypothyroidism malignancy
Pericarditis Investigations & Management
Investigations
ECG changes
the changes in pericarditis are often global/widespread, as opposed to the ‘territories’ seen in ischaemic events
‘saddle-shaped’ ST elevation
PR depression: most specific ECG marker for pericarditis
all patients with suspected acute pericarditis should have transthoracic echocardiography
Management
treat the underlying cause
a combination of NSAIDs and colchicine is now generally used for first-line for patients with acute idiopathic or viral pericarditis
Type 1 RTA
distal)
inability to generate acid urine (secrete H+) in distal tubule
causes hypokalaemia
complications include nephrocalcinosis and renal stones
causes include idiopathic, rheumatoid arthritis, SLE, Sjogren’s, amphotericin B toxicity, analgesic nephropathy
absolute contraindication to the use of regional anaesthesia such as spinal, epidural or plexus block?
Therapeutic anticoagulation is an absolute contraindication to the use of regional anaesthesia due to the risk of bleeding and the severity of a hematoma within the rigid space of the central nervous system.
Ankylosing spondylitis
Features
typically a young man who presents with lower back pain and stiffness of insidious onset
stiffness is usually worse in the morning and improves with exercise
the patient may experience pain at night which improves on getting up
Clinical examination
reduced lateral flexion
reduced forward flexion - Schober’s test - a line is drawn 10 cm above and 5 cm below the back dimples (dimples of Venus). The distance between the two lines should increase by more than 5 cm when the patient bends as far forward as possible
reduced chest expansion
lithium toxciity precipitated by
Toxicity may be precipitated by:
dehydration
renal failure
drugs: diuretics (especially thiazides), ACE inhibitors/angiotensin II receptor blockers, NSAIDs and metronidazole.
Diclofenac NSAID - contraindications
Diclofenac is now contraindicated with any form of cardiovascular disease
Degenerative cervical myelopathy
DCM symptoms can include any combination of [1]:
Pain (affecting the neck, upper or lower limbs)
Loss of motor function (loss of digital dexterity, preventing simple tasks such as holding a fork or doing up their shirt buttons, arm or leg weakness/stiffness leading to impaired gait and imbalance
Loss of sensory function causing numbness
Loss of autonomic function (urinary or faecal incontinence and/or impotence) - these can occur and do not necessarily suggest cauda equina syndrome in the absence of other hallmarks of that condition
Hoffman’s sign: is a reflex test to assess for cervical myelopathy. It is performed by gently flicking one finger on a patient’s hand. A positive test results in reflex twitching of the other fingers on the same hand in response to the flick.
(GOLD Standard - MRI of cervical spine if cervical suspected )
primary hyperparathyroidism
features
Features - ‘bones, stones, abdominal groans and psychic moans’
polydipsia, polyuria
peptic ulceration/constipation/pancreatitis
bone pain/fracture
renal stones
depression
hypertension
primary hyperparathyroidism
investigations
Investigations
raised calcium, low phosphate
PTH may be raised or (inappropriately, given the raised calcium) normal
technetium-MIBI subtraction scan
pepperpot skull is a characteristic X-ray finding of hyperparathyroidism
Treatment
the definitive management is total parathyroidectomy
conservative management may be offered if the calcium level is less than 0.25 mmol/L above the upper limit of normal AND the patient is > 50 years AND there is no evidence of end-organ damage
calcimimetic agents such as cinacalcet are sometimes used in patients who are unsuitable for surgery
Ottawa Rules with for ankle x-rays
The Ottawa Rules with for ankle x-rays have a sensitivity approaching 100%
An ankle x-ray is required only if there is any pain in the malleolar zone and any one of the following findings:
bony tenderness at the lateral malleolar zone (from the tip of the lateral malleolus to include the lower 6 cm of posterior border of the fibular)
bony tenderness at the medial malleolar zone (from the tip of the medial malleolus to the lower 6 cm of the posterior border of the tibia)
inability to walk four weight bearing steps immediately after the injury and in the emergency department
New York Heart Association (NYHA) classification
NYHA Class I
no symptoms
no limitation: ordinary physical exercise does not cause undue fatigue, dyspnoea or palpitations
NYHA Class II
mild symptoms
slight limitation of physical activity: comfortable at rest but ordinary activity results in fatigue, palpitations or dyspnoea
NYHA Class III
moderate symptoms
marked limitation of physical activity: comfortable at rest but less than ordinary activity results in symptoms
NYHA Class IV
severe symptoms
unable to carry out any physical activity without discomfort: symptoms of heart failure are present even at rest with increased discomfort with any physical activity
DDX breathing difficulty in children
Infection (ie croup, URTI) If stridor present - Larynomalcia, asthma Allergy Cardiac (malformation in young children)
croup
presentation
Parainfluenza viruses
Features stridor barking cough (worse at night) fever coryzal symptoms
croup
when to admit
CKS suggest admitting any child with moderate or severe croup. Other features which should prompt admission include:
< 6 months of age
known upper airway abnormalities (e.g. Laryngomalacia, Down’s syndrome)
uncertainty about diagnosis (important differentials include acute epiglottitis, bacterial tracheitis, peritonsillar abscess and foreign body inhalation)
croup investigations
the vast majority of children are diagnosed clinically
however, if a chest x-ray is done:
a posterior-anterior view will show subglottic narrowing, commonly called the ‘steeple sign’
in contrast, a lateral view in acute epiglottis will show swelling of the epiglottis - the ‘thumb sign’
croup management
Management
CKS recommend giving a single dose of oral dexamethasone (0.15mg/kg) to all children regardless of severity
prednisolone is an alternative if dexamethasone is not available
Emergency treatment
high-flow oxygen
nebulised adrenaline
Acute epiglottitis
Haemophilus influenzae type B.
Prompt recognition and treatment is essential as airway obstruction may develop. Epiglottitis generally occurs in children between the ages of 2 and 6 years. The incidence of epiglottitis has decreased since the introduction of the Hib vaccine
Features rapid onset unwell, toxic child stridor drooling of saliva
Acute epiglottitis
management
Management
immediate senior involvement, including those able to provide emergency airway support (e.g. anaesthetics, ENT)
endotracheal intubation may be necessary to protect the airway
if suspected do NOT examine the throat due to the risk of acute airway obstruction
the diagnosis is made by direct visualisation but this should only be done by senior staff who are able to intubate if necessary
oxygen
intravenous antibiotics
Parainfluenza virus
croup
Rhinovirus
cold
Streptococcus pneumoniae
he most common cause of community-acquired pneumonia
Haemophilus influenzae
Community-acquired pneumonia
Most common cause of bronchiectasis exacerbations
Acute epiglottitis
Staphylococcus aureus
Pneumonia, particularly following influenza
Mycoplasma pneumoniae
Atypical pneumonia
Flu-like symptoms classically precede a dry cough. Complications include haemolytic anaemia and erythema multiforme
Pneumocystis jiroveci
Common cause of pneumonia in HIV patients. Typically patients have few chest signs and develop exertional dyspnoea
Mycobacterium tuberculosis
Causes tuberculosis. A wide range of presentations from asymptomatic to disseminated disease are possible. Cough, night sweats and weight loss may be seen
Wheeze questions
- Infection - systemic illness
- Associated symptoms
-Associated with excersies
Associated with environment (pet, dust, smoking, mould, damp,
_ Imms
Ddx Cyanosis
- Illness and infection
- cardiac (TOF, ebsteins, tricuspid atresia, transposition)
Medications (quinones)
Resp - choanal atresia, Pierre Robin Sequence, airway hemangioma, vascular rings/slings, cystic hygroma, and micrognathia
Blood related disorders - Polycythemia, Methemoglobinemia
pansystolic murmur at his lower left sternal edge and a loud P2.
Ventricular septal defect
typical features of heart failure in child
breathlessness, difficulty feeding, poor growth at an early age
VSD presentation
associations
classically a pan-systolic murmur which is louder in smaller defects
chromosomal disorders (e.g. Down’s syndrome, Edward’s syndrome, Patau syndrome) and single gene disorders such as Non-congenital causes include post myocardial infarction
VSD complications
Complications aortic regurgitation* infective endocarditis Eisenmenger's complex right heart failure pulmonary hypertension: pregnancy is contraindicated in women with pulmonary hypertension as it carries a 30-50% risk of mortality
ostium secundum
stium secundum (70% of ASDs)
associated with Holt-Oram syndrome (tri-phalangeal thumbs)
ECG: RBBB with RAD
Ostium primum
present earlier than ostium secundum defects
associated with abnormal AV valves
ECG: RBBB with LAD, prolonged PR interval
Coarctation of the aorta presentation
infancy: heart failure
adult: hypertension
radio-femoral delay
mid systolic murmur, maximal over back
apical click from the aortic valve
notching of the inferior border of the ribs (due to collateral vessels) is not seen in young children
Coarctation of the aorta associations
Associations Turner's syndrome bicuspid aortic valve berry aneurysms neurofibromatosis
hypertrophic obstructive cardiomyopathy associated pulse
bisferiens pulse (double pulse).
Aortic stenosis management
VR if symptomatic, otherwise cut-off is gradient of 40 mmHg
Features of severe aortic stenosis
narrow pulse pressure slow rising pulse delayed ESM soft/absent S2 S4 thrill duration of murmur left ventricular hypertrophy or failure
Aortic regurgitation features
ifficulty breathing at night, occasional palpitations and tight chest pain. On examination, he has a collapsing pulse and a laterally shifted apex beat
murmur = early diastolic
Abdominal pain ddx in children
- infection (Gastroenteritis)
-Constipation
_ Appendcitis
Merkles adentisi - Hernia
Intussception
Allergery
Hischsprung
IBS
coalic
-
Attention Deficit Hyperactivity Disorder presentaion
- inattentiveness
hyperactivity and impulsiveness
associated mood or behaviour disorders
Attention Deficit Hyperactivity Disorder management
watch and wait
(CAMHS ref needed)
Drug therapy should be seen as a last resort and is only available to those aged 5 years or more
Methylphenidate is first line in children
f there is inadequate response, switch to lisdexamfetamine;
Methylphenidate side effects
ide-effects include abdominal pain, nausea and dyspepsia. In children, weight and height should be monitored every 6 months
Features Bronchiolitis
eatures
coryzal symptoms (including mild fever) precede:
dry cough
increasing breathlessness
wheezing, fine inspiratory crackles (not always present)
feeding difficulties associated with increasing dyspnoea are often the reason for hospital admission
Bronchiolitis - NICE recommend immediate referral (usually by 999 ambulance) if they have any of the following:
apnoea (observed or reported)
child looks seriously unwell to a healthcare professional
severe respiratory distress, for example grunting, marked chest recession, or a respiratory rate of over 70 breaths/minute
central cyanosis
persistent oxygen saturation of less than 92% when breathing air.
Bronchiolitis- management
Management is largely supportive
humidified oxygen is given via a head box and is typically recommended if the oxygen saturations are persistently < 92%
nasogastric feeding may be needed if children cannot take enough fluid/feed by mouth
suction is sometimes used for excessive upper airway secretions
causes Cerebral palsy
Causes
antenatal (80%): e.g. cerebral malformation and congenital infection (rubella, toxoplasmosis, CMV)
intrapartum (10%): birth asphyxia/trauma
postnatal (10%): intraventricular haemorrhage, meningitis, head-trauma
presentations Cerebral palsy
Possible manifestations include: abnormal tone early infancy delayed motor milestones abnormal gait feeding difficultie.
Cerebral palsy
Management
as with any child with a chronic condition a multidisciplinary approach is needed
treatments for spasticity include oral diazepam, oral and intrathecal baclofen, botulinum toxin type A, orthopaedic surgery and selective dorsal rhizotomy
anticonvulsants, analgesia as required
Exanthems
eruptive skin rashes associated with a fever or other constitutional symptoms
Causes of maculopapular eruptions
Measles (rubeola) Rubella Erythema infectiosum (slapped cheek) Exanthum subitum (roseola) Lyme disease Pityriasis Drug-related eruptions Erythema multiforme
Causes of diffuse erythema with desquamation
Scarlet fever
Toxic shock syndrome
Staphylococcal scaled skin syndrome
Kawasaki disease
Measles rash
erythematous maculopapular rash beginning on the head, with a cephalocaudad progression.
Blue-white Kopliks spots occurring on the buccal mucosa opposite the second molar and lasting around 1-2 day
Measles management
Measles is a notifiable illness and notification is required based on clinical suspicion.
Children diagnosed with measles should be kept off school until 5 days after the appearance of the rash.
The treatment of measles is largely symptomatic and the majority of children will recover uneventfully.
Meckel’s diverticulum
presentation
Presentation (usually asymptomatic)
abdominal pain mimicking appendicitis
rectal bleeding
Meckel’s diverticulum is the most common cause of painless massive GI bleeding requiring a transfusion in children between the ages of 1 and 2 years
intestinal obstruction
secondary to an omphalomesenteric band (most commonly), volvulus and intussusception
Anaphylaxis presentation
Anaphylaxis may be defined as a severe, life-threatening, generalised or systemic hypersensitivity reaction.
Common identified causes of anaphylaxis:
food (e.g. nuts) - the most common cause in children
drugs
venom (e.g. wasp sting)
Anaphylaxis management
Adrenaline is by far the most important drug in anaphylaxis and should be given as soon as possible.
also give Hydrocortisone and Chlorphenamine
Adrenaline can be repeated every 5 minutes if necessary. The best site for IM injection is the anterolateral aspect of the middle third of the thigh.
Management following stabilisation:
patients who have had emergency treatment for anaphylaxis should be observed for 6–12 hours from the onset of symptoms, as it is known that biphasic reactions can occur in up to 20% of patients
sometimes it can be difficult to establish whether a patient had a true episode of anaphylaxis. Serum tryptase levels are sometimes taken in such patients as they remain elevated for up to 12 hours following an acute episode of anaphylaxis.v
Anaphylaxis test after episode to confirm
serum tryptase levels rise following an acute episode
Acute exacerbations of COPD features
Features
increase in dyspnoea, cough, wheeze
there may be an increase in sputum suggestive of an infective cause
patients may be hypoxic and in some cases have acute confusion
The most common bacterial organisms that cause infective exacerbations of COPD are:
Haemophilus influenzae (most common cause)
Streptococcus pneumoniae
Moraxella catarrhalis
Infective exacerbations of COPD managements
NICE guidelines from 2010 recommend the following:
increase frequency of bronchodilator use and consider giving via a nebuliser
give prednisolone 30 mg daily for 5 days
it is common practice for all patients with an exacerbation of COPD to receive antibiotics. NICE do not support this approach. They recommend giving oral antibiotics ‘if sputum is purulent or there are clinical signs of pneumonia’
the BNF recommends one of the following oral antibiotics first-line: amoxicillin or clarithromycin or doxycycline.
pneumonia causes
bacterial pneumonia is by far the most common type of pneumonia
Streptococcus pneumoniae = most common
Haemophilus influenzae = COPD
Staphylococcus aureus = occurs in patient following influenza infection
Klebsiella pneumoniae = alcoholics
Pneumonia Bloods
Bloods
full blood count: would usually show a neutrophilia in bacterial infections
urea and electrolytes: check for dehydration (remember the ‘U’ for urea in CURB-65, see below) and also other changes seen with some atypical pneumonias
CRP: raised in response to infection
Pneumonia management
Patients with pneumonia require the following:
antibiotics: to treat the underlying infection
supportive care: for example oxygen therapy if the patients is hypoxaemic, intravenous fluids if the patient is hypotensive or shows signs of dehydration
CURB- 65 score
Pneumonia - Discharge criteria and advice post-discharge
Discharge criteria and advice post-discharge
NICE recommend that patients are not routinely discharged if in the past 24 hours they have had 2 or more of the following findings: temperature higher than 37.5°C respiratory rate 24 breaths per minute or more heart rate over 100 beats per minute systolic blood pressure 90 mmHg or less oxygen saturation under 90% on room air abnormal mental status inability to eat without assistance.
They also recommend delaying discharge if the temperature is higher than 37.5°C.
Pneumothorax risk factors
Risk factors
pre-existing lung disease: COPD, asthma, cystic fibrosis, lung cancer, Pneumocystis pneumonia
connective tissue disease: Marfan’s syndrome, rheumatoid arthritis
ventilation, including non-invasive ventilation
catamenial pneumothorax is the cause of 3-6% of spontaneous pneumothoraces occurring in menstruating women. It is thought to be caused by endometriosis within the thorax
Pneumothorax symptoms
Symptoms tend to come on suddenly. Features include: dyspnoea chest pain: often pleuritic sweating tachypnoea tachycardia
Primary pneumothorax
management
Recommendations include:
if the rim of air is < 2cm and the patient is not short of breath then discharge should be considered
otherwise, aspiration should be attempted
if this fails (defined as > 2 cm or still short of breath) then a chest drain should be inserted
patients should be advised to avoid smoking to reduce the risk of further episodes - the lifetime risk of developing a pneumothorax in healthy smoking men is around 10% compared with around 0.1% in non-smoking men
Secondary pneumothorax management
Recommendations include:
if the patient is > 50 years old and the rim of air is > 2cm and/or the patient is short of breath then a chest drain should be inserted.
otherwise aspiration should be attempted if the rim of air is between 1-2cm. If aspiration fails (i.e. pneumothorax is still greater then 1cm) a chest drain should be inserted. All patients should be admitted for at least 24 hours
if the pneumothorax is less the 1cm then the BTS guidelines suggest giving oxygen and admitting for 24 hours
regarding scuba diving, the BTS guidelines state: ‘Diving should be permanently avoided unless the patient has undergone bilateral surgical pleurectomy and has normal lung function and chest CT scan postoperatively.’
triad of PE
and clinical signs
pleuritic chest pain, dyspnoea and haemoptysis.
The relative frequency of common clinical signs is shown below:
Tachypnea (respiratory rate >20/min) - 96%
Crackles - 58%
Tachycardia (heart rate >100/min) - 44%
Fever (temperature >37.8°C) - 43%
PE suspected
If a PE is suspected a 2-level PE Wells score should be performed:
linical probability simplified scores
PE likely - more than 4 points
PE unlikely - 4 points or less
If a PE is ‘likely’ (more than 4 points) arrange an immediate computed tomography pulmonary angiogram (CTPA). If there is a delay in getting the CTPA then interim therapeutic anticoagulation should be given until the scan is performed.
interim therapeutic anticoagulation used to mean giving low-molecular weight heparin
NICE updated their guidance in 2020. They now recommend using an anticoagulant that can be continued if the result is positive.
this means normally a direct oral anticoagulant (DOAC) such as apixaban or rivaroxaban
test in PE
CTPA is now the recommended initial lung-imaging modality for non-massive PE. Advantages compared to V/Q scans include speed, easier to perform out-of-hours, a reduced need for further imaging and the possibility of providing an alternative diagnosis if PE is excluded
if the CTPA is negative then patients do not need further investigations or treatment for PE
V/Q scanning may be used initially if appropriate facilities exist, the chest x-ray is normal, and there is no significant symptomatic concurrent cardiopulmonary disease. V/Q scanning is also the investigation of choice if there is renal impairment (doesn’t require the use of contrast unlike CTPA)
Pulmonary embolism and renal impairment →
V/Q scan is the investigation of choice
Massive PE + hypotension
- thrombolyse
bloods PE
Pulmonary embolism causes hyperventilation, causing a drop in arterial carbonic dioxide partial pressure and thus alkalosis.
Features of pulmonary oedema on a chest x-ray may include:
Features of pulmonary oedema on a chest x-ray may include:
interstitial oedema
bat’s wing appearance
upper lobe diversion (increased blood flow to the superior parts of the lung)
Kerley B lines
pleural effusion
cardiomegaly may be seen if there is cardiogenic cause
Tricuspid regurgitation signs
Pan systolic mumur
JVP increase
Hepatomegaly
Heave
Tricuspid regurgitation causes
Right V INFARCT
Pulmonary hypertension
Rheumatic heart disease
Infective endo
Ébstekns
NSTEMI
All patients should receive
aspirin 300mg
nitrates or morphine to relieve chest pain if required
Clopidogrel
optic neuritis causes
Causes
multiple sclerosis
diabetes
syphilis
optic neuritis features
Features
unilateral decrease in visual acuity over hours or days
poor discrimination of colours, ‘red desaturation’
pain worse on eye movement
relative afferent pupillary defect
central scotoma
optic neuritis management
Management
high-dose steroids
recovery usually takes 4-6 weeks
Prognosis
MRI: if > 3 white-matter lesions, 5-year risk of developing multiple sclerosis is c. 50%
abdo signs
A number of eponymous abdominal signs are noted. These include:
Rovsings sign- appendicitis
Boas sign -cholecystitis
Murphys sign- cholecystitis
Cullens sign- pancreatitis (other intraabdominal haemorrhage)
Grey-Turners sign- pancreatitis (or other retroperitoneal haemorrhage)
BV causes and treatment
Bacterial vaginosis (BV) describes an overgrowth of predominately anaerobic organisms such as Gardnerella vaginalis
Features
vaginal discharge: ‘fishy’, offensive
asymptomatic in 50%
Amsel’s criteria for diagnosis of BV - 3 of the following 4 points should be present
thin, white homogenous discharge
clue cells on microscopy: stippled vaginal epithelial cells
vaginal pH > 4.5
positive whiff test (addition of potassium hydroxide results in fishy odour)
Management oral metronidazole for 5-7 days 70-80% initial cure rate relapse rate > 50% within 3 months the BNF suggests topical metronidazole or topical clindamycin as alternatives.
BV in pregnancy
Bacterial vaginosis in pregnancy
results in an increased risk of preterm labour, low birth weight and chorioamnionitis, late miscarriage
it was previously taught that oral metronidazole should be avoided in the first trimester and topical clindamycin used instead. Recent guidelines however recommend that oral metronidazole is used throughout pregnancy. The BNF still advises against the use of high dose metronidazole regimes
hypocalcaemia causes
auses
vitamin D deficiency (osteomalacia)
chronic kidney disease
hypoparathyroidism (e.g. post thyroid/parathyroid surgery)
pseudohypoparathyroidism (target cells insensitive to PTH)
rhabdomyolysis (initial stages)
magnesium deficiency (due to end organ PTH resistance)
massive blood transfusion
acute pancreatitis
hypocalcaemia Management
Management
acute management of severe hypocalcaemia is with intravenous replacement. The preferred method is with intravenous calcium gluconate, 10ml of 10% solution over 10 minutes
intravenous calcium chloride is more likely to cause local irritation
ECG monitoring is recommended
further management depends on the underlying cause
Bells palsy presentation
Features
lower motor neuron facial nerve palsy - forehead affected*
patients may also notice post-auricular pain (may precede paralysis), altered taste, dry eyes, hyperacusis
Bells palsy management
prednisolone 1mg/kg for 10 days should be prescribed for patients within 72 hours of onset of Bell’s palsy. Adding in aciclovir gives no additional benefit
eye care is important - prescription of artificial tears and eye lubricants should be considered
large fluid volumes risk
hyperchloraemic acidosis
stroke post coag
Aspirin 300 mg daily for 2 weeks should be given immediately after an ischaemic stroke is confirmed by brain imaging. Following this, clopidogrel 75 mg daily should be given long-term -if it can be tolerated and is not contraindicated.
If clopidogrel is contraindicated or not tolerated, then the patient should be given modified-release dipyridamole alongside low dose aspirin.
Age-related macular degeneration presentation
Patients typically present with a subacute onset of visual loss with:
a reduction in visual acuity, particularly for near field objects
difficulties in dark adaptation with an overall deterioration in vision at night
fluctuations in visual disturbance which may vary significantly from day to day
they may also suffer from photopsia, (a perception of flickering or flashing lights), and glare around objects
Age-related macular degeneration treatment
zinc with anti-oxidant vitamins A,C and E reduced progression of the disease by around one third.
anti-VEGF agents (wet) - instituted within the first two months of diagnosis of wet ARMD if possible.
Laser photocoagulation does slow progression of ARMD where there is new vessel formation, although there is a risk of acute visual loss after treatment, which may be increased in patients with sub-foveal ARMD. For this reason anti-VEGF therapies are usually preferred.
Central retinal vein occlusion presentation
Features
sudden, painless reduction or loss of visual acuity, usually unilaterally
severe retinal haemorrhages are usually seen on fundoscopy
Herpes simplex keratitis presentation
Features red, painful eye photophobia epiphora visual acuity may be decreased fluorescein staining may show an epithelial ulcer
Herpes simplex keratitis management
Management
immediate referral to an ophthalmologist
topical aciclovir
Rentral retinal artery occlusion
causes sudden unilateral visual loss
due to thromboembolism (from atherosclerosis) or arteritis (e.g. temporal arteritis)
features include afferent pupillary defect, ‘cherry red’ spot on a pale retina
retinal detachment presentaition
Peripheral curtain over vision + spider webs + flashing lights in vision
(painless loss of vision)
amaurosis fugax
Painless, transient monocular blindness together with the description of a ‘black curtain coming down’
Tunnel vision is the concentric diminution of the visual fields
Causes
Causes papilloedema glaucoma retinitis pigmentosa choroidoretinitis optic atrophy secondary to tabes dorsalis hysteria
Acute angle closure glaucoma is associated with ?
hypermetropia,
primary open-angle glaucoma is associated with
myopia
Acyanotic heart disease
most common causes (blood contains oxygen)
ventricular septal defects (VSD) - most common, accounts for 30% atrial septal defect (ASD) patent ductus arteriosus (PDA) coarctation of the aorta aortic valve stenosis
Cyanotic heart disease
Cyanotic - most common causes
tetralogy of Fallot
transposition of the great arteries (TGA)
tricuspid atresia
Anti-dsDNA
SLE
Anti-CCP
RA
Anti-La
Sjogren’s syndrome. It can also be found in patients with SLE, however, it is not very specific.
ANCA
ANCA is an antibody targeted against neutrophils. It is seen in patients with autoimmune vasculitis.
Anti-centromere
Anti-centromere antibodies are characteristic of the CREST syndrome which is the cutaneous form of systemic sclerosis. CREST stands for calcinosis, Raynaud’s, oesophageal dysmotility, sclerodactyly and telangiectasia.
metoclopramide avoid when
bowel obstruction
as could cause a perforation in bowel obstruction.
Osteochondritis dissecans presentation
Patients typically present with a subacute onset of:
Knee pain and swelling, typically after exercise
Knee catching, locking and/or giving way - more constant and severe symptoms are associated with the presence of loose bodies
Feeling a painful ‘clunk’ when flexing or extending the knee - indicating the involvement of the lateral femoral condyle
Osteochondritis dissecans signs
Joint effusion
Full range of movement in the joint without signs of ligamentous instability
External tibial rotation when walking - if medial femoral involvement
Tenderness on palpation of the articular cartilage of the medial femoral condyle, when the knee is flexed
Wilson’s sign for detecting medial condyle lesion - with the knee at 90° flexion and tibia internally rotated, the gradual extension of the joint leads to pain at about 30°, external rotation of the tibia at this point relieves the pain
Osteochondritis dissecans investigations
Investigations:
X-ray (anteroposterior, lateral and tunnel views) - may show the subchondral crescent sign or loose bodies
MRI - used to evaluate cartilage, visualise loose bodies, stage and assess the stability of the lesion
CT - may be used in preoperative planning and in cases where MRI is not available or contraindicated
Scintigraphy - may be used to guide treatment as it may show increased uptake in the fragments - a sign of osteoblastic activity
treatments have not been shown to improve mortality in patients with chronic heart failure?
furosemide
Heart failure management
The first-line treatment for all patients is both an ACE-inhibitor and a beta-blocker
Second-line treatment is an aldosterone antagonist
Third-line treatment should be initiated by a specialist. Options include ivabradine, sacubitril-valsartan, hydralazine in combination with nitrate, digoxin and cardiac resynchronisation therapy
antibiotics for Exacerbations of chronic bronchitis
Amoxicillin or tetracycline or clarithromycin
antibiotics for Uncomplicated community-acquired pneumonia
Amoxicillin (Doxycycline or clarithromycin in penicillin allergic, add flucloxacillin if staphylococci suspected e.g. In influenza)
antibiotics for Pneumonia possibly caused by atypical pathogens
Clarithromycin
antibiotics for Hospital-acquired pneumonia
Within 5 days of admission: co-amoxiclav or cefuroxime
More than 5 days after admission: piperacillin with tazobactam OR a broad-spectrum cephalosporin (e.g. ceftazidime) OR a quinolone (e.g. ciprofloxacin)
Impetigo treatment
Topical hydrogen peroxide, oral flucloxacillin or erythromycin if widespread
Cellulitis treatment
Flucloxacillin (clarithromycin, erythromycin or doxycycline if penicillin-allergic)
Co-amoxiclav (clarithromycin, + metronidazole if penicillin-allergic)
Animal or human bite treat
Co-amoxiclav (doxycycline + metronidazole if penicillin-allergic)
Salicylate poisoning presentation
present with nausea, vomiting, tinnitus and headache. In more severe overdoses, hyperventilation and a secondary respiratory alkalosis develops.
give IV sodium bicarb
benzodiazepine overdose.
Flumazenil
CLL is associated with
warm autoimmune haemolytic anaemia
The Mackler triad for Boerhaave syndrome:
vomiting, thoracic pain, subcutaneous emphysema. It typically presents in middle aged men with a background of alcohol abuse.
= oesphgealo perforation
Plummer-Vinson syndrome
Triad of:
dysphagia (secondary to oesophageal webs)
glossitis
iron-deficiency anaemia
Treatment includes iron supplementation and dilation of the webs
Orlistat
weight loss
inhibiting gastric and pancreatic lipase to reduce the digestion of fat
Features suggestive of hypernatraemic dehydration:
jittery movements increased muscle tone hyperreflexia convulsions drowsiness or coma
X-linked recessive inheritance
males only effected
X-linked recessive disorders are transmitted by heterozygote females (carriers) and male-to-male transmission is not seen.
ie haemophilia A
life treating asthma attack
SpO2 <92% PEF <33% best or predicted Silent chest Poor respiratory effort Agitation Altered consciousness Cyanosis
risk factors for erectile dysfunction
Other than increasing age, risk factors include:
cardiovascular disease risk factors: obesity, diabetes mellitus, dyslipidaemia, metabolic syndrome, hypertension, smoking
alcohol use
drugs: SSRIs, beta-blockers
assessment for erectile dysfunction
t all men have their 10-year cardiovascular risk calculated by measuring lipid and fasting glucose serum levels.
Free testosterone should also be measured in the morning between 9 and 11am. If free testosterone is low or borderline, it should be repeated along with follicle-stimulating hormone, luteinizing hormone and prolactin levels. If any of these are abnormal refer to endocrinology for further assessment.
erectile dysfunction management
PDE-5 inhibitors (such as sildenafil, ‘Viagra’)
Vacuum erection devices are recommended as first-line treatment in those who can’t/won’t take a PDE-5 inhibitor.
Other points
for a young man who has always had difficulty achieving an erection, referral to urology is appropriate
people with erectile dysfunction who cycle for more than three hours per week should be advised to stop
normocytic anaemia with low serum iron, low TIBC but raised ferritin
anaemia of chronic disease
Sideroblastic anaemia
a microcytic anaemia with raised serum iron levels.
a microcytic anaemia, low ferritin and a raised TIBC, not the current clinical picture.
iron def
Subcapsular cataracts may be associated with what medication
steroids (Allopurinol less strong link )
) Myotonic dystrophy is associated with what eye problem
dot cataracts
Whipple’s triad of symptoms of for insluinoma
) hypoglycaemia with fasting or exercise, 2) reversal of symptoms with glucose, and 3) recorded low BMs at the time of symptoms is hallmark for an insulinoma
insluinoma features
Features
of hypoglycaemia: typically early in morning or just before meal, e.g. diplopia, weakness etc
rapid weight gain may be seen
high insulin, raised proinsulin:insulin ratio
high C-peptide
Rhabdomyolysis causes
Causes
seizure
collapse/coma (e.g. elderly patients collapses at home, found 8 hours later)
ecstasy
crush injury
McArdle’s syndrome
drugs: statins (especially if co-prescribed with clarithromycin)
Hypothyroidism causes a euvolaemic hyponatraemia
blood results
Plasma osmolality low
NA in urine = high
The recommended dose of adrenaline to give during advanced ALS
1mg
Hodgkin’s lymphoma - best prognosis =
lymphocyte predominant
Intramuscular ceftriaxone is the treatment of choice for
gonnorhoae
Bifascicular block
combination of RBBB with left anterior or posterior hemiblock
e.g. RBBB with left axis deviation
Trifascicular block
Trifascicular block
features of bifascicular block as above + 1st-degree heart block
metformin not tolerated GI
If metformin is not tolerated due to GI side-effects, try a modified-release formulation before switching to a second-line agent
Lithium monitoring
When checking lithium levels, the sample should be taken 12 hours post-dose
after starting lithium levels should be performed weekly and after each dose change until concentrations are stable
once established, lithium blood level should ‘normally’ be checked every 3 months
after a change in dose, lithium levels should be taken a week later and weekly until the levels are stable.
Lithium SE
Adverse effects
nausea/vomiting, diarrhoea
fine tremor
nephrotoxicity: polyuria, secondary to nephrogenic diabetes insipidus
thyroid enlargement, may lead to hypothyroidism
ECG: T wave flattening/inversion
weight gain
idiopathic intracranial hypertension
leucocytosis
hyperparathyroidism and resultant hypercalcaemia
GCS
Motor response
- Obeys commands
- Localises to pain
- Withdraws from pain
- Abnormal flexion to pain (decorticate posture)
- Extending to pain
- None
Verbal response
- Orientated
- Confused
- Words
- Sounds
- None
Eye opening
- Spontaneous
- To speech
- To pain
- None
autoimmune hep - presentation
Features
may present with signs of chronic liver disease
acute hepatitis: fever, jaundice etc (only 25% present in this way)
amenorrhoea (common)
ANA/SMA/LKM1 antibodies, raised IgG levels
liver biopsy: inflammation extending beyond limiting plate ‘piecemeal necrosis’, bridging necrosis
duloxetine
duloxetine. This acts as a serotonin/norepinephrine reuptake inhibitor and its common side effects include nausea, dizziness and insomnia.
Lacunar strokes can present with
unilateral motor disturbance affecting the face, arm or leg or all 3.
complete one sided sensory loss.
ataxia hemiparesis.
patient refuses IM ceftriaxone in gonorrhoea
oral cefixime + oral azithromycin
optimal treatment in HNF1A-MODY.
Sulfonylureas (e.g. gliclazide)
live attenuated vaccines which should not be given in immunocompromised patients are:
Yellow fever Oral polio Intranasal influenza Varicella Measles, mumps and rubella (MMR) BCG
most frequent malaria
Falciparum malaria is the commonest type of malaria
recent parovirus in pregnancy immunology
Rubella
IgG positive & IgM negative - shows immunity to parvovirus. Reassure, no further action.
IgG negative & IgM positive - non-immune. Recent parvovirus infection in last 4 weeks. Refer immediately for further tests/fetal medicine.
IgG negative & IgM negative - repeat test in 4 weeks. If both tests still negative, this confirms susceptibility, but no recent infection. Reassure, further action required only if subsequent exposure occurs.
Dupuytren’s contracture
Specific causes include: manual labour phenytoin treatment alcoholic liver disease diabetes mellitus trauma to the hand
Orbital cellulitis présentation
Presentation Redness and swelling around the eye Severe ocular pain Visual disturbance Proptosis Ophthalmoplegia/pain with eye movements Eyelid oedema and ptosis Drowsiness +/- Nausea/vomiting in meningeal involvement (Rare)
Orbital cellulitis investigations
nvestigations
Full blood count – WBC elevated, raised inflammatory markers.
Clinical examination involving complete ophthalmological assessment – Decreased vision, afferent pupillary defect, proptosis, dysmotility, oedema, erythema.
CT with contrast – Inflammation of the orbital tissues deep to the septum, sinusitis.
Blood culture and microbiological swab to determine the organism. Most common bacterial causes – Streptococcus, Staphylococcus aureus, Haemophilus influenzae B.
Felty’s syndrome
RA + splenomegaly + low white cell count)
Irradiated blood products when
Irradiated blood products are used to avoid transfusion-associated graft versus host disease
Neonates up to 28 days post expected date of delivery
Pregnancy: Elective transfusions during pregnancy (not during labour or delivery)
Immunocompromised (e.g. chemotherapy or congenital)
Patients with/previous Hodgkins Disease
HIV
Injury to the AC joint - injury
AC joint injuries are graded I to VI depending on the degree of separation.
Grade I and II injuries are very common and are typically managed conservatively including resting the joint using a sling.
Grade IV, V and VI are rare and require surgical intervention.
The management of grade III injuries is a matter of debate and often depends on individual circumstances.
sialadenitis
inflammation of the salivary gland likely secondary to obstruction by a stone impacted in the duct. The duct from the submandibular gland drain into the floor of the mouth and purulent discharge from this duct causes a foul taste in the mouth.
Oesophageal adenocarcinoma is associated with
GORD or Barrett’s
Constipation in children history
poor diet and fluid intake
history of cerebral palsy
learning difficulties, or spinal cord problems;
psychological factors (e.g., depression, abuse, ADHD, autism, oppositional disorder),
weaning, toilet training, start of schooling or other causes of stress may be present; vague abdominal pain, painful defecation (infants may extend their legs and squeeze anal and buttock muscles to prevent stooling;
constipation in children exam
examination findings may be minimal (mild abdominal tenderness, stool in rectum); abdominal distension in severe cases or in small children; faecal mass palpable on abdominal or rectal examination
constipation in children management
- Dietary changes remain a common initial recommendation, particularly increased intake of fluids and dietary fibre.
- osmotic agents ie lactulose or polyethylene glycol (PEG) (quicker response, over 1)
- Some children may require the addition of a short-term stimulant laxative (e.g., senna) to achieve regular bowel movements.
If impaction present given osmotic lax 1st line
Appendicitis history
history of sharp or stabbing periumbilical pain that migrates to the right lower quadrant (RLQ); anorexia, fever, vomiting, and/or diarrhoea may be present; occurs in all age groups but is rare in infants
Appendicitis exam
positive McBurney’s sign (RLQ pain and tenderness to palpation at a point two-thirds along a line from the umbilicus to the anterior superior iliac spine); positive Rovsing’s sign (pain in the RLQ in response to left-sided palpation, suggesting peritoneal irritation); positive psoas sign (pain in the RLQ when child placed on left side and right hip gently hyperextended, suggesting irritation to the psoas fascia and muscle); positive obturator sign (RLQ pain on internal rotation of the flexed right thigh);
Appendicitis management
Seek immediate surgical input and consider involving critical care for any patient with suspected appendicitis and signs of shock or sepsis.
Think fluids, abx and access - consider if patient is acutely unwell and in shock.
Laparoscopic appendicectomy is the first choice for most adults
Gastroenteritis history
vague abdominal pain with nausea and vomiting; diarrhoea with or without mucus in stool; recent travel or contact with sick individual(s) or ingestion of suspected food and drink; >10 days suggests parasitic or non-infectious cause; fever, chills, myalgia, rhinorrhoea, upper respiratory symptoms
Gastroenteritis on exam
diffuse abdominal pain without evidence of peritonitis (no guarding or rebound tenderness); abdominal distension; hyperactive bowel sounds; mucus in stool (bacterial or parasitic); signs of volume depletion (tachycardia, hypotension, dry mucous membranes, poor capillary refill, sunken fontanelle in infants); low-grade fever, lethargy and/or irritability, reduced response to noxious stimuli, abnormal temperature
Gastroenteritis management
access dehydration
rehydrate if needed
Daily fluid maintenance requirement is 100 mL/kg for the first 10 kg body weight, 50 mL/kg for the next 10 kg, and 20 mL/kg for each subsequent 1 kg over 20 kg. This is usually supplied by the age-appropriate diet.
For infants who are breast-fed, breastfeeding should be continued.
ondansetron should be considered when vomiting interferes with ORT.
UTI in children management
age dependant
Neonates under 6 weeks
- IV abx
infants >6 weeks to <2 years children and adolescents : systemically stable - oral cefixime
if unstable - need IV abx
Intussuspection presentation / history
usually infant between 3 months and 12 months of age presenting with colicky abdominal pain, flexing of the legs, fever, lethargy, and vomiting; Henoch-Schonlein purpura (HSP) may be initiating factor in an older child (usually <11 years of age); vague abdominal complaints; severe, cramp-like abdominal pain; child may be inconsolable
Intussuspection exam
may see gross or occult blood that may be mixed with mucus and have ‘red currant jelly ‘ appearance, abdominal tenderness, and palpable abdominal mass; signs of HSP may be present in older child (rash of palpable purpura, blood in the stools)
confirm with USS
Intussuspection treatment
1st line - fluid resuscitation Reduction should be first attempted by contrast enema
2nd (when contrast enema is contra ie in peritonitis, perforation, and hypovolaemic shock) - surgical reduction
merkles diverticulum history
typically aged <2 years; may present with abdominal pain (may be intermittent or mimic acute appendicitis), and/or painless passage of bright red blood per rectum (haematochezia); often asymptomatic
merkles diverticulum exam
dark red, maroon, or ‘red currant jelly’ stools; abdominal tenderness with guarding and rebound (may suggest diverticulitis);
merkles diverticulum investigation
Pertechnetate scan is best
ectopic focus or ‘hot spot’; enhancement of diverticulum
merkles diverticulum management
symptomatic - surgical excision of the diverticulum
crohns disease history
crampy abdominal pain, intermittent diarrhoea, bloody diarrhoea if colitis a feature (blood less common in Crohn’s disease than in ulcerative colitis), weight loss, fatigue, family history of inflammatory bowel disease
crohns disease exam
ulcers, evidence of weight loss, pallor, abdominal tenderness, abdominal mass, perianal fistula, perirectal abscess, anal fissure, perianal skin tags; extraintestinal manifestations including iritis, arthritis, sacroiliitis, erythema nodosum, pyoderma gangrenosum
crohns disease investigation
FBC:
leukocytosis, anaemia, thrombocytosis
CRP and ESR - raised
colonoscopy with biopsy:
may demonstrate inflammation, friability, ulcer formation, and oedema
crohns disease management
budesonide - a modified-release corticosteroid, which is active particularly at the terminal ileum
prednisolone: 0.5 to 0.75 mg/kg/day orally, taper gradually according to response (consider adverse effect profile)
immunmodulator therapy ie azathioprine
or mercaptopurine: or methotrexate (with folic acid)
biological therapy
TNF-alpha inhibitors infliximab and adalimumab
testicular torsion history
acute-onset testicular pain; nausea, and vomiting; history of recurrent episodes suggests repeated episodes of testicular torsion followed by spontaneous detorsion; history of trauma may be present
testicular torsion exam
tender, oedematous testicle; affected testicle may appear higher than unaffected testicle with horizontal lie; associated scrotal erythema and oedema; absent cremasteric reflex; usually no pain relief with elevation of the scrotum
testicular torsion investigations
duplex Doppler ultrasound of scrotum:
presence of fluid and the whirlpool sign (the swirling appearance of the spermatic cord from torsion as the ultrasound probe scans downwards perpendicular to the spermatic cord); absent or decreased blood flow in the affected testicle
giardiasis history
history of travel, contaminated water/food, IgA deficiency, foul-smelling watery/fatty stools, abdominal pain, bloating, or weight loss
giardiasis investigation
giardiasis - stool culture - This remains the most definitive investigation.
Inexpensive, but requires microscopic expertise and specialised laboratories.
giardiasis treatment
metronidazole 1st line
Nitroimidazoles (e.g., metronidazole and tinidazole) are first choice for these patients and bind with parasite DNA causing death of the trophozoite.
paromomycin in pregnancy (1st Trimenster`0
Labyrinthitis history
history of vertigo, dizziness, hearing loss, tinnitus, otalgia, and flu-like symptoms; irritation of the vestibular system can be secondary to trauma, central nervous system or ear infection, or vestibular neuritis
Labyrinthitis risk factors
Key risk factors include viral infections, acute or chronic otitis media, meningitis, cholesteatoma, and inner ear malformations.
Labyrinthitis treatment
Symptoms of acute vertigo episodes can be treated with vestibular suppressants and anti-emetics
ie promethazine:
malrotation history
onset <1 month age with bilious vomiting; more concerning symptoms include haematochezia, abdominal distension, and shock; for older children, presents as chronic vomiting and poor weight gain
malrotation exam
examination initially normal but may demonstrate rapid progression to acute abdomen secondary to bowel necrosis; there is a high risk of midgut volvulus and intestinal necrosis
malroation investigation
plain abdominal x-ray:
obstruction: dilatation of the stomach and duodenum
needs emergency surgery
aaa screening
In England, abdominal aortic aneurysm screening (AAA) is offered to men during the year they turn 65.
If normal (<3cm) the patient will require no further future scans as the chances of developing a AAA after 65 years old is small.
Carbimazole
hyrotoxicosis. It is typically given in high doses for 6 weeks until the patient becomes euthyroid before being reduced.
Mechanism of action
blocks thyroid peroxidase from coupling and iodinating the tyrosine residues on thyroglobulin → reducing thyroid hormone production
in contrast propylthiouracil as well as this central mechanism of action also has a peripheral action by inhibiting 5’-deiodinase which reduces peripheral conversion of T4 to T3
Adverse effects
agranulocytosis
crosses the placenta, but may be used in low doses during pregnancy
Argyll-Robertson pupil
Argyll-Robertson pupil is one of the classic pupillary syndrome. It is sometimes seen in neurosyphilis. A mnemonic used for the Argyll-Robertson Pupil (ARP) is Accommodation Reflex Present (ARP) but Pupillary Reflex Absent (PRA)
Features
small, irregular pupils
no response to light but there is a response to accommodate
Causes
diabetes mellitus
syphilis
Orthostatic hypotension
Orthostatic hypotension can be diagnosed when there is:
a. A drop in systolic BP of 20mmHg or more (with or without symptoms)
b. A drop to below 90mmHg on standing even if the drop is less than 20mmHg (with or without symptoms)
c. A drop in diastolic BP of 10mmHg with symptoms (although clinically much less significant than a drop in systolic BP).
SSRI + NSAID = =
GI bleeding risk - give a PPI
Genital warts
90% are caused by HPV 6 & 11
Management
topical podophyllum or cryotherapy are commonly used as first-line treatments depending on the location and type of lesion. Multiple, non-keratinised warts are generally best treated with topical agents whereas solitary, keratinised warts respond better to cryotherapy
imiquimod is a topical cream which is generally used second line
genital warts are often resistant to treatment and recurrence is common although the majority of anogenital infections with HPV clear without intervention within 1-2 years
Venous leg ulcers
presentation
Most due to venous hypertension, secondary to chronic venous insufficiency (other causes include calf pump dysfunction or neuromuscular disorders)
Ulcers form due to capillary fibrin cuff or leucocyte sequestration
Features of venous insufficiency include oedema, brown pigmentation, lipodermatosclerosis, eczema
Location above the ankle, painless
Deep venous insufficiency is related to previous DVT and superficial venous insufficiency is associated with varicose veins
Doppler ultrasound looks for presence of reflux and duplex ultrasound looks at the anatomy/ flow of the vein
Management: 4 layer compression banding after exclusion of arterial disease or surgery
If fail to heal after 12 weeks or >10cm2 skin grafting may be needed
Marjolin’s ulcer presentation
Squamous cell carcinoma
Occurring at sites of chronic inflammation e.g; burns, osteomyelitis after 10-20 years
Mainly occur on the lower limb
Arterial ulcers presentation
Occur on the toes and heel Painful There may be areas of gangrene Cold with no palpable pulses Low ABPI measurements
Neuropathic ulcers presentation
Commonly over plantar surface of metatarsal head and plantar surface of hallux
The plantar neuropathic ulcer is the condition that most commonly leads to amputation in diabetic patients
Due to pressure
Management includes cushioned shoes to reduce callous formation
Pyoderma gangrenosum presentation
Associated with inflammatory bowel disease/RA
Can occur at stoma sites
Erythematous nodules or pustules which ulcerate
retractile testis
testis that appears in warm conditions or which can be brought down on clinical examination and does not immediately retract
neoplastic spinal cord compression is suspected
high-dose oral dexamethasone should be given whilst awaiting investigations
benign prostatic hyperplasia management
Alpha-1 antagonists
BPH typically presents with lower urinary tract symptoms (LUTS), which may be categorised into:
voiding symptoms (obstructive): weak or intermittent urinary flow, straining, hesitancy, terminal dribbling and incomplete emptying storage symptoms (irritative) urgency, frequency, urgency incontinence and nocturia post-micturition: dribbling complications: urinary tract infection, retention, obstructive uropathy
prophylaxis for contacts of patients with meningococcal meningitis
Oral ciprofloxacin (preferred ) ( or rifampicin)
most useful prognostic marker in paracetamol overdose?
An elevated prothrombin time signifies liver failure in paracetamol overdose and is a marker of poor prognosis.
acute pericarditis management
- combination of NSAID and colchicine
Otosclerosis describes the replacement of normal bone by vascular spongy bone. It causes a progressive conductive deafness due to fixation of the stapes at the oval window. Otosclerosis is autosomal dominant and typically affects young adults
features
Onset is usually at 20-40 years - features include: conductive deafness tinnitus normal tympanic membrane* positive family history
Otosclerosis management
hearing aid
bstructive urinary calculi and signs of infection
urgent renal decompression and IV antibiotics due to the risk of sepsis
Sarcoidosis is a multisystem disorder of unknown aetiology characterised by non-caseating granulomas. It is more common in young adults and in people of African descent
Features
acute: erythema nodosum, bilateral hilar lymphadenopathy, swinging fever, polyarthralgia
insidious: dyspnoea, non-productive cough, malaise, weight loss
skin: lupus pernio
hypercalcaemia: macrophages inside the granulomas cause an increased conversion of vitamin D to its active form (1,25-dihydroxycholecalciferol)
Lyme disease management
Management of suspected/confirmed Lyme disease
doxycycline if early disease. Amoxicillin is an alternative if doxycycline is contraindicated (e.g. pregnancy)
people with erythema migrans should be commenced on antibiotic without the need for further tests
ceftriaxone if disseminated disease
Jarisch-Herxheimer reaction is sometimes seen after initiating therapy: fever, rash, tachycardia after first dose of antibiotic (more commonly seen in syphilis, another spirochaetal disease)
OCD management
he most appropriate initial management would be a form of low-intensity psychological therapy. NICE guidelines recommend exposure and response prevention as a beneficial therapy for patients with OCD.
The use of selective serotonin re-uptake inhibitors is also recommended by NICE guidelines, but is typically commenced following a stepwise approach where non-pharmacological interventions are recommended first.
Chronic insomnia
may be diagnosed after three months, if a person has trouble falling asleep or staying asleep at least three nights per week
medication in insomnia
hypnotics:
The hypnotics recommended for treating insomnia are short-acting benzodiazepines or non-benzodiazepines (zopiclone, zolpidem and zaleplon).
Diazepam is not recommended but can be useful if the insomnia is linked to daytime anxiety.
Use the lowest effective dose for the shortest period possible.
If there has been no response to the first hypnotic, do not prescribe another. You should make the patient aware that repeat prescriptions are not usually given.
It is important to review after 2 weeks and consider referral for cognitive behavioural therapy (CBT).
oculogyric crisis
oculogyric” refers to the bilateral elevation of the visual gaze, but several other responses are associated with the crisis.
= dsytonia
Tricyclic antidepressants (TCAs) ie imipramine side effects
Common side-effects drowsiness dry mouth blurred vision constipation urinary retention lengthening of QT interval
antimuscarinic side-effects are more common with imipramine than other types of tricyclic antidepressants.
Akathisia
sense of inner restlessness and inability to keep still
Metformin should be stopped f when
following a myocardial infarction due to the risk of lactic acidosis.
typical carboxyhaemoglobin levels
3% non-smokers
< 10% smokers
10 - 30% symptomatic: headache, vomiting
> 30% severe toxicity
Drug-induced thrombocytopenia (probable immune-mediated)
quinine
abciximab
NSAIDs
diuretics: furosemide
antibiotics: penicillins, sulphonamides, rifampicin
anticonvulsants: carbamazepine, valproate
heparin
Ethylene glycol toxicity management (antifreeze)
Fomepizole (IV), an inhibitor of alcohol dehydrogenase, is used as the first-line treatment for ethylene glycol toxicity. Fomepizole is superior antidote than ethanol because it is safer and easy to dose and administer.
Contraindications of metformin
chronic kidney disease: NICE recommend that the dose should be reviewed if the creatinine is > 130 µmol/l (or eGFR < 45 ml/min) and stopped if the creatinine is > 150 µmol/l (or eGFR < 30 ml/min)
metformin may cause lactic acidosis if taken during a period where there is tissue hypoxia. Examples include a recent myocardial infarction, sepsis, acute kidney injury and severe dehydration
iodine-containing x-ray contrast media: examples include peripheral arterial angiography, coronary angiography, intravenous pyelography (IVP); there is an increasing risk of provoking renal impairment due to contrast nephropathy; metformin should be discontinued on the day of the procedure and for 48 hours thereafter
alcohol abuse is a relative contraindication
Drugs to avoid in renal failure
antibiotics: tetracycline, nitrofurantoin
NSAIDs
lithium
metformin
Drugs likely to accumulate in chronic kidney disease - need dose adjustment in renal failure
most antibiotics including penicillins, cephalosporins, vancomycin, gentamicin, streptomycin digoxin, atenolol methotrexate sulphonylureas furosemide opioids
Rifampicin tb
mechanism of action: inhibits bacterial DNA dependent RNA polymerase preventing transcription of DNA into mRNA
potent liver enzyme inducer
hepatitis, orange secretions
flu-like symptoms
Isoniazid tb
mechanism of action: inhibits mycolic acid synthesis
peripheral neuropathy: prevent with pyridoxine (Vitamin B6)
hepatitis, agranulocytosis
liver enzyme inhibitor
Pyrazinamide
tb
mechanism of action: converted by pyrazinamidase into pyrazinoic acid which in turn inhibits fatty acid synthase (FAS) I
hyperuricaemia causing gout
arthralgia, myalgia
hepatitis
Ethambutol tb
mechanism of action: inhibits the enzyme arabinosyl transferase which polymerizes arabinose into arabinan
optic neuritis: check visual acuity before and during treatment
dose needs adjusting in patients with renal impairment
Methotrexate monitoring
FBC, LFT, U&E
Caution should always be exercised when combining diuretics. However, which one of the following combinations is always contraindicated?
Amiloride and spironolactone a
hyperkalemia
Steroid responsiveness COPD
Asthmatic features/features suggesting steroid responsiveness in COPD:
previous diagnosis of asthma or atopy
a higher blood eosinophil count
substantial variation in FEV1 over time (at least 400 ml)
substantial diurnal variation in peak expiratory flow (at least 20%)
Acromegaly: management
Trans-sphenoidal surgery is the first-line treatment for acromegaly in the majority of patients
Dopamine agonists
for example bromocriptine
the first effective medical treatment for acromegaly, however now superseded by somatostatin analogues
effective only in a minority of patients
Somatostatin analogue directly inhibits the release of growth hormone for example octreotide effective in 50-70% of patients may be used as an adjunct to surgery
Pegvisomant
GH receptor antagonist - prevents dimerization of the GH receptor
once daily s/c administration
very effective - decreases IGF-1 levels in 90% of patients to normal
doesn’t reduce tumour volume therefore surgery still needed if mass effect
Drug-induced urinary retention
The following drugs may cause urinary retention:
tricyclic antidepressants e.g. amitriptyline
anticholinergics
opioids
NSAIDs
disopyramide
Thyrotoxic storm treatment
beta blockers, propylthiouracil and hydrocortisone
ACR results
NICE recommendations for referral to a nephrologist:
a urinary albumin:creatinine ratio (ACR) of 70 mg/mmol or more, unless known to be caused by diabetes and already appropriately treated
a urinary ACR of 30 mg/mmol or more, together with persistent haematuria (two out of three dipstick tests show 1+ or more of blood) after exclusion of a urinary tract infection
consider referral to a nephrologist for people with an ACR between 3-29 mg/mmol who have persistent haematuria and other risk factors such as a declining eGFR, or cardiovascular disease
Management
ACE inhibitors (or angiotensin II receptor blockers) are key in the management of proteinuria
they should be used first-line in patients with coexistent hypertension and CKD
if the ACR > 70 mg/mmol they are indicated regardless of the patient’s blood pressure
open angle glaucoma treatment
NICE guidelines:
first line: prostaglandin analogue (PGA) eyedrop
second line: beta-blocker, carbonic anhydrase inhibitor, or sympathomimetic eyedrop
if more advanced: surgery or laser treatment can be tried2
open angle glaucoma features
Features
severe pain: may be ocular or headache
decreased visual acuity
symptoms worse with mydriasis (e.g. watching TV in a dark room)
hard, red-eye
haloes around lights
semi-dilated non-reacting pupil
corneal oedema results in dull or hazy cornea
systemic upset may be seen, such as nausea and vomiting and even abdominal pain
Metformin predisposes to lactic acidosis
should therefore be used with caution in patients with acute kidney injury
adverse effects if metformin
dverse effects
gastrointestinal upsets are common (nausea, anorexia, diarrhoea), intolerable in 20%
reduced vitamin B12 absorption - rarely a clinical problem
lactic acidosis* with severe liver disease or renal failure
Nerve at risk during a total hip replacement
Sciatic nerve
MRSA management
uppression of MRSA from a carrier once identified
nose: mupirocin 2% in white soft paraffin, tds for 5 days
skin: chlorhexidine gluconate, od for 5 days. Apply all over but particularly to the axilla, groin and perineum
The following antibiotics are commonly used in the treatment of MRSA infections:
vancomycin
teicoplanin
linezolid
Headache: red flags
compromised immunity, caused, for example, by HIV or immunosuppressive drugs
age under 20 years and a history of malignancy
a history of malignancy known to metastasis to the brain
vomiting without other obvious cause
worsening headache with fever
sudden-onset headache reaching maximum intensity within 5 minutes - ‘thunderclap’
new-onset neurological deficit
new-onset cognitive dysfunction
change in personality
impaired level of consciousness
recent (typically within the past 3 months) head trauma
headache triggered by cough, valsalva (trying to breathe out with nose and mouth blocked), sneeze or exercise
orthostatic headache (headache that changes with posture)
symptoms suggestive of giant cell arteritis or acute narrow-angle glaucoma
a substantial change in the characteristics of their headache
mild to moderate dementia management
Acetylcholinesterase (AChE) inhibitors (donepezil, galantamine, and rivastigmine) [NICE, 2006; NICE, 2011]:
These drugs can be used for mild to moderate Alzheimer’s disease but must only be prescribed by healthcare professionals with expertise in this area …
Memantine is an option for managing Alzheimer’s disease for people with:
Moderate Alzheimer’s disease who are intolerant of, or have a contraindication to, AChE inhibitors or
Severe Alzheimer’s disease.
tonsilitis criteria
The criteria are as follows: • Temperature >38ºC • Tender anterior cervical lymphadenopathy • Absence of a cough • Exudate present on tonsils
TURP syndrome what is this
TURP syndrome is a rare and life-threatening complication of transurethral resection of the prostate surgery.
It is caused by irrigation with large volumes of glycine, which is hypo-osmolar and is systemically absorbed when prostatic venous sinuses are opened up during prostate resection. This results in hyponatremia, and when glycine is broken down by the liver into ammonia, hyper-ammonia and visual disturbances.
RF TURP syndrome
There are risk factors for developing TURP syndrome are : surgical time > 1 hr height of bag > 70cm resected > 60g large blood loss perforation large amount of fluid used poorly controlled CHF
Adhesive capsulitis presents
painful stiff shoulder with restriction of active and passive range of motion in abduction, internal and external rotation.
Sensineural hearing loss
t has a diverse range of pathologies including common causes such as:
Presbycusis (most common)
Noise-induced hearing loss
Congenital infections (e.g. rubella, CMV)
Neonatal complications (e.g. kernicterus or meningitis)
Drug induced deafness (aminoglycosides).
Vascular pathology (stroke, transient ischaemic attacks)
Pharmacodynamic interactions with Methotrexate
Trimethoprim and Methotrexate are anti-folate agents. This means that there is an increased risk of Methotrexate toxicity,
AKI following contrast risks
An increased risk of AKI is associated with: chronic kidney disease, diabetes with chronic kidney disease, heart failure, renal transplant, age 75 or over, hypovolaemia, increasing volume of contrast agent, and intra-arterial administration of contrast agent.
Pharmacological management of chronic COPD
Step 1
Starting with a Short acting B2 agonist (SABA)/ short acting muscarinic antagonist (SAMA). These are continued as the patient goes up the management steps.
Step 2
For patients with persistent exacerbations but no asthmatic features (e.g. asthma/atopy history, raised eosinophils, reduced FEV1 or diurnal variations in peak flow) or evidence of steroid responsiveness then add a long acting B2 agonist (LABA) AND a long acting muscarinic antagonist (LAMA).
For patients with persistent exacerbations with asthmatic features or evidence of steroid responsiveness increase management to long acting B2 agonist (LABA) and inhaled corticosteroid in combination (ICS).
Step 3
If patients on a LABA + LAMA combination are still getting daily symptoms that affect their activities of daily living then a 3 month trial of LAMA + LABA + ICS should be considered. If this does not work then it should be reverted back to LABA + LAMA.
If any patient on Step 2 is getting more than one severe or two moderate exacerbations in a year then LAMA + LABA + ICS should be started.
Step 4
If patients are still symptomatic consider specialist referral.
drug induced lupus
Drug induced lupus (DIL) typically presents as a less severe form of systemic lupus erythematosus (SLE) which starts while taking an offending medication, and completely resolves after it is discontinued. Although DIL can present with any feature of SLE, the most common features are:
Systemic upset (fever / fatigue / myalgia).
Arthritis (non-erosive) or arthralgia.
Serositis in the form of pleurisy or pericarditis.
check for
Acquired melanocytic naevus
Acquired melanocytic naevus
Occur in childhood and evolve through a number of steps:
Junctional: flat + pigmented (due to melanocytes at the basal layer of the epidermis)
Compound: raised + pigmented (due to melanocytes at the basal layer of the epidermis + deep in the dermis)
Intradermal: raised + pale (due to melanocytes deep in the dermis)
Antibodies associated with dermatomyositis
constitutional symptoms, symmetrical muscle weakness and a characteristic rash (heliotrope rash, shawl rash, mechanic’s hands). Creatine kinase is markedly raised and Anti-Jo1 antibodies are characteristically raised as well. A muscle biopsy will show evidence of Dermatomyositis.
Imatinib
Imatinib is a tyrosine kinase inhibitor
treatment of chronic myeloid leukaemia (CML) in 2001.
Common side effects include fluid retention, headache, diarrhoea, loss of appetite, weakness, nausea and vomiting, abdominal distension, oedema, rash, dizziness, and muscle cramps. Serious side effects may include myelosuppression, heart failure, and liver function abnormalities.
Causes of high output cardiac failure
auses of high output cardiac failure can be remembered by the mnemonic AAPPTT:
Anaemia Arteriovenous malformation Paget's disease Pregnancy Thyrotoxicosis Thiamine deficiency (wet Beri-Beri)
Complications of nephrotic syndrome
lose immunoglobulins in their urine. This is because the damage to the glomerular capillary walls causes increased permeability to proteins. This means that these patients are at an increased susceptibility to infection. In particular they are susceptible to staphylococcal and pneumococcal infections.
Peri-operative Management of Insulin Dependent Diabetes
Peri-operative management principles of insulin use are:
Put the patient as early on the theatre list as possible minimising the amount of time the patient is nil by mouth.
Stop long acting insulin the night before.
Stop any other insulin and begin sliding scale insulin infusion from when the patient is placed nil by mouth.
Continue infusion until patient is able to eat post-operatively.
Switch to normal insulin regimen around their first meal.
broad complex tachycardia
A broad complex tachycardia will have a heart rate of more than 100 and widened QRS complexes. These patients can be stable or unstable.
Patients with a broad complex tachycardia should be managed according to the ALS algorithm. All patients should be maintained on high flow oxygen and IV access obtained.
Adverse signs are:
Blood pressure <90mmHg (systolic) Heart rate >150 Chest pain Heart failure If a patient displays adverse signs, the patient should be prepared for DC cardioversion.
If the patient is stable, they should be started on 300mg IV amiodarone over 1h followed by an infusion of 900mg amiodarone over 24h.
The patient should be urgently reviewed by cardiology and intensive care.
Haemofiltration should be considered if the following are present;
Pulmonary oedema Refractory hyperkalaemia Severe metabolic acidosis Uraemia Drug overdose e.g. aspirin overdose
Muscle spasm pain in palliative care
The management of pain in palliative care patients in important but can be challenging, and a history is key to ascertaining the best course of treatment.
Simple, conservative measures such as heat, massage and relaxation should always be considered.
Transcutaneous electric nerve stimulation can be used if there is a specific trigger point.
PO diazepam is the first line treatment for spasmodic pain, titrated to effect. Baclofen is a GABA receptor agonist may also be used as a second line.
Torsades de points
orsades de points is a polymorphic ventricular tachycardia, a heart rhythm that may arise in a patient with a prolonged QT interval.
Patients present with feeling generally unwell, palpitations, chest pain, dizziness and syncope. Sudden cardiac death may also occur.
Causes of torsades de points include;
Abnormal electrolytes
Drugs - clarithromycin, anti-psychotics, fluoxetine, cimetidine, lithium, sotalol
Genetic conditions
Treatment of torsades de points is primarily supportive using the ABCDE algorithm. DC cardioversion is indicated if the patient is unstable. Isoprenaline and pacing can be used if the patient is stable, and advice should be sought from a specialist.
chronic mesenteric ischaemia
Chronic mesenteric ischaemia typically presents in elderly patients. Patients have risk factors for arterial disease (smoking, diabetes, high cholesterol, previous MI etc.) or embolic disease (such as atrial fibrillation).
Patients typically present with diffuse, colicky abdominal pain which is worse after eating. Weight loss is a common feature, as patients avoid eating due to the pain. There may be associated diarrhoea and melaena or haematochezia (secondary to mucosal sloughing).
On physical examination there is commonly abdominal tenderness. An epigastric bruits may be present (secondary to turbulent flow in the narrowed vessels).
Management of narrow complex tachycardias (regular)
ABCDE adverse features (shock, syncope, heart failure, or myocardial ischaemia), emergency synchronised direct current (DC) cardioversion is indicated
trial vagal manoeuvres (carotid sinus massage or Valsalva manoeuvre).
If vagal manoeuvres fail, adenosine should be administered (initially as a 6 mg intravenous bolus, and if this fails 12 mg followed by a further 12 mg is trialled).
Management of narrow complex tachycardias (irregular)
ABCDE adverse features (shock, syncope, heart failure, or myocardial ischaemia), emergency synchronised direct current (DC) cardioversion is indicated
Atrial fibrillation with onset less than 48 hours is typically managed with rhythm control (LMWH followed by flecainide if there is no structural heart disease, or amiodarone if there is structural heart disease).
Atrial fibrillation with onset more than 48 hours is typically managed with rate control (i.e. metoprolol or bisoprolol or verapamil, or digoxin if there are signs of heart failure) and anticoagulation
investigation for aortic dissection diagnosis
CT angiogram is used to diagnose dissection
Acute causes of AR
Infective endocarditis, with valve destruction and leaflet perforation. It can also cause perivalvular abscesses, which can rupture into the left ventricle
Aortic dissection, which can cause regurgitation by primarily impeding valve closure
Traumatic rupture of the valve leaflets, caused by blunt chest trauma or deceleration injury
Iatrogenic causes include balloon valvotomy or trans catheter aortic valve implantation (TAVI)
Chronic causes of AR
Chronic valvular causes of AR include:
Calcific aortic valve disease (age related)
Myxomatous degeneration
Congenital disease e.g. bicuspid aortic valve
Rheumatic heart disease - most common cause in the developing world
Infective endocarditis
Rheumatic causes e.g. rheumatoid arthritis, antiphospholipid syndrome
Marfan’s syndrome
Presentation of Acute AR
Sudden cardiovascular collapse Pulmonary oedema Pallor Sweating Peripheral vasoconstriction
(Early diastolic murmur)
Presentation of Chronic AR
Exertional dyspnoea
Orthopnoea
Paroxysmal nocturnal dyspnoea
Stable angina can also develop in some patients with severe AR, even in the absence of coronary artery disease. This is due to reduction in diastolic coronary perfusion.
(Early diastolic murmur)
Investigations for AR
Echocardiogram is the definitive investigation for aortic regurgitation (AR).
Surgical intervention in aortic regurgitation (AR) is indicated in the following situations
Significant enlargement of the ascending aorta
Symptomatic AR
Asymptomatic AR with the following parameter findings:
Poor left ventricular ejection fraction (<= 50%)
Left ventricular end diastolic diameter more than 70mm or left ventricular end systolic diameter mote than 50mm
Infective endocarditis refractory to medical therapy
Aortic stenosis (AS) is associated with a classic triad of symptoms:
Heart failure
Syncope
Angina
ECG findings for AS
Increased QRS complex voltage
Left axis deviation
Poor R-wave progression
AS can be judged to be severe via the following parameters
Peak gradient > 40 mmHg (note, in severe left ventricular dysfunction, a low peak gradient can be falsely reassuring)
Valve area < 1.0 cm^2
Aortic jet velocity >4 m/s
ndications for intervention in AS
All patients with symptomatic aortic stenosis
Asymptomatic patients with a left ventricular ejection fraction (LVEF) < 50%
Asymptomatic patients with an LVEF > 50% who are physically active, and who have symptoms or a fall in blood pressure during exercise testing
Aortic valve peak velocity > 5.5 m/s^2
Severe calcification and peak velocity progression >= 0.3 m/s^2
Markedly elevated BNP levels without other explanation
Severe pulmonary hypertension (pulmonary artery systolic pressure > 60mmHg)
intervention in AS
TAVI is favoured with patients with severe comorbidities, previous heart surgery, frailty, restricted mobility, and those older than 75 years of age.
SAVR is favoured for patients who are low risk and less than 75 years of age.
CHADS2VASc score components
C: 1 point for congestive cardiac failure.
H: 1 point for hypertension.
A2: 2 points if the patient is aged 75 or over.
D: 1 point if the patient has diabetes mellitus.
S2: 2 points if the patient has previously had a stroke or transient ischaemic attack (TIA).
V: 1 point if the patient has known vascular disease.
A: 1 point if the patient is aged 65-74.
Sc: 1 point if the patient is female.
Management of VF
Management is according to the Advanced Life Support guidelines:
The initial priorities will be as for the Basic Life Support: ensure the airway is patent, check for signs of life (pulse and breathing), and commence CPR.
Ventricular fibrillation is a shockable rhythm: the next step is to administer defibrillation (unsynchronised cardioversion using a 200 J biphasic shock).
Chest compressions should then be resumed.
1 mg adrenaline (10 ml 1:10 000) plus 300 mg amiodarone should be administered after the 3rd shock. Adrenaline should subsequently be administered every 3-5 mins (after every alternate shock).
Management of pulseless Ventricular tachycardia (VT)
If there is no pulse the patient should be managed according to the Advanced Life Support algorithm:
VT is a shockable rhythm so a 200 J bi-phasic (unsynchronised) shock should be administered.
CPR should be resumed for 2 minutes before re-checking the rhythm.
Intravenous adrenaline (1 mg of 10 ml 1:10 000 solution) and amiodarone (300 mg) should be administered after delivery of the 3rd shock.
Adrenaline should be administered every 3-5 minutes thereafter (after every alternate shock).
Management of Ventricular tachycardia with a pulse with adverse features
If there is a pulse but the patient shows adverse features (shock, syncope, myocardial ischaemia, or heart failure) the patient should be managed according to the Resuscitation Council tachyarrhythmia algorithm:
Administer a synchronised DC shock (up to 3 attempts).
After seeking expert help amiodarone (300 mg intravenously over 10-20 minutes followed by 900 mg over 24 hours) should be administered.
Management of Ventricular tachycardia with a pulse with no adverse feature
Management of Ventricular tachycardia with a pulse with no adverse features
Management is with amiodarone (300 mg intravenously over 20-60 minutes followed by 900 mg over 24 hours)
Signs of Cardiac Tamponade can be remembered by Beck’s Triad.
Signs of Cardiac Tamponade can be remembered by Beck’s Triad.
Hypotension
Quiet heart sounds
Raised JVP
Bradyarrhythmias requiring pacemakers
Complete heart block (whether asymptomatic or symptomatic)
Mobitz type 2 heart block (whether asymptomatic or symptomatic)
Symptomatic sick sinus syndrome
Permanent bradyarrhythmias caused by a myocardial infarct (typically anterior infarcts - arrhythmias caused by inferior infarcts tend to be temporary)
Tachyarrhythmias requiring pacemakers
Tachyarrhythmias requiring permanent pacing are those that are resistant to pharmacological therapy.
These forms of permanent pacing are typically dual chamber (with one lead in the right atrium and one lead in the right ventricle).
Bi-ventricular pacemaker (in which a 3rd wire is placed in a branch of the coronary sinus, to allow left ventricular pacing and ventricular synchronisation) is an option if the left ventricular ejection fraction is <35%.
Hypertrophic cardiomyopathy
Hypertrophic cardiomyopathy is the commonest genetic heart condition. It is often the cause of sudden cardiac death in young people and athletes. (AD)
Many patient are asymptomatic Generally presents in young adults Exertional syncope Shortness of breath Chest pain Palpitations Heart failure Double apex pulse Ejection systolic murmur at the lower left sternal edge that may get louder during exercise and reduce if lying supine.
ECG findings in MR
P-mitrale (a broad notched P wave due to left atrial enlargement)
Right ventricular hypertrophy
Right axis deviation.m
Causes of right heart strain
Right heart strain is caused by pathologies affecting the pulmonary vasculature such as
Pulmonary emboli Pulmonary hypertension Chronic lung disease Pulmonary stenosis Pneumothorax
ECG features of right heart strain
Sinus tachycardia (most common) Right ventricular strain pattern (ST depression and T wave inversion in right ventricle and inferior leads) RBBB Right axis deviation P pulmonale S1Q3T3 Atrial arrhythmias
Managment of AF
1.Aspirin
Statin
Sublingual GTN
Beta blocker or rate limiting calcium channel blocker
- beta blocker and long-acting dihydropyridine calcium channel blocker.
- A 3rd medication should only be added if the patient is symptomatic despite 2 anti-anginal drugs. Coronary angiography should be arranged unless contraindicated as PCI may be required.
Contraindications in WPW
Digoxin and NDP-CCBs (e.g. verapamil) are contraindicated for long term use because they may precipitate ventricular fibrillation.
If the patient is experiencing supraventricular tachycardia the management depends on whether the patient is stable or unstable, and if stable the type of arrhythmia:
prevent pathological fractures in bone metastases
Bisphosphonates and denosumab can be used to prevent pathological fractures in bone metastases. If the eGFR < 30, denosumab is preferred
Medical management of a miscarriage
vaginal misoprostol alone
drugs should be avoided in breast feeding
antibiotics: ciprofloxacin, tetracycline, chloramphenicol, sulphonamides psychiatric drugs: lithium, benzodiazepines aspirin carbimazole methotrexate sulfonylureas cytotoxic drugs amiodarone
loop diuretic. where do they act
inhibits the Na-K-Cl cotransporter in the thick ascending limb of the loop of Henle
Acute angle closure glaucoma and priamry assocaitions
Acute angle closure glaucoma
is associated with hypermetropia, where as primary open-angle glaucoma is associated with myopia
Water deprivation test: cranial DI
urine osmolality after fluid deprivation: low
urine osmolality after desmopressin: high
Nephrogenic DI water dep
urine osmolality after fluid deprivation: low
urine osmolality after desmopressin: low
Symptoms of Hypoalbuminaemia
Peripheral oedema (due to reduced oncotic pressure, fluid moves to tissues) - starts in ankles and progresses up the body Ascites
certain circumstances when the creatine equation may not be accurate. Examples include:
Amputation - reduced muscle mass and body weight
Pregnancy
Very high or low BMI
High protein meals
Under 18s - never validated
Extremely old patients - never validated and likely to have low muscle mass
Hypercalcaemia is defined as correct calcium >2.65mmol/L.
Management
Aggressive IV fluids (corrects dehydration, protects the kidneys and increases calcium excretion)
Bisphosphonates (inhibits osteoclast activity reducing calcium release)
Further management to prevent recurrence (depending on the cause):
Chemotherapy (malignancy)
Surgical resection (malignancy)
Radiotherapy (malignancy)
Steroids (sarcoidosis)
Calcitonin
Furosemide
Hypernatraemia is defined as serum sodium concentration >145mmol/L.
Clinical Features
Lethargy
Weakness
Signs;
Confusion
Agitation
Seizures
Coma
treat with IV fluids
Hyperphosphataemia may be treated with
phsophate binders (eg. sevelamer 800mg TDS PO during meals)
Clinical features of hypocalcaemia can be remembered by the mnemonic ‘SPASMODIC’.
SPASMODIC:
S – Spasms (Trousseau's sign) P – Perioral parasthaesia A – Anxiety/Irritability S – Seizures M – Muscle tone increase (colic, dysphagia) O– Orientation impairment (i.e. confusion) D – Dermatitis I – Impetigo herpetiformis C – Chvostek's sign
Management of severe hypokalaemia
Management of severe hypokalaemia
Severe:
Continuous cardiac monitoring
Check and correct magnesium (low magnesium causes renal potassium wasting)
IV infusion of 1L 0.9% saline containing 40mmol potassium chloride.
Note that maximum peripheral potassium infusion rate is 10mmol/hour.
If faster rates required, a central line will neeed to be inserted
Avoid glucose and bicarbonate solutions
Treat cause(s)
The management of hyponatraemia depends on the cause:
Hypovolaemic: IV normal saline Treat underlying cause Euvoleamic: SIADH Fluid restriction ADH receptor antagonists (e.g. tolvaptan, deomeclocycline) Oral sodium and furosemide Hypothyroidism Levothyroxine Hypervolaemic: Fluid restriction Treat underlying cause
Causes of lactic acidosis
Tissue hypoxia (Type A) Shock (e.g. cardiogenic, hypovolaemic, haemorrhagic) Hypoxia Acute mesenteric ischaemia Limb ischaemia Severe anaemia Seizures Vigorous exercise Abnormalities in metabolism of lactate (Type B) Diabetic ketoacidosis Cancer Liver disease Inborn errors in metabolism Drugs: Metformin - impairs liver metabolism of lactate Aspirin
Normal anion gap acidosis is the result of one of three pathologies:
Increased loss of HCO3-, such as;
Diarrhoea
High output ileostomy
Ureterosigmoidostomy
Impaired kidney resorption (e.g. acetazolamide treatment)
Renal tubular acidosis type 2
Hypoaldosteronism
Adrenal insufficiency
Mineralocorticoid receptor block (e.g. spironolactone treatment)
Increased production of H+, such as; Toluene poisoning Lysine or arginine administration (found in total parental nutrition) Decreased excretion of H+, such as; Renal tubular acidosis types 1 and 4
Management of osteomalcia
A vitamin D level of < 25 nmol/L = deficiency, requires high dose treatment initially followed by maintenance treatment.
A vitamin D level of between 25-50 nmol/L = insufficiency, can be treated with long term maintenance therapy alone.
Lifestyle advice:
Safe sun exposure
Dietary intake of vitamin D and calcium
Long term maintenance supplements
SIADH managment
Management revolves around offloading this excess water:
Fluid restriction (up to 750ml/day) and treat underlying cause ADH antagonists (e.g. tolvaptan, deomeclocycline) Oral sodium and furosemide
vestibular schwannomas which cranial nerves effected
Cranial nerves V, VII and VIII
cardiogenic shock
PAP CO and SVR
Pulmonary artery occlusion pressure - high
CO - Low
Systemic vascular resistance - high
Hypovolaemia
PAP CO and SVR
Pulmonary artery occlusion pressure - low
CO - Low (decreased preload)
Systemic vascular resistance - high
Septic shock
PAP CO and SVR
Pulmonary artery occlusion pressure - low
CO - high
Systemic vascular resistance - low
prophylaxis of oesophageal bleeding
A non-cardioselective B-blocker (NSBB) is used for the prophylaxis of oesophageal bleeding
ie Propranolol
e investigation of choice for reflux nephropathy
Micturating cystography
safer opioid to use in patients with moderate to end-stage renal failure
Oxycodone
Klinefelter’s syndrome is associated with
karyotype 47, XXY.
Features
often taller than average
lack of secondary sexual characteristics
small, firm testes
infertile
gynaecomastia - increased incidence of breast cancer
elevated gonadotrophin levels but low testosterone
Diagnosis is by karyotype (chromosomal analysis).
Oesophageal cancer
Dysphagia may be associated with weight loss, anorexia or vomiting during eating
Past history may include Barrett’s oesophagus, GORD, excessive smoking or alcohol use
Hypertrophic obstructive cardiomyopathy (HOCM)
Management
Management Amiodarone Beta-blockers or verapamil for symptoms Cardioverter defibrillator Dual chamber pacemaker Endocarditis prophylaxis*
Drugs to avoid in HOCM
Drugs to avoid
nitrates
ACE-inhibitors
inotropes
The British Thoracic Society (BTS) state that the following are the main indications for placing a chest tube in pleural infection:
Patients with frankly purulent or turbid/cloudy pleural fluid on sampling should receive prompt pleural space chest tube drainage.
The presence of organisms identified by Gram stain and/or culture from a non-purulent pleural fluid sample indicates that pleural infection is established and should lead to prompt chest tube drainage.
Pleural fluid pH < 7.2 in patients with suspected pleural infection indicates a need for chest tube drainage.
confirm stone diagnosis imagine (renal colic)
non contrast CT
pontaneous bacterial peritonitis: most common organism
E. coli
HRT for women at risk of venous thromboembolism
transdermal
Bile-acid malabsorption may be treated with c
cholestyramine
Hyperemesis gravidarum, diagnostic criteria triad:
5% pre-pregnancy weight loss
dehydration
electrolyte imbalance
Left ventricular hypertrophy and deep ST depression and T-wave inversions
hypertrophic obstructive cardiomyopathy.
Charcot’s cholangitis triad:
fever, jaundice and right upper quadrant pain
Beta-blockers are contraindicated in patients with asthma when managing atrial fibrillation
what do you give instead?
CCB ie n. Diltiazem
Blepharitis may be associated with
seborrhoeic dermatitis, dry eye syndrome and acne rosacea
osmotic diuretic that may be used in patients with raised ICP
IV mannitol
otitis media - Indications for antibiotics in children are:
Indications for antibiotics in children are:
Perforated eardrum
<2 years old and bilateral
Present for ≥4 days
<3 months old
Examples of acyanotic heart disease
Ventricular septal defect
Coarctation of the aorta
Patent ductus arteriosus
Types of brain tumours in children include:
Craniopharyngioma: originates from the pituitary gland and presents with homonymous hemianopia from pressure on the optic chiasm.
Astrocytoma: graded from 1 (pilocytic astrocytoma) to 4 (glioblastoma multiforme). Grade 1 tumours have an excellent prognosis (95% 5 year survival). Grade 4 tumours have a poor prognosis (20% 5 year survival). Grade 4 astrocytomas may cross the corpus callosum, giving a characteristic ‘butterfly glioma’ appearance on CT.
Ependymomas (tumours of the cells of the ventricular system)
Meningioma (tumours of arachnoid cells of the meninges)
bronchiolitis obliterans organism
Whilst bronchiolitis obliterans is a relatively rare complication of bronchiolitis it is most commonly associated with adenovirus infection.
complication of RSV
Hyponatraemia is commonly seen as a complication in bronchiolitis caused by respiratory syncytial virus (RSV).
Congenital Adrenal Hyperplasia (CAH)
s a genetic defect in an enzyme in the synthesis of steroid hormones. Patients can present within a few weeks of birth, with evidence of vomiting and dehydration - suggests that this is the most common and also most severe of the CAH syndromes: classical “salt-wasting” 21-hydroxylase deficiency.
Calculating paediatric doses using WETFLAG
Weight: (Age + 4) * 2 Energy: 4J/kg Tube size: (Age/4) + 4 Fluids: 20ml/kg normal saline bolus (10ml/kg if septic, trauma or in heart failure) Lorazepam: 0.1mg/kg Adrenaline: 10 micrograms/kg Glucose: 2ml/kg of 10% dextrose
Glandular fever
EBV
illness worsened by antibiotics
Risk of speenic rupture -
Meconium ileus is managed with
with ‘drip and suck’ (stomach drainage with an NG ryles tube, and IV fluids), along with enemas to remove the sticky meconium. In severe cases, surgery may be necessary.
