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4th Year > ACC > Flashcards

ACC Flashcards

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1
Q

Things to do in A (5)

A 
Airway patency - suction and maintain
Are they talking?
15L/min O2
C-spine check
Tracheal position
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2
Q

Things to do in B (8)

A 
Chest injuries and expansion
Respiratory Effort
RR
O2 Sats
Auscultate and percuss
ABG
CXR
PEFR
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3
Q

Things to do in C (7)

A 
Cap refill
Urine output (+confusion)
Pulses
BP
Auscultate
IV access - bloods and fluids
ECG (+ echo)
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4
Q

Likely bloods needed (8)

A 
FBC
U+E
LFT
Clotting
CRP
X-match
Group and Save
Cultures
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5
Q

Things to do in D (4)

A

GCS
BGL
Pupils
Temperature

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6
Q

Things to do in E (3)

A

Quick exposure
Abdo/neuro/spinal exam
Get help etc.

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7
Q

STEMI Management

A

MONAP

Morphine 1-10mg + Metoclopramide 10mg
Oxygen
GTN spray 2 puffs
Aspirin 300mg
PCI within 12hrs/90mins of Dx - give Ticagrelor and LMWH (Fondaparinux) before
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8
Q

What if PCI is impossible?

A

Fibrinolysis with Altepase and LMWH

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9
Q

NSTEMI Management

A

MONAG

Morphine 1-10mg + Metoclopramide 10mg
Oxygen
GTN spray 2 puffs
Aspirin 300m
Grace Score
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10
Q

What does the Grace score tell us?

A 
<1.5% = Clopidogrel 300mg
1.5-3% = Fondaparinux 2.5mg
>3% = PCI within 96hrs with Clopidogrel, LMWH and IV Eptifibatide
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11
Q

Post N/STEMI Management

A

COBRAS + lifestyle

Clopidogrel 75mg OD
Omega 3
Bisoprolol 2.5mg OR
Ramipril 2.5mg OD
Aspirin 75mg OD
Statin (Atorvastatin 80mg OD)
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12
Q

Which LMWH should be used with renal impairment?

A

Enoxaparin

NOT Fondaparinux

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13
Q

Post-PCI anticoagulation

HAS-BLED 0-2

A 
0-6m = Warfarin, Aspirin, Clopidogrel
6-12m = W + A or C
Lifelong = Warfarin/NOAC?
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14
Q

Post-PCI anticoagulation

HAS-BLED >2

A 
0-4wks = W, A, C
1-12m = W + A or C
Lifelong = Warfarin?
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15
Q

When to PCI (4)

A

<12hrs since onset
New LBBB or ongoing chest pain after Tx
ST elevation >1mm in 2 limb leads
ST elevation >2mm in 2+ consecutive chest leads

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16
Q

Blood markers for MI

A

Troponin T & I - increases at 3hrs, peak at 24hrs, can’t perform within 2hrs (might be 6hrs), <5 rules out MI
Creatinine Kinase - increases at 4-8hrs, peaks at 24hrs

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17
Q

Aortic dissection Sx

A

Sudden, severe, tearing chest pain
Radiates into back
Syncope
Dyspnoea

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18
Q

Types of Aortic Dissection

A 
70% = Ascending Aorta = Type A (35% mortality)
30% = Descending Aorta = Type B (15% mortality)

Debakey I = Asc + Desc
Debakey II = Asc only - associated with MI + neuro Sx
Debakey III = Desc only - associated with AKI

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19
Q

Aortic Dissection risk factors

A

Male >50yrs
HTN
Aortic stenosis/bicuspid valve

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20
Q

Aortic Dissection CXR findings (5)

A 
Wide mediastinum
Double knuckle aorta
R-side tracheal deviation
Pleural effusion L>R
Separated aortic wall
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21
Q

Diagnostic test for Aortic Dissection

A

CT angiogram

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22
Q

Aortic Dissection management

A

Treat as shock
IV Beta-blocker
Type A = open stent graft repair
Type B = endovascular repair

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23
Q

Signs of acute severe asthma

A

PEFR 33-50%
HR >110
RR >25
Incomplete sentences

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24
Q

Signs of acute life-threatening asthma

A 
PEFR <33%
Sats <92%
Silent chest
Poor respiratory effort
Cyanosis
Confusion
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25
Sign for near fatal asthma
PaCO2 >6 = may need mechanical intervention
26
Management of Acute Asthma
O SHIT ME Oxygen 15L Salbutamol 5mg O2-driven nebs, repeat every 10-15mins Hydrocortisone 200mg/Prednisolone 40mg Ipratropium bromide 500mcg neb if severe/life-threatening Theophylline 5mg/kg IV bolus if no improvement Mag Sulph 2g IV
27
Management of COPD exacerbation
O SHIT Oxygen 15L - careful not to drive sats too high Salbutamol 5g + IpBromide 500mcg air-driven nebs, repeat 10-15mins Hydrocortisone 200mg IV/Prednisolone 40mg Aminophylline 5mg/kg bolus if no improvement (CO2 increasing, GCS decreasing) BiPAP if unable to expel adequate CO2 -> pH increasing
28
Infective exacerbation of COPD Abx
Amoxicillin, Doxycycine or Erythromycin Often A+D 7 days
29
CAP organisms
``` Strep pneumoniae Mycoplasma Moraxella catarrhalis S aureus HiB ```
30
HAP organisms
Gram -ve enterbacteria S aureus Pseudomonas Klebsiella
31
What is CURB65?
``` Confusion - AMTS <8 Urea >7 RR >30 BP <90 systolic >65yrs old ``` ``` 0-1 = Home 2 = Admit 3+ = ICU ```
32
What is temporal arteritis?
Immune-mediated vasculitis of posterior ciliary arteries Associated with polymyalgia rheumatica
33
Why is temporal arteritis important to diagnose?
Can cause ischaemic optic neuritis -> vision loss
34
Who should you suspect temporal arteritis in?
>50yr old with new acute headache
35
What are the features of temporal arteritis?
Diffuse superficial headache and scalp tenderness, esp over temporal artery Jaw claudication - worse with eating Distended throbbing temporal artery Transient vision loss Nausea Fever Sweat
36
What investigations do you need for temporal arteritis?
Temporal artery biopsy = definitive ESR and CRP both increased
37
What is the management of temporal arteritis?
Oral prednisolone 60mg daily Vision changes = seen same day No vision changes = assess response in 48hrs Reduce dose over several months, Tx for 1-2yrs Also start Aspirin and PPI daily
38
What is a venous sinus thrombosis?
Thrombosis in brain venous channels Most commonly sagittal sinus (47%) and transverse sinus (35%)
39
Who is at risk of a venous sinus thrombosis?
``` Thrombophilia Nephrotic syndrome Pregnancy COCP Malignancy Chronic inflammation etc. ```
40
What are the features of a venous sinus thrombosis?
``` Headache Vomiting Seizures Increased ICP - papilloedema, risk of herniation Vision changes ``` May present like stroke May cause haemorrhage
41
What investigations are needed for a venous sinus thrombosis?
Head CT/MRI D-dimer APTT Clotting/thrombophilia screen
42
What is the management of venous sinus thrombosis?
LMWH then Warfarin (INR 2-3) | Thrombolysis with altepase if not resolved in 2(?) days
43
What is likely to cause an extradural haemorrhage?
Temporal bone fracture -> damage to Middle Meningeal Artery
44
What happens with MMA bleed?
Lose consciousness, return to full consciousness, deteriorate again with raised ICP
45
Where is a subdural haemorrhage most likely to occur from?
Bridging vein between brain and dura
46
5 signs of basal skull fracture
Panda eyes - orbital bruising Battle sign - mastoid bruising (takes days to appear) Subconjunctival haemorrhage Bleeding from auditory meatus/haemotympanum CSF otorrhoea/rhinorrhoea
47
When should you perform a head CT within <1hr following head injury? (7)
``` GCS <13 initially GCS <15 2hrs post-injury Suspected skull fracture Signs of basal skull fracture Focal neurological deficit Post-trauma seizure >1 episode of vomiting ```
48
When should you perform a head CT within 8hrs following head injury? (5)
Age >65yrs Hx of bleeding/clotting disorders On Warfarin Dangerous mechanism of injury eg. high fall, hit by car >30mins retrograde amnesia of events prior to injury
49
When should you perform a head CT within <1hr following head injury on a CHILD? (8)
``` Suspicion of NAI GCS <14 initially GCS <15 <1yr old or 2hrs post-injury <1yr with bruise/swelling/laceration >5cm on head Suspected fracture or tense fontanelle Focal neurological deficit Post-trauma seizure 2+ of: drowsy, LoC, amnesia >5mins, 3+ episodes of vomiting, dangerous mechanism ```
50
What is Cushing's reflex?
Triad of: - Increased BP - Irregular breathing - Bradycardia Late sign of raised ICP - may indicate imminent brain herniation
51
What pupil signs may you get with raised ICP?
Ipsilateral pupil dilation Due to temporal lobe herniation pressing on oculomotor nerve
52
What are the high risk factors for C-spine injury? (3)
>65yr old Dangerous mechanism Extremity paraesthesia (Any of these = 3-view C-spine X-ray within 1hr) 'Sixty five, Fast drive, Sense deprive - Image if alive'
53
What are the low risk factors for C-spine injury? (5)
``` Simple rear-end MCV Delayed neck pain Sitting in ED Ambulatory at ANY TIME Absence of midline tenderness (Any of these = low risk, none of these = C-spine X-ray) ``` 'Slow wreck, Slow neck, Sitting down, Walking 'round, C-spine fine - Range the spine'
54
What is if they are low-risk for C-spine injury?
Range of movement Can they rotate their neck 45 degree each way Yes = fine, No = C-spine X-ray 'If you can look both ways, you can cross the road... without imaging'
55
What is the prognosis of a space-occupying lesion?
<50% survival at 5yrs
56
What are the features of primary brain tumours?
Headache - worse when lying, bending, coughing, wakes patient up Vomiting Increased ICP - papiloedema, I/L pupil dilation etc Decreased GCS (late) Focal neurology - CN VI palsy most common (Lateral Rectus palsy) Behaviour changes Visual disturbances Seizures <50%
57
What investigations are necessary for a brain tumour?
CT +/- MRI | Avoid LP due to coning risk
58
What is the management of brain tumours?
Dexamethasone 4mg TDS for raised ICP Surgical removal if possible + chemo-radiotherapy Seizure prophylaxis
59
What would localise a lesion to the temporal lobe? (4)
Amnesia Hallucination of sound/smell Dysphasia Contralateral homonymous hemianopia
60
What would localise a lesion to the frontal lobe? (4)
Contralateral hemiparesis Personality change Broca's aphasia Unilateral anosmia
61
What would localise a lesion to the parietal lobe? (3)
Contralateral hemisensory loss Astereogenesis - inability to recognise objects from touch alone Sensory inattention
62
What would localise a lesion to the occipital lobe?
Contralateral visual field loss | Diplopia/polyopia
63
What would localise a lesion to the cerebellum? DASHING
``` DASHING Dysdiadochokinesis + past-pointing Ataxia Slurred speech Hypotonia Intention tremor Nystagmus Gait abnormalities ```
64
What is meningitis?
Inflammation of the meninges | Often viral/bacterial
65
What are the common bacterial causes by age-group?
``` Neonate = Group B Strep >3m = N. Meningitidis, Strep pneumoniae, HiB Adults = N. Meningitidis (G-), Strep. pneumoniae (G+) ```
66
What are the common viral causes?
Enterovirus HSV1 Coxsackie
67
What are the features of meningitis?
Headache Photophobia Neck stiffness Purpuric non-blanching rash (septic)
68
What are the features of meningitis in an infant?
``` Drowsy/decreased GCS Vomiting Irritable Feverish Seizures Opisthotonus Bulging fontanelle High-pitched crying Not feeding ```
69
What will an LP show for viral meningitis?
Clear CSF Normal plasma glucose ratio Normal protein 15-1000 LYMPHOCYTES
70
What will an LP show for bacterial meningitis?
Cloudy CSF Low glucose, <50% of plasma High protein, >1g/L 10-5000 NEUTROPHILS
71
What will an LP show for TB meningitis?
Cloudy CSF with fibrin web Low glucose, <50% of plasma High protein, >1g/L 10-1000 LYMPHOCYTES
72
What is the management of bacterial meningitis?
Benzylpenicillin IM in the community ``` <3m = IV 2g cefotaxime + IV ampicillin (Listeria cover) >3m = IV 2g cefotaxime + dexamethasone once confirmed bacterial with LP ```
73
What is the management of viral meningitis?
Supportive | Self-limiting after 4-10 days
74
What is the San Francisco Syncope Rule?
CHESS ``` CHF Hx Haematocrit <30% ECG abnormality SoB Systolic BP <90 ``` Any of these = high-risk of adverse outcome
75
What types of stroke are there?
``` 85% = ischaemic 15% = haemorrhagic ```
76
What are the features of a stroke?
Sudden onset focal neurology lasting for >24hrs ``` BEFAST Balance problems Eye - visual disturbance Face drooping Arm weakness Speech slurred Time to call 999 ```
77
What is the Rosier score? (7)
``` One point for each of: Contralateral arm weakness Contralateral leg weakness Ipsilateral facial weakness Slurred speech Visual field defect Seizure (-1) LoC/syncope (-1) ``` 1+ = likely having a stroke
78
What bloods do you need if you suspect a stroke?
``` FBC U&E LFT Glucose Lipids Clotting Cardiac enzymes Group and Save ```
79
When do you need a head CT within 1hr if you suspect a stroke? (5)
``` <4hrs since Sx - thrombolysis window GCS <13 Risk of bleeding - oral anticoagulation or bleeding disorder Severe headache at onset Evidence of raised ICP ```
80
What else might you need if you suspect and anterior circulation stroke? (3)
Echo Carotid doppler 24hr ECG
81
What is the initial management of a stroke?
Head CT Thrombolysis if <4hrs with Altepase 900mcg/kg (max 90mg) IV over 60mins SaLT to assess swallow, NBM in meantime Admit to stroke ward Haemorrhagic = some suitable for surgery
82
What is the management of a TIA?
Within 1 week = 300mg Aspirin and urgent assessment | >1 week ago = assessment with 7 days
83
What is secondary prevention of strokes?
``` Triple anti + lipids Antiplatelet = Clopidogrel 75mg OD Anti-HTN = BP control Anti-coagulation = Warfarin/NOAC Lipids = Statin ``` Influenze vaccine No driving for 1 month
84
What is in the HAS-BLED score?
``` Hypertension Abnormal renal or liver function Stroke Hx Bleeding disorder Labile INR Age >65 Drugs or alcohol ``` Max score = 9, >2 = high risk of bleeding
85
How does DKA arise?
Lack of insulin -> Low cellular glucose uptake -> Ketone metabolism used
86
Who gets DKA?
Younger females, unknown diabetes Hx
87
What are the features of DKA?
``` Polyuria and polydipsia Severe dehydration Nausea and vomiting Hyperventilation - Kussmaul breathing Pear-drop breath Cramps Drowsiness ```
88
What investigations should you do if you suspect DKA?
Blood Glucose - very high U&E - raised urea, raised Na+, raised/lowered K+ FBC - may have raised WCC Plasma osmolarity ABG/VBG - metabolic acidosis with respiratory compensation Urine - shows ketones +++ ECG, CXR, MSU, cultures
89
What is the broad management of DKA?
ABCDE Fluid replacement Insulin infusion
90
What is the fluid replacement regime for DKA?
``` 1L 0.9% NaCl over 1hr 1L NaCl + K+ over 2hrs 1L NaCl + K+ over 2hrs 1L NaCl + K+ over 4hrs Continue until rehydrated ``` K+ = 40mmol/L KCl provided K+ 3.5-5.5 When glucose <14, add 10% glucose 125ml/hr If Na+ >160 = consider 0.45% saline for first 3L K+ given to prevent insulin-induced hypokalaemia
91
What is the insulin infusion regime for DKA?
50 units ACTRAPID insulin IV at 0.1 units/kg/hr
92
When can you transfer a DKA patient to recovery?
pH >7.3 | Blood ketones <0.6mmol/L
93
What is the management of a seizure lasting >5mins in an adult?
IV Lorazepam 4mg over 2mins OR PR Diazepam 10mg Repeat at 10mins if no effect If alcoholism/malnourished = Pabrinex 2 pairs IV over 10mins
94
What is the management of a seizure lasting >20mins in an adult?
IV Phenytoin 20mg/kg over 20mins OR IV Phenobarbital 10mg/kg over 10mins Call anaesthetist
95
What is the management of a seizure lasting >40mins in an adult?
Rapid Sequence Induction with Thiopentone
96
What causes a subarachnoid haemorrhage?
Rupture of Berry aneurysm in Circle of Willis 5% of all haemorrhagic strokes
97
What are the features of a SAH?
Thunderclap headache - sudden and severe, worse upon bending neck Radiates behind occiput Nausea, vomiting Impaired consciousness/drowsy Early focal neurology - most often CN III palsy
98
What is the Hunt and Hess scale?
Assesses severity of SAH Grade 1 = asymptomatic, <5% mortality Grade 2 = mod headache, no neurological deficit except for CN palsy Grade 3 = drowsiness, confusion, mild focal deficit Grade 4 = stuporous, mod hemiparesis, early decerebrate Grade 5 = deep coma, decerebrate, 70% mortality Surgery for grades 1 and 2
99
What investigations may be useful for SAH?
Head CT with contrast = 95% diagnostic within 24hrs LP >12hrs after onset if Hx suggestive but CT -ve - shows bloody than xanthochromic CSF CT angiogram - identify location of aneurysm
100
What is the immediate management of SAH?
Urgent neurosurgery Correct hypotension Nimodipine to reduce vasospasm IV mannitol 200ml of 10% to reduce ICP
101
What are the features of vasovagal syncope?
``` Onset over a few seconds LoC usually <2mins Preceding visual disturbance, light headedness, sweating Prompt full recovery Cannot occur lying down ```
102
What investigations are necessary for a vasovagal syncope?
ECG - exclude arrhythmias FBC, U&E, BGL CVS + neuro exam Lying and standing BP
103
What are the ECG red flags following LoC? (3)
Conduction abnormality eg. BBB, heart block Long or short QT ST or T wave abnormalities
104
What are the red flags following LoC? (6)
``` ECG red flags Hx or signs of heart failure Transient LoC on exertion New unexplained breathlessness FHx of sudden cardiac death <40yrs Heart murmur ``` Any of these = urgent CV assessment within 24hrs
105
What are the features of an uncomplicated faint? (3 P's)
Posture - prolonged standing Provoking factors - pain, medical procedure Prodromal Sx - hot, sweating
106
What are the features of simple alcohol withdrawal?
``` Within 12hrs of stopping Anxiety and restlessness Tremor Tachycardia Insomnia Sweating ```
107
What are the features of Delirium Tremens?
``` 72hrs after stopping Same as simple withdrawal + autonomic hyperactivity Hyperreflexia Gross tremor Dilated pupils Confusion Hallucinations ```
108
What is Wernicke's disease?
Triad of: - Ophthalmoplegia (nystagmus, CN VI palsy) - Ataxia (cerebellar) - Confusional state
109
What is Korsakoff's syndrome? (4)
Confusion Pyschosis Amnesia Confabulation
110
What is alcoholic ketoacidosis?
Stop drinking -> repeated vomiting and starvation -> dehydration and fatty acid breakdown
111
What are the 7 signs of alcohol dependency?
TWRPCHR ``` Tolerance Withdrawal Repertoire Primacy Compulsion Harm Reinstatement ```
112
What is the treatment of alcohol withdrawal?
Chlordiazepoxide 10-30mg decreasing daily over 7 days Pabrinex to prevent WKS - Nourished and well = 300mg thiamine oral daily - Malnourished = IM OD 3-5 days
113
What is the treatment of delirium tremens?
In hospital IV diazepam PRN for sedation IV pabrinex to prevent WKS Treat seizures as per
114
What drugs are available to maintain alcohol abstinence?
Acamprosate - reduce cravings | Disulfiram - adverse alcohol reactions
115
How is paracetamol usually metabolised?
Inactivated by conjugation in the liver
116
How does paracetamol OD become toxic?
Overruns conjugation Produces NAPQI which is inactivated by glutathione When glutathione runs out = toxic NAPQI remains Causes necrosis of liver and kidney tubules
117
What are the features of paracetamol OD?
1st 24hrs = asymptomatic or N&V After 24hrs = hepatic necrosis -> RUQ pain and jaundice Then encephalopathy, hypoglycaemia, oliguria, renal failure
118
When should you check paracetamol level?
4 hours after OD
119
What blood test best predicts liver damage?
INR
120
What is the treatment regime for paracetamol OD?
``` Wait 4hrs/for paracetamol level then give Parvalex 1st bag over 1hr 2nd bag over 4hrs 3rd bag over 16hrs Continue until INR <1.3 ```
121
When do you stop treatment of paracetamol OD?
INR <1.3
122
What do you do if they present <4hrs post-paracetamol OD?
Wait until 4hrs then measure levels and start Tx
123
What do you do if they present 4-8hrs post-paracetamol OD?
Wait for levels and start Tx | Maximum Parvalex efficacy in this window
124
What do you do if they present 8-15hrs post-paracetamol OD?
Take paracetamol levels and start Tx before getting them back
125
What do you do if they present >15hrs post-paracetamol OD?
Give Parvalex | Levels mean nothing here
126
What do you do if they've had a staggered paracetamol OD?
Give Parvalex | Levels mean nothing here
127
When to consider liver transplant after paracetamol OD?
pH <7.3 Lactate >3 after fluids, strongly consider if >3.5 All 3 of: Creatinine >300, INR >6.5, Grade III/IV encephalopathy
128
What do you do if the patient has an allergic reaction to Parvalex?
Stop infusion Give anti-histamine Wait 30mins Restart with a reduced dose
129
What are the 6 P's of ischaemic limbs?
``` Pain Pallor Pulseless Paraesthesia Paralysis Perishingly cold ```
130
What would suggest an embolus as opposed to thrombus in acute ischaemic limb?
Acute onset Suggestive source eg. AF Clear 'end' to ischaemic area No previous claudication
131
What would suggest a thrombus as opposed to embolus in acute limb ischaemia?
Slow onset No suggestive source Previous claudication
132
What is the management of acute limb ischaemia?
``` Thrombus = heparinisation followed by angioplasty Embolus = prompt embolectomy ```
133
When must revascularisation occur by in acute limb ischaemia?
4-6hrs to prevent permanent necrosis and rhabdomyolysis, causing liver failure
134
What investigations are important in acute limb ischaemia?
``` Bloods - FBC, U&E, CK, Coag ECG CXR ABG Urinalysis Echo/angiogram if thrombus suspected ```
135
What are the features of cellulitis?
Warm red painful skin with well-defined margin
136
What are the serious complications of periorbital cellulitis? (4)
Central retinal vein occlusion Optic nerve compression Cavernous sinus thrombosis Meningitis
137
What organism would a would swab be likely to grow in cellulitis?
S aureus
138
What is the treatment of localised cellulitis?
Oral flucloxacillin | 2nd line = Clindamycin
139
What is the treatment of systemic/above knee cellulitis?
IV fluclox/co-amox + benzylpenicillin
140
What is the treatment of paediatric periorbital cellulitis and why is it important?
IV ceftriaxone | To prevent posterior spread causing meningitis, orbital cellulitis or cavernous sinus thrombosis
141
What investigation do you need if you suspect orbital cellulitis?
MRI to assess spread
142
What are the features of a DVT?
``` Leg pain Calf swelling >3cm larger than contralateral Warmth Tenderness Dilated superficial veins ```
143
What investigations do you need for a DVT?
Measure calves D-Dimer Well's score - determines need for USS USS
144
What are the components of the Well's score? (10)
``` Cancer (active or last 6m) Recent immobilisation/paralysis Bed-ridden for 3 days or major surgery in last 12wks Localised tenderness over deep veins Entire leg swollen Calf swelling >3cm Pitting oedema in Sx leg only Nonvaricose collateral superficial veins Previous DVT Alternate Dx at least as likely (-2) ``` 0 = low risk, 1-2 = moderate, 3+ = high-risk
145
What is the treatment of DVT?
LMWH for 1 week | Oral anticoagulants for 3 months
146
What is gout?
Deposit of crate crystals in a joint | 90% caused by impaired excretion
147
What is a Tophi?
Deposit of crate crystals and other substances at the surface of joints, typically seen in gout
148
What are the features of gout?
Sudden agonising red swelling and pain of big toe MPJ
149
What are some precipitating factors of gout? (6)
``` Dehydration Diuretic Too much food Trauma Surgery Infection ```
150
What investigations do you need for gout?
Joint aspirate Serum urate >600mmol Joint xray Bloods - FBC, LFT, ESR, CRP
151
What does the joint aspirate of gout show?
Yellow fluid WCC 2,000-50,000 Bifringent crystals
152
What does the joint xray of gout show?
Lytic lesions
153
What is pseudo gout?
Sx of gout but joint xray shows chonedrocalcinosis = single white line Caused by calcium pyrophosphate crystals
154
What is the initial treatment of gout?
NSAIDs eg. diclofenac PPI Colchicine Steroids - for patients who cannot take NSAIDs or Colchicine
155
What is the prophylaxis for gout?
Allopurinol - may trigger an attack so wait 3wks before starting Avoid purine-rich foods eg. red wine, alcohol, fish, red meat Avoid aspirin
156
What is a major risk of septic arthritis?
Complete joint destruction within 24hrs
157
What organism causes septic arthritis?
S aureus
158
What organism causing septic arthritis would cause pustules on distal limb and polyarthralgia?
N. gonorrhoea
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What are the features of septic arthritis?
One hot red swollen immobile joint, extremely painful | Systemic features eg. fever, rigors
160
What investigations do you need with septic arthritis?
Synovial fluid MC+S Blood cultures Bloods - FBC, CRP Joint xray - may show destruction
161
What is the initial management of septic arthritis?
Drainage +/- prosthesis removal Splinting IV flucloxacillin 4-6wks (IV Cefotaxime if gonococcal)
162
What is an abdominal aortic aneurysm?
Permanent dilation of aorta >3cm
163
Where are most AAAs?
Generally infrarenal | Often saccular/fusiform
164
Who gets AAAs?
Male smokers >50 with HTN and hyperlipidaemia
165
What are the features of a ruptured AAA?
``` Abdominal pain radiating into back/groin Expansile and pulsatile abdominal mass Grey-Turner's and Cullen's signs = Retroperitoneal bleeding Drowsy/reduced GCS Low BP and absent femoral pulse Shock ```
166
What investigations do you need for an AAA?
USS FBC, U&E, LFT, G&S, X-match, ESR, CRP CXR ECG
167
When do you repair an unruptured aneurysm?
If >5.5cm on USS 3. 0-4.5cm = US annually 4. 5-5.5cm = US 3 monthly
168
How is an AAA repaired?
Prophylactic surgery = EVAR | Ruptured surgery = aortic clamping and Dacron graft
169
What are 4 causes of bowel perforation?
Intestinal obstruction Peptic ulcer disease Diverticulitis Appendicitis
170
What are the features of bowel perforation?
Rapid onset sever abdominal pain Acute pyrexia and vomiting Peritonitis May have absent bowel sounds
171
What does an abdominal xray of a perforated bowel show?
Pneumoperitoneum = air under diaphragm
172
What investigations do you need for a bowel perforation?
CXR/AXR ABG - acidotic Bloods - increased WCC, amylase, lactate Urgent CT once stable
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What is the initial management of a bowel perforation?
``` Fluids Morphine Cyclizine Abx - co-amoxiclav + metronidazole (?cef,met,gent) NBM - NG tube Surgical repair ```
174
What causes an appendicitis?
Obstruction of lumen -> inflammation and oedema (6-12hrs) -> necrosis and perforation (24-36hrs) -> peritonitis
175
What are the early features of an appendicitis?
Central colicky pain worse with movement N, V & D Mild fever
176
What are the later features of an appendicitis?
``` McBurney's sign = RIF pain Rigid abdomen with involuntary guarding Rovsing's sing Mucus-coated faeces Swinging pyrexia ```
177
What investigations may be useful for appendicitis?
Urine dip = increased nitrates + WCC Bloods = increased WCC, CRP + neutrophilia >75% USS = 90% sensitive
178
What is the treatment of acute appendicitis?
Abx = cef+met +/- gent Appendectomy Fluids, analgesia, antiemetic, NBM
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What are the causes of pancreatitis? | I GET SMASHED
``` Idiopathic Gall stones Ethanol Trauma Steroids Mumps Autoimmune Scorpions Hyperlipid/Ca/TF -aemia ERCP Drugs eg. diuretics, tetracyclines ```
180
What are the features of acute pancreatitis?
Constant epigastric pain radiating to back Worse with alcohol, relieved by sitting forward Epigastric guarding + rigidity Anorexia & vomiting Decreased bowel sounds GT and Cullun's signs
181
What is diagnostic of acute pancreatitis?
Amylase >600
182
What may an AXR show with acute pancreatitis?
Retroperitoneal fluid = no psoas shadow
183
What is the modified Glasgow Score?
PANCREAS ``` PaO2 <8 Age >55yrs Neutrophils >15 Calcium <2 Renal function: urea >16 Enzyme: amylase >600 Albumin >32 Sugar: glucose >10 ```
184
What is the initial management of acute appendicitis?
``` Fluids + O2 IM Pethidine/other analgesia Antiemetic Abx Catheter NBM + NGT LMWH Surgery ```
185
Where do bowel obstructions occur?
Sigmoid colon = young | Caecal volvulus = old
186
What will an AXR show in a small bowel obstruction?
Step ladder appearance = regular bands
187
What will an AXR show in a large bowel obstruction?
Haustral fold and faecal mass
188
What will an AXR show win all bowel obstruction?
Distended loops Gas absent distal to blockage Air in billiary tree = gallstone ileus
189
What are the features of a bowel obstruction?
``` Sever colicky abdominal pain Distended abdomen Tinkling bowel sounds Constipation - absolute Empty rectum on PR N&V - may be bilious ```
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What causes a small bowel obstruction? (3)
Adhesions Hernia Tumours
191
What causes a large bowel obstruction? (3)
Malignancy Diverticular disease Volvus
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What is the management of a bowel obstruction?
DRIP and SUCK NBM + NG tube to decompress bowel IV fluids to rehydrate IV morphine and cyclizine (avoid metoclopramide) Neostigmine in paralytic obstruction?
193
What is acute cholecystitis?
Acute inflammation of the gall bladder | 90% due to gallstones at neck of GB
194
What are the classic risk factors for gallstones?
``` Fair Fat Female 40 Fertile ```
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What do the bloods of cholecystitis show?
Increased WCC, CRP, glucose, amylase | Derranged LFTs
196
What is the most important investigation for cholecystitis?
USS Shows dilated CBD >5cm, gallstones and thickened GB wall Tender on pressing probe
197
What causes cholangitis?
Biliary stasis from stones (90% cholesterol stones) | Causes infection, generally E. coli, Klebsiella, S faecalis, anaerobes
198
What age range is generally associated with cholangitis?
50-60yrs
199
What is Charcot's Triad?
RUQ pain Fever Jaundice
200
What is Reynolds Pentad?
``` RUQ pain Fever Jaundice Shock Altered mental state ```
201
What are the features of cholecystitis?
RUQ colicky pain radiating to R shoulder and worse with fatty foods Murphy's sign = breathing in while pressure on RUQ increases pain Fever N&V Sometimes obstructive jaundice
202
What is the initial management of cholecystitis?
NBM, analgesia Abx = co-amoxiclav Consider urgent cholecystectomy or T-tube drainage
203
What is the initial management of cholangitis?
Essentially the same as cholecystitis | Drainage is the definitive Tx
204
When is biliary colic worse?
In the mornings and after food
205
What 3 types of gallstones are there?
Cholesterol Bile pigment - from bile stasis = brown, from haemolytic = black Mixed
206
What are the features of obstructive jaundice?
Yellow Dark urine Steatorrhoea

4th Year (15 decks)

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