Acute emergencies and pre-hospital care

Question 1

What are the criteria for refering a patient from primary care to nephrology?

Answer 1

HTN after a trial of 4 different anithypertensive agents
eGFR <30 decreased by >5 in a year
Albumin:creatinine ratio > 70 not known to be associated with diabetes
ACR > 30 with persitence haematuria (UTI excluded)
Suspected or rare genetic causes of CKD
Suspected renal artery stenosis
Supsected complications of CKD e.g. anaemia, gout, secondary hyperparathyroidsim

Question 2

How does a subdural haematoma prsent?

Answer 2

Fluctuating GCS on a background of head injury
CT finidngs of a cresent shaped haemorrhage
Delayed presentation due to lower pressure (venous system)
Intracranial bleed between the meningeal layers of the dura matter and arachnoid matter

Question 3

How does a subarachnoid haemorrhage present?

Answer 3

Sudden onset severe thunderclap headache associated with vomiting and a rapid drop in GCS
Occurs between the arachnoid membrane and the pia matter
The normally black subarachnoid cisterns and sulci may appear white in acute hemorrhage on CT
On CT scans, subarachnoid hemorrhage (SAH) appears as a high-attenuating, amorphous substance that fills the normally dark, CSF-filled subarachnoid spaces around the brain

Question 4

What triad does rhabdomyolysis inculde?

Answer 4

Dark urine
Generalised muscle weakness
Myalgia

Question 5

What CK level is diagnostic of rhabdomyolysis?

Answer 5

> 5x normal range

Question 6

What is Horner’s syndrome?

Answer 6

Anhidrosis
Miosis (small pupils)
Pstosis

Question 7

Why might there be arm pain and weakness in Horners syndrome?

Answer 7

INvasion of the brachial plexus

Question 8

When should you be suspicious of necrotising fasciitis?

Answer 8

An important consideration in all patients with skin infection is necrotising fasciitis, also known as Eron class IV cellulitis. Highly suggestive clinical features include pain out of proportion to the exam, crepitus and symptoms of systemic toxicity (e.g. pyrexia, hypotension).

Question 9

When might trigeminal neuralgia warrant MRI?

Answer 9

Red flag symptoms and signs that may suggest a serious underlying cause (e.g. deafness/aural involvement, optic neuritis, family history of multiple sclerosis, age of onset under 40 years).

Question 10

Treating GCA with visual compromise?

Answer 10

Treatment with 60mg oral prednisolone stat and urgent referral to rheumatology and ophthalmology to be seen same working day

Question 11

Initial management of an anyphlactic reaction?

Answer 11

Give 0.5ml of 1:1000 adrenaline IM

Consider half dose if taking amitriptyline, beta blockers, or imipramine

Question 12

Initial management of choking adult?

Answer 12

. Stand behind them and slightly to one side & support their chest with one hand & lean
them forward so the object blocking their airway will come out of their mouth.

Question 13

Management of acute angle glucoma in community?

Answer 13

Oral acetazolamide and contact opthalmology immediately for urgent admission
Lie supine

Question 14

How does acute angle gluacoma present?

Answer 14

Hyperacute visual changes
Painful red eye - unilateral
Pupil fixed and dilated

Question 15

If a patient presents in primary care with a single TIA (resolved) in the last week what action should be taken?

Answer 15

300mg loading dose aspirin (if not already on oral anticoagulation)
Refer for specialist review within 24hrs

Question 16

If a patient presents in primary care with a single TIA (resolved) 7-10 days ago what action should be taken?

Answer 16

300mg loading dose aspirin (if not already on oral anticoagulation)
Refer for specialist review within 7 days

Question 17

If a patient presents with an un-resolved TIA or multiple TIAs in 7 days what action should be taken by GP?

Answer 17

Urgent admission to hospital

300mg aspirin loading dose if not already on anticoagulation