Qbank1 Flashcards
Osteoporosis, investigation
Diagnosis -
postmenopausal/men >50yrs
+ fracture
Scoring-
DXA
Garvan fracture risk indicator
Osteoporosis, treatment
Low risk without fracture -
falls reduction
exercise
diet, no smoking, no alcohol
education and support
The rest:
Bisphosphonates
Denosumab (rank ligand inhibitors)
Oestrogen replacement
Strontium ranelate (antiosteoporotic agent)
Triad for primary adrenal crisis
Low serum sodium
Low serum glucose
High serum potaaaium
- consider diagnosis in unexplained severe dehydration or shock
Adrenal crisis, management
Investigation
Cortisol
ACTH
17 hydroxyprogesterone
Plasma renin activity
Urinary steroid and sodium
serum pH, electrolytes and glucose
Treatment
1. steroid replacement - hydrocortisone, fludrocortisone
(glucocorticoid if mild or moderate)
2. IV fluids
3. Dextrose
4. Electrolyte adjustments
5. Treat trigger
SINBAD clasification system
- All other characteristics are scored 0
- > 3 severe ulceration
Score of 1 each
SITE - Midfoot and hindfoot
ISCHAEMIA - Clinically reduced pedal blood flow
NEUROPATHY - Sensation lost
BACTERIAL INFECTION - Present
AREA - > 1cm
DEPTH - Reaching muscle / tendon or deeper
Diabetic foot ulcer antibiotics
NONE
- just debridement and dressing
MILD
- Flucloxacillin,
- Mod Pen allergy(Cefalexin)
- Severe Pen allergy (Clindamycin)
MODERATE
- Flucloxacillin + Metronidazole
- Mod pen allergy (Cefazolin/Cefalexin + Metronidazole)
- Severe pen allergy (Clindamycin)
SEVERE
- Amoxicillin Clavulanic Acid / Piptaz
- Mod pen allergy (Cefepime + Metronidazole)
- Severe pen allergy (Clindamycin + Ciprofloxacin)
Pheochromocytoma triad
Episodic headache, sweating, and tachycardia.
Thyroxine dose adjustments
Halflife of 7-10 days
Initial doses increased every 3-4 weeks
Full benefit 3-4 months
Monitoring every 4-6 weeks until near euthyroid
Nipple discharge differentials
MILKY - medications, hyperprolactinemia (adenoma, etc)
MULTICOLORED - duct ectasia, comedomastitis
PURULENT - mastitis, abscess
WATERY SEROUS/BLOODY - intraductal papilloma, malignancy, premalignant lesion
Nipple discharge differentials
MILKY - medications, hyperprolactinemia (adenoma, etc)
MULTICOLORED - duct ectasia, comedomastitis
PURULENT - mastitis, abscess
WATERY SEROUS/BLOODY - intraductal papilloma, malignancy, premalignant lesion
Renal artery stenosis, referral criteria
Category 1 (<30 days)
Confirmed RAS + worsening renal function/hypertension
Category 2 (<90 days)
Incidental RAS of >60%
Category 3 (<365 days)
None
Requirements
History
UE
Renal USS
Acute coronary syndrome, initial management
IF OUTPATIENT:
1. Refer via ambulance for assessment
2. Aspirin
3. Sublingual GTN
IF A AND E:
1. ECG (q15 mins)
2. Biomarkers (cardiac troponin)
3. obtain Chest x-ray (old/new record)
4. Morphine if with ongoing chest pain
5. Oxygen if <93% or <88%
6. GTN if with ongoing chest pain
7. Aspirin
- If ECG is negative then repeat assessment for other life threatening causes
Acute coronary syndrome, high risk features of chest pain
Refer if with any of the following:
1. ongoing/repetitive chest pain after treatment
2. elevated troponin
3. persistent ST depression/T wave inversion
4. ST elevation (>2 leads)
5. Haemodynamic compromise
6. sustained ventricular tachycardia
7. syncope
8. known LV Ejection fraction (<40%)
9. prior ACS
Acute coronary syndrome, treatment
- GOLD STANDARD
PCI - < 12 hrs from onset, PCI not available
FIBRINOLYTICS (tenecteplase, alteplase, streptokinase)
+
ANTITHROMBIN (enoxaparin, heparin)
+
ANTIPLATELET (clopidogrel)
THEN
Coronary Angiography - Failed fibrinolysis
PCI - > 12 hrs from onset but still with chest pain
PCI
Hypertension, measurement methods
INITIAL/CVD RISK CALCULATORS
Clinic blood pressure >140/90
CONFIRMATORY
Ambulatory blood presure
Home monitioring
Hypertension, treatment targets
TREATMENT INITIATED AT:
Low absolute CVD risk >160/90mmHg
Moderate absolute CVD risk
>140/90mmHg
TREATMENT GOALS:
Uncomplicated hypertension
<140/90mmHg
CKD
<140/90mmHg
High cardiovascular risk
<120/90mmHg
Hypertension, initial medications
Uncomplicated:
1. ACEI - captopril, enalapril, etc
2. ARB - losartan, candesartan, etc
3. Calcium channel blockers - veralpamil, diltiazem, nifedipine, etc
4. Thiazide diuretics - hydrochlorothiazide, indapamide
- ACEI + ARB = Increased side effects
Specific conditions
1. CKD + Albuminuria - ACEI, ARB
2. MI - ACEI, Beta blocker
3. Symtomatic Angina - BB, CCB
4. CHF - ACEI, BB
5. Intolerant to ACEI - ARB
Rate control drugs
Amiodarone
Dronedarone
Rhythm control drugs
BB
CCB
Digoxin
Heart failure, basic investigation
ECG
Chest x-ray
Transthoracic echocardiogram
Acute heart failure, management
Oxygen - <94% O2 sat
Ventilation - persistent shortness of breath
Loop diuretics - acute heart failure
Vasodilators - >90mmHg SBP
Inotropes - Hypoperfusion
Chronic heart failure, management
ACEI: LV EF <49%
Beta Blocker: LV EF <49%
- bisoprolol, carvedilol, metoprolol, nebivolol
Mineralocorticoid receptor antagonist: LV EF <49%
Diuretics: congestion
Cardiac resynchronisation therapy
Implantable cardioverter defibrillators
Pressure monitoring
Surgery
2nd option after ACEI: ARB, ARNI, Ivabradine, Hydralazine, Digoxin, Nutraceuticals
Pericarditis, presentation
Most common symptom: sharp, piercing chest pain in the centre or left side of the chest.
Others:
low fever
heart palpitations
shortness of breath
weakness or fatigue
nausea
dry cough
swelling of the legs or abdomen
Pericarditis, management
INVESTIGATION:
ECG
Chest x-ray
Optional: Echocardiogram, CT scan, MRI
MEDICATION:
NSAID
Colchicine
Pain -relief
Optional: Anitibiotics (causes are usual idiopathic)
Acute limb ischemia, investigation
DSA, CTA, DUS, and CE-MRA
- CT angiography is 1st line
- DSA is gold standard
Myoglobin and creatinine kinase to assess prognosis and treatment
Acute limb ischemia, Initial treatment
Initial medical treatment
analgesia
unfractionated heparin (UFH)
refer to specialist for further management
Superior vena cava syndrome, management
*avoid biopsies due to bleeding risk
Required diagnostic tests
Chest x-ray
Management if cancer related SVC
bronchoscopy with washing
sputum cytology
limited biopsy
local radiation
antineoplastic agents
anticoagulant or fibrinolytic therapy
diuretics
steroids
Bleeding parameter monitoring
aPTT - heparin
BT - platelet function
INR - warfarin
Indications for AAA repair
Male with AAA >5.5 cm
Female with AAA >5.0 cm
Rapid growth >1.0 cm/year
Symptomatic AAA (abdominal/back pain/tenderness, distal embolisation)
Supraventricular tachycardia, management
Unstable
- DC cardioversion
Stable
- Vagal manoeuveres
- Adenosine (avoid in asthma)
- Verapamil (avoid in <1 yr)
Maintenance (as needed)
- Propanolol
- Diltiazem
ECG heart rate estimation
300/Big squares between R-R = HR
Estimate by Big square:
1 = 300
2 = 150
3 = 100
4 = 75
5 = 60
If with arrhythmia
Rs in 6 seconds x 10
Kussmaul’s sign causes
- dropped JVP during expiration and rise in inspiration (normal is reverse)
restrictive cardiomyopathy
constrictive pericarditis
cardiac tamponade
Kussmaul’s sign causes
- dropped JVP during expiration and rise in inspiration (normal is reverse)
restrictive cardiomyopathy
constrictive pericarditis
cardiac tamponade
Acute pulmonary oedema, investigation
ECG
Chest x-ray
troponin/BNP
Blood test; UE, LFT, Glucose, UA, FBE, ABG
Echocardiogram
Acute pulmonary oedema, management
Sitting position
Oxygen via Hudson type mask amd reservoir/CPAP/BiPAP
Glyceril trinitrate - reduce preload
Furosemide
Morphine - reduce preload
Jelly fish sting management
Bluebottle and minor jellyfish
- single sting
Wash sting site with seawater and remove tentacles
Hot water immersion (45°C for 20 mins)
Major box jellyfish
- multiple stings
Apply vinegar and remove tentacles
Commence immediate cardiopulmonary resuscitation on any patient who is unconscious
- analgesics and referral, consider antivenom
Tetanus prophylaxis for wound management
TIG - Dirty wound + Uncertain vaccination history
Tetanus vaccine:
Dirty wound + >5 yrs last vaccine
Clean/minor wound + >10 yrs last vaccine
Uncertain vaccination history
DTPa - <10yrs old
dTpa - 10-18 yrs old
dT - >18 yrs old
Cushing’s triad
Hypertension
Bradycardia
Irregular breathing
- phenomenon in response to increased ICP
Shingles management
Investigation
PCR (optional)
Management
Antiviral (famciclovir, aciclovir, valaciclovir)
- CNS, zoster ophthalmicus, disseminated, immunocompromised
Ongoing pain relief
- Paracetamol, Prednisone, Amitriptyline, Oxycodone
additional options for Postherpetic neuralgia
- gabapentin, pregabalin, topical capsaicin, TENS
Acne classification
Mild - primarily noninflammatory
Moderate - both noninflammatory and inflammatory, a few pustules
Severe - numerous nodules and cysts
Acne treatment, mild
Mild
1st line comedonal - TR
1st line papule - TR + BPO, BPO, topical AB
2nd line - salicylic acid
TR - topical retinoid
BPO - benzoyl peroxide
AB - antibiotics
Acne treatment, Moderate
Moderate
1st line - BPO/ topical AB, BPO + TR
2nd line - add Hormones
BPO - benzoyl
AB - antibiotics
TR - topical retinoid
Acne treatment, Severe
Severe
1st line - Oral isotretinoin
2nd line - Oral AB + TR + BPO, BPO/topical AB
Maintenance - add hormones
AB - antibiotic
TR - tropical retinoin
BPO - benzoyl peroxide
Alopecia areata, management
1st line
child: topical high potency steroid
adult: intralesional corticosteroid injection
2nd line
topical immunotherapy
Severe cases:
rapid progressive, diffuse, extensive, alopecia totalis, alopecia universalis
1st line : systemic treament, topical corticosteroid, topical minoxidil, topical immunotherapy
2nd line: combine 2 or 3 topicals
Melanoma risk factors
greatest to least
x10 previous melanoma
x7 multiple melanotic nevi
x6 multiple dysplastic nevi
x4 previous other skin cancer
x2 1st degree family melanoma
x2 fair complexion
x1.5 UV exposure
First surveillance interval following removal of low risk conventional adenomas only
Low-risk individuals – conventional adenomas
Interval of 10 years
*low-risk conventional adenomas only (1–2 small [<10mm] tubular adenomas without high-grade dysplasia).
First surveillance interval following removal of high risk conventional adenomas
Interval of 5 years:
• 1–2 tubular adenomas with HGD or tubulovillous or villous adenomas, all of which are <10mm
• 3–4 tubular adenomas without HGD, all of which are <10mm.
Interval of 3 years:
• 1–2 tubular adenomas with HGD or tubulovillous or villous adenomas (with or without HGD), some are ≥10mm
• 3–4 tubular adenomas, some are ≥10mm
• 3–4 tubulovillous and/or villous adenomas and/or HGD, all <10mm.
First surveillance interval following removal of ≥5 conventional adenomas only
5–9 adenomas, intervals are
• 3 years if all tubular adenomas <10mm without high grade dysplasia (HGD)
• 1 year if any adenoma ≥10mm or with HGD and/or villosity.
≥10 adenomas, interval is 1 year
First surveillance intervals following removal of serrated polyps (± conventional adenomas)
Clinically significant serrated polyps only
5 years: 1–2 sessile serrated adenomas all <10mm without dysplasia.
3 years:
• 3–4 sessile serrated adenomas, all <10mm without dysplasia • 1–2 sessile serrated adenomas ≥10mm or with dysplasia, or hyperplastic polyp ≥10mm
• 1–2 traditional serrated adenomas, any size.
1 year:
• ≥5 sessile serrated adenomas <10mm without dysplasia
• 3–4 sessile serrated adenomas, one or more ≥10mm or with dysplasia
• 3–4 traditional serrated adenomas, any size
With synchronous conventional adenomas
5 years for:
• 2 in total, sessile serrated adenoma <10mm without dysplasia.
3 years for:
• 3–9 in total, all sessile serrated adenomas <10mm without dysplasia
• 2–4 in total, any serrated polyp ≥10mm and/or dysplasia
• 2–4 in total, any traditional serrated adenoma.
1 year for:
• ≥10 in total, all sessile serrated adenomas <10mm without dysplasia
• ≥5 in total, any serrated polyp ≥10mm and/or dysplasia
• ≥5 in total, any traditional serrated adenoma. Synchronous high-risk conventional adenoma (tubulovillous or villous adenoma, with or without HGD and with or without size ≥10mm)
3 years for:
• 2 in total, sessile serrated adenoma <10mm, without dysplasia
• 2 in total, serrated polyp ≥10mm and/or dysplasia
• 2 in total, any traditional serrated adenoma.
1 year for:
• ≥3 total adenomas, sessile serrated adenoma any size with or without dysplasia
• ≥3 total adenomas, one or more traditional serrated adenoma.
First surveillance interval following removal of large sessile or laterally spreading adenomas
interval should be 12 months after en-bloc excision of large sessile and laterally spreading lesions.
interval should be 6 months after piecemeal excision of large sessile and laterally spreading lesions.
When to stop surveillance colonoscopy
> 75 years with charleson score of >4
80 years
Small bowel obstruction investigations
Blood tests: FBC, EUC, LFTs, lipase, BSL, an ECG and a CXR. Beta-HCG in women of childbearing age, VBG for lactate.
Plain films: Initial imaging should include upright CXR and erect/supine AXR films (or lateral decubitus)
CT abdomen: provides more information than plain films. May be useful to identify the specific site (i.e. transition point) and severity of the obstruction (partial vs complete). It will also give information about the aetiology, by identifying hernias, masses or inflammatory changes, and potential complications, such as ischaemia or perforation.
Findings that suggest small bowel obstruction include:
-Dilated loops of small bowel proximal to the obstruction > 3 cm
-Predominantly central dilated loops
-Three instances of dilatation > 2.5 - 3 cm
-Valvulae conniventes are visible
-Gas-fluid levels if the study is erect, especially suspicious if >2.5 cm in width and in same loop of bowel but at different heights (> 2 cm difference in height).
High-grade mechanical obstruction may also present with the following features:
-Gasless abdomen
-String-of-beads sign: small pockets of gas within a fluid-filled small bowel
Gonorrhea high risk population
- men who have sex with men
- young (heterosexual) Aboriginal and Torres Strait Islander people living in remote and very remote areas
- travellers returning from high prevalence areas overseas
Gonoccocal treatment
Uncomplicated genital and anorectal infection
- Ceftriaxone 500 mg IMI, stat. in 2 mL 1% lignocaine
PLUS
Azithromycin 1 g PO, stat
Uncomplicated pharyngeal infection
- Ceftriaxone 500 mg IMI, stat. in 2 mL 1% lignocaine
PLUS
Azithromycin 2 g PO, stat
Adult gonococcal conjunctivitis
- Ceftriaxone 1 g IMI, stat. in 2 mL 1% lignocaine
PLUS
Azithromycin 1 g PO, stat
Treatment advice
1. Reduced susceptibility to ceftriaxone and azithromycin is emerging in urban Australia
2. Pharyngeal mucosa makes it the most likely site of treatment failure
3. If a patient has an intrauterine device (IUD), leave it in place and treat as recommended
4. Advise no sexual contact for 7 days after treatment is commenced, or until the course is completed and symptoms resolved, whichever is later.
5. Advise no sex with partners from the last 2 months until the partners have been tested and/or treated
6. Recommend partner notification
7. Provide patient with factsheet.
8. Notify the state or territory health department.
9. Consider testing for other STI
10. Consider human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP)
Turner Syndrome
Females - hearing, vision and fertility
Treatment with hormones can help
Cause - all or part of one of X chromosomes is missing
Warfarin guidelines
Therapeutic level: INR 2-3
<4.5, bleeding absent (lower or omit next dose, test in 2 days)
4.5-10, bleeding absent (stop doses, test in 1 day, restart at reduced dose), (optional: observation, vit k)
> 10, bleeding absent (stop doses, give vit K, test at 12 hrs)
with minor bleeding (<10 vit k, >10 refer)
with major bleeding (stop doses, vit k, prothrombinex, FFP, continuous test until <5)
Post stroke depression medication
fluoxetine - SSRI, 1st for PSD, CI bleeder
citalopram - SSRI, 2nd for PSD, selective but weaker
sertraline - SSRI, 2nd for PSD
amitriptyline - TCA, but Disturbing anticholinergic SE
Alzheimer disease medications
CHOLINESTERASE INHIBITORS
- cardiac relaxant (rest and digest functions)
Donepezil
Rivastigmine
Galantamine
NMDA RECEPTOR ANTAGONIST
- neuroprotective
Memantine
Insomnia treatment
CBT > 3 months insomnia
BY CHOICE
sleep onset difficulties - temazepam, zolpidem, zopiclone
waking after a few hours - nitrazepam, oxazepam
circadian disruption secondary to shift work or genetic predisposition - melatonin
DRUG CLASS
Benzodiazepines (long half life)- temazepam, nitrazepam, oxazepam and flunitrazepam
- effective in reducing sleep onset latency and increasing sleep duration, exert an anxiolytic effect
Non-benzodiazepines (short half life) - zolpidem and zopiclone
Dual orexin receptor antagonists - Suvorexant
2ND LINE
Antidepressants - insomnia patients with comorbid depression
- amitriptyline, doxepin, nortriptyline, mirtazapine and agomelatine
Bipolar disorder treatment
ACUTE
1st trimester: Antipsychotic - risperidone, olanzapine and haloperidol
Lithium
2nd and 3rd trimester: Mood stabilizer - lithium, valproate
Breast feeding (no psychosis) - valproate
MAINTENANCE
Lithium
Optional antipsychotic - quetiapine and olanzapine
Alcohol withdrawal syndrome
1st line - diazepam
Senior, Liver disease - lorazepam, oxazepam
2nd line for psychotic featured - haloperidol,droperidol
Atrial fibrillation treatment
Unstable - cardioversion
Stable <2 days - treat underlying condition
Stable >2 days - anticoag + rate control/cardiovert later
anti coag - warfarin, heparin
rate control - CCB (vera or diltia), BB (olol), Digoxin, Antiarryth (darone)
Medication for overdoses
Hypnotics - supportive
Acetaminophen - NAC
Salicylates - CHO, K
Opioids - Naloxone
Sympathomimetics - Benzo
Antimuscarinic - Benzo (physostigmine)
Cholinergic - Atropine, Pralidox
