Third Year Flashcards
What is the CURB-65 Score?
Used to assess Pneumonia severity:
1 point for each:
Confusion Urea (7 or more) Respiratory rate (30 or more) Blood pressure (less than 90 mmHg Systolic or 60 mmHg Diastolic or less) Aged 65 or over
0-1 Low severity (risk of death < 3%)
2 Moderate severity (risk of death 3-15%)
3-5 High severity (risk of death > 15%)
Do not routinely discharge patients with community‑acquired pneumonia if in the past 24hours they have had 2or more of the following findings:
- temperature higher than37.5°C
- respiratory rate 24breaths per minute or more
- heart rate over 100beats per minute
- systolic blood pressure 90mmHg or less
- oxygen saturation under 90%on room air
- abnormal mental status
inability to eat without assistance.
What 6 parameters make up the NEWS?
Respiration Rate Oxygen Saturations Supplemental Oxygen Temperature Systolic Blood pressure Heart Rate Level of Consciousness
Define Hospital/nosocomial acquired pneumonia
Hospital acquired pneumonia (HAP) is defined as new onset of symptoms along with a compatible x-ray developing more than 48 hoursafterthe patient’s admission to hospital.
An immediate antibiotic prescription and/or further appropriate investigation and management should only be offered to patients (both adults and children) in the following situations:
if the patient is systemically very unwell
if the patient has symptoms and signs suggestive of serious illness and/or complications (particularly pneumonia, mastoiditis, peritonsillar abscess, peritonsillar cellulitis, intraorbital and intracranial complications)
if the patient is at high risk of serious complications because of pre-existing comorbidity. This includes patients with significant heart, lung, renal, liver or neuromuscular disease, immunosuppression, cystic fibrosis, and young children who were born prematurely
if the patient is older than 65 years with acute cough and two or more of the following criteria, or older than 80 years with acute cough and one or more of the following criteria:
hospitalisation in previous year
type 1 or type 2 diabetes
history of congestive heart failure
current use of oral glucocorticoids.
What 4 things should indicate Dialysis is required?
Hyperkalemia
Pulmonary Oedema
Metabolic acidosis
Uraemic encephalopathy (confusion, myoclonic jerks, seizures, coma) or uraemic pericarditis (inflammation of pericardial sac)
If a urine dipstick comes back at Blood ++++ but no bleeding history is indicated, what is the important differential?
Rhabdomyolysis: the myoglobin in the urine cannot be distinguished from haemoglobin so will give a false positive on dipstick
What is required to classify a UTI as ‘recurrent’
Three resolved UTIs in less than 12 months
What are the symptoms of Hyperglycaemia?
- Polyuria
- Polydipsia
- Unexplained weight loss
- Visual blurring
- Genital thrush
- Lethargy
What is diagnostic of Diabetes on a venous capillary sample?
11.1 mmol/L or above for non fasting
7 mmol/L or above for fasting
What are the 9 key care essentials for Diabetes?
- Blood pressure
- Blood glucose
- Eye check
- Foot check
- Cholesterol level
- HbA1c
- GFR/Renal function
- Renal protein e.g. Microalbuminuria
- Weight
- Smoking
What dose of Folic acid should women take who require the higher dose? And what constitutes being high risk?
Some women have an increased risk of having a pregnancy affected by a neural tube defect, and are advised to take a higher dose of 5 milligrams (mg) of folic acid each day until they are 12 weeks pregnant. Women have an increased risk if:
- they or their partner have a neural tube defect
- they have had a previous pregnancy affected by a neural tube defect
- they or their partner have a family history of neural tube defects
- they have Diabetes
Normal ABG Values
pH: 7.35 – 7.45 pO2: 10 – 14kPa pCO2: 4.5 – 6kPa Base excess (BE): -2 – 2 mmol/l Bicarbonate (HCO3): 22 – 26 mmol/l
What is Base excess?
Base excess is the amount of strong base which would need to be added or subtracted from a substance in order to return the pH to normal (7.40).
A value outside of the normal range (-2 to +2 mEq/L) suggests a metabolic cause for the acidosis or alkalosis.
A high base excess (more than +2 mEq/L) indicates a metabolic alkalosis.
A low base excess (less than -2 mEq/L) indicates a metabolic acidosis.
Why is Lactate on an ABG?
Lactate is produced as a by-product of anaerobic respiration.
A raised lactate can be caused by any process which causes tissue to use anaerobic respiration.
Lactate is therefore a good indicator of poor tissue perfusion.
What is Respiratory compensation?
If a metabolic acidosis develops the change is sensed by chemoreceptors centrally in the medulla oblongata and peripherally in the carotid bodies.
The body responds by increasing depth and rate of respiration therefore increasing the excretion of CO2 to try to keep the pH constant.
The classic example of this is ‘Kussmaul breathing’ the deep sighing pattern of respiration seen in severe acidosis including diabetic ketoacidosis.
Here you will see a low pH and a low pCO2 which would be described as a metabolic acidosis with partial respiratory compensation (partial as a normal pH has not been reached).
What is Metabolic compensation?
In response to a respiratory acidosis, for example in CO2 retention secondary to COPD, the kidneys will start to retain more HCO3 in order to correct the pH.
Here you would see a low normal pH with a high CO2 and high bicarbonate.
This process takes place over days.
It is important to ensure that the compensation that you see is appropriate, i.e. as you would expect. If not then you should start to think about mixed acid base disorders.
What is type 1 Respiratory failure?
Type one respiratory failure is diagnosed when there is a PO2 less than 8 and a PCO2 which is low or normal.
T1RF is caused by pathological processes which reduce the ability of the lungs to exchange oxygen, without changing the ability to excrete CO2.
Causes of T1RF include pulmonary embolus, pneumonia, asthma and pulmonary oedema.
What is type 2 Respiratory failure?
T2RF is defined as a PaO2 of less than 8 and a raised PaCO2.
A problem with the lungs.
A problem with the mechanics of respiration.
A problem with the control of respiration.
Pulmonary problems: COPD, Pulmonary Oedema, Pneumonia
Mechanical problems: Chest wall trauma, Muscular dystrophies, Motor neurone disease, Myasthenia Gravis
Central problems: Opiate overdose, acute CNS disease
Causes of tracheal deviation?
Away from lesion:
- Large Pleural effusion
- Tension pneumothorax
Towards lesion:
- Lobar collapse
- Pneumonectomy
- Pulmonar fibrosis
Urea and Electrolyte normal ranges?
Sodium: 135-145 mmol/l Potassium: 3.5 - 5.0 mmol/l Urea: 2-7 mmol/l Creatinine: 55-120 umol/l Bicarbonate: 22-28 mmol/l Chloride: 95-105 mmol/l
Normal ranges of Liver function tests?
Bilirubin 3-17 umol/l Alanine transferase (ALT) 3-40 iu/l Aspartate transaminase (AST) 3-30 iu/l Alkaline phosphatase (ALP) 30-100 umol/l Gamma glutamyl transferase (yGT) 8-60 u/l Total protein 60-80 g/l
Normal ranges for Full blood count?
Haemoglobin Men: 135-180 g/l Women: 115-160 g/l Mean cell volume 82-100 fl Platelets 150-400 * 109/l White blood cells 4.0-11.0 * 109/l Neutrophils 2.0-7.0 * 109/l Lymphocytes 1.0-3.0 * 109/l
Causes of Night sweats?
TB Infective endocarditis Cancer (lymphoma is most common) Hyperthyroidism Menopause
Causes of Pleuritic chest pain?
- Pneumothorax
- Pleural effusion
- Pleuritis
- Empyema
- Pericarditis
- Pulmonary embolism
Incidence of Kidney neoplasms?
Renal cell carcinomas (RCCs), which originate within the renal cortex, are responsible for 80 to 85 percent of all primary renal neoplasms. Transitional cell carcinomas of the renal pelvis are the next most common (approximately 8 percent). Other parenchymal epithelial tumors, such as oncocytomas, collecting duct tumors, and renal sarcomas, occur infrequently. Nephroblastoma or Wilms’ tumor is common in children (5 to 6 percent of all primary renal tumors), while renal medullary carcinoma is a rare form of RCC seen in sickle cell disease.
75-80% of RCCs are clear cell carcinomas.
Causes of Clubbing?
Infective Endocarditis Pulmonary Fibrosis Bronchioectasis Lung Cancer Inflammatory bowel disease Cirrhosis Hyperthyroid?
Four main types of Supraventricular Tachycardia?
AF
Paroxysmal supraventricular tachycardia
Atrial flutter
Wolff-Parkinson White syndrome
Glasgow Coma scale: what does E stand for?
Eyes:
4 - Eyes open spontaneously
3 - Eyes open to verbal command, speech or shout
2 - Eyes open to pain (not applied to face)
1 - No eye opening
Glasgow Coma scale: what does V stand for?
Verbal:
5 - Oriented
4 - Confused conversation but able to answer questions
3 - Inappropriate responses, words discernible
2 - Incomprehensible sounds or speech
1 - No verbal response
Glasgow Coma scale: what does M stand for?
Motor:
6 - Normal/obeys command for movement
5 - Purposeful movement to painful stimulus
4 - Withdraws from pain
3 - Abnormal (spastic) flexion to pain, decorticate posture
2 - extensor to pain (rigid), decerebrate position
1 - no response
What different are the different categories of GCS in terms of overall points?
Minor brain injury = 13-15 points
Moderate brain injury = 9-12 points
Severe brain injury = 3-8 points
What is Sheehan’s Syndrome?
Infarction of the Pituitary gland after postpartum haemorrhage. Decreased secretion of all pituitary hormones, majority of cases are due to a pituitary adenoma or treatment of the adenoma.
What are the New York Heart Association types of heart failure?
Class I: no limitation is experienced in any activities; there are no symptoms from ordinary activities.
Class II: slight, mild limitation of activity; the patient is comfortable at rest or with mild exertion.
Class III: marked limitation of any activity; the patient is comfortable only at rest.
Class IV: any physical activity brings on discomfort and symptoms occur at rest.
What are the causes of Pancreatitis?
IGETSMASHED
Idiopathic Gallstones Ethanol Trauma Steroids Mumps/Malignancy Autoimmune Scorpion sting/spider bite Hyperlipidemia, hypercalcemia, hyperparathyroidism ERCP Drugs
First four are the most common causes
Causes of renal papillary necrosis?
Due to an impairment of blood supply and subsequent ischaemic necrosis.
POSTCARDS
Pyelonephritis Obstruction of the urogenital tract Sickle cell disease Tuberculosis Cirrhosis of the liver Analgesia/alcohol abuse Renal vein thrombosis Diabetes mellitus Systemic vasculitis
What is “typical Angina”
Typical anginal pain has these 3 characteristics:
- constricting discomfort in the front of the chest, or in the neck, shoulders, jaw or arms
- precipitated by physical exertion
- relieved by rest or GTN within about 5 minutes.
What is ‘atypical Angina’
Atypical angina has 2/3 of these 3 characteristics:
- constricting discomfort in the front of the chest, or in the neck, shoulders, jaw or arms
- precipitated by physical exertion
- relieved by rest or GTN within about 5 minutes.
Which leads look at the inferior part of the heart?
II, III, aVF
Which leads look at the lateral part of the heart?
I, aVL
Which leads look at the horizontal plane of the heart and which parts of the heart do these leads look at?
VI, V2 = Septal
V3, V4 = Anterior
V5, V6 = Lateral
Advice to give someone having an Angina attack
Stop what they are doing and rest.
Use GTN spray as instructed.
Take a second dose of GTN after five minutes if the pain has not eased.
Call 999 for an ambulance if the pain has not eased after another five minutes (ie 15 minutes after onset of pain), or earlier if the pain is intensifying or you feel unwell
What is Preload?
Volume of blood in ventricles at the end of Diastole (End diastolic pressure)
What is Afterload?
Resistance left ventricle must overcome to circulate blood
What is involved in the Sepsis 6?
- Administer Oxygen - aim to keep above 94%
- Take blood cultures
- Give IV antibiotics
- Give IV fluids
- Check serial lactates
- Measure urine output
What are the 5 principles of the Mental Capacity Act?
- Presumption of capacity (must be assumed to have capacity until proved otherwise)
- A person must be given all practicable help before anyone treats them as not being able to make their own decisions.
- People have the right to make unwise decisions. Cannot treat someone as lacking capacity for this.
- Anything done for or on behalf of a person who lacks capacity must be done in their best interests.
- Should try and act in the least restrictive manner.
Mental capacity act says that a person is unable to make their own decision if they cannot do one or more of the following four things:
- understand information given to them
- retain that information long enough to be able to make the decision
- weigh up the information available to make the decision
- communicate their decision – this could be by talking, using sign language or even simple muscle movements such as blinking an eye or squeezing a hand.
Hypercalcemia symptoms
Moans, Stones, Groans, Bones
Moans: (gastrointestinal conditions)
- Abdominal pain
- Constipation
- Decreased appetite
- Nausea
- Peptic ulcer disease
- Vomiting
Stones: (kidney-related conditions)
- Flank pain
- Frequent urination
- Kidney stones
Groans: (psychological conditions)
- Confusion
- Dementia
- Depression
- Memory loss
Bones: (bone pain and bone-related conditions)
- Bone aches and pains
- Curving of the spine and loss of height
- Fractures
Extreme elevations in Calcium levels may cause coma.
What are the different categories of BMI?
18.5 to 24.9 means you’re a healthy weight
25 to 29.9 means you’re overweight
30 to 39.9 means you’re obese
40 or above means you’re severely obese
When to offer LTOT to people with COPD?
Assess patients if any of the following:
very severe airflow obstruction (FEV1 < 30% predicted). Assessment should be ‘considered’ for patients with severe airflow obstruction (FEV1 30-49% predicted)
cyanosis
polycythaemia
peripheral oedema
raised jugular venous pressure
oxygen saturations less than or equal to 92% on room air
Assessment is done by measuring arterial blood gases on 2 occasions at least 3 weeks apart in patients with stable COPD on optimal management.
Offer LTOT to patients with a pO2 of < 7.3 kPa or to those with a pO2 of 7.3 - 8 kPa and one of the following: secondary polycythaemia nocturnal hypoxaemia peripheral oedema pulmonary hypertension
Causes of Pancreatitis?
The vast majority of cases in the UK are caused by gallstones and alcohol
Popular mnemonic is GET SMASHED
Gallstones
Ethanol
Trauma
Steroids
Mumps (other viruses include Coxsackie B)
Autoimmune (e.g. polyarteritis nodosa), Ascaris infection
Scorpion venom
Hypertriglyceridaemia, Hyperchylomicronaemia, Hypercalcaemia, Hypothermia
ERCP
Drugs (azathioprine, mesalazine*, didanosine, bendroflumethiazide, furosemide, pentamidine, steroids, sodium valproate)
What are the Centaur criteria for Tonsollitis
The Centor criteria* are as follows: presence of tonsillar exudate tender anterior cervical lymphadenopathy or lymphadenitis history of fever absence of cough
Need 3 or more to have a 40-60% chance that infection is group A strep
How long do typical UTRI last?
acute otitis media: 4 days acute sore throat/acute pharyngitis/acute tonsillitis: 1 week common cold: 1 1/2 weeks acute rhinosinusitis: 2 1/2 weeks acute cough/acute bronchitis: 3 weeks
What is Meig’s syndrome?
Benign ovarian tumour, ascites, and pleural effusion.
Exudate pleural effusion causes?
Exudate (> 30g/L protein) infection: pneumonia (most common exudate cause), TB, subphrenic abscess connective tissue disease: RA, SLE neoplasia: lung cancer, mesothelioma, metastases pancreatitis pulmonary embolism Dressler's syndrome yellow nail syndrome
Transudate pleural effusion causes?
Transudate (< 30g/L protein)
heart failure (most common transudate cause)
hypoalbuminaemia (liver disease, nephrotic syndrome, malabsorption)
hypothyroidism
Meigs’ syndrome
What is Whipple’s disease?
Caused by Tropheryma whipplei bacteria.
Causes malabsorption and the most common symptoms are diarrhea, abdominal pain, weight loss, and joint pains.
