random clinical Flashcards
1
Q
What are the thing you look for/think about in a palliative care setting?
A
- resus plan (?continue IVF, NG feeds, IDC)
- palliative meds (GEM: glycopyrrolate, endone, midazolam)
- PRN meds (crisis)
- oral care, pressure sore care
- urinary retention, constipation
- high RR (respiratory/metabolic: acidosis)
- GP informed for pt dying at home to arrange death cert
2
Q
What are the 3 palliative meds and their function?
A
GEM:
- glycopyrrolate /hyoscine (muscarinic anticholinergic, reduce resp secretions (salivary), -> reduce rattly breathing)
- endones / morphine (dyspnoea)
- midazolam (sedatives, benzodiazepines)
3
Q
What are the features of CCF on CXR?
A
ABCDE:
- alveolar edema (bat-wing)
- (kerley) B lines (1-2mm lines in the peripheral lungs)
- cardiomegaly (cardiothoracic ratio > 0.5)
- dilated pulmonary veins
- (pleural) effusion
4
Q
What are the scoring criteria for GCS?
A
Max score: 15, E4V5M6 Eye response (E) 1: Closed 2. Opens in response to pain 3. Opens to speech. 4. Eyes opening spontaneously
Verbal response (V)
- No verbal response
- Incomprehensible sounds.
- Inappropriate words.
- Confused. (some disorientation and confusion.)
- Oriented.
Motor response (M) (sternal rub + supraorbital pressure)
- No motor response
- extensor response (decerebrate posture)
- flexor response (decorticate posture)
- Withdrawal from pain (pull away when nail bed is pinched)
- Localizes to pain (brings hand up beyond chin when supraorbital pressure applied)
- Obeys commands
<=8: severe
9-12: modertate
>12: mild
E not assessable (+1) V intubated (+1)
5
Q
What are the differences between aphasia, dysphasia, dysarthia?
A
Aphasia and dysphasia:
- interchangeably used
- receptive or expressive (unable to understand or express)
- often overlap
- lesion of the dominant hemisphere (usually left)
- Cause: CVAs, space-occupying lesions, TBI, dementia
- receptive: fluent with a normal rhythm and articulation but it is meaningless as they fail to comprehend what they are saying (Wernicke’s area, parietaltemporal lesion), Patients lack awareness of their speech difficulties
- expressive: not fluent and have difficulty forming words and sentences (Broca’s lesion, anterior lesion)
- many other specific different types with corresponding brain areas
Dysarthia
- dysfunction of the muscular control
- unable to form words
- often co-exist with dysphasia
- Slurred and weak articulation with a weak voice
- Cause: strokes, MS, motor neurone disease
6
Q
How common are inguinal hernias in female?
A
- Male: female = 6:1
- indirect hernias are most common, due to non-closure of processus vaginalis
- can happen as sliding hernia (with ovaries, tubes)
- direct IH is rare in women because the broad ligament of uterus supports the inguinal canal
7
Q
What do you see in LP CSF analysis in bacterial vs viral meningitis?
A
Bacterial:
Glucose: low
Protein: very high
WCC: Very high (PMNs)
Viral:
Glucose: normal
Protein: normal/high
WCC: high (lymphocytes, may have PMNs early)
8
Q
What are the symptoms of benzodiazepine (eg valium) withdrawal?
A
- headaches
- anxiety/depressed mood
- muscle pain
- tremors/shakiness
9
Q
Mechanism, uses and S/E of macrolides?
A
- binds to 50S subunit of ribosome, inhibit protein synthesis. Bacteriostatic
- cover everything penicillin does + atypicals in pneumonia: mycoplasma, chlamydia, legionella, mycobacterium avium-complex (MAC) (in AIDS)
- chlamydia/gonorrhoea infection, give both azithro (vs chlam) and ceftriaxone (vs gonorrh) because of common co-infection
- used when allergic for penicillin
Eg:
- erythromycin
- azithromycin
- clarithromycin
S/E:
- well tolerated
- inhibitors of P450
- QT prolongation
10
Q
Mechanism and coverage of cabapenem?
A
Carbapenems (++—):
- inhibits cell wall synthesis
- extremely wide range (+, -)
- covers anaerobes
- not effective against atypicals
Reference:
- meropenem
- imipenem + cilistatin (b-lactamase inhibitor)
(both effective vs pseudomonas)
- ertapenem (highly effective vs anaerobes, not vs pseudomonas)
S/E:
- diarrhoea, nausea, vomiting
11
Q
Mechanism, coverage and SE of aminoglycosides?
A
Aminoglycosides (+—-):
- binds to 30S subunit in ribosomes, inhibit protein synthesis
- wide range,
- used against gram negatives and pseudomonas
- used for listeria
Eg:
- gentamicin
- tobramycin
- amikacin
S/E:
- ototoxicity
- nephrotoxicity
- AVOID IN PREGNANCY
Reference:
- Listeria (gram +) (sepsis, meningitis, encephalitis in newborn, elderly and immunocompromised)
12
Q
Describe the quinolones.
A
Quinolones (+++—):
- inhibit DNA gyrase -> DNA replication
- effective against wide range: gram negatives, staph, strept
- common empirical tx
- good empirical for pneumonia (strept, aspiration, atypicals…)
- UTIs and prostatitis
- intractable infectious diarrhoea
Eg:
- levofloxacin
- ciprofloxacin
- gatiflocaxin
- moxifloxacin
S/E:
- well tolerated
- low risk of tendon rupture
- C diff diarrhoea
- AVOID IN PREGNANCY
13
Q
Mechanism, Uses and SE of vancomycin?
A
Vancomycin (++++):
- inhibits cell wall synthesis
Use:
- wide range of efficacy (gram +, anaerobics)
- against MRSA, C diff
- good choice for empirical (along with sth for gram -, atypicals, eg doxycyclines)
S/E:
- red man syndrome (infusion related reaction)
- diarrhoea, nausea, vomiting
14
Q
Where do u find anaerobes? Name 2 antianaerobes and their uses.
A
- anerobes are present in intra-abdominal infections
Eg:
Metronidazole, clindamycin
Uses:
- metronidazole (below diaphragm, eg C diff), nucleic acid synthesis
- clindamycin (above diaphragm), 50S
15
Q
When do you use trimethoprim/sulfamethoxazole (TMP-SMX)?
A
- UTI for those non allergic, otherwise: - nitrofurantoin)
- pneumocystis jirovecii
16
Q
What Abx for pseudomonas?
A
- piperacillin/tazobactam (tazocin) (first line)
- ceftazidime, cefipime (if allergic)
- gentamicin, amikacin, tobramycin (used for systemic instability)
- meropenem, imipenem
17
Q
What Abx for MRSA?
A
MRSA:
- vancomycin
- tigecycline
- linezolid
18
Q
Microbes in CAP? Abx in CAP?
A
In order of prevalence:
- Strept pneumo»> H influ (G-), Klebsiella pneumo (G-), pseudomonas, s aureus, moraxella catarrhalis (G-),
- **atypicals: Mycoplasma pneumo, Chlamydia pneumo, Legionella)
Abx:
- *Inpatient:
- benzylpenicillin IV + doxy
- step down to amox + doxy
Severe: (sepsis)
- ceftriaxone IV + azithromycin IV
Outpatient:
- amox OR doxy
19
Q
Microbes and Abx for meningitis.
A
Meningitis (N. meningitides, H. influenzae, strept pneumoniae)
- Ceftriaxone
+/- vancomycin (if G+ diplococci)
+/- corticosteroid
20
Q
What are the 3 types of Abx hypersensitivity reaction?
Examples of severe reactions?
A
- IgE-mediated immediate hypersensitivity
- within 1 to 2 hours of exposure
- urticaria, angioedema, bronchospasm or anaphylaxis - IgE-independent (non-allergic) immediate hypersensitivity
- usually caused by direct mast-cell degranulation
- eg ‘red-man’ syndrome
- Mx: prophylactic antihistamines and slowing the infusion rate
3.Delayed-type hypersensitivity (T-cell mediated)
- several days after tx
- macular, papular or morbilliform rash
- **more common than immediate reactions
- **commonly occur with intercurrent infection
- reactions may not be reproducible
- not strongly predictive of a future reaction
Severe types:
1. DRESS (drug rash with eosinophilia and systemic symptoms) — eosinophilia, dermatitis and liver dysfunction
- Stevens–Johnson syndrome / toxic epidermal necrolysis (SJS/TEN)—a very rare, acute and potentially fatal skin reaction characterised by sheet-like skin and mucosal loss.
- serum sickness—characterised by vasculitic rash, arthralgia/arthritis, and sometimes fever and proteinuria.
- commonly with cefaclor and sulfonamides (SMX).
21
Q
What is the standard regime for fluids for a day in a normal person?
Daily req of Na, K, Cl and glucose?
Daily fluid req?
Normal total blood volume?
A
‘Standard’ regime for one day is:
- 1L NS (+30 KCl) + 2L 4% & 1/5th (+ 30KCl)
- rate 125ml/h
Use KCl if no concern for hyperkalemia.
Overall req= maintenance + fluid deficit + ongoing loss
Daily req of Na, K, Cl are both 1 mmol/kg/day
Glucose: 50-100g/day (1-2L 5% dextrose)
Fluid: 25-30ml/kg/day
Blood volume = 5L
22
Q
What are the different types of fluids for fluid replacement?
A
Crystalloids
- 0.9%Normal Saline (+30KCl)
- 4% & 1/5- (4% glucose, 1/5 n.s.) (+30KCL) (30NaCl, 40glucose /L)
- Hartmann’s (130Na 110Cl 5K 2-3Ca 28lactate)
- Plasmolyte: (140Na 98CL 5K 1.5Mg 27acetate 23gluconate)
(better in cases of met acidosis e.g.renal failure)
Colloids
- resus, helps retain fluid in intravascular space,
- 4% albumin
- Gelofusine
- Fresh frozen plasma
- Good for e.g. CCF pts, lots of extravascular fluid, little intravascular
23
Q
What are the signs of dehydration?
A
- ↑HR, ↓BP, ↓urinary output
24
Q
Causes of S3, S4?
A
S3 (mitral area)
- due to rapid ventricular filling
- L heart failure, dilated ventricles
- normal in children and young adults
S4 (mitral area) (always pathological)
- stiff ventricular wall
- ventricular hypertrophy, previous IHD, primary myocardial diseases
Reference:
S3+S4
- sign of improvement of heart failure
25
Describe the sounds and common cause of systolic murmurs.
What murmur is present in HOCM?
Big 4 + 1:
```
Systolic murmur:
Aortic stenosis (aortic area)
- crescendo-decrescendo mid-systolic murmur
- radiate to carotids
- common cause: calcific AS
```
```
Pulm stenosis (pulm area):
- similar to AS but does not radiate to carotids
```
Mitral regurgitation (mitral area)
- pan-systolic murmur
- radiate to left axilla
- common cause: MI, MV prolapse
Tricuspid regurg (tricuspid area):
- similar to MR, but
- radiate upwards instead
Mitral valve prolapse (mitral area)
- mid-systolic click with late systolic flat murmur
- common cause: sporadic, Marfan's
Others:
HOCM (hypertrophic obstructive cardiomyopathy) (mitral area)
- early systolic murmur that has a harsh diamond shape and ends well before S2
- **2 murmurs: (AS+MR)
- Aortic area: diamond shaped aortic murmur
- Mitral: pansystolic murmur
- also loud S1, and S4
Reference:
AS:
- caused by calcific aortic stenosis (disease of the elderly), RHD, bicuspid valve
MR:
- acute: IE, MI, MV prolapse
- chronic: MV prolapse, RHD, annular calcification, cardiomyopathy
MV prolapse
- sporadic, familial, associated with connective tissue disorder (eg Marfan)
HOCM:
- strong contraction of the left ventricle causes the anterior leaflet to be sucked into the ventricle, blocking the flow into the aorta
- turbulent flow from the left ventricle to the left atrium causes a second murmur. Both occur at the same time
Pathology:
- genetic abnormality of cardic muscle protein -> cannot contract
- causing hypertrophy of LV and interventricular septum
- > reduced filling capability and causes INTERMITTENT OUTFLOW OBSTRUCTION (esp when diastole is short)
- Px: dyspnoea, syncope, sudden death
- screening: systolic ejection murmur that increases with valsalva in children
- echocardiogram (increased septum:LV thickness ratio)
- Dx: genetic test, cardiac biopsy
26
Describe the sound and common cause of diastolic murmurs.
Aortic regurgitation – (Erb’s point (3rd ICS, left))
- early diastolic decrescendo murmur
- starts at S2 and occupies first half of diastole
- IE, RHD>> **Marfan syndrome, congenital, degenerative
Pulmonary regurgitation
- same as aortic regurg
- intensity increases during inspiration
Mitral stenosis
– early opening snap + mid diastolic rumbling
+ late diastolic murmur
- severe: occupies the remainder of diastole
- RHD>> congenital, rheumatoid (SLE, RA)
Tricuspid stenosis
- similar to MS
Reference:
AR: - collapsing pulse, wide pulse pressure
27
What are the screening programs in NSW and how often what age?
Screening programs:
Cervical:
- people aged 25 to 74 five yearly / two years after their last Pap test
- it detects the presence of HPV
OR
- unusual or persistent vaginal bleeding (post-coital, unexplained inter-menstrual or any post-menopausal), discharge (offensive and/or blood stained) or deep persistent dyspareunia can have a cervical test at any age + colposcopy/specialist
Referral to specialist for colposcopy when:
- symptoms described above
- HPV type 16/18
- other types with high-grade squamous intraepithelial lesion (HSIL)
- other HPV infections -> repeat in 12months
Procedure:
- similar to pap, perform an examination using a vaginal speculum and take a sample
- sample medium is liquid-based
- test for the presence of HPV.
- Even if your test shows you have HPV it usually takes 10 or more years for HPV to develop into cervical cancer and cervical cancer is a rare outcome of a HPV infection.
Breast:
- Women aged 50-74 every two years (without breast cancer symptoms), >75 per cent of breast cancers in age >50.
- Women aged 40 - 49, or 75+ should talk to their GP about whether they should have a free screening mammogram.
- Screening mammograms are not effective for women under 40.
- Women with strong family history of breast or ovarian cancer, or with a diagnosis of breast cancer in the past five years, should talk to their GP
Bowel Ca:
- aged 50-74 every two years (without symptoms) to do FOBT
- national bowel cancer screening kit (orderable online / on phone)
- 58% of positive FOBT will have normal colonoscopy, 39% will be diagnosed with a polyp and only 3% will be diagnosed with cancer or suspected cancer
- any positive iFOBT (including just one of the samples) should be investigated by colonoscopy (RR=12 for ca)
- high-risk individuals such as symptomatic, history of colorectal cancer, IBD or certain high-risk genetic disorders, consider colonoscopy screening
Symptoms such as:
- PR bleeding
- changes in bowel habit (diarrhoea, constipation, frequency changes)
- anaemia
- abdominal pain
- constitutional symptoms
Flowchart for risk stratification based on FHx:
Low risk:
- 1 FDR/SDR >55 at dx
- FOBT 2y from age 45
Moderate risk:
- 1 FDR <55
- 2 FDR or 1 FDR + 2 SDR >55
- FOBT 2y from age 40
- colonoscopy 5y from age 50
- consider aspirin 100mg daily
High risk:
- >= 3 FDR/SDR with at least one <55
- FOBT 2y from age 35
- colonscopy 5y from age 45
- consider aspirin 100mg daily
- refer to familial cancer clinic
Diabetes:
- the American Diabetes Association (ADA) recommends every three years in age >=45
28
What is febrile neutropenia/ neutropenic sepsis? (basic, organism, Ix, Tx)
- post chemo (usu after 1 week)
- t>38, ANC < 1000 (normal: 1500-8000)
- risk associated with degree and duration of neutropenia
- only 20-40% will have positive culture
Oragnisms:
- G+: staph,…
- G-
- fungal, viral, atypicals
Ix:
- identification of potential infection site
- CXR, FBC, MSU -> C&S of any lesion
Tx:
- no allergy: tazocin +/- vanc
- rash: ceftazidime
- severe: imipenem/meropenem
- use aminoglycosides for systemic instability (ototoxicity, nephrotoxicity)
- + G.CSF (evidence says no difference)
Px: usually will resettle with Abx as ANC returns normal
29
Malignant spinal cord compression (basic, symptoms, ix, tx)
Malignant spinal cord compression:
- mostly thoracic > lumbar
- consequence: paraplegia, quadraplegis
- frequency: breast (28%), lung (17), prostate (14), lymphoma (5), myeloma (4) renal (4)
```
Symptoms:
- radiculopathy (pain, weakness, paraesthesia,
- autonomic (urinary/bowel)
Ix:
- XR vertebral column
- CT scan
- myelography
```
Tx:
- immediate Tx is crucial
- IV dexamethasone 10mg stat, 4mg QID
- RT (aim: decompression, cytoreduction of tumor)
- surgical indications (spinal instability, failure to respond to RT)
30
Hypercalcemia of malignancy (Px, causes, ddx, ix, tx)?
```
HyperCa of malignancy:
Px:
- dehydration, polydipsia, polyruria
- weight loss
- anorexia
- GI symptoms
```
Causes:
1. Humeral hyperCa of malignancy (80%)
- in malignancy (10-20% of ca pt)
- secretion of PTH related protein (PTHrP)
- > promotes RANKL
- > bone resorption
- > low PTH, high Ca
- typically in advanced/squamous cell/poor prognostic malignancies
- squamous, renal, bladder, breast, ovarian, prostate, colorectal, lymphoma, leukemia
2. osteolytic metastasis(20%)
- breast, MM, leukemia, lymphoma
3. ectopic PTH secretion (rare)
Ddx:
- primary hyperPTH
- less common (sarcoidosis, vitamin D…)
Ix:
- test: Ca, PTH,PTHrP, vitamin D
- typically high Ca, high PTHrP, low PTH
Tx:
- normal saline infusion -> Ca excretion
- bisphosphonate -> prevent osteoclastic activity
31
SVC obstruction (Px, cause, ix, mx)?
```
SVC obstruction:
Px:
- dyspnoea
- facial /arm swelling
- cough
- dysphagia
```
```
Cause:
mediastinal lymphadenopathy
- lung Ca (65%)
- NH lymphoma (10%)
- others (thyoma, thymic Ca, mets)
```
Ix:
- CT chest
- biopsy
Mx:
- high dose steroids
- Tx for cancer
- **anticoagulant for thrombosis
32
Syndrome of inappropriate ADH (basics, cause, Mx)?
Syndrome of inappropriate ADH (SIADH)
- disorder of impaired water excretion caused by the inability to suppress the secretion of ADH
- hyponatremia, hypoosmolality, and a urine osmolality above 100 mosmol/kg
- normal renal function
Causes:
- CNS (stroke, hemorrhage, infection, trauma, and psychosis)
- ectopic production by tumour (SCLC > H&N ca, …)
- pulmonary disease (pneumonia (viral, bacterial, tuberculous) > others)
- drugs
Mx:
- identify underlying cause
- fluid retention
- demeclocycline (induces nephrogenic DI as a S/E)
33
Tumor lysis syndrome (patho, Px, risk fx, complications, Mx)?
Tumour lysis syndrome:
- rapid lysis of tumor cells
- usually post tx, sometimes spontaneous
Pathology:
- releases massive quantities of intracellular contents
- (potassium, phosphate, and nucleic acids that can be metabolized to uric acid)
- > hyperkalemia, hyperphosphatemia, secondary hypocalcemia, hyperuricemia, and acute kidney injury
- High levels of both uric acid and phosphate increase the severity of acute kidney injury because uric acid precipitates readily in the presence of calcium phosphate crystals, and calcium phosphate precipitates readily in the presence of uric acid crystals.
Symptoms:
- nausea, vomiting, diarrhea,
- anorexia, lethargy,
- hematuria,
- heart failure, cardiac dysrhythmias,
- seizures, muscle cramps, tetany,
- syncope, and possible sudden death
Risk factors:
- hematological malignancies (leukemia, lymphoma)
- in malignancy with a high proliferative rate, large tumor burden
- high sensitivity to treatment, initiation of cytotoxic chemotherapy, cytolytic antibody therapy, radiation therapy
- high pretreatment LDH
- pre-existing hyperuricemia/hyperphosphatemia, nephropathy, oliguria
Complications:
- acute renal failure
- arrhythmias
Mx:
- risk stratification
- prophylaxis (IV hydration, allopurinol)
- monitoring electrolytes
34
Ddx and Ix for decreased cognitive function in elderly?
```
Ddx:
Central
- delirium (CAM -> AIDA)
- dementia (mini-mental/RUDAS + CT brain)
- CVA (CVS risks)
```
Metabolic
- B12 (B12)
- Fe (FBC, Fe)
- liver failure (LFT)
- uremia (EUC)
- hypoglycemia (finger prick)
Infective
- meningitis/ecephalitis
Others:
- *thyroid dysfunction (thyroid studies)
- tertiary syphilis
35
Px of hypothyroidism?
Toad like:
- wet clammy skin
- bradykinesia
- bradycardia
- cold intolerant
- swollen/bloated (myxoedema)
- loss of hair
- hyporeflexia
36
Etiology and Mx of non-alcoholic fatty liver disease/steatohepatitis?
Etiology:
- metabolic syndrome:
- hyperlipidemia, hypercholesterolemia
- obesity
- DM
Mx:
- monitoring (LFT, U/S)
- management of CVD risks
- vitamin E for severe steatohepatitis without DM/heart disease
37
Risk factors and Mx of cerebral edema in DKA patients?
- occurs in <1% of children with DKA
- severe acidosis
- high blood urea nitrogen
- age <5
- low pCO2
- use of bicarbs in Tx of DKA
Mx:
- mannitol
- fluids
38
Cluster headache tx?
1st line:
- O2 therapy
- triptans
39
Ca channel blockers? Types and effect
Dihydropyridines:
- amlodipine (long acting)
- nifedipine (short acting)
Effect: potent vasodilator, minimal myocardial depression
Non-dihydropyridines:
- diltiazem (moderate vasodilation, moderate myocardial depression)
- verapamil (less vasodilation, potent myocardial depression)
Indications:
- HT (amlodipine)
- SVT/AF (diltiazem/verapamil)
40
When do you need TMP-SMX for patients with steroid use?
20g prednisone > 4 weeks
| PLUS another cause of immunocompromise (eg, certain hematologic malignancies or a second immunosuppressive drug)
41
What are the common steroid dosage conversion?
dose (anti inflamm) mineralcorticoid
Hydrocortisone: 20 1
Prednisone 5 0.8
Methylpred 4 0.5
Dexamethasone 0.75 minimal
42
What are the indications of VTE prophylaxis?
```
1. Major: SLOMMM
Surgery (~24h post surg)
Lower limb problem (varicose veins)
Obstetrics (pregnancy)
Malignancy
IMmobility
Miscellaneous: Previous VTE
```
2. Minor: COM
Cardio: CCF, MI, HTN
Oestrogen
Miscellaneous: COPD
```
3. Thrombophilia
factor V Leiden
Glycoprotein 20210 mutation
Anti phospholipid syndrome (lupus anti-coag, anti-cardiolipin Ab
ATIII, Protein C/S deficiency
```
43
What are the choices of VTE prophylaxis? When to use each?
Medical:
Clexane 40mg SC daily (standard)
Clexane 20mg SC daily (small patient / renal impairment)
Heparin 5000IU SC BD (CKD: CrCl<30)
```
Mechanical:
TED stocking (less effective than meds)
```
44
How soon do u need to stop/restart NOAC/warfarin/aspirin/clopidigrel before and after surgery?
```
Before:
NOAC: 2d
Warfarin: 5d before + bridging with clexane
Aspirin: 0 or 7d
Clopidigrel: 7d
```
45
Which medication can increase WBC count?
Glucocorticoid increases predominately neutrophils (PMNs)
46
What is procalcitonin test used for?
For bacterial infection in ?sepsis patients
47
How do u calculate potassium replacement in hypokalemia?
| Max infusion rate?
Kdeficit (in mmol) = (Knormal lower limit − Kmeasured) × kg body weight × 0.4
(does not include maintenance 1 mmol/kg/day)
Rate of potassium infusion should not exceed 10 mmol/hour
Choice:
K > 3:
- Slow K (8mmol): 2 tablets 2-3 times per day
- Effervescent (14-28mmol): 2-3 times per day
If K < 3 or symtomatic/ECG:
- IV K: 20-40mmol/L
