YEAR 5 OSCE Flashcards
Breaking Bad News Mnemonic - _______
S: Setting
P: Perception
I: Invitation
K: Knowledge
E: Emotions and empathy
S: Strategy and summary
S stands for setting the scene. This first part may be difficult to show in an OSCE situation. On the wards, doctors need to make sure that the setting is appropriately private. This means that bad news should preferably not be made behind a paper curtain, as this does not constitute real privacy. The doctor should also make sure that there are no disturbances: they should turn off their phone and hand their bleep to the nurse-in-charge if at all possible.
P stands for perception. This means that the candidate should make an obvious attempt early in the consultation to try and check the patient’s understanding about what has happened so far. In this case, the patient has a very poor insight into the situation, which is not his fault. This makes the task much more difficult. It also highlights the importance of always making it clear, why certain investigations are being performed. If one doctor decides not to fully explain the situation, like the GP in this case, they will make the task much more difficult for the next clinician. If doctors are doing investigations to look for the possibility of cancer, the patient should be informed.
I stands for invitation. This is an invitation that the candidate gives to the patient - they will ask whether the patient wishes to know the results of the tests. It may be appropriate at this point to fire a “warning shot” so that they are aware that the news is not going to be good. Excellent candidates may also ask whether they would like to continue the conversation now or whether they would like someone with them. This signposts to the patient (and the examiner) that you are about to break bad news and you are being sympathetic to the patient’s needs.
K stands for knowledge. This represents the need to actually convey the bad news to the patient. This needs to be done in an unambiguous, clear way. On the wards, patients often take in very little of what is said to them in these circumstances, therefore, it is a real test of the candidate’s communication skills. Excellent candidates will check understanding, allow the patient to ask questions and relay information in non-medical, universal terms.
E stands for empathy. This is self-explanatory. Despite what may be assumed, empathy can be learned and practiced. The more candidates practice these types of conversations, the better they will become at them. Stressed candidates are less likely to display empathy. Communication skills such as these are seen on the wards to different degrees. Excellent candidates will learn from what the good examples that they see on placement.
S stands for strategy and summary. This is the final stage of the conversation. Candidates should try and come up with a joint plan with the patient. They will also summarise the case and check understanding.
This station has the added complication that the patient is already upset with the health service in general. It is not uncommon for patients to have hidden agendas when coming into a consultation. Excellent candidates will be able to discuss the patient’s concerns in a non-confrontational manner.
Excellent candidates will behave in a calm and considered manner, even if patients have insulted them or their profession. Candidates are likely to become frustrated with patients who behave in this way, however, they must remember that often there are very valid reasons. Doctors should always consult in a non-judgemental manner.
Although there is still some doubt in this case, as a histological diagnosis has not been made, candidates should not be overly optimistic or try and appease a distressed patient. This will only cause more pain in the long run as there is enough evidence to support the diagnosis of metastatic bowel cancer which has a poor prognosis.
Candidates should not guess about the prognosis if they do not know. It is impossible to answer the question “how long do I have left” with a precise length of time. Candidates should not attempt this. Excellent candidates will be honest and try to explain in an empathetic manner that they cannot answer such a question. They will reassure the patient that the whole multidisciplinary team will work hard to help the patient in every way possible.
Emergency Contraception Discussion.
4 things to explore in presenting complaint _____
DCMMP - DOLLY CAN MANIPULATE MY PENIS
- Details of sexual intercourse (When/Who/Consensual/Regular partner/ Age of partner)
- Current contraception (type/reason for failure)
- Menstrual history (LMP/Regularity/ Cycle length/ Estimated day pf ovulation - 14 days before next menstrual period is due) - luteal phase always 14 days.
- Medications? CYP inducing medications can lower effectiveness of EllaOne and Levonelle (ex. TCA’s/Antiepileptics/macrolides/anti-psychotics etc.)
- Pregnancy? Have they already taken emergency contraception this cycle?
Always advise screening for STI’s in unprotected sex.
Emergency contraception options?
IUD
EllaOne
Levonelle
Counselling points for EllaOne And Levonelle
Can restart normal hormonal contraception 5 days after EllaOne and 2 days after Levonelle
Barrier protection in the meantime.
When restarting COCP - Use barrier protection for 7 days.
When restarting Progesterone only pill - Use barrier protection for 2 days.
NB - Levonelle can be taken again in same cycle but not EllaOne.
Contraindications to Emergency Contraception
IUD ____
EllaOne ____
Levonelle ____
IUD
- Pregnancy
- Gynae cancers
- PID <3months
- Copper allergy or Wilsons disease
- Small uterine cavity
EllaOne
- Pregnancy
- Asthma / Liver disease
- < 18 yo
Levonelle
- Pregnancy
- **Acute Porphyria ** - Abdominal pain (particularly in luteal phase)/Dark urine/N+V/Motor neuopathy and seizures (late signs)
Remember EllaOne and Levonelle may be less effective if patient is taking other enzyme inducing medication (anti-epileptics/ anti-psychotics/ macrolides - clarithromycin / TCAs etc)
Side effects of Emergency contraception
IUD ____
EllaOne and Levonelle ____
IUD
- Pain on insertion (use ibuprofen)
- Infection
- Menorrhagia/Dysmenorrhoea
- Vasovagal (1/10)
- Expulsion (1/20)
- Perforation (1/1000)
EllaOne and Levonelle
- PV bleeding (at any time - immediately/at menses/after menses)
- Nausea and Vomiting
- Pelvic and Breast Pain
- Headache
X-RAY Interpretation Steps
- Patient and scan details (Time / AP / PA / Erect or supine)
- RIPE
- ABCDE
RIPE
Rotation - medial side of spinous process should be equidistant from borders of vertebral columns
Inspiration - At least 5/6 anterior ribs should be visible (or 11/12 posterior ribs)
Picture area - Lung apices and costodiaphragmatic recesses/costophrenic angles should be visible. Lung apices shouldnt be above clavicle and scapulae should be out of the way.
Exposure - Verterbral bodies should be visible behind cardiac shadow (over exposure = too black / Underexposure = Too white)
ABCDE
Airway - Tracheal deviation (away from a pneumothorax/large effusion or towards a collapsed lung)
Breathing - Lung fields and pleura
Air
Fluid
Consolidation
Lobar collapse
Lesions
Pleura: thickening and lung borders for pneumothorax
**Circulation **-
Heart size - <50% ribcage (cardiomegaly suggests HF)
Heart position - can be displaced in lobar collapse or pleural effusion
Heart shape and borders - NB right border = right atrium Left border = Left ventricle
Great Vessels - Aortic knuckle (i.e arch should be visible)
Mediastinal width (< 8cm - if not - aortic dissection)
Diaphragm -
Position and shape - right slightly higher due to liver usually. FLAT in COPD due to emphysema and hyper inflated lungs pushing down on diaphragm.
Costophrenic angle - blunting indicates an effusion
Air below diaphragm - Abdo viscus Perforation
Extra things -
Bones (trace if clinically suspiscious i.e trauma etc)
Soft tissues - swelling/ surgical emphysema or subcutaneous air/ masses/ calcification of aorta
To summarize I would look at previous films and ascertain the clinical hx.
Summarize and suggest differentials.
COPD SIGNS ON XRAY
Hyperinflation (>8 anterior ribs above diaphragm)
Flat Hemidiaphragms (emphysema and hyperinflation pushes D down)
Bullae (black lesions more air)
Decreased lung markings
Prominent Hila
Heart failure signs on XRAY
ABCDE
Alveolar shadowing/oedema (bats wings)
B-Lines (kerley) - interstitial oedema
Cardiomegaly
Diversion of blood to upper lobe
Effusion
What does CURB 65 stand for? What are its uses and scores?
CURB65 is a tool used to estimate severity of community acquired pneumonia at time of presentation by evaluating mortality data
It allows clinicians to decide on inpatient vs outpatient treatment
Also allows clinicians to decide on intensity of inpatient treatment including PO vs IV antibiotics, and escalation of monitoring / care to HDU/ITU setting
Points are scored for
Confusion AMTS ( abbreviated mental test score) < 7/10
Urea value >7mmol/l
RR>30/min
SBP <90 or DBP <60
Age >65
0-1 - outpatient care with oral antibiotics and repeat chest x-ray in 6 weeks is appropriate
2 - Inpatient admission is warranted
3 or above - inpatient admission, IV antibiotics, and consideration of HDU/ITU care may be appropriate
DEATH CERTIFICATE
Criteria to be met before filling in certificate?
- Pupils fixed and dilated with no response to light.
- No central pulse (1min)
- No Respiratory effort/Breath sounds on auscultation (1min)
- No heart sounds (1min)
- No pain response to trapezius squeeze
Criteria for death certficate as the doctor filling out the form.
- Must have seen the patient in last 14 days before or after death
- Must have provided care to patient in last illness before death
- Registered GMC
- Knowdledge and belief of cause of death
- Must not meet criteria for referral to coroner
Criteria for referral to coroner
- In hospital <24hrs
- Unknown cause of death
- In custody
- Any suspicious circumstances
- Any drugs involved
- Acute alcohol
- Industrial deaths
- Any blame
- Following accident/fall/violence
- Operation <1 yr
- Unknown identity
End of life/Anticipatory medications for which symptoms?
Medications for pain
Conversion of patient’s usual daily dose of opiate analgesia to a 24 hour dose for use via a syringe pump, with 1/6-1/10 of the daily dose prescribed as ‘breakthrough’ analgesia. Should be reviewed every 24 hours.
- Morphine
First line for pain management
Good for all types of pain
Monitor for constipation
Monitor for unwanted sedation
Please note that when coverting from oral morphine to subcutaneous morphine, you must divide the total dose by two - Diamorphine
- Oxycodone
- Alfentanyl
Useful for patients with renal failure who cannot take morphine
**Breathlessness **
May be a result of disease process (e.g. lung cancer, anaemia)
Therapeutic oxygen
Morphine
Midazolam
Nausea and vomiting
Levomepromazine
Cyclizine
Haloperidol
Metoclopramide
For people in the last days of life with obstructive bowel disorders who have nausea or vomiting, consider:
hyoscine butylbromide as the first‑line pharmacological treatment
octreotide (somatostatin analogue) if the symptoms do not improve within 24 hours of starting treatment with hyoscine butylbromide.
Medications for restlessness and confusion
Haloperidol
Levomepromazine (sedative)
Midazolam
Respiratory tract secretions
Hyoscine hydrobromide
Hyoscine butylbromide (BUSCOPAN)
Glycopyrronium
Atropine
(antimuscurinics/anticholinergics)
- NICE Guidance: Care of dying adults in the last days of life - NICE Clinical Knowledge Summary (CKS): Palliative care - general issues
https://bnf.nice.org.uk/medicines-guidance/prescribing-in-palliative-care/
Causes of Hyperkalaemia?
- Reduced excretion from kidneys
- Release from cells
- Acidosis
- Drugs
- Reduced excretion from kidneys
AKI
and
Addison’s
- Cellular Release:
Rhabdomyolysis
Digoxin Toxicity (NB - Can be precipitated by hypokalemaia) - “Reverse tick sign” on ECG
Tumour Lysis Syndrome
Massive Haemolysis
- Acidosis:
DKA or any other metabolic acidosis
- DRUGs that reduce K+ excretion from the kidneys : **KBANK **:
K+ containing laxatives (movicol/fybogel)
Beta Blockers
ACE inhibitors
NSAIDs
Potassium Sparing Diuretics (i.e aldosterone antagonists - spironolactone/eplerenone etc.) but also diuretics in general
Heparin (which inhibits aldosterone release)
and
Ciclosporin
Hyperkalaemia is a potentially life threatening electrolyte abnormality.
Treat K+ >___ mmol/L or any hyperkalaemia with ECG changes with the following;
Give 10ml of 10% _____ (or chloride) over 10 mins - this is cardioprotective
Intravenous ____ (10u soluble insulin) in 25g ____ (50mL of 50% or 125ml of 20% glucose) - insulin causes intracellular K+ shift and glucose to required to prevent hypoglycaemia
Nebulised salbutamol - also causes intracellular K+ shift
Treatment with sodium bicarbonate is controversial
Other aspects of management:
Check contributing drugs (e.g. ACE inhibitors, spironolactone)
Once initial measures completed, recheck urea and electrolytes and ECG and glucose
Urinary potassium
Hyperkalaemia is a potentially life threatening electrolyte abnormality.
Treat K+ >6.5mmol/L or any with ECG changes with the following;
Give 10ml of 10% calcium gluconate (or chloride) over 10 mins - this is cardioprotective
Intravenous insulin (10u soluble insulin) in 25g glucose (50mL of 50% or 125ml of 20% glucose) - insulin causes intracellular K+ shift and glucose to required to prevent hypoglycaemia
Nebulised salbutamol - also causes intracellular K+ shift
Treatment with sodium bicarbonate is controversial
Other aspects of management:
Check contributing drugs (e.g. ACE inhibitors, spironolactone)
Once initial measures completed, recheck urea and electrolytes and ECG and glucose
Urinary potassium
Causes of Hyponatraemia?
Remember to classify into:
Hypovolaemic (In the elderly dehydration is a very common cause especially in patients with dementia)
Euvolaemic (SIADH / Hypothyroidism)
Hypervolaemic
and drugs:
Thiazide diuretics > Loop Diuretics > K+ sparing diuretics
Hyponatraemia Management
What is the role of the medical examiner?
Medical examiners are senior medical doctors who are contracted for a number of sessions a week to provide independent scrutiny of the causes of death, outside their usual clinical duties. They are trained in the legal and clinical elements of death certification processes.
The purpose of the medical examiner system is to:
provide greater safeguards for the public by ensuring independent scrutiny of all non-coronial deaths
ensure the appropriate direction of deaths to the coroner
provide a better service for the bereaved and an opportunity for them to raise any concerns to a doctor not involved in the care of the deceased
improve the quality of death certification
improve the quality of mortality data.
Causes of Falls in the elderly?
Sensory Disturbance: (visual impairment/vestibular dysfunction/peripheral neuropathy)
Cognitive impairment: Dementia/Delirium
Polypharmacy: Anticholinergics/Opiates/Benzo’s/Antihypertensives
Co-morbidities
Enviromental Hazards: (loose rug)
Physical Ageing Process/Frailty
Orthostatic Hypotension
Motor problems: Gait and Balance problems/ Muscle weakness
When a health professional feels that the person with power of attorney may not be acting in the patients best interests, who could they contact?
Alert the office of the public guardian who will investigate and can apply to the court of protection. Colleagues, safeguarding lead, defence union also useful
What measures should be taken to reduce the risk of delirium during an admission?
- Ensure team of healthcare professionals who are familiar to the person at risk.
- Avoid moving people within and between wards; worth reflecting on the realityof hospital care and the difficulty in achieving this.
- Specialist MDT assessment and personalised care plan. Liaison geriatrics / joint care.
- Appropriate lighting and clear signage / a clock and a calendar should also be easily visible.
- Re-orientate frequently.
- Facilitate regular visits from family and friends.
- Address dehydration and / or constipation.
- Avoid unnecessary catheterisation / lines / restrictions.
- Encourage mobility and keep mobile / active when able.
- Assess for pain, including non-verbal clues of pain and address pain adequately.
- Carry out a medication review.
- Encourage good nutritional intake
- Ensuring hearing and visual aids are available to and used by people who need them, and that they are in good working order.
- Promote good sleep patterns and sleep hygiene.
- Consider alcohol withdrawal regime.
Be vigilant for withdrawal symptoms and
treat if required.
Common causes of delirium can be remembered using the mnemonic ______ :
DELIRIUMS
D - Drugs and Alcohol (Anti-cholinergics, opiates, anti-convulsants, recreational)
E - Eyes, ears and emotional (reduced input)
L - Low Output state (MI, ARDS, PE, CHF, COPD) - low oxygen
I - Infection
R - Retention (of urine or stool)
I - Ictal
U - Under-hydration/Under-nutrition
M - Metabolic (Electrolyte imbalance, thyroid, wernickes
(S) - Subdural, Sleep deprivation
or can use
PINCH ME
- Pain
- Infection
- Nutritional compromise
- Constipation
- Hydration (dehydration / electrolyte disturbance)
- Medication
- Environmental
Treatment of Hyperkalaemia if K+ is > 6.5 mmol/L or ECG changes / Symptomatic
Hyperkalaemia is a potentially life threatening electrolyte abnormality.
Treat K+ >6.5mmol/L or any with ECG changes with the following;
Give 10ml of 10% calcium gluconate (or chloride) over 10 mins - this is cardioprotective
Intravenous insulin (10u soluble insulin) in 25g glucose (50mL of 50% or 125ml of 20% glucose) - insulin causes intracellular K+ shift and glucose to required to prevent hypoglycaemia
Nebulised salbutamol - also causes intracellular K+ shift
Treatment with sodium bicarbonate is controversial
Other aspects of management:
Check contributing drugs (e.g. ACE inhibitors, spironolactone)
Once initial measures completed, recheck urea and electrolytes and ECG and glucose
Urinary potassium
Which patient profile requires breaking confidentiality and informing social services?
Children (<18)
and
Adult w/o capacity
Which patient profile requires NOT breaking confidentiality and not referring to social services or any other body?
Adults with capacity who have not given their consent
Options for safeguarding referral in children/adults w/o capacity and adults w/ capacity?
Children and adults w/o capacity - social services
Adults with capacity - police / Local domestic abuse service/ counselling service/ social services
If you feel an urgent social services assessment is required or the child is at immediate risk , then an ____ can be sought if required.
**Emergency protection order **
In a domestic abuse station, make sure to establish the details of the abuse / take a good social history/ and establish RISK.
For example ____
- Type (physical/sexual/emotional)
- Perpetrator (Who is it/ whats the relationship)
- Pattern (when/are drugs and alcohol involved)
- Timeframe (how long/has the abuse been escalating?)
- Coping (how have they coped/have they tried anything to stop it or get away?)
- Who else is involved (any children or vulnerable adults?)
Social History
* Who do they live with
* Are there weapons in the house
* Does the patient have an emergency safety plan? - if not construct one with patient and signpost police
* Do they work
RISK Assessment
* To patient: Do they currently feel in danger? What would happen if they go home?
* Has it affected their mood? have they considered harming themselves or taking their own life?
* Any children or vulnerable adults involved?
Which drugs should be avoided in the elderly where possible?
NSAIDS
Benzodiazepines
Anti-cholinergics
Tricyclic Antidepressants
Glibenclamide (causes hypoglycaemia)
Doxasozin (adrenergic antagonist - BPH)
Which phenotyoical frailty assessment score can be used to assess a patients frailty on acute admission to the hospital?
Remember frailty can be assessed by 4 major main themes:
Cumulative
Phenotypical
Surrogates
“Eyeball”
Bournemouth Criteria:
> 90 - automatically frail
Age: 75-89 - 2 of the following to be considered frail:
Immobility
Incontinence
Cognitive impairment (i.e dementia/delirum - does not include learning disabilities)
Instability (i.e falls)
Iatrogenesis (i.e polypharmacy - > 5 drugs)
*65-75 - need to be instituionalised (nursing/residential home)
A comprehensive geriatric assessment includes which team members and which domains of assessment?
Patient/ Their care giver and
- Doctors • Nurses
- Therapy (OT/PT/Nutrition/swallow etc)
- Social services
- Community services
- Pharmacist
*CGA is not a form but a process of accumulating data on patient by all team members*
Includes:
- Physical Assessment (illness/pain/incontinence/nutrition?ADL’s etc)
- Psychological (Sleeping/Mental Health/Alcohol)
- Social
- Medication review
These domains all inform care plan for patient.
Frailty Management
• Gold Standard: Comprehensive Geriatric Assessment: MDT
approach holistic assessment considering physical issues, function,
environment/ support, _mobility and balanc_e, psychological issues
and medication. Care plans can be put in place
- Exercise interventions: core strength, flexibility, balance, endurance training
- Good nutrition, considering total protein intake, calcium and vitamin D
- Role for BMI reduction? Raised BMI associated with poor outcomes
• Medication reviews
• Advance care planning
Other than falls, what other risk factors increase the risk of a fragility fracture? (2 mark)
•Previous osteoporotic fragility fracture.
- Current or frequent recent use of oral corticosteroids.
- Low body mass index (less than 18.5 kg/m2)
- Smoker.
- Alcohol intake > 14 units per week.
- A secondary cause of osteoporosis
How would you assess risk of a fragility fracture ?
- Calculate 10 year fragility fracture score (eg FRAX or Qfracture)
- https://www.sheffield.ac.uk/FRAX/ - Fracture Risk Assessment Tool
- DEXA if score >10% or Straight to DEXA if PMH fragility fracture
Maureen returns to her GP having had a DEXA scan showing a T-score of -1.5.
What does the T-Score on a DEXA scan relate to?
- Osteopenia: T score _____
- Osteoporosis T-score ____
Normal range T score _____.
T score: A measurement of bone mineral density as compared to that of a 30 year old adult (Z score: compares your BMD to what is normal in someone your age and body size)
- Osteopenia: T score -1 to -2.4
- Osteoporosis T-score -2.5 and below
Normal range T-score -1 and above
Drugs particularly associated with adverse outcomes in
frailty
• Anticholinergics: unsteadiness, blurred vision, dry mouth,
urinary retention, confusion
• Benzodiazepines: falls, regular use increases all-cause
mortality, confusion
• Opioids: constipation, falls, delirium
• NSAID: AKI and gastric ulceration
• Antihypertensives: AKI, falls
What is the acute management of Ischaemic Stroke?
Patients should be approached in the DR ABCDE manner.
Airway protection (in patients presenting with depressed consciousness) and aspiration precautions (in patients presenting with swallowing impairment) are very important.
Subsequent stroke management depends on whether the stroke is ischaemic or haemorrhagic. CT head should be performed on arrival to the emergency department to distinguish ischaemic from haemorrhagic stroke. (The most sensitive test for confirming ischaemic infarct is a diffusion weighted MRI. This is generally used if the diagnosis is unclear but is not normally possible in the emergency setting due to logistical challenges)
Alteplase (tissue plasminogen activator) is indicated in patients presenting within 4.5 hours of symptom onset and with no contraindications to thrombolysis (e.g. recent head trauma, GI or intracranial haemorrhage, recent surgery, acceptable BP, platelet count, and INR).
Mechanical Thrombectomy can be performed in patients with anterior circulation strokes within 6 hours of symptom onset, provided that they have a good baseline functional status and lack of significant early infarction on initial CT scan. Mechanical Thrombectomy can also be performed in posterior circulation strokes up to 12 hours after onset.
If hyper-acute treatments are not offered, patients should receive aspirin 300 mg orally once daily for two weeks. If hyper-acute treatments are offered (i.e thrombolysis or Thrombectomy), aspirin is usually started 24 hours after the treatment and following a repeat CT Head that excludes any new haemorrhagic stroke.
What Stroke investigations would you do to identify cause of stroke? (post-acute)
In ischaemic stroke: carotid ultrasound (to identify critical carotid artery stenosis), CT/MR angiography (to identify intracranial and extracranial stenosis), and echocardiogram (if a cardio-embolic source is suspected). In young patients further investigation e.g. a vasculitis screen or thrombophilia screen may be necessary.
In haemorrhagic stroke: serum toxicology screen (sympathomimetic drugs e.g. cocaine are a strong risk factor for haemorrhagic stroke).
Further investigations to quantify vascular risk factors include:
- serum glucose (all patients with stroke should be screened for diabetes with a fasting plasma glucose or oral glucose tolerance test)
- serum lipids (to check for raised total cholesterol/LDL cholesterol).
Stroke management (chronic i.e secondary stroke prevention)
Mnemonic HALTSS: + MDT!!!
Hypertension:
No benefit in lowering the blood pressure acutely (as this may impair cerebral perfusion) unless there is malignant hypertension (systolic blood pressure >180 mmHg). Anti-hypertensive therapy should, however, be initiated 2 weeks post-stroke.
Antiplatelet therapy:
Patients should be administered Clopidogrel 75 mg once daily for long-term antiplatelet therapy.
In patients with ischaemic stroke secondary to atrial fibrillation, however, warfarin (target INR 2-3. or a direct oral anticoagulant (such as Rivaroxaban or Apixiban) is initiated 2 weeks post-stroke.
Lipid-lowering therapy:
Patients should be prescribed high dose atorvastatin 20-80 mg once nightly (irrespective of cholesterol level this lowers the risk of repeat stroke).
Tobacco:
Offer smoking cessation support.
Sugar:
Patients should be screened for diabetes and managed appropriately.
Surgery:
Patients with ipsilateral carotid artery stenosis more than 70% should be referred for carotid endarterectomy.
Rehabilitation and supportive management will include an MDT approach with involvement of physiotherapy, occupational therapy, speech and language therapy, and neurorehabiliation.
Risk Factors for Falls
A history of falls is one of the strongest risk factors for a fall - after a first fall, people have a 66% chance of having another fall within a year
Conditions that affects balance, mobility or strength, such as arthritis, diabetes, incontinence, stroke, syncope, or Parkinson’s disease.
Other conditions, including muscle weakness, poor balance, visual impairment, cognitive impairment, depression, and alcohol misuse.
Polypharmacy, or the use of psychoactive drugs (such as benzodiazepines) or drugs that can cause postural hypotension (such as anti-hypertensive drugs).
Environmental hazards, such as loose rugs or mats, poor lighting, uneven surfaces, wet surfaces (especially in the bathroom), loose fittings (such as handrails), and poor footwear.
The more risk factors a person has, the greater their risk of falling.
Falls can also be a sign of underlying health issues, such as frailty
MDT Management of Falls in the Elderly
- Analgesia titration to allow mobility.
- Orthopaedic support, but likely non-surgical (“conservative”) management.
- Delirium risk reduction (Lighting/clock/continuation of staff).
- Medication review - hold ACEi / beta-blocker / alpha blocker with low B.P.
-
Multi-factorial falls assessment, including gait and balance / lying and standing B.P / medication review / Alert technology whilst inpatient, certainly patient activated “call bell” for assistance but with dementia consider automated system such as a falls alert mat / consider “bay tag” observation
with cognitive impairment. - Treat other co-morbidities (for example, constipation,pneumonia)
- Patient education with falls risk.
- Further cardiac monitor (ECG)
- Further falls risk assessment as MDT as part of discharge planning including:
o Medication review when lying and standing B.P are known.
o Gait and balance specialist assessment and balance and strengthening exercise programme and review walking aids.
o Environmental review with interventions.
o Vitamin D supplementation - check levels, fragility fracture / osteoporosis secondary prevention.
o Assistive technology (falls sensor for possible future falls to alert and avoid “long lie”).
Key points to ascertain in a history of falls?
When did you fall?
Did anyone see you fall?
Where did you fall?
What happened before/during/and after?
How many times have you fallen over the last few months?
Bone health - previous fractures / family history of fracture / smoking, alcohol /
calcium intake
Previous Mobility
Which tools can be used to identify non-specific cognitive dysfunction?
And which tool can be used to specifically assess for delirium?
Non-specific
MOCA
MMSE
10/4 AMT
6-CIT
Delirum Specific
4AT
How do you assess capacity?
Assume capacity unless patient gives you reason to doubt
Public Health England Guidance on diagnosis of UTI in people > ___ states: “Do not perform urine dipsticks.
65
Dipsticks become more unreliable with increasing age over 65 years.
Up to half of older adults, and most with a urinary
catheter, will have bacteria present in the bladder / urine without an infection.
This “asymptomatic bacteriuria” is not harmful, and although it causes a positive urine dipstick, antibiotics are not beneficial and may cause harm.”
Contraindications to thrombolysis (alteplase rTPA - recombinant tissue plasminogen activator) in ischaemic stroke
Recent surgery (14 days)
Recent head trauma
Intracranial or GI bleed (< 21 days)
Low Platelets (<100,000/µl )
INR < 1.7
Hypertension (S: >185 or D: >110)
Investigations in falls
Bedside
- Vital signs (BP/HR/RR/SpO2/Temperature - Sepsis/Bradycardia)
- Lying and standing blood pressure (Orthostatic hypotension)
- Urine dipstick (Infection/Rhabdomyolysis (+++ blood))
- ECG (Bradycardia/Arrhythmias)
- Cognitive screening (e.g. AMT - Cognitive impairment)
- Blood glucose (Hypoglycaemia secondary to poor oral intake)
Bloods
- Full blood count (Anaemia/Infection (raised white cells)
- Urea and electrolytes (Dehydration/Electrolyte abnormalities/ Rhabdomyolysis)
- Liver function tests (Chronic alcohol use)
- Bone profile
(Calcium abnormalities in malignancy/Over-supplementation of calcium)
Imaging
- Chest X-ray
(Pneumonia) - CT head
(Chronic or acute subdural/Stroke) - Echo (Valvular heart disease e.g aortic stenosis)
Specialist
- Tilt table test
- Dix-Hallpike test (Benign paroxysmal positional vertigo)
- Cardiac monitoring (e.g. 48hr tape) If no symptoms during monitoring episode in hospital.
HPC falls? (i.e Details to be established)
WHO
Who has seen you fall?
Ensure adequate collateral history including addressing the when, where, what and why.
WHEN
* When did you fall?
* What time of day?
* What were they doing at the time?
Looking upwards (vertebrobasilar insufficiency)
Getting up from bed (postural hypotension)
WHERE
*Where did you fall?
*In the house, or outside?
WHAT
*What happened before/during and after the fall?
Before
- Was there any warning?
- Was there any dizziness/chest pain or palpitations?
During
- Was there any incontinence or tongue biting? (indicating seizure activity)
- Was there any loss of consciousness?
- Was the patient pale/flushed? (may indicate vasovagal attack)
- Did the patient injure themselves?
- What part of the body had the first contact with the floor?
After
*What happened after the fall?
*Was the patient able to get themselves up off the floor?
*How long did it take them?
*Was the patient able to resume normal activities afterwards?
*Was there any confusion after the event? (head injury)
*Was there any weakness or speech difficulty after the event? (e.g. stroke/TIA)
WHY
*Why do you think you fell?
*May have tripped over a rug or started a new medication
HOW
*How many times have you fallen over the last 6 months? Allows you to gauge the severity of the problem
DO A FULL SYSTEMS REVIEW CARDIO/NEURO/RENAL etc
If a patient is >18 yo and lacks capacity it is the doctors duty to make the decision on their behalf, acting in their best interests under the mental capacity act (note not mental health act). The relatives/friends have no right to make the decision unless they have _____.
If a life changing decision needs to be made and the patient has no family/friends to consult about their best interests, an _____ can be requested.
If you are stopping a patient without capacity from doing things (ex. leaving the hospital) you must fill out a _____.
Power of attorney
Independent mental capacity advocate (IMCA)
Deprivation Of Liberty Safeguard form (DOLS)
Supraventricular Tachycardia (SVT) is any ____ complex tachycardia characterised by a heart rate of more than 100 bpm and a QRS width of less than ____ ms on an ECG.
Atrial Fibrillation (AF), AV Re-entry Tachycardia (AVRT) and AV Nodal Re-entry Tachycardia (AVNRT) are examples of SVTs.
Patients with adverse features should be given _____ .
These features can be remembered by the mnemonic HISS, which stands for:
______
narrow
120
Drugs that potentiate the effect of adenosine and thus contraindicate the use of adenosine.
Dipyridamole (antiplatelet)
Carbamazepine
Adenosine cannot be given to ____ and thus ____ is used instead.
Asthmatics
Verapamil
Adenosine is known to regulate myocardial and coronary circulatory functions. Adenosine not only dilates coronary vessels, but attenuates beta-adrenergic receptor-mediated increases in myocardial contractility and depresses both sinoatrial and atrioventricular node activities.
Complications of SVT can include:
Syncope
Deep vein thrombosis
Embolism
Cardiac tamponade
Congestive cardiac failure
Myocardial infarction
Death
Clinical features of serotonin syndrome can be split into neurological and autonomic.
Neurological features:
Autonomic features:
Neurological:
- Altered mental state
- Tremor
- Ataxia
- Hyperreflexia.
Autonomic:
- Tachycardia
- Hypertension
- Diarrhoea
- Hyperthermia
NB - Distinct from *Neuroleptic malignant syndrome *which is caused by anti-psychotics or sudden reduction in dopaminergics (i.e parkinson’s).
Predominant neurological feature of NMS is also** rigidity **
Investigations and Management of pulmonary oedema due to Left Ventricular Failure.
Investigations
Bedside observations
Arterial blood gas
ECG
Troponin if concerned about a new cardiac event
Serum BNP
Chest X-ray
Management - POUR SOD
- Take an ABCDE approach
- Sit the patient up
- Administer oxygen
- Ensure IV access
- IV Furosemide (40mg stat)
- Consider non-invasive ventilation such as CPAP if failed medical therapy (usually in an intensive care setting)
- Consider further therapies in the intensive care setting such as invasive ventilation and inotropic support if the above fails
https://www.nice.org.uk/guidance/cg187/chapter/1-Recommendations
Management of Paracetamol overdose:
If ingestion less than 1 hour ago + dose >150mg/kg: Activated charcoal
If ingestion <4 hours ago: Wait until 4 hours to take a level and treat with N-acetylcysteine based on level using** nomogram**
If ingestion 4-15 hours ago: Take immediate level and treat based on level
If staggered overdose ( which is defined as being an overdose taken over > 1 hour) or ingestion >15 hours ago: Start N-acetylcysteine immediately
Obtain following bloods:
FBC
Urea and Electrolytes
INR
Venous gas
If a patient presents after 16 hours, there is *uncertainty about timing * or has a staggered overdose then NAC should be started regardless of the nomogram.
NAC is associated with anaphylactoid reactions. These are not true anaphylactic reactions and can usually be managed by stopping the infusion temporarily and then restarting at a lower rate.
Consider need for transfer to liver unit if blood tests are worsening
Management Flow chart:
https://emj.bmj.com/content/19/3/202
Emergency management of DKA?
Treating DKA (FIG-PICK)
Follow local protocols carefully.
**F **– Fluids – IV fluid resuscitation with normal saline.
If patient is alert, not significantly dehydrated and able to tolerate oral intake without vomiting –> encourage oral intake and give subcutaneous insulin injection.
If patient is vomiting, confused, or significantly dehydrated –> give IV fluids (initial bolus of 10ml/kg 0.9% NaCl then discuss with a senior) and insulin infusion at 0.1 units/kg/hour 1hr after starting IV fluids.
If there is evidence of shock, the initial bolus should be 20ml/kg.
If patient is shocked or comatose –> ABCDE approach for emergency resuscitation
Do not stop intravenous insulin infusion until 1 hour after subcutaneous insulin has been given.
**I **– Insulin – Add an insulin infusion (e.g. Actrapid at 0.1 Unit/kg/hour)
*G - Glucose – Closely monitor blood glucose and add a dextrose infusion if below a certain level (e.g. 14 mmol/l)
P – Potassium – Closely monitor serum potassium (e.g. 4 hourly) and correct as required
** I ** - Infection – Treat underlying triggers such as infection
** C ** - Chart fluid balance
K - Ketones – Monitor blood ketones (or bicarbonate if ketone monitoring is unavailable)
Establish the patient on their normal subcutaneous insulin regime prior to stopping the insulin and fluid infusion.
Remember as a general rule **potassium should not be infused at a rate of more than 10 mmol per hour.
Aim for:
(1) a reduction in blood ketones of 0.5 mmol/L/hour
if unavailable
(2) a reduction in blood glucose of 3mmol/L/hr or Increase in venous bicarbonate of 3mmol/L/hr
Diabetic ketoacidosis (DKA) is a medical emergency that is characterised by ____ , _____ and _____ .
Specific cut off for these markers that indicates DKA ____.
hyperglycaemia
acidosis
ketonaemia
Specific values to make the diagnosis:
- Ketonaemia: 3mmol/L and over
- Blood glucose over 11mmol/L
- Bicarbonate below 15mmol/L or venous pH less than 7.3
**NB: ** - Hyperglycaemia may not always be present.
Emergency Management of PE:
Massive PE and HD unstable - ______
Acute PE and stable - _____
Recurrent PE or Anticoagulation resistant - _____
Unstable: Thrombolysis - (Streptokinase/Alteplase - seek senior input)
Stable: LMWH or UFH infusion (5 days - and INR >2 on 2 consecutive days) -** bridge with NOAC or Warfarin **
NB
- Provoked PE - 3 months DOAC and check INR.
- Unprovoked PE - 6 months DOAC and check INR
(Side note: remember warfarin takes time to titrate INR but also can be reversed quickly with Vit.K)
Recurrent or treatment resistant: Inferior Vena Cava Filter
NICE visual summary:
https://www.nice.org.uk/guidance/ng158/resources/visual-summary-pdf-11193380893
TCA’s are _ and _ inhibitors.
Signs of a TCA overdose include:
Investigations
Management
Tricyclic antidepressants are noradrenaline and serotonin re-uptake inhibitors, and can be fatal in overdose.
They can cause drowsiness, coma, seizures and cardiac dysrhythmia.
Clinical Features
Signs of a TCA overdose include:
Neurological and cardiovascular!
Drowsiness
Confusion
Arrhythmias
Seizures
Vomiting
Headache
Flushing
Dilated pupils (not pinpoint as in opiate toxicity)
Investigations
Bloods: FBC, UE, CRP, LFTs, Venous Blood gas (look for evidence of acidosis)
**ECG **may show evidence of QT interval prolongation which can precipitate a cardiac arrhythmia.
Management
Overall management is supportive and dictated by the patient’s symptoms (sodium bicarbonate can be used).
Patients should be reviewed by intensive care if any concerns about their airway (particularly in drowsy patients) or severe metabolic acidosis that might require renal replacement therapy.
Activated charcoal can be considered within 2-4 hours of the overdose
What is the best prognostic marker of acute liver failure in acetaminophen overdose?
Prothrombin time (INR)
The King’s College Criteria (of which INR is a component) can be used in patients with acute liver failure due to acetaminophen in order to assess their prognosis and facilitate assessment for consideration of a hepatic transplant.
ECG interpretation method
Details - patient/time/previous ECG’s
Rate - Rhythm strip X 6
Rhythm - count boxes between each QRS wave (use ruler and dots if neccessary)
P wave - Present before every QRS? Yes - sinus NO? - AF etc.
PR interval - <200ms or 5 boxes (each box 40ms or 0.04 secs). NO? - heart block. Primary secondary etc.
QRS wave - < 3 boxes or 120ms/0.12 seconds. NO? - Bundle Branch BLock (BBB). - William Marrow (V1 and V6)
ST segments - Compare with isoelectric line after the complex.
(ST elevation is caused by a lack of blood supply to the muscle. The potassium channels responsible for depolarization are ATP dependent and thus cannot open when there is a lack of blood)
T waves - inverted or flattened more than twice in each segment?
Axis - look at leads 1 and 3
If lead 3 is greater in amplitude than lead 1 - consider axis deviation
If leads arriving - right axis deviation
If leads leaving - left axis deviation
Everything else is normal.
Other stuff - QT/QTc Interval / P wave morphology / Ventricular hypertrophy / Strain (amplitude of QRS - can be nromal in a skinny person)
Hallmark 2 treatments of cocaine induced NTEMI (vasospasm)
Benzodiazepine (diazepam)
Labetalol (beta and alpha blocker)
Antidote to benzodiazepine overdose?
Flumazenil
(a selective GABAA receptor antagonist)
Only given in rare life-threatening circumstances
Acute Pulmonary Oedema Management
ABCDE - treat as appropriate
Remember **POUR SOD MAN **
Pour away IV fluids
Oxygen (high flow)
Diuretic (IV furosemide 40mg)
Morphine (venous system dilatory effect and reduces preload)
Anti-emetic (Metaclopramide 10mg IV)
Nitrates in severe pulmonary oedema (IV if systolic bp >110 2 sprays if systolic BP > 90)
Step up therapy if this is refractory:
Treat any other underlying cause (arrythmia/MIValvular dysfunction etc)
CPAP
Inotropes and Intra-aortic balloon therapy (ICU)
Long Term Heart failure Treatments (Pharmacological and non -phramacological)
Treat underlying cause if appropriate
Pharmacological therapy:
ABAL
ACEi/ARB
Beta-blocker
Diuretic if fluid overloaded
If this fails to control symptoms:
Aldosterone antagonist or Ivabradine
Non-Pharmacological:
Cardiac resynchronisation therapy if ORS > 0.12s/ 3 squares
ICD if risk of Ventricular arrythmia
*Ivabradine is a heart-rate-lowering agent that acts by selectively and specifically inhibiting the cardiac pacemaker current (If), a mixed sodium-potassium inward current that controls the spontaneous diastolic depolarization in the sinoatrial (SA) node and hence regulates the heart rate.
This is based on NICE guidelines 2018. See the full guidelines before implementing treatment.
Refer to specialist (NT-proBNP > 2,000 ng/litre warrants urgent referral)
Careful discussion and explanation of the condition
Medical management (see below)
Surgical treatment in severe aortic stenosis or mitral regurgitation
Heart failure specialist nurse input for advice and support
Additional management:
Yearly flu and pneumococcal vaccine
Stop smoking
Optimise treatment of co-morbidities
Exercise at tolerated
Causes of Hyperkalaemia?
3 causes:
- Reduced excretion from kidneys
- Release from cells
- Acidosis
- Reduced excretion from kidneys:
AKI
and
Addison’s
DRUGs that reduce K+ excretion from the kidneys : **KBANK **:
K+ containing laxatives (movicol/fybogel)
Beta Blockers
ACE inhibitors
NSAIDs
Potassium Sparing Diuretics (i.e aldosterone antagonists - spironolactone/eplerenone etc.) but also diuretics in general
Heparin (which inhibits aldosterone release)
and
Ciclosporin
- Cellular Release:
Rhabdomyolysis
Digoxin Toxicity (NB - Can be precipitated by hypokalemaia) - “Reverse tick sign” on ECG
Tumour Lysis Syndrome
Massive Haemolysis
- Acidosis:
DKA or any other metabolic acidosis
Hyperkalaemia is a potentially life threatening electrolyte abnormality.
Treat K+ >___ mmol/L or any hyperkalaemia with ECG changes with the following;
Give 10ml of 10% _____ (or chloride) over 10 mins - this is cardioprotective
Intravenous ____ (10u soluble insulin) in 25g ____ (50mL of 50% or 125ml of 20% glucose) - insulin causes intracellular K+ shift and glucose to required to prevent hypoglycaemia
Nebulised salbutamol - also causes intracellular K+ shift
Treatment with sodium bicarbonate is controversial
Other aspects of management:
Check contributing drugs (e.g. ACE inhibitors, spironolactone)
Once initial measures completed, recheck urea and electrolytes and ECG and glucose
Urinary potassium
Hyperkalaemia is a potentially life threatening electrolyte abnormality.
Treat K+ >6.5mmol/L or any with ECG changes with the following;
Give 10ml of 10% calcium gluconate (or chloride) over 10 mins - this is cardioprotective
Intravenous insulin (10u soluble insulin) in 25g glucose (50mL of 50% or 125ml of 20% glucose) - insulin causes intracellular K+ shift and glucose to required to prevent hypoglycaemia
Nebulised salbutamol - also causes intracellular K+ shift
Treatment with sodium bicarbonate is controversial
Other aspects of management:
Check contributing drugs (e.g. ACE inhibitors, spironolactone)
Once initial measures completed, recheck urea and electrolytes and ECG and glucose
Urinary potassium
Causes of Hyponatraemia?
Remember to classify into:
Hypovolaemic (In the elderly dehydration is a very common cause especially in patients with dementia)
Euvolaemic (SIADH / Hypothyroidism)
Hypervolaemic
and drugs:
Thiazide diuretics > Loop Diuretics > K+ sparing diuretics
Hyponatraemia Management
Tumour lysis syndrome occurs ___ days after chemotherapy whereas neutropenic sepsis is more likely to occur ___ days after chemotherapy.
A few days (around 3)
10 or more days
Tunour lysis syndrome is a condition which typically presents a few days after chemotherapy and is common for haematological malignancies, particularly non-Hodgkin lymphomas. The administration of chemotherapy can cause significant cell death in mitotically active tumours, resulting in the extravasation of intracellular contents such as nucleic acids into the circulation. These are then broken down into uric acid and phosphate. Uric acid can precipitate in renal tubules leading to an acute kidney injury, which may cause the anuria as reported by this patient. Raised phosphate levels sequester free Ca2+ ions in the bloodstream, leading to hypocalcaemia and its characteristic symptoms, such as tetany (cramps) and vomiting.
This man has significant risk factors for tumour lysis syndrome and combined with anuria means that he may have an acute kidney injury. The most appropriate management for this should be fluid resuscitation in the first instance, particularly given his hypotension.
___ can be given in patients suffering from neutropenic sepsis to stumulate bone marrow production of white blood cells.
G-CSF - Granulocyte Colony Stimulating Factor
Febrile Neutropenia can be defined as a temp > ____ and a neutrophil count < ____
38 degrees
0.5 ×109/L
A ____ score is used to determine risk of febrile neutropenia in cance patients.
A score of > ___ is considered low risk
MASCC (Multinational Association for Supportive Care in Cancer)
> 21
*YOU WANT A HIGH SCORE*
https://www.mdcalc.com/calc/3913/mascc-risk-index-febrile-neutropenia
Management of a patient presenting with acute MSSC?
1) Thorough history and examination (including neurological and PR exam) to
identify neurological deficits.
2) Referral for imaging: whole spine MRI scan is the gold standard for suspected
metastatic spinal cord compression.
3) If spinal cord compression is suspected - commence high dose
Dexamethasone 16 mg stat then 8 mg BD until imaging complete.
Follow local policy for urgent investigation and a protein pump inhibitor (e.g.
Omeprazole or Lansoprazole) if needed.
4) If pain is not controlled by step 2 of analgesics, we would escalate to step 3 (strong opioids + non opioids). This means commencing the patient on an opioid preparation (preferably on M/R (modified release) opiate, given he was taking step 2
analgesia) and stopping codeine PRN.
Consider co-prescription of a laxative and / or an antiemetic.
Additional Screen:
- FBC (rule out infection and neutropenia)
- U+E’s and LFT’s before opiate
- Bone Scan
- Myeloma Screen
(Discussion points: timescale for requesting urgent imaging, within a week vs within
24 hours - depending on clinical scenario i.e Bladder/Bowel dysfunction)
List differentials for a RIF mass
Appendix abscess / Mass (omentum envelopes inflammed appendix giving a mass like feeling on palpation)
Hepatomegaly
Crohn’s
Caecal carcinoma
Meckels diverticulum (paeds)
Ileo-ceacal stricture (Yersinia and TB - 2 rare but important differentials to be excluded with CXR)
List the causes of Pancreatitis
I GET SMASHED
Iatrogenic Gall stones Ethanol (alcohol) Trauma Steroids Mumps Autoimmune Scorpion bite Hyperlipidaemia ERCP Drugs (Azothioprine/ Anticonvulsants (ex. sodium valproate) / Antimicrobials (metronidazole) / Diuretics (ex. Thiazides and Furosemide)
List post surgical complications of GI surgery
Infection (Suture site/from laporotomy/UTI/ Hospital acquired pneumonia) DVT/PE Haemorrhage Obstruction Paralytic ileus (bowel goes to sleep) Anastomotic leak
Name the 3 Features of Charcot’s Triad and which condition this indicates.
Fever (usually with rigors)
Jaundice
RUQ pain
Ascending Cholangitis (infection of the biliary tree)
5 risk factors for acute cholecystitis
5F's Female Forty Fat Fertile Family History
Pregnancy / oral contraceptives (oestrogen causes more bile to be secreted into bile duct) / any condition that causes haemolysis (sickle cell disease etc) / Malabsorption (ileal resection / crohns)
What is the normal diameters of the Small bowel / Large bowel / Appendix / Caecum ?
3-6-9 rule
Small bowel <3cm
Large bowel <6cm
Appendix <6mm
Caecum <9cm
What is Murphy’s sign?
Apply pressure to RUQ and ask patient to inhale. Cessation of inspiratory effort due to pain in RUQ is indicative of Gall bladder Inflammation (i.e cholecystitis and not biliary colic).
Name 6 complications of gall stones
Acute Pancreatitis
Gall bladder mucocoele (mucous filled overdistended gall bladder - can become infected and lead to empyema)
Porcelain gall bladder (calcified gall bladder wall)
Small bowel obstruction (lodge at ileo-coecal valve)
Ascending cholangitis (infection of biliary tree)
List the Glasgow-Imrie score criteria that determines the severity of Pancreatitis?
Remember Mnemonic PANCREAS (1 point for each)
PaO2 (<60 mmHg / < 8kPa ) Age (> **55** y/o) Neutrophilia (>15) Calcium (<2) uRea (>16) Enzymes (LDH > 600 AST/ALT > 200) Albumin (<32) Sugar (glucose >10)
If 3 or greater - Severe pancreatitis is likely
https://www.mdcalc.com/calc/3287/glasgow-imrie-criteria-severity-acute-pancreatitis
State Courvoisier’s Law:
Painless jaundice and palpable RUQ mass is indicative that pathology is not caused by gall stones and thus an obstructing pancreatic or biliary neoplasm until proven other wise. Could also be a gall bladder stricture.
Name the most common infective organisms in ascending cholangitis
E.Coli (27%) / Klebsiella (16%) / Enterococcus (15%)
List the Features of Reynad’s Pentad and the pathology this pentad is associated with.
RUQ pain Fever Jaundice Hypotension Confusion
Cholangitis (patients may also present with tachycardia)
List the causes of cholangitis.
Usually due to obstruction of the biliary tree
Gall stones
ERCP
Cholangiocarcinoma
More rarely
Primary sclerosing cholangitis
Ischaemic cholangiopathy (damage/stricturing of biliary tree due to lack of blood flow).
Parasitic infection
What is the initial steps of management in cholangitis
IV Fluids
Broad spec Antibiotics (do not delay and wait for culture results as these patients can become septic very quickly)
Analgesia
Other investigaitons
LFTs
Bloods (FBC)
Culture
Imaging:
Ultrasound for stones and duct dilatation
MRCP if dilatation but no stone identified on ultrasound
ERCP for biliary decompression sphincterotomy/stenting if stone identified.
Patient may need laparoscopic cholecystectomy in the long term.
If patient too unwell for ERCP then a percutaneous transhepatic cholangiography (PTC) can be performed.
Give the ages and associated symptoms that need urgent investigation for bowel cancer.
Refer 2 ww
> 40 - Unexplained weight loss and abdominal pain
50 - Unexplained rectal bleeding (haematochezia)
60 - Iron deficient anaemia or change in bowel habit
Or Positive FIT test
Causes of Pseudo-Obstruction
Surgery (orthopaedic)
Severe illness (cardiac ischaemia)
Trauma
Electrolyte imbalance (Hypercalcaemia/Hypomagnesaemia/Hypothyroidism/Hypokalaemia)
Neurological (Parkinsons/MS/Hirschsprung’s disease)
Medications (Opiates/Calcium channel blockers/Anti-depressants)
Identify the management steps of pseudo-obstruction.
Conservative (i.e Nil by mouth/ IV fluids/ NG tube if vomiting)
If this fails to resolve within 48hrs
Endoscopic decompression with flatus tube
Failing this
IV Neostigmine (anticholinesterase) - should be avoided if possible due to complications.
Surgery required if all this fails or evidence of perforation
Pre-op assessment Includes _______
****PMH **(including anesthesia history - previus rxns or FH/ Sickle Cell disease)
ASA grade
**Consent **
**Fasting **
Bloods (FBC/U+Es/LFTs/HbA1C/ABG/Clotting/Group + save/Crossmatch)
Investigations (ECG/Echo/Lung function tests (if resp disease)
MRSA Screening
**Medication changes - **
Stop:
Anticoagulants** - Bleeding
** COCP or HRT - VTE risk
* Corticosteroids - adrenal suppression
Diabetes* **- Sulfonylureas (gliclazide - hypoglycaemia)/ Metformin (metabolic acidosis) /SGLT2 (DKA)
**
VTE prophylaxis **
Medications that need to be stopped prior to surgery
Anticoagulants
COCP/HRT (4 weeks beforehand)
Steroids (adrenal suppression)
Diabetes (sulfonylureas/SGLT2 inhibitors/Metformin)
Which antiemetics should be avoided in a bowel obstruction secondary to a mechanical obstruction, as they stimulate peristalsis?
What would the most appropriate choice of antiemetic be?
Prokinetic antiemetics such as metoclopramide should be avoided in a bowel obstruction secondary to a mechanical obstruction, as they stimulate peristalsis.
**Cyclizine **would be an appropriate choice of antiemetic.
Remember
*Adhesional obstruction tends to be managed _____ (drip and suck) for a period of time (up to ____ hours).
*Obstruction **without ** previous surgery usually requires operative intervention.
A _____ study can be an aid to decision making after 48 hours of conservative management.
Contrast reaching the colon predicts resolution without surgery. The hypertonic contrast medium itself can be therapeutic.
Conservatively
72 hrs
gastrografin contrast
file:///Users/cianohalloran/Downloads/Emergency%20General%20Surgery%20%20Commissioning%20Guide.pdf
What are the diameters of bowel obstruction?
3-6-6-9 rule !
Principles of Pre-Operative Care?
Pre-op assessment
Consent
Bloods (including group+save/Crossmatch)
Fasting
Medication Changes
VTE risk assessment
Surgery school (expectations in recovery/associated risks and side effects)
History in Pre-op clinic
Pre-op history -
PMH
PSH
Medications
Allergies
Adverse response to anaesthesia or FH of response to anaesthesia
Smoking
Alcohol
Pregnancy / Sickle Cell FH /
Cardio and Resp exam
ASA grade according to the patients health
ASA Grades
The American Society of Anesthesiologists (ASA) grading system classifies the physical status of the patient for anaesthesia. Patients are given a grade to describe their current fitness prior to undergoing anaesthesia/surgery:
ASA I – normal healthy patient
ASA II – mild systemic disease
ASA III – severe systemic disease
ASA IV – severe systemic disease that constantly threatens life
ASA V – “moribund” and expected to die without the operation
ASA VI – declared brain-dead and undergoing an organ donation operation
E – this is used for emergency operations
Investigations prior to surgery
Bloods:
- FBC/U+E’s/LFTs/Clotting or INR
- Group and Save / Crossmatch
- HbA1C
- ABG
Imaging:
- ECG
- ECHO
- Lung function tests (ex.spriometry etc)
MRSA screening
Fasting before an operation typically involves ____ hrs of no food or feeds before and operation.
____ hrs of no fluids
6 hrs no food
2hrs no fluids
Medications changes before surgery
Anticoagulants (warfarin can be continued due to rapid reversal with vit.k / DOACs stopped 24-72 hrs before surgery)
Diabetic medications
- Sulfonylureas (glicazide - hypoglycaemia)
- Metformin (lactic acidosis)
- SGLT2 inhibitors (dapaglifozin - DKA)
start **variable rate insulin infusion ** plus **sliding scale ** of glucose / sodium/ potassium for optimal control of electrolytes
Steroids - can cause adrenal suppression
COCP/HRT (stopped 4 weeks previously if oestrogen containing due to increased risk of VTE)
VTE prophylaxis at Pre-op
Every patient admitted to hospital should be assessed for their risk of venous thromboembolism (VTE). Surgery, particularly where the patient is likely to be immobilised (e.g., orthopaedic surgery), significantly increases the risk of venous thromboembolism. There are local and national policies on reducing the risk that involve:
Low molecular weight heparin (LMWH) such as enoxaparin
DOACs (e.g., apixaban or rivaroxaban) may be used as an alternative to LMWH
Intermittent pneumatic compression (inflating cuffs around the legs)
Anti-embolic compression stockings
Principles of Capacity
Understand Info
Retain it
Weigh up the pros and cons
Communicate their decision
Post Operative / Enhanced Recovery
Enhanced recovery aims to get patients back to their pre-operative condition as quickly as possible, by encouraging independence, early mobility and appropriate diet.
There are increased nutritional requirements after the physiological stress of surgery, so sufficient calories are very important.
The aim is to discharge as soon as possible. This leads to better outcomes for the patient.
The principles of enhanced recovery are:
***Good preparation for surgery *(e.g., healthy diet and exercise)
**Minimally invasive surgery **(keyhole or local anaesthetic where possible)
Adequate analgesia
**Good nutritional support ** around surgery
Early return to oral diet and fluid intake
Early mobilisation
**Avoiding drains and NG tubes where possible, early catheter removal
**
Early discharge
Examination and Investigations and management in suspected neutropenic sepsis?
Examination:
DRABCDE
Systems-based examinations
ENT
Fundoscopy
DO NOT perform DRE until antibiotics given)
Investigations:
Blood tests from complete
- 2 sets of blood cultures
- FBC blood cell count, WCC, inflammatory markers
- U+E’s
- LFTs
- Clotting screen — if abnormal may indicate coagulopathy/DIC.
Imaging
* CXR
* Serology and PCR for viruses e.g. CMV
* Sputum, urine, stool samples, CT scans etc. where clinically indicated.
* Swabs from any indwelling lines
Patients at high risk:
- Have sustained, significant neutropenia that is expected to last more than 7 days.
- Are clinically unstable
- Have an underlying malignancy and are being treated with high-intensity chemo
- Have significant co-morbidities
Management of Neutropenic Sepsis
Management
DRABCDE approach
And then sepsis 6! - BUFALO and blood gas
- Give oxygen therapy to people with reduced oxygen saturation or with an increase in oxygen requirement over baseline, to maintain oxygen saturation above 94% unless contraindicated.
*Take blood tests and microbiology samples including: - Blood gas including glucose and lactate measurement — hypoglycaemia may result from depleted glycogen stores; hyperglycaemia may result from the stress response to sepsis; hyperlactataemia is a non-specific indicator of cellular or metabolic stress and is a marker of illness severity, with a higher level predictive of higher mortality rates.
- Blood culture — ideally done before antibiotic administration.
- Full blood count — white cell count may be high or low; thrombocytopenia may indicate disseminated intravascular coagulation (DIC), but may also be chemotherapy- or tumour-related.
- C-reactive protein (CRP) — may indicate infection and/or inflammation.
- Creatinine, urea and electrolytes — may indicate dehydration and/or acute kidney injury.
- Liver function tests — increased bilirubin or alanine aminotransferase (ALT) levels may indicate cholestasis or other liver dysfunction, and may be chemotherapy-induced.
- Clotting screen — if abnormal may indicate coagulopathy/DIC.
- Urine analysis and culture, sputum microscopy and culture, chest X-ray, and additional investigations such as chest CT or bronchoalveolar lavage may be indicated if there is severe or prolonged neutropenia. This may allow identification of the source of infection, pathogen(s) and sensitivities, and subsequent tailoring and/or de-escalation of antibiotic therapy if appropriate. Source control to eliminate a focus of infection may be possible, such as abscess drainage, debridement of infected tissue, removal of infected devices or foreign bodies, or surgery.
- Give an intravenous broad-spectrum antibiotic at the maximum recommended dose. - The choice of antibiotic will depend on the person’s age, clinical presentation, most likely source of infection, recent antibiotic use, and local antibiotic prescribing guidelines.
Antibiotic treatment should not be delayed until neutropenia is confirmed.
Anti-pseudomonal cover is important for people with suspected neutropenic sepsis, so a first-line choice may be monotherapy with piperacillin/tazobactam, depending on local protocols. Prolonged antibiotic therapy may be needed. - Prolonged fever or failure to improve clinically may suggest fungal or atypical infection requiring additional specialist assessment and treatment.
- Give an intravenous fluid bolus to restore tissue perfusion.
- Check serial lactate measurement.
- Check urine output, monitor fluid balance hourly and monitor the person’s clinical condition. This may include **risk stratification using a clinical prediction rule such as the Multinational Association of Supportive Care in Cancer (MASCC) **prognostic index to identify people at low risk of complications.
If low risk can give oral antibiotics (quinolone + co-amoxiclav)
Features suggesting low risk:
* Hemodynamically stable
* Doesn’t have acute leukaemia
* No organ failure
* No soft tissue infection
* No indwelling lines
- For most patients, they need empirical IV treatment with piperacillin and tazobactam (tazocin - pseudomonas cover), with added coverage for MRSA or gram-negatives if thought at risk.
- A macrolide should also be added if diagnosed with pneumonia (to cover atypical organisms)
Daily measures of fever and baseline bloods until the patient is apyrexial and neutrophil count above 0.5x10^9^
When the neutrophil count is normal, has been afebrile for 48 hours and blood tests have normalized, antibiotics can be stopped.
- Prophylaxis with a **fluoroquinolone **can be offered
Specific Things to garner in HX of suspected neutropenic sepsis ?
History:
- Type and timing of chemo regimen and any other immunosuppressive medication being taken.
- Localizing symptoms e.g right lower-quadrant pain associated with neutropenic enterocolitis
- Recent infections and antibiotics used
- Latent infections are known to reactivate (e.g. TB), sick contacts, blood transfusions
- Co-morbidities
- Any intravascular device
What does the mnemonic ‘SNOOP’ stand for when assessing red flags for headaches?
The mnemonic “SNOOP”, without the “D-O-double G”, summarizes some of the red flags.
“S” is for systemic symptoms like fever or weight loss.
“N” is for neurological symptoms, like weakness, sensory deficits, or vision loss.
The first “O” is for a new or sudden onset headache.
The second “O” is for other associated conditions, like trauma.
The “P” stands for progression or pattern, such as a headache that is worsening in severity or frequency.
**Remember COCP can also cause headache**
The mnemonic VIVID can be used to remember the sinister causes of headache. What does it stand for?
Vascular - Extradural or Subdural Hematoma/ Subarachnoid/ Cerebral venous sinus thrombosis/ cerebellar infarct.
Infection - Encephalitis/Meningitis
Vision threatening - Giant cell arteritis/ Glaucoma/ Cavernous sinus thrombosis/ Pituitary apoplexy (tumour outgrows blood supply and bleeds)
Intracranial pressure: SOLs: Neoplasm/ Brain abscess/ Cyst/ Cerebral oedema (trauma/altitude), hydrocephalus, malignant hypertension/ IIH/ Viagra or GTN
Dissection - Aortic/ Carotid/ Vertebral
What is the abortive and prophylactic treatment of migraine?
Abortive
Mild :
- NSAIDs/Acetaminophen
Moderate/Severe:
- Triptans (Serotonin/5-HT agonist. ex Sumatriptan)
- Metaclopramide/Prochlorperazine (Dopamine antagonists) - for nausea and vomiting
- Aspirin
Prophylactic: (only useful if migraines are very frequent such as 2 weeks, and only effective 50% of the time)
1st line:
- Beta Blocker/ Candesartan (good side effect profile)/ Amitryptilline
2nd line:
- Anti-epileptics (ex. topiramate - teratogenic can cause cleft lip and palate and valproate) - not to be used in female of child bearing age.
Acupuncture Vitamin B2 (Riboflavin) supplementation
What is the prophylactic and abortive treatment of cluster headaches?
Abortive:
Oxygen (at least 12L/min) and/or Triptans (Ex sumatriptan 6mg subcutaneously or intranasally)
Prophylactic:
1st line: Verapamil (Ca Channel Blocker)
2nd line: Lithium
Prednisolone
What is the recommended treatment for someone with a tension headache?
Acetaminophen/NSAIDs
List a number of migraine triggers
Stress
Bright lights
Strong smells
Foods (ex. Chocolate/cheese/caffeine)
Abnormal sleep patterns
Menstruation (NSAIDS - mefanamic acid and triptans most suitable therapy)
Dehydration
Trauma
Physical overexertion
Biochemical Markers in treatment of DKA to aim for
Aim for:
(1) a reduction in blood ketones of 0.5 mmol/L/hour
if unavailable
(2) a reduction in blood glucose of 3mmol/L/hr or Increase in venous bicarbonate of 3mmol/L/hr
Components of the PESI Score? (Pulmonary Embolism Severity Index)
Age
Sex (males higher mortality)
Cancer
Heart Failure
Chronic Lung Disease
Hypotension (<100 systolic)
Tachycardia
Raised RR
Temperature (<36)
Sats <90
Altered Mental state
https://www.mdcalc.com/calc/1304/pulmonary-embolism-severity-index-pesi
Causes of central abdominal pain
- Bowel obstruction
- early appendicitis
- acute gastritis
- acute pancreatitis
- ruptured abdominal aortic aneurysm.
Less common but extremely important causes include ** ischaemic bowel disease.**
It is important to consider non-gastrointestinal causes such as:
- Pneumonia
- Acute coronary syndrome
- Diabetic ketoacidosis.
Causes of Large Bowel Obstruction
- Colonic tumour
- Strictures – secondary to diverticular disease, or other conditions such as inflammatory bowel disease or post-surgical anastomosis
- Volvulus – sigmoid or caecal
- Hernias
- Adhesions
(In order of most common^)
Investigations in Large Bowel Obstruction?
Initial Investigations
In a patient presenting with potential intestinal obstruction, peritonitis is a worrying sign and the consideration to transfer to theatre must be considered.
Some basic investigations that should be done include:
Bloods:
*FBC (Looking for leukocytosis or anaemia)
*U+Es (Organ dysfunction or signs of hypovolaemia)
*Lactate (An important examination to establish if there is bowel ischaemia or necrosis) It can be falsely low – the liver can break down lactate quickly so may not increase until late in the presentation
*Amylase (Always important in all cases of acute abdomen)
*Group and Save
* VBG (can be useful to evaluate for end-organ and for the immediate assessment of any metabolic derangement secondary to dehydration or excessive vomiting - metabolic acidosis)
Imaging:
*Abdominal and chest X-ray
*Assess in upright position to look for pneumoperitoneum
*Absence of air in the rectum can indicate complete obstruction
* Abdominal X ray – helps to establish diagnosis of large bowel obstruction
- CT Abdomen with contrast can be useful to establish cause (e.g. malignancy), as well as provide other useful information such as transition point and distinguishing between caecal and sigmoid volvulus.
Further Investigations once patients are stabilised - If no peritonitis is present and the patient is stable, the following investigations may further help:
- CT abdomen and pelvis with contrast: best diagnostic test
-Establishes underlying cause
-Establishes site of obstruction
-Establishes partial vs. complete obstruction - Small bowel contrast study using gastrograffin
- Can be used as a therapeutic measurement in partial SBO, as presence of contrast in rectum 24 hours after ingestion of substance establishes resolving partial SBO – hence reducing need for surgery
- MRI abdomen (No better than CT scan but can be useful in young patients to avoid doses of ionising radiation)
- US abdomen
Not as good as CT but can be used in children to avoid ionising radiation exposure - Diagnostic laparotomy/laparoscopy
Used to distinguish between partial and complete obstruction if no clear evidence on imaging
Management of Large Bowel Obstruction?
Management
- Supportive care – analgesia, IV fluids, anti-emetics
- Decompression of sigmoid volvulus – using flexible sigmoidoscope
- The majority of patients (70%) with large bowel obstruction require surgical intervention – laparoscopic or open colonic resection. This can involve a primary anastomosis or stoma formation.
- Palliative care – a proportion of patients who present with malignant large bowel obstruction are not candidates for surgery. Palliative stenting of the obstruction can be performed to help relieve symptoms.
Causes of small bowel obstruction:
Causes of small bowel obstruction
Factors outside of the bowel:
- Adhesions
Most common cause in the Western World
Previous intra-abdominal operations are the main risk factor for development of adhesions. The larger the operation, the more likely the development of adhesions - Intra-abdominal hernia
- Incarcerated hernias cause acute obstruction
Factors relating to the bowel wall:
*Crohn’s disease
*Appendicitis
Factors relating to inside the bowel:
*Malignancy
*Foreign body ingestion
*Gallstone ileus
Diseases causing small bowel obstruction in children include:
*Intussusception
*Volvulus
*Intestinal atresia
*Appendicitis
Clinical Presentation of bowel obstruction:
Small bowel obstruction most commonly presents with the following features:
- Abdominal pain with distension (Initially colicky pain that becomes continuous)
- Bloating and vomiting (often bilious)
- Failure to pass flatus or stool
- History of abdominal/gynaecological surgery or hernia
*Tympanic, high-pitched bowel sounds on examination
*Empty rectum on examination in complete bowel obstruction
*They may have a fever and can be significantly fluid-depleted. Peritonitis indicates severe bowel obstruction, with complications developing. This requires urgent surgical intervention.
Simple or partial SBO will generally continue to pass some flatus/stool with a mild temperature.
If untreated, SBO can lead to ischaemic or necrotic bowel as well as perforation.
Management of small bowel obstruction:
Management of small bowel obstruction
- Initially, manage according to resuscitation protocols (ABCDE)
- Correction of fluid and electrolytes reduce operative risk before surgery for obstruction
- Fluid resuscitation and NG tube to aspirate content for decompression (‘Drip and suck’) - 80% effective in adhesion caused SBO
- Surgery if conservative measures fail. The exact surgery depends on the cause but might include:
- Adhesionolysis
- Bowel resection
- Closure of hernias
- Tumour resection
The differential diagnoses for a patient presenting with suspected bowel obstruction
The differential diagnoses for a patient presenting with suspected bowel obstruction include
- pseudo-obstruction
- paralytic ileus
- toxic megacolon
- constipation
Pseudo-obstruction vs Ileus:
Pseudo-obstruction is clearly limited to the colon alone, whereas ileus involves both the small bowel and colon.
Initial Seizure Investigations/management
ABCDE approach
Recovery position
Jaw thrust
Nasopharyngeal airway (trismus aka jaw clenching prevents OPA)
Oxygen 15L NRM
IV Access
NEWS2 Score
Blood glucose
FBC including calcium and clotting and antiepileptic drug levels
ECG
MRI/CT (focal lesions or bleed)
EEG
Lumbar if Meningitis/encephalitis
Pharmacological:
IV Lorazepam 4mg or PR Diazepam 10mg
10 mins
Repeat
10 mins
IV phenytoin 18mg/kg (maz 2g at 50mg/min and cardiac monitoring)
30 mins
General anasthesia ICU
also consider IV pabrinex and IV glucose
List the main causes of epilepsy.
Remember *VITAMINS*
Vascular (Ischaemic/Haemorrhagic Stroke)
Infection (Meningitis/Encephalitis/Brain Abscess)
Trauma / Toxins (Amphetamine overdose/Alcohol withdrawal/ Isoniazid (TB drug)
Autoimmune (CNS vasculitis or SLE)
Metabolic (Hyponatraemia/Hypocalcaemia/Hypo or Hyper glycaemia/ Hyperthyroidism/ Uraemic Hepatic and Wernickes Encephalopathy)
Idiopathic (epilepsy)
Neoplasm
Syncope
