Acute Medicine Exam Flashcards
(68 cards)
Spinal Mets - Surgery vs Radiotherapy
The main indications for surgical decompression are uncertain cause with no histology, radioresistant tumour e.g. sarcoma/melanoma, unstable spine, previous RT, major structural compression, cervical cord lesion, solitary vertebral metastasis.
Indications for radiotherapy radiosensitive tumour, several levels of compression, unfit for major surgery, patient choice.
The real extra benefit of surgical decompression would seem to be for the non-ambulant patient with a single site of cord compression and a prognosis of >3 months
Ilio-femoral DVT Rx options
Catheter-directed thrombolytic therapy should be considered in those patients who have symptomatic iliofemoral DVT if they have had symptoms for <14 days, have good functional status, >1 year to live, and low bleeding risk. An IVC filter would be considered if the patient was unable to be anticoagulated (e.g. recent intracranial bleed) or if they had recurrent VTEs despite adequate anticoagulation therapy.
HIV Associated Kaposi Rx
Kaposi’s sarcoma is caused by human herpesvirus-8. The majority of cases of Kaposi’s sarcoma associated with HIV infection respond to HAART. In the minority that does not respond to HAART, treatment with chemotherapy or radiotherapy can be offered. HIV-associated KS typically occurs in patients who have low CD4+ T-cell counts (10,000 copies/mL).
Biphosphonates
These drugs are pyrophosphate analogues that bind to hydroxyapatite crystals in bone matrix and inhibit osteoclastic bone resorption. They have no effect on parathyroid hormone or parathyroid-related protein.
Demyelinating diseases
Inflammatory:
- Multiple sclerosis
- Acute-disseminated encephalomyelitis,
- Acute Haemorrhagic Leucoencephalitis
- Progressive multifocal leucoencephalopathy
(PML) and - Pontine Myelinolysis
- Extrapontine myelinolysis.
- Hypoxic-Ischemic Demeylination
Acute inflammatory demyelination in a patient «_space;10 years of age is more likely to be due
to ADEM.
Multiple Sclerosis Presentation
Common presenting features include:
= weakness, paraesthesia or focal sensory loss, optic neuritis, diplopia, ataxia and vertigo.
= Autonomic motor abnormalities of
bladder, bowel and sexual function are common.
Other manifestations can include
= painful muscle spasms,
= trigeminal neuralgia,
= fatigue and depression,
= subtle cognitive difficulties,
= psychiatric disturbances and seizures
MS Diagnostic Approach
A simple practical approach relies on a combination of a
= myelin stain (as luxol fast blue/ cresyl violet/ solochrome cyanin,
= a macrophage marker (eg, antibody to CD68) and
= a stain for axons (eg, Palmgen silver impregnation/ immunohistochemistry for neurofilament proteins) to subdivide plaques into the following:
1. Active plaques
2. Inactive plaques
3. Chronic Active plaques
4. Shadow plaques
Leucodystrophies
The leucodystrophies are progressive,
usually inherited, disorders of myelin metabolism, and tend to be of onset in childhood and to produce symmetrical, diffuse loss of myelin and degeneration of white matter, sometimes associated with accumulation of metachromatic material or multinucleated cells. The leucodystrophies most likely to be confused with multiple sclerosis are adrenoleucodystrophy and adrenomyeloneuropathy, in both of which there is inflammation and demyelination that can, particularly in the brain stem, appear plaque-like.
Patients with adrenoleucodystrophy and adrenomyeloneuropathy also have high levels of saturated, very long-chain fatty acids in their brain and plasma.
Acute (Marburg-type) multiple sclerosis
a rare, fulminant variant of
multiple sclerosis. It is believed, based on anecdotal evidence, to affect children and young adults usually. Some patients diagnosed with this disease may have had aggressive forms of ADEM. This designation may also overlap acute inflammatory demyelination presenting as a space-occupying lesion.
Neuromyelitis optica (Devic’s disease)
This variant of MS is characterised by the development of optic neuritis and acute transverse myelitis within days, weeks or occasionally months of each other.
Most patients present with visual loss and subsequently develop paraplegia and
sensory loss, but the order may be reversed.
Neuromyelitis optica is pathogenetically distinct from most other types of multiple sclerosis in that the demyelination is antibody dependent and complement mediated.2
ADEM - Acute Disseminated Encephalomyelitis
The most prominent clinical features are usually ataxia, headache and weakness.
Other manifestations can include vomiting, slurring or impairment of speech, extraocular or other cranial nerve nerve palsies, agitation, seizures, lethargy, delirium and stupor.
Approximately 80% of patients
make a full recovery. Although ADEM is classically a monophasic disease, relapses have been reported in 5–10% of cases (multiphasic disseminated encephalomyelitis)
Central Pontine & Extra-Pontine Myelinolysis
The presentation is usually rapid onset of confusion, limb weakness (often progressing to spastic tetraparesis) and mutism. Other frequent manifestations include ataxia,
dysphagia and hypotension.
Movement disorders (dystonia,
choreoathetosis and parkinsonism) occur in some patients and are probably related to EPM
CPM is a monophasic demyelinating disease of the pons and lower midbrain. It most often occurs in association with alcoholic liver disease or correction of hyponatraemia, some times with Post Liver transplant High ciclosporin levels, Hypernatremia etc
Concentric sclerosis (Balo´’s sclerosis)
This rare and unmistakable variant of multiple sclerosis is characterised by lesions composed of alternate bands of demyelinated and myelinated white matter, forming concentric rings or irregular stripes.
Concentric sclerosis is often rapidly progressive. However, the distinctive lesions may be admixed with other, typical plaques and can occur in chronic multiple sclerosis.
Haemoptysis causes
Tracheal source - malignant invasion
Airways source - COPD, Bronchiectasis, bronchial dieulafoy disease, ca bronchus
Pulmonary vascular source - LVF, Mitral stenosis, PE, PAH, AV malformations,
Lung parenchymal source - pneumonia, Fungal infections, TB, Aspergillosis, crack cocaine inhalation, Granulomatosis with polyangitis, Amyloidosis of lung
*Diffuse alveolar** - haemolytic or autoimmune disorders causing small vessel vasculitis, warfarin use,
Haemoptysis Tip
Anterior spinal artery arises from bronchial artery in 5% cases and embolization as treatment for massive Haemoptysis can lead to paraplegia.
Risk scores for chest pain
- Modified Goldman Score
- TIMI risk score
- GRACE risk score
- HEART risk score
- Vancouver chest pain rule
- European society of cardiology(ESC) 0/1 Hr algorithm
High fever problems
- In first trimester can cause birth defects like anencephaly
- Increases insulin requirements and can cause metabolic changes
- Fever with rash and eosinophilia indicates DRESS syndrome
- Can cause irreversible protein denaturation and hence brain damage if very high > 41c
Reversible cerebral vasoconstriction syndrome
Thunderclap headache during the postpartum
period precipitated by the Valsalva maneuver or
recumbent positioning may indicate reversible cerebral
vasoconstriction syndrome.
Ottawa Subarachnoid bleed Clinical decision rule
For patients with acute non traumatic headache: get neuroimaging if:
- age > 40
- neck pain or stiffness
- witnessed LOC
- onset during exertion
- thunderclap headache
- limited neck flexion on examination
Headache treatment options in ED
Ketorolac/Diclofenac
Prochlorperazine + Diphenhydramine
Metoclopramide + ketorolac
High flow oxygen
Low dose Ketamine infusions
Dihydroergotamine
Sumatriptan for migraine without aura
Lasmiditan (5HT agonist) for migraine
CGRP monoclonal antibodies: Erenumab, Fremanezumab, Galcanezumab
Acute dysuria in women, D/d
- Acute cystitis
- Acute pyelonephritis
- Vaginitis: candida, bacterial, HSV, Trichomonos
- Urethritis/Cervicitis
- Interstitial cystitis/ painful bladder syndrome
Established causes of urinary incontinence
- Urge incontinence due to detrusor overactivity.
- Stress incontinence due to urethral incompetence. Most common after radical prostatectomy. During cough immediate urinary leak. Delayed leak after many seconds suggests uninhibited bladder contraction rather than urethral ie cause 1.
- Overflow incontinence - dribbling after passing urine. Post void urine present in UB. Commonly due to - BPH, strictures, ca prostate, bladder neck contracture etc
Workings of an ICD
- Shock is delivered by a dedicated lead which can be1. Single lead in RV or 2. Dual lead, one in RV and another in SVC.
- Can deliver upto 6 shocks, (biphasic only) - first shock is 25 jules and subsequent 35 jules.
- after first shock, there is a blank phase of 520 milliseconds followed by 1200 milliseconds of NO pacing phase to avoid inappropriate pacing during vulnerable phase of QRS
- if the first shock is unsuccessful & VF is detected, device charges, a window of 900 milliseconds begins - if QRSis detected during this window: synchronous shock is delivered, if NOT - asynchronous shock is delivered.
It delivers second shock even if rhythm changes, called committed shock
-
Workings of an ICD
- Shock is delivered by a dedicated lead which can be1. Single lead in RV or 2. Dual lead, one in RV and another in SVC.
- Can deliver upto 6 shocks, (biphasic only) - first shock is 25 jules and subsequent 35 jules.
- after first shock, there is a blank phase of 520 milliseconds followed by 1200 milliseconds of NO pacing phase to avoid inappropriate pacing during vulnerable phase of QRS
- if the first shock is unsuccessful & VF is detected, device charges, a window of 900 milliseconds begins - if QRSis detected during this window: synchronous shock is delivered, if NOT - asynchronous shock is delivered.
It delivers second shock even if rhythm changes, called committed shock
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