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Year 5/6 > Yr6 PACES > Flashcards

Yr6 PACES Flashcards

1
Q

What are important points of any cardio px you have to say?

A

On general insp: well + not tachypnoeic

O/e of hands: nad, pulse, BP

O/e of H+N: no pallor, carotid artery character, JVP

On insp of chest: no scars

On palpation: apex beat not displaced + no heave or thrills

On auscultation: HS 1+2 audible w no added sounds

Lung bases, peripheral oedema, obs chart

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2
Q

JVP

A

Check all the way up to the ear lobes, biphasic, impalpable

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3
Q

Systolic Murmurs

A

Aortic Stenosis
Mitral Regurg
Tricuspid Regurg

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4
Q

Aortic Stenosis

A

Loudest in the aortic area

Radiates to the neck

A/w narrow pulse pressure, slow rising carotid pulse, thrill in the aortic area

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5
Q

Mitral Regurg

A

Quiet S1, pansystolic murmur loudest in the apex best heard on inspiration, S3

Radiates to the axilla

A/w displaced apex beat and apical thrill

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6
Q

What does mitral valve prolapse sound like?

A

MR but w a mid-systolic click

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7
Q

Tricuspid Regurg

A

Loudest in the tricuspid area

Best heard on INSpiration

A/w elevated JVP, left parasternal heave, palpable liver

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8
Q

Diastolic Murmurs

A

Aortic Regurg
Mitral Stenosis
Tricuspid Stenosis

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9
Q

Aortic Regurg

A

Early diastolic murmur loudest at the left lower sternal edge when sitting forward

Best heard held in EXpiration

A/w eponymous signs, collapsing pulse, dynamic apex

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10
Q

Mitral Stenosis

A

Loud S1 and audible S2 followed by an opening snap and MDM

A/w AF, malar flush, tapping non-displaced apex beat, left parasternal heave

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11
Q

What causes a loud S2?

A

HTN + Pulm HTN (will also have a left parasternal heave)

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12
Q

What is a left parasternal heave a sign of?

A

Right ventricular hypertrophy

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13
Q

What are S3 and S4 due to?

A

S3: rapid ventricular filling

S4: atrial contraction against stiff ventricles

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14
Q

What are the stages of clubbing?

A

1: inc fluctuancy of bed
2: loss of angle b/w nail and bed
3: inc curvature of nail
4: expansion of terminal phalanx

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15
Q

Wheeze Ddx

A

Asthma COPD Pulm Oedema Anaphylaxis Malignancy

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16
Q

Fine Crepitations Ddx

A

Fibrosis + HF

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17
Q

Coarse Crepitations Ddx

A

Bronchiectasis + Pneumonia NB: may change w cough and should ask to sample sputum

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18
Q

Proximal Myopathy Ddx

A

Polymyositis, Dermatomyositis, Cushing’s Disease Plus working through surg seize: MG/LEMS, HIV, hereditary, sarcoidosis, paraneoplastic, drugs eg statins

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19
Q

Peripheral Neuropathy Ddx

A

Diabetes, Alcohol, B12 Deficiency Plus working through surg seize: GBS/CIDP, HIV, hereditary, sarcoidosis, paraneoplastic, drugs eg metronidazole

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20
Q

What are the headlines for treating acute asthma/copd?

A

Oxygen, Bronchodilators, Steroids

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21
Q

What are the headlines for treating PE?

A

Oxygen, Anticoagulation, Analgesia

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22
Q

What reflexes do you want to offer as part of the CN exam?

A

Jaw Corneal Gag

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23
Q

Pneumothorax O/E

A

Trachea - deviated away Expansion - reduced Fremitus - decreased Percussion - resonant Auscultation - absent Added - occasional click

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24
Q

Pleural Effusion O/E

A

Trachea - deviated away Expansion - reduced Fremitus - decreased Percussion - stoney dull Auscultation - absent Added - occasional rub

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25
Q

Pneumonia O/E

A

Trachea - central Expansion - reduced Fremitus - increased Percussion - dull Auscultation - bronchial Added - crackles

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26
Q

Collapse/Lobectomy/Pneumonectomy O/E

A

Trachea - towards Expansion - reduced Fremitus - decreased Percussion - dull Auscultation - absent Added - none

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27
Q

Rheumatoid ILD vs Bronchiectasis

A

O/e: if there’s a sputum pot nearby + quality of crackles Ix: PFTs inc spirometry, lung volumes, gas transfer (restrictive vs obstructive) + HRCT (honeycombing and ground glass vs dilatation and mucus plugging)

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28
Q

Bronchiectasis Px

A

Clubbed Bilateral coarse insp crackles which alter but do not fully clear w coughing Findings consistent w bronchiectasis Ddx: pneumonia + ILD

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29
Q

Asthma Px

A

Salbutamol Inhaler Resonant and symmetrical percussion w equal air entry and no added sounds Findings consistent w controlled asthma Ddx: physiological normal chest + COPD Ascertain if any prev ITU admissions or night sx

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30
Q

ILD Px

A

Sup O2 at 2L/min via nasal cannula w RR of 20 Features of rheumatoid hands w/o clubbing, characteristic find end insp crackles, peripheral oedema Findings consistent w pulmonary fibrosis perhaps 2° to RA w pulm HTN leading to RHF requiring LTOT

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31
Q

COPD Px

A

Prolonged exp phase and pursed lip breathing Signs of hyperinflation specifically red cricosternal distance, loss of cardiac dullness and displaced liver edge No features of pulm htn or cushings Findings consistent w COPD

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32
Q

Ddx for Collapsing Pulse (3)

A

AR Normal psychological state eg pyrexic or pregnant High output state eg anaemia or thyrotoxicosis

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33
Q

What are the signs of hyperinflation? (3)

A

Red cricosternal distance, loss of cardiac dullness, displaced liver edge

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34
Q

What are the signs of portal HTN? (4)

A

SAVE Splenomegaly Ascites Varices Enlarged Abdo Veins

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35
Q

What are the signs of CLD? (4)

A

PDGS Palmar Erythema Dupuytren’s Contracture Gynaecomastia Spider Naevi

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36
Q

Workup for Acute Abdomen

A

NBM Fluids Analgesia Antiemetics Antibiotics Bleeding Risk Allergies Airway Difficulty Refer to Surgeons Monitor Vitals

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37
Q

What should you say if you don’t know the abx?

A

Consult local guidelines and microbiology for a suitable course of action

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38
Q

Where is the best place to look for jaundice?

A

Sclera + under the tongue

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39
Q

How do you elicit Quincke’s sign?

A

Ask the pt to push their finger into the table and observe for the border b/w red and pale move to pulse

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40
Q

Mx of OA

A

Confirm dx w hx, exam, ix Take an MDT approach w PT, OT, podiatrist Consrv: manage RFs ie optimise weight, diet, low impact exercise, ensure other medical conditions are well controlled + applying warm/ice packs Med: analgesia up WHO pain ladder + intra-articular steroid injections Surg: referral to ortho for osteotomy, arthrodesis and more likely arthroplasty

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41
Q

Mx of Open Fracture

A

ATLS NV Status Photograph Soaked Gauze Abx + Tetanus Restrict Xrays Theatre Rehab

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42
Q

Mx of NOF#

A

Upon admission MMSE, seen by orthogeris, operate within 36hrs Intracapsular: 1,2,Screw + 3,4,Austin-Moore Extracapsular: inter DHS + sub nail Mobilise early w physio and minimise risk of future falls and osteoporosis

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43
Q

Mx of Bronchiectasis

A

Ix: Obstrc Spirometry, Sputum Cultures, HRCT, Immunoglobulins, Sweat Test, Aspergillus Markers Tx: MDT, Smoking Cessation, Pulm Rehabilitation Plus: physio, abx, correct underlying cause

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44
Q

Mx of ILD

A

Ix: Drug Hx, Complement, Autoantibodies, Precipitins, CXR, HRCT, PFTs, BAL, Echo Tx: MDT, Smoking Cessation, Pulm Rehabilitation Plus: ambulatory O2, LTOT, antifibrotics for IPF, immunosuppressives for CTD/sarcoid related, transplant workup

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45
Q

Mx of HF

A

Acute: 1. Sit Up & Call Help 2. Diamorphine 1.25mg 3. Furosemide 40mg 4. GTN Spray x2 SL Chronic: 1. CAGES, Dec RFs, Vaccines 2. ACEi/ARB/Hydralazine + BB 3. Add MRA 4. Specialist

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46
Q

Mx of Pneumonia

A

Calculate CURB-65: confusion, urea >7, RR >30, SBP <90, Age >65 If 0-1: home - PO amoxicillin 500mg/8h If >=2: hosp - PO amoxicillin 500mg/8h AND clarithromycin 500mg/12h If >=3: ICU - IV augmentin 1.2g/8h AND clarithromycin 500mg/12h F/U @ 6wks

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47
Q

AF

A

Ix: Hx (ETOH/Caffeine), Obs (Pulse/HTN), Bloods (TFTs/BNP/D-dimer), ECG, Echo (IHD/RHD) Unstable Tx: DCCV +/- Amiodarone Stable Tx: Rate (BB/CCB +/- Digoxin), Rhythm (DCCV or Flecainide/Amiodarone), Anticoag (CHA2DS2-VASc vs HAS-BLED)

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48
Q

STEMI

A

Atypical px in elderly + women Anteroseptal - LAD: V1-4 Lateral - LCX: V5-6, I, aVL Inferior - RCA: II, III, aVF Tx: MONAT + PCI/Thrombolysis Comps: FAM ie Failure, Arrhythmias, Murmurs

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49
Q

What are the signs of decompensation? (4)

A

JBAE Jaundice Bruising Asterixis Encephalopathy

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50
Q

What causes massive splenomegaly? (4)

A

MF CML Malaria Leishmaniasis

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51
Q

Ddx for RIF Pain

A

GI: appendicitis, mesenteric adenitis, terminal ileitis GY: ectopic, tubo-ovarian, endometriosis GU: stone, UTI, cystitis

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52
Q

Hepatomegaly Causes

A

Hepatic: hepatitis, cirrhosis, budd-chiari, NAFLD, hereditary haemochromatosis Cardiac: cor pulmonale, right valvular disease, right heart failure Other: infection, malignancy, myeloproliferative

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53
Q

Splenomegaly Causes

A

Vascular: haemolysis, leukaemia, lymphoma, CML, MF, portal HTN Infective: malaria, leishmaniasis, hydatid disease, EBV, CMV, HIV, TB, IE, chlamydia psittaci Inflam: sarcoid, amyloid, pancreatitis, RA, SLE, sjogrens

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54
Q

What are the causes of HF?

A

LHF: HTN, IHD, L Side Valves RHF: LHF, Cor Pulmonale, R Side Valves

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55
Q

How do you px normal auscultation of the lungs?

A

There was equal air entry and symmetrical vesicular breathing in all zones bilaterally

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56
Q

What are you looking for in the hands?

A

Gen: clubbing, tar staining, colour/temp Cardio: evidence of IE + CRT Resp: evidence of steroid use + RA GI: evidence of CLD + koilonychia/leukonychia

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57
Q

Why do you look at the armpits in the abdo exam?

A

Acanthosis Nigricans - benign, T2DM, stomach malignancy Hair Loss - shaven, IDA, malnutrition

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58
Q

Stridor Ddx

A

Quinsy Epiglottitis Foreign Body Anaphylaxis Malignancy

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59
Q

How should you describe any ABG?

A

Met/Resp Acid/Alk AND T1RF/T2RF

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60
Q

How should you categorise your ix?

A

Bedside

Bloods

Imaging

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61
Q

How would you counsel someone w chest pain to go to the hospital?

A

The pain is sometimes a sign of the body telling us the heart isn’t getting enough blood

I wouldn’t want you to go away and for something more serious to happen

Explore dislike of hospital and suggest you can call ahead to reduce the wait time when they get there

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62
Q

Cardio SRV

A 
Chest Pain
Dyspnea
Orthopnea
PND
Syncope
Palpitations
Leg Swelling
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63
Q

GI SRV

A 
Dysphagia
Odynophagia
Nausea + Vomiting
Haematemesis
Abdo Pain
Bowel Habit
Blood + Mucus
Mouth Ulcers
Itchy Eyes
Rashes
Jaundice
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64
Q

MSK SRV

A 
Pain
ROM
Swelling
Stiffness
Crepitus
Locking
Giving Way
Instability
Trauma
Fever
Diabetes
Smoking
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65
Q

Chest Pain: SOCRATES + ECG

A 
Site
Onset
Character
Radiation
Timing
Exacerbation
Severity
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66
Q

SOB: NOTEP + ABG

A 
Nature
Onset
Timing
Exacerbation
Progression
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67
Q

Neuro SRV

A 
Headaches
Seizures
Blackouts
Vision
Speech
Strength
Sensation
Face/Arms/Legs
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68
Q

Resp SRV

A 
Chest Pain
Dyspnea
Cough
Sputum
Haemoptysis
Wheeze
Triggers
Leg Pain
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69
Q

Gen SRV

A 
ICE
FLAWS
Prev Ep
Recent Illness
Close Contacts
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70
Q

Cardiac RFs

A 
HTN
Cholesterol
Diabetes
Stroke
Smoker
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71
Q

Resp RFs

A 
Pets
Allergies
Smoking
Travel
Occupation
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72
Q

GU SRV

A

LUTS: FUND HIPS

Storage - freq, urgency, nocturia, dysuria

Voiding - hesitancy, intermittency, poor stream, straining/incomplete emptying/terminal dribbling

Plus: haematuria, polyuria, polydipsia, vaginal bleeding/discharge, MOSS

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73
Q

What are the cardiac causes of clubbing?

A

CIA: congenital cyanotic heart disease, infective endocarditis, atrial myxoma

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74
Q

What are the respiratory causes of clubbing?

A

Newly Sprouted Fingers:

Neoplasia - bronchogenic carcinoma + mesothelioma

Suppurative - abscess, bronchiectasis, cystic fibrosis, don’t say copd, empyema

Fibrotic - cryptogenic fibrosing alveolitis + connective tissue disease

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75
Q

What are the GI causes of clubbing?

A

The 3 C’s: cirrhosis, coeliac disease, crohn’s/UC

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76
Q

Liver Screen

A 
Sx:
Jaundice
Itchiness
Dark Urine
Pale Stool
RFs:
Tattoos
IVDU
UPSI
Travel
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77
Q

What do you want to investigate most abdominal pathology?

A 
FBC
U+E
LFT
Clotting
Amylase
Lactate
USS
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78
Q

Charcot’s Triad

A

Fever
Jaundice
Abdo Pain

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79
Q

Reynold’s Pentad

A 
Fever
Jaundice
Abdo Pain
Shock
AMS
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80
Q

Courvoisier Law

A

The presence of a palpably enlarged gallbladder with accompanying jaundice is unlikely to be due to gallstones

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81
Q

Mx of Cholecystitis

A

Tbc

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82
Q

Mx of Ascending Cholangitis

A

Tbc

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83
Q

What should you establish if the patient is a diabetic?

A

The type and therefore whether they are at risk of DKA/HHS

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84
Q

Ddx of Palpitations

A

Must ask about chest pain, sob, blackouts

AF
Arrhythmias
Anxiety
Panic Attacks
Medications
Substances
Caffeine
Hyperthyroid
Hypoglycaemia
Pregnancy
Menopause
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85
Q

Headache Red Flags

A 
Papilledema
Seizures
Focal Neuro
Cancer/HIV
Visual Disturbance
Postural Change
Pregnancy
N+V
Vasculitis
Diabetes
Worsening
AM Sx
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86
Q

Headache Qs

A

SOCRATES

Sinister: red flags, trauma, first and worst, unilateral, meningism

Non-Sinister: triggers, lacrimation, electric shock sensation, dhx, stress

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87
Q

Kidney vs Spleen

A

Kidney: ballotable, resonant, moves down on insp

Spleen: can’t get above, dull, moves to RIF on insp

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88
Q

Which inguinal hernia is more common?

A

Indirect

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89
Q

Def of a Hernia

A

An abnormal protrusion of a viscus through a defect in it’s containing compartment

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90
Q

Where is the deep inguinal ring located?

A

The midpoint of the inguinal ligament ie ASIS to PT

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91
Q

Where are inguinal and femoral hernias found in relation to the pubic tubercle?

A

Inguinal: superior + medially

Femoral: inferior + laterally

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92
Q

Tx of Groin Hernia

A

Open (Lichtenstein repair - can be done under LA day case) vs Lap (either TEP or TAP - both require GA)

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93
Q

What do you look for next after identifying a midline sternotomy scar? Why?

A

Ddx: CABG, valve repair, congenital heart disease, pacemakers, ICD

Leg scars for vein harvest

Arm scars for arterial harvest

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94
Q

Pacemaker vs ICD

A

An ICD will have thick coils on CXR

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95
Q

What do relatively small scars on the top, bottom and left side of the chest indicate?

A

S/C ICD

No leads within the heart

Smaller risk of infection and vasc comps

But cannot place in thin individuals nor do advanced pacing

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96
Q

Ddx for splinter haemorrhages and nail fold infarcts (3)

A

Infective endocarditis, Rheumatoid vasculitis, systemic sclerosis

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97
Q

What can you do if you’re struggling to feel the apex beat?

A

Try in held expiration and in left lateral decubitus position

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98
Q

How would you finish your cardiac exam?

A

Full hx PLUS check temp (endocarditis), dipstick urine (diabetes, HTN, glomerulonephritis), ECG (rhythm disturbance)

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99
Q

What should you do if a young woman presents cyanotic?

A

O/E: clubbing, scars underneath the breasts, signs of right heart strain

Ix: bloods (polycythaemia, IDA, liver function, uric acid levels), ECG (AF, p pulmonale, RVH), echo (right heart catheterisation)

Rx: oxygen, diuretics, consider referral to PH centre for vasodilators, avoid pregnancy

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100
Q

What are the signs of right heart strain? (5)

A

Loud and palpable P2, systolic V waves in an elevated JVP (raised venous pressure), parasternal heave (RV hypertrophy), pulm regurg, tricuspid regurg +/- pulsatile liver

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101
Q

What are the possible cardiac causes to consider in the cyanotic pt? (2)

A

Shunt + Pulmonary HTN

NB: they are linked as you could get PH secondary to an old shunt

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102
Q

If you hear a murmur on the left sternal edge what is it most likely going to be?

A

VSD > Tricuspid Regurg

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103
Q

What is the sign called when a murmur is louder in inspiration?

A

Carvallo’s Sign

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104
Q

What is Eisenmenger’s syndrome?

A

L-R shunt -> R-L shunt

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105
Q

What are the three most common causes of Eisenmenger’s in order?

A

VSD
ASD
PDA

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106
Q

Why do cyanotic pts get IDA?

A

Chronic hypoxaemia, activation of hepcidin, same mechanism as ACD

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107
Q

What is the gold standard to look at right heart pressures?

A

Right heart catheterisation

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108
Q

What ix do you perform in pts w chronic cyanotic cardiac disease?

A

CT chest for ILD causing the pulm HTN + V/Q scan for thromboembolic disease in lungs

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109
Q

What rx should you give pulm HTN pts? (2)

A

Warfarin + Digoxin

110
Q

What is the most common cause of pulm HTN?

A

Systemic HTN

111
Q

What are the signs of CO2 retention? (3)

A

Bounding pulse, flapping tremor, red palms

112
Q

COPD O/E

A

Obstructive Picture

Inspection: big chest, breathless at rest, leaning forward, use of accessory muscles, cough

Key Signs: plethoric, CO2 retention, tar staining, hyperinflation, prolonged maximal exhalation, pursed lip breathing, cor pulmonale

113
Q

Bronchiectasis O/E

A

Obstructive Picture

Inspection: clubbing, lots of sputum, cachexia

Key Signs: insp click, early to mid insp creps that DO shift w coughing, yellow curved nails and lymphoedema in legs

114
Q

What does a pt w COPD who gets clubbing suggest?

A

Developed bronchogenic carcinoma

115
Q

Fibrosis O/E

A

Restrictive Picture

Inspection: clubbing, cyanosis, on oxygen, steroid signs, Rheumatic hands, CREST, ank spond, thoracotomy scars, cachexia

Key Signs: dull percussion note + fine end resp creps that DON’T shift w coughing

116
Q

Why are pts w bronchiectasis cachexic?

A

The recurrent chest infections put the pt in a hyperinflammatory state throughout the year

117
Q

How would you finish your resp exam?

A
  • Full hx PLUS check temp, sputum, peak flow/bedside spirometry, bloods, ABG, CXR/CT
  • Any evidence the pt is on tx such as oxygen therapy
  • Closing statement regarding associations and causation
118
Q

What are the relevant resp negatives? (5)

A

Breathless at rest, clubbing, tar staining, LNs, pulm HTN/RHF

119
Q

What is a/w secondary polycythaemia?

A

Gout

.’. If a pt presents w gout check their haemoglobin

120
Q

What’s a reduced cricoid-sternal distance?

A

Less than three fingers

121
Q

How long does a maximal exhale that is suggestive of an obstructive defect take?

A

> 6s

122
Q

What bloods do you want to do for ILD?

A

FBC - secondary polycythaemia + raised eosinophil count

Inflam Markers - ESR, RF, cANCA, pANCA, anti-GBM

PLUS: ACE and Ca (sarcoidosis), precipitins (hypersensitivity pneumonitis), CK (polymyositis)

123
Q

What bloods do you want to do for bronchiectasis?

A

Serum immunoglobulin levels + Aspergillus serology

124
Q

What does the sputum look like during a pseudomonas infection?

A

Blackish Green

125
Q

What does PESTO stand for in resp histories?

A 
Pets
Exercise
Smoking
Travel
Occupation
126
Q

What do you look for next after identifying a Rutherford-Morrison scar? Why?

A

Look to the neck for a parathyroidectomy scar hidden in the neck crease

127
Q

Px of CKD

A

On general insp: well, not tachypnoeic, also notably not Cushingoid

O/e of hands: AV fistula in the left arm w signs of recent use + BP was elevated at 150/90 in keeping w renal impairment

O/e of H+N and chest: nad

On insp of abdo: scar in LIF w a firm underlying mass which was smooth and non-tender w/o overlying erythema consistent w a kidney transplant

The rest of abdo was SNT, no organomegaly, BS were present

The current mode of RRT is likely to be adequate as the pt is euvolemic w/o signs of pedal oedema

The cause of the pts ESRF is not readily apparent and I would like to enquire about RFs for chronic kidney disease such as diabetes and HTN

I would also like to dipstick the urine to look for glucosuria and blood or protein which may indicate an underlying glomerulonephritis

128
Q

Px of CLD

A

On general insp: cachectic

O/e of hands: clubbing + palmar erythema

O/e of H+N: conjunctival pallor + elevated JVP

On insp of chest: multiple spider naevi in the distribution of the SVC

On insp of abdo: distended with dilated veins which fill away from the umbilicus suggestive of caput medusae

On palpation: I noted eight finger breadths of smooth non-tender hepatomegaly extending below the right costal margin w no associated splenomegaly

On percussion: I noted a distended abdomen with shifting dullness in keeping w ascites which is non-tense

On auscultation: BS were present

There was peripheral oedema likely from hypoalbuminaemia

These findings would be most consistent w a dx of cirrhotic liver disease w some evidence of decompensation

Valuable ix would inc a liver US to confirm the cirrhosis and blood screen looking for causes and signs of liver dysfunction

129
Q

Signs of uraemia

A

1st Sign: hiccups -> pruritus

PLUS loss of appetite, malaise, pericarditis w pericardial rub

130
Q

Signs of fluid overload

A

Unable to lie flat, breathless, on oxygen

Raised JVP + pedal oedema

131
Q

Signs of immunosuppression

A

Violacious striae, other steroid signs, inc risk of chronic infection, reactivation of herpes, ca esp skin

Cyclosporin - gum hypertrophy + tremor

Tacrolimus - diabetes mellitus + tremor

Azathioprine - anaemia + liver fibrosis

132
Q

How do you assess graft function?

A

Failure: anaemic, fluid overload, uraemic, active RRT methods

Rejection: tenderness and heat over the graft

133
Q

Ddx RIF Masses (3)

A

Caecal malignancy, crohns, adenopathy

134
Q

What bloods do you do for pts w CKD?

A

Assuming chronic: bicarbonate, potassium, urea, Cr, Hb, PTH, calcium, phosphate

PLUS urine PCR

135
Q

Why would you check for parotid swelling in an abdomen exam?

A

A/w alcoholic liver disease

136
Q

How long do you need to check for liver flap?

A

30secs

137
Q

What is key to accurately stating the pt has hepatomegaly?

A

Percuss for the top edge as well

138
Q

How would you finish your abdo exam?

A

Full hx +/-:

  • Urine dip to look for nitrites and leucocytes which may indicate infection as a cause of decompensation AND glucosuria as diabetes is a RF for NASH
  • Perform a DRE to look for melaena as a cause of decompensation
  • Examine external genitalia looking for signs of loss of secondary sexual characteristics
  • Examine CVS to look for underlying valvular heart disease
  • Examine neuro to look for signs of chronic alcohol use such as cerebellar ataxia and peripheral neuropathy
139
Q

What are the causes of decompensation? (3)

A

Infection, Constipation, Alcohol

PLUS meds (sedatives, NSAIDs, XS diruetics), any source of inc protein/nitrogen (GI bleed + renal failure), HCC

140
Q

How do you px hepatomegaly?

A

Describe: size, smooth, irregular, tender, pulsatile

Causes: cirrhosis, cancer, congestion, infiltrative, inflam, riedel’s lobe

141
Q

Why do liver pts get palmar erythema, spider naevi, gynaecomastia, lack of body hair, testicular atrophy?

A

Inc in relative oestradiol:testosterone ratio as a result of dec production of albumin and sex hormone binding globulin

142
Q

What bloods would you do for a CLD pt?

A

Gen: Hb, MCV, Pl, LFTs, U+Es, coag screen, albumin

Viral: Hep A IgM, Hep B sAg, Hep C Ab

AI: serum Igs, anti smooth muscle, ANA

143
Q

What are the signs of portal HTN? (4)

A

SAVE

Splenomegaly
Ascites
Varices
Encephalopathy

144
Q

What is the consequence of splenomegaly?

A

Hypersplenism - sequestration of the platelets - thrombocytopenia

145
Q

Why are varices in liver pts so catastrophic?

A

They’re already thrombocytopenic and have an elevated INR

146
Q

How many of all pts w portal HTN have gastric varices?

A

20%

147
Q

What is the mortality of a varices haemorrhage?

A

20%

148
Q

Tx to relieve pressure on the portal vein

A

TIPSS

149
Q

How is decompensation defined?

A

It describes the comps of advanced liver disease: any of ascites, jaundice, encephalopathy

150
Q

How does XS diuretics lead to decompensation?

A

The hypoK results in dec renal ammonia clearance

151
Q

What are the signs of hepatic encephalopathy?

A

1st Sign: diurnal sleeping pattern disturbance

Asterixis -> Bradykinesia -> Areflexia -> Decerebrate -> Coma

152
Q

What should you always think about adding to your conservative mx?

A

MDT, Referrals, Pt Education

153
Q

CVS RFs

A 
HTN
Diabetes
Cholesterol
Strokes
Smoker
154
Q

What are you inspecting for in neuro examinations?

A

DWARFS: deformity, wasting, asymmetry, rashes, fasciculations, swelling and scars

155
Q

What may small scars inferiorly to a midline sternotomy represent?

A

Drains

156
Q

What are the cardinal signs of hyperinflation?

A
  1. Red Cricosternal Distance
  2. Loss of Cardiac Dullness
  3. Displaced Liver Edge
157
Q

Examining a skin lesion

A

Intro: chaperone, full exposure, any pain

General insp: number, location, distribution, objects, equipment

Closer insp: size, outline, discrete/confluent, colour, shape

Palpate: surface (texture, elevation, crust, temp) + deep (consistency, fluctuance, mobility, tenderness)

Systemic: hands and elbows, hair and scalp, mucous membranes

Complete: swab/scrap, dermatoscopy, biopsy

158
Q

What are the different distributions of skin lesions?

A

Acral - hands and feet

Extensor - elbows and knees

Flexural - axillae, cubital fossae, genitals

Follicular - face, chest, axillae

Dermatomal - confined and don’t cross the midline

Seborrhoeic - face and scalp

159
Q

What is the different morphology of skin lesions?

A

Macule - flat <1.5cm diameter

Patch - flat >1.5cm diameter

Papule - raised <0.5cm diameter

Nodule - raised >0.5cm diameter

Vesicle - clear fluid filled <0.5cm diameter

Bulla - clear fluid filled >0.5cm diameter

Pustule - pus contained lesion <0.5cm diameter

Abscess - pus contained lesion >0.5cm diameter

Furuncle - staph infection around or within a hair follicle

Carbuncle - above plus adjacent hair follicles

160
Q

How do you assess a pigmented lesion?

A

ABCDEF

Asymmetry

Border

Colour

Diameter

Elevation + Evolution

Finally look for other suspicious lesions and examine the regional lymph nodes

161
Q

Long Term Central Venous Line

A

The remnant of the line is tunnelled s/c which dec incidence of infection Indicated for longterm parenteral nutrition, longterm IV abx or chemo

162
Q

Nasopharyngeal Airway

A

What: Nasopharyngeal Airway Why: provide a non-def airway for pts who are semi conscious and unable to tolerate a guedel or have a clenched jaw Sized: diameter of the pts little finger How: by using a rotational action up to the flared end which prevents it becoming irretrievable CIs: base of skull # and facial trauma/surg Comps: damage to nasopharynx, intracranial placement, laryngospasm, vomiting

163
Q

How do you structure your answer for any instrument?

A

What? Why? Size? How? CIs? Comps?

164
Q

What are the two definitive airways?

A

Endotracheal Tube + Tracheostomy

165
Q

Drains: Open vs Closed

A

Open - fluid collect in stoma or guaze - inc risk of infection

Closed - tubes into bag or bottle - dec risk of infection

166
Q

Instrument

A

What: Oropharyngeal Airway Why: provide a non-def airway for pt w impaired level of consciousness at risk of upper airway collapse or if the manual manoeuvres are unsuccessful Sized: distance b/w maxillary incisors to angle of mandible How: in adults inserted upside down and rotated within the oral cavity + in children inserted the correct way up CIs: a conscious person w intact gag reflex + foreign body obstrcing airway Comps: damage to teeth, palate, oropharynx + improper sizing can lead to bleeding

167
Q

What are the signs of a base of skull #? (4)

A

Racoon eyes w tarsal plate sparing, postauricular ecchymosis, haemotympanum, CSF otorrhoea

168
Q

Image

A

What: iGel - buccal cavity stabiliser, epiglottic rest, gastric channel Why: a supraglottic airway used as a step prior to intubation esp for short elective procedures <4hrs, cardiac arrests, prehosp airway mx Sized: according to the pts weight How: use K-Y jelly, insert w the number facing towards you when behind the pt who is in the ‘sniffing the morning air’ position, glide downwards and backwards along the hard palate until the tip is in the oesophageal opening, taped down CIs: non fasted, trismus, >40cm H2O ventilation pressure Comps: leak + aspiration

169
Q

Endotracheal Tube

A

What: Endotracheal Tube Why: def airway thus preventing aspiration used commonly in trauma cases, long surg w general anaesthetics and pts w GCS <8 Sized: age, sex, height - position checked by looking for symmetrical rising of chest on ventilation, bilateral breath sounds, no gurgling over epigastrium How: inserted into trachea via oropharynx using a laryngoscope and Eschmann Tracheal Tube Introducer by anaesthetist, tape to secure tube in airway, inflate balloon w air below vocal cords to maintain position and protect from aspiration CIs: Mallampati score of >=3 + sev airway obstrc where a cricothyrotomy might instead be indicated Comps: inappropriate placing, injury to larynx esp vocal cords, pneumothorax, atelectasis, infection, sore throat, tracheal stenosis

170
Q

Tracheostomy

A

What: Temporary Tracheostomy Why: def airway thus preventing aspiration used acutely in maxillofacial surgery or electively in ITU pts for more efficient ventilation w dec dead space Sized: How: via transverse incision made 1cm above sternal notch CIs: Comps: injury to oesophagus or recurrent laryngeal nerve, haemorrhage, pneumothorax, sore throat, tracheal stenosis

171
Q

Laryngoscope

A

What: Laryngoscope - if blades are curved it’s McKintosh va straight it’s Miller Why: aids intubation + dx of vocal problems and stricture Comps: soft tissue injury, pharynx/larynx scarring, ulceration, abscess

172
Q

Nasal Cannula

A

What: Nasal Cannula Why: Comps: nasal sores + epistaxis therefore encourage use of water based creams

173
Q

What is a key principle of administering oxygen via venturi or high flow nasals?

A

You can give an exact FiO2 as air flow > PIFR

174
Q

What is the avg peak insp flow rate in a healthy individual?

A

20L/min

175
Q

What are examples of variable devices ie the FiO2 is dependent on PIFR? (3)

A

Nasal Cannula, Hudson Mask, NRB

176
Q

How do you measure PIFR?

A

Spirometry

177
Q

Tesio vs Hickman

A

Tesio - doesn’t have a dacron cuff, buried deeper, used for haemodialysis therefore double lumen Hickman - dacron cuff, tunnelled s/c, used for long term parental nutrition/abx/chemo therefore single lumen

178
Q

Venturi

A

What: Venturi - uses Bernouli principle to mix oxygen w room air Why: deliver b/w 2-15L/min at a fixed FiO2 Comps

179
Q

NRB

A

What: Non-Rebreather Mask - ensure the bag in full before placing Why: deliver up to 15L/min and ~85% FiO2 Comps:

180
Q

Self-Inflatable Bag-Valve-Mask

A

What: Self-Inflatable Bag-Valve-Mask Why: Comps: barotrauma from lung inflation + aspiration/vomiting from gastric insufflation

181
Q

NIV

A

CIs: drowsiness + pneumothorax

182
Q

LMA vs iGel

A

Ultimately that would be the anaesthetists decision: The LMA-Protector provides a better airway seal The iGel is faster to insert, a/w less mucosal injury, allows for easier gastric tube insertion

183
Q

Uncuffed ET

A

Used in children <8yo as the smallest diameter of the airway is the cricoid ring However may have to place again if the sizing is wrong, doesn’t allow for as high ventilation pressures or protect against aspiration as well

184
Q

Drains: Active vs Passive

A

Active - maintained under suction - eg redivac following mastectomy, neck dissection, joint replacement

Passive - drains by pressure differentials, overflow, gravity - eg stoma, NGT, robinsons, foleys

185
Q

What are the different types of venturi valves?

A

Blue: 2-4L/min = 24% O2 White: 4-6L/min = 28% O2 Yellow: 8-10L/min = 35% O2 Red: 10-12L/min = 40% O2 Green: 12-15L/min = 60% O2

186
Q

Devers Retractor

A

This is a Devers retractor. I have used it in open abdominal surgery to allow the surgeon to operate.

187
Q

Self-Retaining Retractor

A

This is a self-retaining retractor. I have seen this used to hold wounds open during an appendicectomy and hernia repairs.

188
Q

Forceps

A

These are the two common types of forceps: toothed for skin + nontoothed for inside the peritoneal cavity

189
Q

Scalpels

A

These are the two common types of scalpels: disposable and non-disposable

190
Q

Feeding NG Tube

A

What: Feeding NGT - fine bore w radio-opaque guide wire Why: long term enteral nutrition for pts post op, ITU, unsafe swallow Sized: tip of nose round ear to epigastrium How: consent pt, place aqua gel on tip, go along the floor of the nasal passage, ask pt to keep swallowing as you advance, confirm correct placement CIs: base of skull # and facial trauma/surg Comps: NGT+feeding ie nasal trauma, misplacement, blockage, refeeding syndrome, electrolyte imbalance, feed intolerance

191
Q

Ryles Tube

A

What: Ryle’s Tube - wide bore w metal tip, clear, stiff Why: part of the drip and suck tx for bowel obstrc to decompress + insert drugs or contrast into the GIT Comps: the larger diameter inc risk of nasal trauma + misplacement and blockage

192
Q

How do you ensure the NGT is in the correct place?

A

Document: the pH aspirate is <5.5, bubbling upon epigastrium auscultation following air insertion, on CXR bisects the carina and tip sits below the diaphragm in the gastric bubble

193
Q

High-Flow Nasals

A

Humidified and well tolerated V high flow can be achieved

194
Q

Describe bubbling and swinging wrt chest drains?

A

Bubbles - air is being expelled during expiration Swinging - the fluid going up and down the tube during insp/exp Swinging w/o bubbles shows all the air from the pneumothorax is out

195
Q

If the drain doesn’t stop bubbling what does this suggest? And what should you do?

A

There’s a fistula -> requires specialist intervention

196
Q

TED Stockings

A

What: TED Stockings Why: mechanical VTE prophylaxis usually used in conjunction w pharmacological eg LMWH to prevent DVTs CIs: pts w arterial disease

197
Q

Two-Way Catheter

A

What: Two-Way Urinary Catheter - Male v Female Why: therapeutic ie retention and immobile pts + diagnostic ie measure UO and collect sterile sample Sized: inc Charrière inc circumference usually 12-14Ch for adults How: consent pt, clean w saline and anaesthetise w instillagel, use ANTT, wait until urine starts to drain, inflate the ballon w 10ml of water, attach bag, ensure foreskin repositioned, document CIs: consider suprapubic access if urethral injury, high riding prostate, pelvic fracture, scrotal haematoma Comps:

198
Q

Three-Way Catheter

A

What: Three-Way Irrigation Catheter Why: allows for bladder irrigation in pts w haematuria at risk of clot formation Comps:

199
Q

Foley vs Long-Term Urinary Catheter

A

Foley: <28d + latex Long-Term: <3m + silicone

200
Q

Approach to Chest Radiograph

A

Pt+Image Details, RIPE, Most Obv Abnormality, A-F, Ddx

201
Q

Approach to Abdominal Radiograph

A

Pt+Image Details, RPE, Most Obv Abnormality

  1. Bowel Gas Pattern 2. Extraluminal Gas 3. Soft Tissues 4. Calcification 5. Masses 6. Bones
202
Q

Approach to MSK Radiograph

A

Pt+Image Details, Most Obv Abnormality, JOAST, Ddx

203
Q

Trachea Deviation

A

Ipsilateral: collapse, fibrosis, surgery Contralateral: tension pneumothorax + pleural effusion

204
Q

Bowel: Small vs Large

A

Small: valvulae conniventes vs Large: haustral folds

The 3-6-9 Rule: small, large, caecum PLUS appendix <6mm

205
Q

Insert Image (EDH)

A

Extradural Haematoma: lentiform ie lens shaped + biconvex ~ Day Lucid Interval

206
Q

Insert Image (SDH)

A

Subdural Haematoma: crescentic ie moon shaped + concave ~ Wk Lucid Interval

207
Q

Insert Image (SAH)

A

Subarachnoid Haemorrhage: the star sign ie presence of blood within the basal cisterns and sulci

208
Q

Hickman

A

What Why: the dacron cuff prevents back tracking of infection and forms a bond w surrounding tissue to prevent line migration Sized How CIs Comps

209
Q

Approach to CT Head

A

Midline Shift + Symmetry

210
Q

Rigler’s Triad

A

SBO Pneumobilia Ectopic Calcified GS

211
Q

What does JOAST stand for?

A

Joint Outline Attitude Soft Tissues Texture

212
Q

What does RIPE stand for?

A

Rotation Inspiration Penetration Exposure

213
Q

CT vs MRI

A

CT - more detailed bony structures, white bone, black water unless contrast MRI - more detailed soft tissues, T1 black water, T2 white water

214
Q

What layers do you pass through during an epidural?

A

Skin S/c Fat Supraspinous Interspinous Ligamentum Flavum

215
Q

What is the composition of the crystalloids?

A

0.9% Sodium Chloride: 154 Na, 154 Cl, 300 OsmolaLity Hartmann’s: 131 Na, 112 Cl, 5 K, 4 Ca, 29 HCO3, 281 OsmolaLity 5% Dextrose: 50g Dextrose + 278 OsmolaLity

216
Q

Where outlines the mediastinum on a chest radiograph?

A

Right atrium, ascending aorta, SVC, aortic arch, main pulmonary artery, left ventricle

217
Q

Where does one tend to aspirate and why?

A

Right lower lobe as the right bronchus is more vertically oriented

218
Q

What does the majority of the hila consist of?

A

The lower lobe pulmonary arteries

219
Q

Where do you first see a pleural effusion?

A

Obscured CP angles

220
Q

What places opacification in the right middle lobe?

A

Up to the horizontal fissure and loss of right heart border

221
Q

What is the radiological sign of consolidation?

A

Air Bronchograms Plus inc density and no volume loss

222
Q

Ddx for Consolidation

A

Pus - Pneumonia Fluid - Oedema/Haemorrhage Cancer - Adenocarcinoma

223
Q

Bronchopneumonia vs Pulm Oedema

A

If there’s NOT bilateral perihilar appearance, blunting of the CP angles, enlarged upper lobe veins think bronchopneumonia > oedema

224
Q

Bronchopneumonia vs Multifocal Adenocarcinoma

A

If there’s NO raised WCC and the pt is systemically well think cancer or bleed > pneumonia

225
Q

How do you work through A-F of a CXR?

A

A: Trachea B: Hila C: Mediastinum D: Diaphragm E: 🔼 Bones + Lines F: 🔽 Fields + Pleura

226
Q

What are the signs of COVID pneumonitis?

A

Patchy peripheral areas of ground glass opacification and consolidation w a mid/lower zone predominance

227
Q

Left Lower Lobe Collapse

A

Mediastinal shift towards ie volume loss in hemithorax, ‘sail sign’ triangular opacity behind heart, obscured diaphragm, unable to visualise the descending thoracic aorta, depression of left hilum

228
Q

What are the sinister underlying causes of lobar collapse?

A

Central obstructing cancer + FB aspiration

229
Q

What are the signs of emphysema?

A

Inc anterior ribs + flattened diaphragm

230
Q

Left Upper Lobe Collapse

A

Mediastinal shift towards ie volume loss in hemithorax, veil-like opacity in upper zone, obscured heart border, still able to visualise the descending thoracic aorta, elevation of left hilum

231
Q

Where does the oblique fissure run in a lateral view?

A

Ant CP angle to T4

232
Q

What is the sail sign indicative of?

A

Left Lower Lobe Collapse

233
Q

Collapse vs Surgery

A

You’d expect to see clips following surgery and the main bronchus would be cut near the carina

234
Q

What is the usual cause of an entire lung collapse?

A

Cancer obstructing the main bronchus

235
Q

Ddx for White Hemithorax

A

Lung Collapse Pleural Effusion

236
Q

What does lobulated pleural thickening suggest?

A

Malignant Mesothelioma

237
Q

What does pulmonary TB look like on CXR?

A

Typically affects the upper lobes giving mixture of consolidation, nodular shadowing and cavitation

238
Q

Which cancers cause miliary metastases?

A

Thyroid + Renal

239
Q

Miliary TB vs Metastases

A

The pt will be septic if it’s TB

240
Q

Where do inhalational and haematogenous disease tend to occur?

A

Inhalational - Upper Zones Haematogenous - Lower Zones

241
Q

Pulmonary Nodule vs Mass

A

> 3cm

242
Q

What is characteristic of lung cancer on CXR?

A

Solitary mass w spiculated edge

243
Q

Ddx for Dark Hemithorax

A

Pneumothorax

244
Q

What are the causes of pneumomediastinum? (3)

A

Spontaneous A/W Pneumothorax Oesophageal Rupture

245
Q

What should you be worried about if the pt is SOB and they have a normal CXR?

A

PE

246
Q

What is pathognomonic for pulm oedema?

A

Septal ie Kerley B Lines

247
Q

What are causes of non-cardiogenic pulm oedema?

A

Altered Permeability > Inc Osmotic Pressure Neurogenic, ARDS, TRALI, RAS, heroin induced, near drowning, high altitude

248
Q

Which part of the colon is fixed/variable?

A

Fixed ascending/descending/rectum as they’re retroperitoneal Variable transverse/sigmoid as they have mesentery

249
Q

What causes the bowel to dilate? (3)

A

Distal mechanical obstruction, ischaemia, sick bowel

250
Q

What is the Rigler sign?

A

A sign of pneumoperitoneum when gas outlines both sides of the bowel wall

251
Q

What is the sign of a sigmoid volvulus?

A

Coffee bean sign: distended loop of colon arising from the pelvis

252
Q

What are the two types of caecal volvulus?

A
  1. Axial Torsion 2. Caecal Bascule

+/- Small Bowel Obstruction

253
Q

What is the 10 day rule for women of child bearing age?

A

Imaging of abdomen/pelvis using ionising radiation should be restricted to the first 10 days following onset of menstruation

254
Q

How can you tell if an AXR is adequate in terms of both penetration and coverage?

A

You can see the vertebrae, edges of the pelvis and down to the greater trochanters

255
Q

What causes cavitary lung lesions?

A

Infectious: strep, klebsiella, mycobacterium, aspergillosis, parasites Non-Infectious: cancer, GPA, congenital

256
Q

What do you need if the CXR does not show a rib fracture or splenic injury but there’s clinical suspicion?

A

CT

257
Q

CVC vs PICC

A

Length + Lumen

258
Q

MRI: T1 vs T2

A

We commonly use T1 to visualise anatomy and T2 to visualise disease: look at the water which will be black in T1 and white in T2

259
Q

What is Chilaiditi’s sign?

A

An incidental finding where gas containing bowel is positioned between the right diaphragm and the liver which is often misdiagnosed as pneumoperitoneum

260
Q

What sign is pathognomonic of SBO?

A

The presence of a ladder pattern on an erect film showing fluid air levels within each loop of bowel

261
Q

What does a diaphragmatic hernia look like on a CXR?

A

The diaphragmatic border is lost and the hemidiaphragm is elevated with a fluid level in the gastric buddle and absence of lung markings

262
Q

Mx of SBO

A

‘Drip and Suck’

Gain IV access to take bloods inc vbg for lactate and immediate electrolytes then start IV fluids and place a catheter to monitor fluid balance

Place a NG tube to decompress the distended stomach, give analgesia and antiemetics, keep NBM and discuss w surg team, CT AP to determine level of obstrc and cause, monitor obs closely

263
Q

Abdo: Stoma Qs

A

Define a stoma

Indications for a stoma

Ileostomy vs Colostomy

Why would you do a colostomy

How do you know it’s functioning

Indications for an emerg Hartmanns

Complications of a stoma

How much fluid would be normal to lose from a stoma

When do you remove it

264
Q

Abdo: Pancreatitis Qs

A

What would be possible ddx

List the causes of acute pancreatitis

Why do you get Cullens, Grey Turners, Foxs

What ix would you perform

What are the three reasons you’d get an AXR

Difference b/w MRCP + ERCP

What scoring system is used

How does this affect mx

General mx principles

265
Q

Abdo: Upper GI Bleeding Qs

A

What would be possible ddx

What is the Mackler triad of Boerhaave syndrome

Which ix would you perform

What is the difference b/w XM + G&S

What scoring system is used

How does this affect mx

General mx principles

266
Q

Abdo: Stoma Examination

A 
Site
Lumen
Sprout
Effluent
Surrounding
Comps

Listen for bowel sounds + pt cough

Look for scars + abdo exam if indicated

267
Q

SVR: Scar Examination

A 
Location
Orientation
Size
?Well Healed
?Incisional Hernia

.’. Consistent w _ op for _ condition

268
Q

I+I: What are the three indications for an AXR?

A

Obstrc/volvulus, UC toxic megalon/lead pipe, foreign body

NEVER CONSTIPATION

269
Q

I+I: What should you say if they show you an xray of a limb in one plane?

A

Ask for another view to ascertain if there is a fracture

270
Q

T+O: Mx of Fracture

A

ATLS, Assess NV Status, 4R’s

Closed: once stable non-op document NV status, analgesia, activity modification, reduce, casts, splints, traction + operative fixation

Open: photograph, cover w saline soaked gauze, give IV abx + tetanus, splint and xray, debride + washout +/- fixation

If GA3b require plastics input for graft

If GA3c require vasc surgeons for shunt bypass before exfix, vasc repair, debridement, dressing, def fixation

Finally physio would be involved for rehabilitation: use, move, strengthen, WB

271
Q

What are the usual things to forget in examinations?

A

Core Three: cap refill, flap, JVP, lymph nodes, sacral/peripheral oedema

CN: insp | UL: pronator drift | LL: rombergs + gait

Year 5/6 (20 decks)

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