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3rd Yr Med Flashcards

(222 cards)

1
Q

Stable Angina Features:

A

No pain at rest
No raised Trop
No ECG changes

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2
Q

Unstable Angina Features:

A

Pain at rest
No raised Trop
Transient ECG changes (ST Depress, T wave Invers)

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3
Q

nSTEMI Features:

A

Pain at rest
Raised Trop
ECG changes (ST Depress, T wave Invers)

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4
Q

STEMI Features:

A

Pain at rest
Raised Trop
ECG changes (ST Elev, LBBB)

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5
Q

Stable Angina Mx

A
Aspirin 75mg
ACEi/ARB
SL GTN
Statin
(Rate control: Beta-blocker, CCB, Ivabradine)
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6
Q

Unstable Angina/nSTEMI Mx

A
Morphine + Antiemetic
O2
Fondaparinux
SL GTN
Aspirin 300mg Stat (75mg OD)
Repeat ECG + Angiography
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7
Q

STEMI Mx + Tx

A
Morphine + Antiemetic
O2
LMWHep
SL GTN
Aspirin 300mg Stat (75mg)
Repeat ECG + Angiography

Tx:
(w/ in 90mis): PPCI (w/ Prasugrel)
Thrombolysis (IV Alteplase)
(Aspirin continued indefinitely, Prasugrel/Clopidogrel continued for 12 months)

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8
Q

HF Class

A

NYHA:

1: No limitations
2: Mild limitations
3: Severe limitations
4: Sx at rest

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9
Q

HF Ix

A

BNP/ANP
Echo (Trans-oesophageal)
CXR
(ECG, Trop)

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10
Q

HF Meds

A

Cardiac meds:
Beta-blockers, CCB (Diltazem, Verapamil), Ivabradine (Slows HR w/out drop in BP)

Diuretics:
Furosemide, Thiazides, ACEi/ARB (If HT), Spironolactone (If Hypokalaemic)

Venodilators:
CCB (Amlodipine), GTN/Nitrates, Hydralazine

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11
Q

ECG Analysis

A
Rate
Rhythm
Axis (LAD, RAD)
P waves
QRS
PRi (0.12-0.2s)
QRS (0.12s)
QT (0.2s)
R -> S Progress (L/RBBB)
ST Elev/Depress
T wave (Tall/Flat/Invers)
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12
Q

AF Mx

A

Rate control:
Beta-blocker, CCB, Digoxin

Rhythm control:
Beta-blocker, Amiodarone
(If < 48hrs: DC Cardioversion)

Anti-coag:
Rivaroxaban 15mg BD (21 days), 20mg OD

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13
Q

Bradyarrhythmia Mx

A

SAN ( + Sx): Pacemaker

AVN:
1/2T1 + Syncopal: Cardiac Monitor
2T2/3 + Sx: Permanent Cardiac Pacemaker

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14
Q

Tachyarrhythmia Mx:
SVT
VT

A

SVT:
Vasovagal manoeuvres
IV Adenosine 6mg (If NSR: Re-entry - Anti-arrhythmic, If no NSR: AF)
Cardioversion (DC, Amiodarone)

VT:
Amiodarone
DC Cardioversion

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15
Q

HT Mx

A

< 55yo, Diabetic:

ACEi/ARB (+/- CCB +/- Thiazide-like D)

> 55yo, Black:

CCB (+/- ARB/ACEi +/- Thiazide-like D)

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16
Q
Features:
AS
AR
MR
MS
A

AS: (D, Carotids, Holding breath)
Eject-Syst, Cres-decres, Rad to Carotids

AR: (D, Leant forward, Exp)
Early Diast, Decres

MR: (D, L, Exp)
Pan-Syst, Blowing, Rad to Axillae

MS: (Bell, L, Exp)
Opening snap, Mid-Diast, Rumbling

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17
Q

Non-funct Pit Adenoma Mx

Prolactinoma Mx

A

Non-funct Pit Adenoma Mx:
Surg/RadioTx w/ HRT (GH, HC, Oestrog/Prog/Test, Thyroxine)

Prolactinoma Mx:
D2 (Dopamine) Agonists: Cabergoline, Bromocriptine

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18
Q

Acromegaly Ix

A
Raised IGF-1, PRL (Co-secreted w/ GH)
Failed OGTT (Fails to Supp GH)
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19
Q

Acromegaly Mx

A

Surg
GHIH (Somatostatin)
GH Antag
Dopamine Agonists (Prevent Release of GH)

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20
Q

DI Features

A

Polydipsia
Polyuria (Large Vol, Diluted Urine: > 3L/day), Nocturia
Low Urine Osmolality (< 300)
High Serum Osmolality (> 295)

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21
Q

DI Mx

A

Cranial:
Vasopressin (Exogenous ADH)

Nephrogenic:
Reduced NaCl/Protein Intake +/- Diuretic
(Carbamazepine: Sensitises Renal Tubules)

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22
Q

SIADH Sx + Mx

A

Fluid Retention (Small Vol, Concentrated Urine)

Mx:
Fluid restrict (+/- Diuretic)
Demeclocycline/Tolvaptan (ADH Antag)

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23
Q

Cushings D Patho + Complications

A

Pit Adenoma secreting ACTH

+/- DM, HT, Osteoporosis

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24
Q

Cushings D Ix

A

Raised ACTH/Cortisol, Low CRH, (Raised Glu, BP)
Raised 24hr Urinary Cortisol
Failed Dexamethasone Supp Test (Low-dose does not Supp ACTH)

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25
Cushings D Mx
Trans-sphenoidal Surg
26
Cause of Secondary Adrenal Insuff + Sx
LT Steroid use => Supp of ACTH => Low Cortisol Hypoglycaemia, (Normal Aldosterone: Normal BP) Weakness, Fatigue Immunosupp
27
Secondary Adrenal Insuff Mx
Stop Steroids | HRT: Cortisol Supp (HC)
28
Addisons Patho, Features + Complication
Auto-Immune Adrenal Destruction (Ald Def): ``` Low Ald/Cortisol (HypoT/HypoGlyc) Low Adrenals (Hair loss, Reduced Libido) High ACTH (Hyperpigmentation) ``` Addisonian Crises during stress/illness
29
Addisons Ix
9am ACTH/Cortisol levels (-) SynACTHen Stim Test (Low Cortisol) U+Es (Hyponatraemia, Hypokalaemia, Raised Urea), HypoGlyc, Anaemia
30
Addisons Mx
HRT: Fludrocortisone, HC (Double dose when ill) Steroid card (Reg Fluids - IV Dextrose + HC when ill)
31
Bilat Adrenal Hyperplasia Patho + Features
Adrenal Enlargement => Excess Aldosterone/Cortisol HT, Raised ICP Cushings Synd
32
Bilat Adrenal Hyperplasia Mx
Spironolactone (Aldosterone Antag) | Bilateral Adrenalectomy
33
Klinefelters Features
(47, XXY): Tall, feminised Man (Infertility, Gynaecomastia) Small, male Ext Genitalia (Hypogonadism)
34
Turners Features
(45, XO) Small, androgynous, Woman (w/ webbed neck) Ambiguous Ext Genitalia
35
AIS Features
(Test Def/Insens): Ambiguous Genitalia + Undescended testis Amenorrhoea, Infertility
36
CAH Features
(21-Hydroxylase Def): Ambiguous Genitalia Excess Test (Male characteristics/Virilisation: Deep voice, Hair growth, Cliteromegaly, Acne, Amenorrhoea) Cortisol/Aldosterone Def (Addisonian/Cushing Crisis)
37
Pheochromocytoma Sx
Headache Palpitations/TachyC Sweating (Anxiety/Panic, HT, HyperGlyc)
38
Pheochromocytoma Ix + Mx
``` 24hr Urinary Metanephrines + Catecholamines CT CAP (Mets) ``` Mx: Alpha-block (Phenoxybenzamine, Doxazocin) Beta-blocker Surg
39
Causes of HypoTh
Hashimotos (Anti-Th AB's) Diet (I2 Def) Med (Amiodarone, Lithium) Post-partum Thyroiditis, Sheehans Synd
40
HypoTh Ix + Mx
T3/4, TSH Th-Peroxidase AB's Mx: Levothyroxine
41
Causes of HyperTh
Graves (Auto-AB's Stim TSH-R) Nodular D Thyroiditis (Viral Inf, Amiodarone, Post-partum)
42
HyperTh Ix
T3/4, TSH TSH-R AB's Thyroid USS (Confirm Nodules) Nuclear Tc/I2 Uptake Scan (Assess Act): Uniform (Graves), Single (Nodule), None (Thyroiditis)
43
HyperTh Mx
Beta-blocker (Control Sx) Carbimazole (Th Peroxidase Antag) Radioactive I2 Thyroidectomy
44
HypoTh vs HyperTh Sx
``` Weight changes HR (Brady/Tachy) GI (Constipation/Diarrhoea) Cold/Heat Intolerance Depression/Anxiety Hypo/Hyper-reflexia ```
45
Specific Sx: HypoTh Graves
HypoTh: Myxoedema (Puffy Eyes) Graves: Proptosis (Eyes protrude) Pre-tibial Myxoedema
46
Hypercalcaemia Causes + Sx
Primary Hyper-PTH/Osteoporosis, RCC/Squamous CLC (Secreting PTHrP) => Stones, Moans, Groans, Bones, Psych ECG changes Polyuria/Polydipsia (Nephrogenic DI)
47
Hypercalcaemia Ix + Interpretations
PTH (High: HyperPTH, Low: Malig) | (PTH => Bone Turnover): High ALP, Low Phosphate
48
Hypercalcaemia Mx
IV Fluids (w/ careful electrolyte monitoring)
49
Hypocalcaemia Causes + Sx
Diet/Hypo-Mg2+ (Low Ca2+), Renal D/Lack of Sunlight (Low Vit D) => ECG changes Myalgia/Paraesthesia Spasms (Laryngomalacia, Carpo-pedal) Seizures
50
Hypocalcaemia Mx
Ca2+ Supp
51
DM Diagnosis Criteria
Fasting Glu: > 7mmol Random: > 11mmol HbA1c: > 6.5 (48mmol)
52
DKA Def/Criteria
HyperGlyc (> 11mmol) Ketones (> 3mmol) Acidosis (pH < 7.33)
53
DKA Ix + Mx
Hourly Glu + Ketones FRII (IV Actrapid 0.1 Units/Kg/hr) IV 0.9% NaCl (+/- Dextrose, K+)
54
HHS Def/Criteria
HyperGlyc (> 30mmol w/out Ketoacidosis) HypoVol Serum Osmolality > 320 (2Na + Glu+ Urea)
55
HHS Ix + Mx
Hourly Glu + Ketones IV Fluids (1L/hr, 1L/4hr, 1L/4hr) +/- K+ LMWHep
56
DM Complications: ST LT
ST: Lipodystrophy Hyper/Hypo Episodes LT: ``` Microvasc: Nephropathy, Retinopathy, Periph Neuropathy, Immunosupp (UTI, Pneumonia, Thrush) ``` Macrovasc: Stroke/TIA, CVS D/HT, Ulcers/Gangrene (Periph Ischaemia - PVD)
57
Oesophageal Dysmotility Types + Features
Achalasia: (Non-distensible LOS): Bird-beak (Ba Swallow) Diffuse Oesophageal Spasm: (No control of Peristalsis): Corkscrew (Ba Swallow) Hypercontractile: Nutcracker (Ba Swallow)
58
Oesophageal Dysmotility Ix + Mx
Ba Swallow Endoscopy Manometry Mx: SM Relaxants (CCB: Nifedipine, Nitrates) Myotomy Pneumatic Baloon Dilation
59
GORD Mx
PPi H2 Antag (Ranitidine) Alignates (Gaviscon)
60
Mallory-Weiss Tears Patho
Excess Vomiting => Tears w/in Endothelium of Oesophagus | => Bleeding
61
UGIB Mx
``` Variceal: Fluid Resus IV PPi IV ABx + Terlipressin (ADH Antag) OGD (Band/Stent) ``` ``` Non-Variceal: Fluid Resus IV PPi OGD (+/- Radioembolization/Surg) Post-OGD PPi ```
62
SB vs LB Obstruct Ix
Erect CXR: Air under Diaphragm ``` AXR: SB: > 3cm, Central, Valv Conniventes (All the way across) ``` LB: > 6cm, Periph, Haustra (Part way across) Contrast CT: ID Level of Obstruct
63
SB/LB Obstruct Mx + Surg Indications
NBM (Bowel Rest) IV Fluids (+ Electrolytes) NGT (Bowel Decompress) (Stop Opiates) Surg (Strangulated Hernia/Reversible Cause, > 48hrs, Ischaemia, Perf)
64
Coeliacs D Patho, Ix + Mx
Auto-Immune React to Gluten w/in S Intestine => Lymphocytic Infiltration + Villous Atrophy Ix: Raised Tissue Transglutaminase (tTG) Mx: Gluten-free Diet
65
Appendicitis Ix
``` FBC, U+Es, LFTs, CRP Amylase/Lipase (Excl Pancreatitis) Urinalysis (Excl UTI) ECG, Trop (Excl MI) Preg test (Excl Preg) ```
66
Appendicitis Mx
Opiates + Antiemetic Appendectomy (If Perf: ABx)
67
PBC Eped + Features
Middle-aged Women Early: Asymptomatic, Fatigue + Pruritus Late: Cholangitis (Granulomatous Inflamm of Bile Ducts) => Cirrhosis
68
PBC Mx
Cholestyramine (Reduce Pruritus) Ursodeoxycholic Acid (Improves Survival) Liver Transplant
69
PSC Eped + Features
Younger men w/ Autoimmune D Early: Progress Obstruct Jaundice Late: Cirrhosis, Cholangiocarcinoma
70
PSC Mx
Cholestyramine (Reduce Pruritus) Ursodeoxycholic Acid (Improves LFTs) Liver Transplant
71
Biliary Colic vs Acute Cholecystitis vs Ascending Cholangitis
``` Biliary Colic: RUQ Pain (1-5hrs after meal), N+V ``` Acute Cholecystitis: RUQ Pain, N+V, Fever, TachyC ``` Ascending Cholangitis: Charcots Triad (RUQ Pain, Fever, Jaundice), Reynolds Pentad (+ Confusion, HypoT) ```
72
Biliary Colic/A Cholecystitis/Asc Cholangitis Ix + Mx
LFTs, ERCP Mx: Stone removal Cholecystectomy (w/ Bile Salt replacement) ERCP (w/ Biliary Decompress) IV ABx (If Asc Cholangitis: Tazocin 4.5g TDS)
73
Pancreatic Ca Features: Head Tail
Head: Painless, Obstruct Jaundice Vague Epigastric Pain/Mass Tail: DM Sx Loss of Enzymes (Malnutrition, Loose Stools)
74
Pancreatic Ca Ix
Amylase, Lipase, LFTs ERCP/MRCP AXR CA19.9, CEA, aFP
75
Causes of Pancreatitis
``` G: Gallstones E: Ethanol T: Trauma S: Scorpion/Spider Venom M: Mumps A: Autoimmune S: Steroids H: Hyperlipidaemia, Hypercalcaemia, Hypothermia E: ERCP D: Drugs ```
76
Pancreatitis Ix
FBC, U+Es, LFTs Raised Amylase/Lipase (More Sens) AXR ERCP/MRCP
77
Pancreatitis Mx
``` Reduce Sx (Stop Alcohol, Remove Stones, Opiates) Tx Cause (Electrolytes, ERCP, Steroids => Inflamm) Exocrine Support (DM Insulin) ```
78
Colon Ca Features
L: LIF Constipation, Tenesmus, Late Diarrh Anaemia (Blood of Surf + mixed) R: RIF Diarrh, Late Constipation Anaemia (Blood mixed)
79
Colon Ca Ix
AXR, CT | CEA, aFP, LDH
80
IBD Features (UC vs CD) - 5
``` UC: Rectum -> back (Continuous) Submucosal Inflamm No Granulomas Cobblestone, friable mucosa No Perianal D ``` ``` CD: Ileum (LIF, Skip lesions) Transmural Inflamm Non-caseating Granulomas Fissuring Ulcers, Crypt Abscesses Perianal D (Fistulas , Fissures, Strictures) ```
81
IBD Ix - 5
Faecal Calprotectin, Stool Cult (Excl: C.Diff) FBC, U+Es, LFTs, CRP/ESR Coeliac Serology (Anti-tTG) Serum Ferritin/B12/Folate/Vit.D (Malabsorption => Def) Sigmoidoscopy/Colonoscopy (+/- Biopsy)
82
IBD Mx
Steroids, Azathioprine, Sulfasalazine LMWHep (Acute: IV HC 100mg QDS)
83
Haemorrhoids Features
Prominent Vessels (Vascular bundles) Above (Painless) Below (Painful)
84
Haemorrhoids Classification
1: No Prolapse 2: Reduce Spontaneously 3: Reduce Manually 4: Unable to Reduce
85
Haemorrhoids Mx
GTN/CCB Cream | Staples, Bands, Incision
86
TB Screening
Immigrants from highly Prevalent (Endemic) Countries Healthcare workers HIV (+) Pt's Pt's beginning Immunosuppression
87
Latent TB Tx
Rifampicin + Isoniazid (with Pyridoxine) 3 months or Isoniazid (with Pyridoxine) 6 months (Avoid w/ Pt's > 35yo or at risk of Hepatotoxicity)
88
Active TB Features
Non-resolving Cough Unexplained Persistent Fever Drenching Night Sweats Unexplained Weight loss (Cachexia) ``` Other: Clubbing Lymphadenopathy Hepatosplenomegaly Erythema Nodosum Pleural Effusion Pericarditis ```
89
Active TB Ix + Findings
Sputum samples (3x AAFB + TB test), (If no Sputum: Bronchoscopy) CXR (Cavitating Pneumonia, Pleural Effusion), CT/MRI LN Biopsy + Histology (Caseating Granulomatous Inflamm) LP (Raised Proteins, Reduced Glu, Lymphocytosis)
90
Active TB Mx
2 months of RIFATER (RIPE) | 4 months of RIFINAH (RI)
91
Active TB Mx SE
RIP: Hepatotoxicity (Baseline LFT's) I: Periph Neuropathy (Pyridoxine) E: Retrobulbar Neuritis (Visual Acuity)
92
TB Paradoxical Reaction + Mx
Tx cause Bact to die => Inflamm Mx: Steroids (esp Pericardial + CNS): Prevent Inflamm
93
HIV Tx: | ARVTx
``` ARVTx: 2 Nucleoside Reverse Transcriptase Inhib + 1: Non-nucleoside Reverse Transcriptase Inhib, Boosted Transcriptase/Protease Inhib, Integrase Inhib ```
94
HIV Tx: Prophylaxis Vaccinations
Prophylaxis: (Falling CD4): CD4 < 200: Cotrimoxazole (PCP) CD4 < 50: Azithromycin (Mycobacterium) Vaccinations: Hep B Pneumococcus Annual Flu Vaccine
95
Skin Inf Org + ABx If MRSA: If Penicillin Allergy:
Strep + Staph: Flucloxacillin | If MRSA: Vancomycin (If Penicillin Allergy: Doxycycline, Meropenem)
96
MSK Inf Org + ABx
Strep + Staph: Tazocin
97
Resp Inf Org + ABx Atypical Viral
S Pneumoniae, H Influenzae: Amox, Co-amox, Doxy Atypical (Legionella): Doxy, Fluoroquinolone Viral (Rhino/Adeno/Entero): Oseltamivir
98
GI Inf Org + ABx
Salmonella: Ceftriaxone, Azithromycin C Diff: PO Vancomycin, Metronidazole (IV) Enterobacteria (Campylobacter, E-coli, Shigella): Ciprofloxacin
99
GUN Inf Org + Mx
Gonorrhoea: IM/IV Ceftriaxone Chlamydia: Doxy
100
CNS Inf Org + ABx
Meningitis (N. Men, S Pneum, H Influenzae): IV Ceftriaxone + Dexamethasone Viral (HSV): Aciclovir
101
CVS Inf Org + ABx IE Cult (-)
IE (S Viridans): Benzylpenicillin IE (S Aureus - IVDU): Flucloxacillin IE (Enterococci): Amox (Cult - ): Ceftriaxone
102
``` Dementia Types + Features Vascular D D w/ Lewy Bodies PD w/ D FT D ```
Vascular: Stepwise Progress w/ Risk Factors D w/ Lewy bodies: Gradually Progress (+/- PD Sx) Persistent, Realistic A+V Hallucinations ``` PD w/ Dementia: PD Sx (Bradykinesia, Rigidity, Tremor) precedes Dementia ``` FT Dementia: Early-onset, Complex problems (Loss of Social Inhib)
103
Delirium Mx
``` Reverse Cause: Hypoxia - O2, Electrolytes - Fluids, Inf - ABx, Obstruct/Retention - Laxatives/Catheter) ``` Orient to Time/Place Family members Avoid sedatives/anticonvulsants/Intoxicants
104
Confirming Death
Pupils fixed + Dilated No Resp to Pain No Breath/Heart Sounds (> 1min)
105
K+ Sparing and Non-K+ Sparing Diuretic Examples + SE
K+ Sparing: ACEi/ARB, Spirnolactone => Hyper-K+ Non-K+ Sparing: Thiazides (Inhib NCC in DCT) Loop (Inhib NKCC in Loop of Henle) => Hypo-K+
106
Causes of Hyper-K+
``` CKD +/- K+-rich Diet Drugs (K+-sparing, NSAIDs, Digoxin, Hep, Trimethoprim, Cyclosporin) Intracellular Shift: Decreased SNS (Beta-blockers) Decreased Insulin Decreased pH (Acidosis) Decreased Aldosterone (Addisons) Rhabdomyolysis/Haemolysis/Lysis ```
107
Hyper-K+ ECG changes
Tall, Peaked T waves Prolonged QRS Loss of P waves (=> Asystole)
108
Hyper-K+ Mx
Cardiac protection: IV 10ml 10% Ca2+ Gluconate (10mins) Shift K+ Intracellularly: IV Actrapid 10 Units + 50ml 50% Dextrose Neb Salbutamol 10mg (If Acidotic: IV 500ml 1.4% NaHCO3) Remove Excess: PO/PR Ca2+ Resonium IV 80mg Furosemide
109
Causes of Hypo-K+
Losses (Renal: Diuretics, GI: Reduced Intake, Vom/Diarrh) Intracellular Shift: Increased SNS (Beta-agonists, Adren) Increased Insulin Increased pH (Alkalosis) Increased Aldosterone (Hyperaldosteronism/Cushings, Hyper-RAAS)
110
Hypo-K+ ECG changes
Small T waves U wave (after T) Increase in PRi
111
Hypo-K+ Mx
(PO/IV) K+ and Mg2+ Supplements w/ IV Fluids
112
Causes of Hyper-Na+
Hypervolaemic: Hyperaldosteronism/Cushings Euvolaemic: DI, Hypodipsia Hypovolaemic: Diuretics, Diarrh, Sweating
113
Hyper-Na+ Mx
Hypervolaemic: (Chronic): Fluid restrict +/- Furosemide, (Nutritional Support) Euvolaemic: IV Dextrose Hypovolaemic: (Acute): IV NaCl 0.9%
114
Causes of Hypo-Na+
Hypervolaemic: 3rd Spacing (HF, Cirrhosis, Nephrotic Synd) Polydipsia Euvolaemic: SIADH HypoTh Preg Hypovolaemic: Fluid loss (Vom/Diarrh, Bleeds, Diuretics, Burns) Pancreatitis Hypoaldosteronism (CAH/Addisons)
115
Hypo-Na+ Mx
IV NaCl 0.9%
116
AKI Classification
1: Serum Cr x 1.5-2 2: Serum Cr x 2-3 3: Serum Cr x > 3, UO < 0.5ml/Kg/hr
117
Causes of Pre-renal AKI
Hypoperfusion: Hypovolaemia HF Impaired Auto-regulation (ACEi/ARB, NSAIDs)
118
Pre-renal AKI Ix + Mx
FBC, U+Es, BP, RAAS Mx: Stop meds Tx Hypovolaemia/Sepsis/Anaemia
119
Causes of Renal AKI
Drugs (Nephrotoxins) Inflamm (GN, Vasculitis), Inf Trauma (HT, Sepsis/Ischaemia)
120
Renal AKI Ix + Mx
Urinalysis, Renal Biopsy, CRP/ESR, USS-KUB ``` Mx: Stop Nephrotoxicity meds Tx Cause Assess Fluid balance Steroids (Reduce Inflamm) ```
121
Def ATN + Mx
Fluid-resistant AKI Mx: Stop IV Fluids (+/- => Pulmon Oedema) Fluid restriction + Diuretics
122
Cause of Post-renal AKI, Ix + Mx
Obstruction USS-KUB Mx: Surg
123
RRTx Indications
Uraemic Pericarditis/Encephalopathy Intoxicants (Antifreeze, Methanol, Lithium) Fluid-overloaded despite Diuretics Hyperkalaemia, Metabolic Acidosis despite Tx
124
CKD Causes
Diabetic HT APCKD
125
Diabetic CKD Ix
Raised Urin Albumin : Cr (Raised PCR): > 2.5 (Females)/ > 3.5 (Males) Glu on Dipstick (Evidence of poorly-controlled DM: Retinopathy, Nephropathy, Neuropathy)
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HT in CKD Ix
``` Urin metanephrines (Phaeochromocytoma) Aldosterone : Renin (Hyperaldosteronism) Dexamethasone Supp test (Cushings) T3/4, TSH (HyperTh) MR Angiography (Renal A Stenosis) ```
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DM/HT CKD Mx
ACEi/ARBs (HT + Proteinuria) Statin (Reduce CVS Risk Factors) Screening (Microvascular Complications)
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APCKD Ix + Mx
(+) FHx USS (Kidneys + Liver) Mx: ACEi/ARBs (HT + Proteinuria) Tolvaptan (ADH Antag: Reduce Cysts)
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CKD Classification
eGFR 1: > 90 2: 60-90 3a: 45-60 3b: 30-45 4: < 30
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CKD Complications (Anaemia) Patho - 5
``` Anaemia: Reduced EPO Blood loss + Reduced lifespan of RBC's Uraemic Myelosuppression Fe Def (Absolute: Reduced Absorption, Funct: Inflamm => Raised Hepcidin) Vit B12/Folate Def ```
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CKD Complications (Min Bone D)
Min Bone D: Increased Excretion of PO4- Reduced Synthesis of Vit D (=> Reduced Absorption of Ca2+) Hypocalcaemia => Rise in PTH Hyper-PTH => Increase in ALP (Increase Bone Turnover + Osteoclast Act) => Rise in Serum Ca2+ (Tertiary Hyper-PTH: High PTH + Ca2+) => Vascular/Soft Tissue Calcification + Skeletal PTH Resistance (Osteodystrophy)
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Causes of Nephrotic Synd
Min change D (M Common in Children) Focal Segmental Glomerulosclerosis Membranous Nephropathy
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Nephrotic Synd Features
Proteinuria Hypoalbuminaemia Ascites, Oedema (Hyperlipidaemia)
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Nephrotic Synd Mx
``` Tx Cause ACEi/ARB (HT, Proteinuria) Diuretics (Reduce Oedema) LMWHep Statins (Hyperlipid) ```
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Causes of Nephritic Synd
Autoimmune/Inflamm (SLE, Vasculitis, IgA) | Inf (HIV, Hep B/C, IE, Post-strep)
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Nephritic Synd Features
Oliguria, AKI (Drop in eGFR) Haematuria Proteinuria HT
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Nephritic Synd Mx
``` Tx Cause ACEi/ARB (HT, Proteinuria) Diuretics (Reduce Oedema) LMWHep Steroids (Reduce Inflamm) ```
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Blood Gas Features: Alkalosis Acidosis
Alkalosis (pH > 7): Resp (pCO2 Low) Metabolic (BE High) Acidosis (pH < 7): Resp (pCO2 High) Metabolic (BE Low) - Anion Gap: Na - (HCO3 + Cl) = 8-12 (H+ added: AG > 12, HCO3- lost: AG < 8)
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Causes of Alkalosis + Acidosis
Resp Alkalosis: Hyperventilation Metabolic Alkalosis: Loss of Acid (GI/Renal Loss) Resp Acidosis: Poor Ventilation Metabolic Acidosis: Gain of Acid (Toxins + Renal Fail, Lactic Acidosis, DKA), Loss of Base (GI/Renal Loss)
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Fluid Routine maintenance
H2O: 25-30ml/Kg/day K+/Na+/Cl-: 1mmol/Kg/day Glu: 100g/day
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Fluid Resus Indications + Mx
``` Syst BP < 100 HR > 90 RR> 20 CRT> 2s NEWS > 5 ``` Mx: IV 0.9% NaCl 500ml over 15mins
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Asthma Mx
1: SABA (Blue Reliever) 2: ICS (Brown Preventer) 3: + LTRA (Montelukast) 4: + LABA (w/ SABA, Remove LTRA) 5: LABA + ICS (MART) - Begin Increasing dose of ICS 6: MART + LTRA 7: + Aminophylline/LAMA (Ipratropium)
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Severe vs Life-threatening vs Near-fatal Asthma
Severe: Cannot complete sentences RR > 25, HR > 110, PEFR: 33-50% Life-threatening: Silent Chest, Cyanosis RR < 12, HR < 60, PEFR: < 33%, SpO2 < 92% Near-fatal: Hypercapnia + Hypoxia (T2RF) Req Mech Ventilation
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Acute Asthma Exacerbation Mx: | If Severe/Life-threatening/Near-fatal
``` ABCDE O2 Neb Salbutamol 5mg PO Pred 40mg (If Severe: Neb Ipratropium 500 micrograms) (If Life-threatening: IV Aminophylline) (If Near-fatal: Mech Ventilation) ```
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Asthma Safe Discharge
``` Off Nebs > 24hrs Peak Flow > 75% Nurse R/v PO Pred 40mg 5 days GP f/up w/in 2 days OTP Asthma Clinic w/in 4wks Peak Flow Meter + Written Action Plan ```
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Inadequate Asthma Control Sx - 5
``` Rescue meds > twice a week Sx > twice a week Awakening w/ Sx Excessive SE's or Sx => Activity limitation FEV1: < 80% ```
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Acute COPD Exacerbation Mx - 6
``` ABCDE O2 (88-92%) via Venturi mask Neb Salbutamol 5mg Neb Ipratropium 500 micrograms PO Pred 30mg STAT + OD (7 days) (If Inf: CXR, IV Abx + f/up) ```
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COPD Mx: Care bundle - 2 Med - 5 Surg - 1
Care bundle: Pulmon Rehab Smoking Cessation ``` Med: Bronchodilators (Beta-Agonists) Antimuscarinics (Ipratropium) Steroids, Mucolytics LTOT (Non-smokers w/ SpO2: < 7.3KPa, < 8KPa w/ CP) ``` Surg: Lung Vol Reduction (Lobectomy)
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Bronchiectasis Sx
Large Vol of Clear Sputum Chronic Cough/SOB Obstruct LD
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Bronchiectasis Ix + Findings
``` HR CT (Signet rings: Thickened Alveolar Walls) CXR (Lobar Collapse/Atelectasis, Intercurrent Inf) ```
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Bronchiectasis Mx - 6
Physio (Improve Mucus Clearing) (If MRC Dyspnoea Score > 3: Pulmon Rehab) Bronchodilators Flu Vaccine Reg ABx (After 3 Exacerbations and + Cult) (If Inf Exacerbation: ABx for 14 days, may need to change class if already taking Reg)
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MRC Dyspnoea Score - 5
1: No Sx 2: SOB walking up hill 3: SOB => Slower walking 4: SOB => Stop after 100m or 2mins 5: SOB => Immobility
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Pneumonia Scoring
``` CURB-65: Confusion Urea > 7mmol RR > 30 BP < 90 (Syst) Age > 65yo ```
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Causes of Non-resolving Pneumonia Inf
``` C: Complication (Abscess, Empyema) H: Host (Immunosupp) A: Abx (Inadequate) O: Org (Atypical, Resistant) S: Secondary Diagnosis (PE, Cancer) ```
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Haemoptysis Mx + Ix - 6
``` ABCDE O2 Lie Pt on side of Lesion IV/PO Tranexamic Acid (Antifibrinolytic) Stop Anticoags + NSAIDs ``` CT Aortogram
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Haemoptysis Ddx
Inf (TB, CF, Bronchiectasis, Fungal, Pneumonia) Malig (Primary, Mets) Bleeding D (Vasculitis, Coagulopathy, PE, Arterial Erosion)
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Tension Pneumothorax Criteria
Pleuritic Chest Pain SOB Silent Lung, Hyperresonance, Asymmetrical Chest Expansion Shock (TachyC, HypoT) (Deviated Trachea + Mediastinal Shift Away)
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Tension Pneumothorax Mx
Large Bore Cannula + Chest Drain (2nd IC Space MCL, Above Rib)
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Anaphylaxis Mx
``` ABCDE O2 + Secure Airway Remove Trigger IM Adren 0.5mg (Repeat every 5mins) IV HC 200mg + Chlorpheniramine 10mg ```
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PE Sx + Signs
Sx: Sudden, Constant, Severe Pleuritic Chest Pain SOB, Cough (+/- Haemoptysis) Signs: (Recent DVT) Shock (TachyC, HypoT) Pulmon HT, RV Strain
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PE Mx + Ix
``` ABCDE O2 Anticoag IV Alteplase (Thrombolysis) (Confirm RV Strain: CT/Echo/ECG) ```
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Def FEV1 + FEVC
FEV1: Vol of Air expelled in 1s after Max Inspiration FEVC: Total Vol of Air expelled after Max Inspiration
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Obstructive vs Restrictive Lung Function
Obstruct: (FEV1:FEVC 50%) Normal/Low FEVC Reduced FEV1 Restrict: (FEV1:FEVC 90%) Reduced FEVC Reduced FEV1
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TB Supp Mx - 4
Admit to SR Specialist TB Nurse Notify Public Health Start ABx
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CF Advice - 8
``` No Smoking Annual Flu Vaccine Avoid other CF Pt's or Pt's w/ Pneumonia Avoid Smokers Avoid Animals/Composts (Aspergillus) Avoid Jacuzzis (Pseudomonas) Clean + Dry Nebulisers Regularly Frequent fluids + NaCl Tablets (esp during Illness/Exertion) ```
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Lung Ca Sx + Complications
Hoarse Voice, Dysphonia SOB, Dry Cough, Haemoptysis B Sx Lymphadenopathy SVCO (Facial Oedema, Engorged Neck Veins, Airway Compromise) Horner's Synd (Miosis, Anhidrosis, Ptosis, Enopthalmos)
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Lung Ca Paraneoplastic Syndromes
Anaemia, Clubbing SIADH (Small Cell LC) Cushings (Small Cell LC) Hyper-PTH/Hypercalcaemia (Squamous Cell LC)
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Lung Ca Ix
CXR Staging CT (Spiral Thorax + Abdo) US-guided FNA of LN
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ILD Sx - 4
SOB Dry Cough Restrictive Lung Pattern (Reduced FEV1 + FEVC) Weight loss
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Transudate vs Exudate
Transudate: (Prot < 30g/L): HF Cirrhosis Hypo-Albumin Exudate: (Prot > 30g/L): Inf (HIV, TB) Malig Inflamm
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Pleural Effusion Ix
US-guided Pleural Aspiration: Biochem (Protein, LDH, pH, Cytology) Microbiology (Microscopy, Culture + Sensitivity)
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``` Added Lung Sounds Features: Crackles Wheeze Stridor Pleural Rub ```
Crackles: Inspiratory (Opening of Alveoli) Fine (Fibrosis) + Coarse (Effusion, Consolidation) Wheeze: Continuous, Musical High-pitch (Bronchospasm) + Low-pitch/Rhonchi (Secretions) Stridor: Inspiratory, High-pitch Whistle (Large Airway Obstruct) Pleural Rub: Inspiratory, Grating (Friction of Inflamm Pleura)
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OA Xray changes
Loss of Joint space Osteophytes Subchondral Sclerosis Subchondral Cysts
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RA Xray changes
Loss of Joint Space Erosions Soft Tissue swelling Soft Bones (Osteomalacia)
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OA Mx
OT/PT Walking Aids Analgesia (NSAIDs, Paracetamol, Opiates) Surg (Joint Replacement/ Fusion)
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RA Mx: Conservative Med Surg
OT/PT +/- Walking Aids Analgesia (Opiates) DMARDs (After 2 Failed DMARDs: Monoclonal AB's - Rituximab: CD20 Inhib) Surg (Joint Replacement)
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Sero (-) Spondyloarthropathies Types + Features
(+) HLA-B27, (-) RhF Psoriatic Enteropathic Reiters Ankylosing Spondylitis
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Psoriatic Features
``` R: Rheumatoid Arthritis (Hands + Wrists) O: Oligo (2-4 Joints) A: Arthritis Mutilans (Erosions => Deformities) D: Dactylitis (Sausage-shaped fingers) S: Sacroiliac Back Pain (Psoriatic Plaques) ```
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Enteropathic Features + Mx
IBD Asymmetrical Arthritis of Digits Mx: DMARDs + Anti-TNF (Avoid NSAIDs - IBD)
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Reiters Synd Features, Ix, Mx
(Knee) Arthritis following Urethritis (STI) + Conjunctivitis Severe, Unilat Pain (Unable to Flex/Ext Passively/Actively) Fever, Raised WCC Ix: Joint Asp Mx: IV ABx 6wks
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Ankylosing Spondylitis Features - 3
Back/Buttock Pain (Radiates Up) Spinal Deformities (Kyphosis, Scoliosis) + Reduced/Asymmetrical Chest Wall Expansion LL Weakness/Paraesthesia
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Sjogrens Sx + Ix
``` M: Myalgia A: Arthritis D: Dry Eyes F: Fatigue R: Raynaud's E: Enlarged Parotids D: Dry Mouth ``` Ix: Raised Anti-Ro/La, RhF
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Sjogrens Mx
Anti-Inflamm | Frequent fluids, Eye Lubricants
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SLE Sx
S: Serositis (Pericarditis, Pleurisy) O: Oral Ulcers A: Arthralgia P: Photosensitive Rash
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SLE Ix
Normal CRP, Raised ESR/PV Anti-Ro/La, Anti-dsDNA Haem changes (Anaemia, Thrombocytopaenia, Leukopaenia + Low Complement Proteins)
186
SLE Mx
Anti-Inflamm (DMARDs) | Sun Protection
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PMR Sx + Ix
Widespread Pain (Shoulders, Neck/Spine, Hips) Fatigue, Fever, Weight Loss Headache (Associated w/ GCA) Ix: Raised CRP/ESR (+) ANA/ANCA
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PMR Mx | No Improvement
15mg Prednisolone, (Methotrexate: Steroid-sparing) | If no Improvement w/in 18 month: Reconsider Ddx - Cancer, RA
189
GCA Sx
``` Jaw Claudication Scalp Tenderness Unilat Throbbing/Pulsating Headache Vision changes (Diplopia, Blindness) (Associated w/ PMR) ```
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GCA Ix + Mx
Temple A Biopsy (Giant Cell Granulomas + Necrotising Vasculitis) Mx: Prednisolone 60mg 2wks Aspirin (Prevent VTE) (If Vision changes: IV Methylpred 1g)
191
Osteopaenia/Osteoporosis Features + Ix
Rib/Vertebral #'s w/out Trauma ``` Ix: Dexa scan (T: < -1) ```
192
Vasculitis Sx - 6
``` Fever Fatigue Weight loss Rash Haematuria SOB ```
193
Vasculitis Mx
ID Cause, Stop Drugs | Steroids/DMARDs (Excl Inf before starting)
194
Gout vs Crystal Arthropathy
Gout: (-) Bifringent Crystals Crystal Arthropathy: (+) Bifringent Crystals
195
Gout Mx
Diet/Lifestyle changes (Reduce Meat/Alcohol, Avoid Dehydration) Acute: NSAIDs, Colchicine Prophylaxis: Allopurinol
196
Crystal Arthropathy Mx
Acute: NSAIDs Prophylaxis: Colchicine
197
Fibromyalgia Triad + Sx
Pain, Poor sleep, Fatigue Vague, Widespread Pain (Above + Below, Bilat) Fibrofog (Diff Conc) Diff Sleeping, Exercising Fatigue, Fever, Weight loss
198
Fibromyalgia Ix
``` Normal Ix (No Raised CRP/ESR/PV) Normal Exam ```
199
Fibromyalgia Mx
Education CBT Amitriptyline
200
Scleroderma Patho, Sx + Ix
Fibrosis of CT => Raynauds, Calcinosis, HT | Ix: +) ANA (Normal CRP/ESR/PV
201
Scleroderma Synd
``` C: Calcinosis Cutis R: Raynauds E: Oesophageal Dysmotility S: Sclerodactyly T: Telangiectasia ```
202
Scleroderma Mx
Scleroderma: Methotrexate (Flares: Prednisolone) Calcinosis: Ca2+ Antagonist HT: ACEi
203
Dermamyositis/Polymyositis Sx + Ix
Acute + Symmetrical M Weakness (=> SOB) Photosensitive Rash Raynauds Ix: Raised CK, ALT Normal CRP
204
Bisphosphonates Indications, Info, SE
Indications: Osteoporosis, (Co-prescribed w/ Steroids) (Ca2+, Vit D Co-prescribed) Taken weekly, w/ water on empty stomach, whilst standing/sitting upright + for 30mins after +/- Oesophagitis (Discontinue)
205
Monoclonal AB's Info
Require TB test | Increased risk of Intracellular Pathogens (Viral/Parasite)
206
Sulfasalazine Contraindications
Aspirin Allergy | Do not take w/ NSAIDs => Kidney Fail, Peptic Ulcers
207
Azathioprine Info
Assess TPMT Act (+/- => Myelosuppression) Reg weekly FBC test for 8wks +/- Skin sensitisation (Sunscreen)
208
Methotrexate Info
Require Contraception + Preg test (Teratogenic) | Weekly doses w/ Folic Acid Supplements
209
Inflamm vs Mech Pain
Inflamm: Improves w/ Activity Fatigue + Syst Sx Mech: Better w/ Rest (Shorter morning Stiffness) No Fatigue/Syst Sx
210
HF (w/ Reduced EF) Mx
ACEi Beta-blocker +/- Spironolactone (Annual Flu Vaccine, One-off Pneumococcal Vaccine)
211
HF CXR Signs
``` A: Alveolar oedema (Bat wing opacities) B: Kerley B lines (Horizontal lines) C: Cardiomegaly D: Dilated upper lobe vessels (Pulmonary Congestion) E: Effusion (Pleural) ```
212
BPH Mx
Alpha-1 Antag (Tamsulosin) 5a-Reductase Inhib (Finasteride) TURP
213
Post-MI Complications
``` Death Arrhythmia Rupture Tamponade HF Valvular D Aneurysm Dressers (Pericarditis) Embolus Recurrence ```
214
COPD Diagnosis + Ix
Post-bronchodilator FEV1 < 0.7 PEFR/Spirometry CXR (Emphysema: Bullae, Hyperinflation: Flattened Diaphragm + Barrel-chest A-P on Lat) FBC (Anaemia/Polycythaemia, Eosinophil Count) BMI (Serum alpha1 Anti-trypsin Def)
215
Asthmatic/Steroid-Responsive Features
Diagnosis of Asthma/Atopy Raised Eosinophil Count Diurnal variation of PEFR Variation of FEV1
216
COPD Step-up Mx
1: SABA/SAMA 2: (If no Asthmatic/Steroid-Resp): SABA + LABA + LAMA (Discontinue SAMA) +/- ICS 2: (If Asthmatic/Steroid-Resp): SABA + LABA + ICS +/- LAMA (Discontinue SAMA) (Prophylactic ABx: Azithromycin)
217
COPD Staging
S1: (Mild): FEV1 > 80% S2: (Mod): FEV1 50-70% S3: (Sev): FEV1 30-50% S4: (V.Sev): FEV1 < 30%
218
GI Tract Blood Supply
Coeliac Trunk (Comm Hep, Splenic, L Gastric) Sup Mesenteric (Middle Colic, Right Colic, Ileocolic, Jejunal + Ileal) Inf Mesenteric (L Colic, Sigmoid, Sup Rectal)
219
GI Anatomy affected by Ulcers
Post Gastric: Splenic A, Pancreas L Curvature: L Gastric A Duodenal: Gastroduodenal A
220
Virchows Triad of Clotting
``` Hypercoaguability (Surg/Trauma, Malig, Preg, Sepsis, Inflamm/Auto-Immune) Endothelial Inj (Atherosclerosis, Vasculitis, Thrombophlebitis) Haemostasis/Turbulent Blood flow (Immobility, AF/Arrhythmias, BradyC/HypoT, Venous Obstruct) ```
221
Acute LVHF Mx
``` (Sit Pt up) Morphine + Antiemetic O2 IV Furosemide 80mg SL GTN (+/- Isosorbide Nitrate +/- CPAP) ```
222
Stroke Ix + Mx
Non-contrast CT Head: - If Haem: Refer to Neurosurg (Do not give Aspirin/Thrombolysis), Reverse Anticoags - If Ischaemic: Aspirin 300mg (If < 80yo + Pc < 4.5hrs => Thrombolysis: IV Alteplase)