Sunday 15th Flashcards
Hepatitis A
- incubation period: 2-4 weeks, RNA picornavirus
- transmission is by faecal-oral spread, often in institutions
- doesn’t cause chronic disease
- flu-like symptoms,
- RUQ pain
- tender hepatomegaly
- cholestatic LFTs: significantly raised ALT
- jaundice
- an effective vaccine is available
Ascending cholangitis
- fever
- right upper quadrant pain
- jaundice
Acute coronary syndrome
All patients should receive:
- aspirin 300mg
- nitrates or morphine to relieve chest pain if required
ECG there is deep ST depression in I-III, aVF, and V3-V6
Deep and widespread ST depression is associated with very high mortality because it signifies severe ischemia usually of LAD or left main origin
Fondaparinux
patients who are not at a high risk of bleeding and who are not having angiography within the next 24 hours
unfractionated heparin
angiography is likely within 24 hours or a patients creatinine is > 265 µmol/l
Ticagrelor and Prasugrel
patient is going to have a percutaneous coronary intervention
- They should generally be given to all patients and continued for 12 months, although this may vary according to bleeding and ischaemic risk
Intravenous glycoprotein IIb/IIIa receptor antagonists (eptifibatide or tirofiban)
patients who have an intermediate or higher risk of adverse cardiovascular events (predicted 6-month mortality above 3.0%), and who are scheduled to undergo angiography within 96 hours of hospital admission
Coronary angiography
- considered within 96 hours of first admission to hospital to patients who have a predicted 6-month mortality above 3.0%
- It should also be performed as soon as possible in patients who are clinically unstable.
Coronary angiography
- considered within 96 hours of first admission to hospital to patients who have a predicted 6-month mortality above 3.0%
- It should also be performed as soon as possible in patients who are clinically unstable
Cullens sign
Severe acute peri-umbilical bruising in the setting of acute pancreatitis
- when there has been intra-abdominal haemorrage
- seen in cases of severe haemorrhagic pancreatitis and is associated with a poor prognosis
- also seen in other cases of intra-abdominal haemorrhage (such as ruptured ectopic pregnancy)
Boas’ sign
In acute cholecystitis there is hyperaesthesia beneath the right scapula
- because the abdominal wall innervation of this region is from the spinal roots that lie at this level
Rovsing’s sign
In appendicitis palpation of the left iliac fossa causes pain in the right iliac fossa
- because the deep palpation induces shift of the appendix (which is inflamed) against the peritoneal surface. This has somatic innervation and will therefore localise the pain
- It is less reliable in pelvic appendicitis and when the appendix is truly retrocaecal
Murphys sign
Asking the patient to take in and hold a deep breath while palpating the right subcostal area»_space; If pain occurs on inspiration, when the inflamed gallbladder comes into contact with the examiner’s hand
- Typically, it is positive in cholecystitis, but negative in choledocholithiasis, pyelonephritis, and ascending cholangitis.
Grey-Turners sign
bruising of the flanks
- Severe, acute pancreatitis due to subcutaneous tracking of inflammatory, peripancreatic exudate from the pancreatic area of the retroperitoneum
- Pancreatic hemorrhage
- Retroperitoneal hemorrhage
- Blunt abdominal trauma
- Ruptured / haemorrhagic ectopic pregnancy
- Ruptured ovarian cyst
- Ruptured spleen
- Spontaneous bleeding secondary to coagulopathy (congenital or acquired)
- Aortic rupture, from ruptured abdominal aortic aneurysm or other causes
Yellow Card scheme
- standard way to report adverse reactions to medications
- Run by the Medicines and Healthcare products Regulatory Agency (MHRA).
Ankylosing spondylitis
- spondyloarthropathy
- HLA-B27 associated
- typically presents in males (sex ratio 3:1) aged 20-30 years old
- Plain x-ray of the sacroiliac joints:
»_space; sacroiliitis: subchondral erosions, sclerosis
»_space; squaring of lumbar vertebrae
»_space; ‘bamboo spine’ (late & uncommon)
»_space; syndesmophytes: due to ossification of outer
fibers of annulus fibrosus
»_space; chest x-ray: apical fibrosis - MRI: Signs of early inflammation involving sacroiliac joints (bone marrow oedema) confirm the diagnosis of AS and prompt further treatment
- Spirometry: may show a restrictive defect due to a combination of pulmonary fibrosis, kyphosis and ankylosis of the costovertebral joints
- encourage regular exercise
- NSAIDs are the first-line treatment: ibruprofen, naproxen
- physiotherapy
- Steroids in flares
- Anti-TNF therapy: etanercept, adalimumab, infliximab, certolizumab
- Anti-IL-7: secukinumab
bacterial vaginosis
- overgrowth of predominately anaerobic organisms such as Gardnerella vaginalis > This leads to a consequent fall in lactic acid producing aerobic lactobacilli resulting in a raised vaginal pH
- vaginal discharge: ‘fishy’, offensive
- asymptomatic in 50%
- Amsel’s criteria for diagnosis of BV - 3 of the following 4 points should be present:
»_space; thin, white homogenous discharge
»_space; clue cells on microscopy: stippled vaginal
epithelial cells
»_space; vaginal pH > 4.5
»_space; positive whiff test (addition of potassium
hydroxide results in fishy odour) - oral metronidazole for 5-7 days, 70-80% initial cure rate
- relapse rate > 50% within 3 months
- topical metronidazole or topical clindamycin as alternatives
In pregnancy:
- results in an increased risk of preterm labour, low
birth weight and chorioamnionitis, late miscarriage
- Recent guidelines however recommend that oral
metronidazole is used throughout pregnancy but
advises against the use of high dose metronidazole
regimes
Electrical alternans
Alternating QRS amplitude that is seen in any or all leads on an electrocardiogram (ECG) with no additional changes to the conduction pathways of the heart
- pathognomic for cardiac tamponade
- typically associated with pericardial effusion via the
“swinging heart” from the fluid surrounding the heart
Cardiac tamponade
Classical features - Beck’s triad:
1) hypotension
2) raised JVP
3) muffled heart sounds
- dyspnoea
- tachycardia
- an absent Y descent on the JVP - this is due to the limited right ventricular filling
- pulsus paradoxus - an abnormally large drop in BP during inspiration
- Kussmaul’s sign = rare
- ECG: electrical alternans
Urgent pericardiocentesis
Constrictive pericarditis
- JVP: X + Y present
- Pulsus paradoxus: absent
- Kussmaul’s sign: paradoxical rise in jugular venous pressure (JVP) on inspiration, or a failure in the appropriate fall of the JVP with inspiration
- Pericardial calcification on CXR
Acute pancreatitis
may cause hypocalcemia
- Lipase from pancreatic cells breaks down mesenteric and peripancreatic fat»_space; liberation of free fatty acids that bind calcium, decreasing the circulating concentration
