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Disability Flashcards

1
Q

what is AVPU?

A

alert
voice - responds to voice
pain - responds to pain e.g. sternal rub/ trapezius squeeze
Unresponsive

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2
Q

what is the GCS scoring system?

A 
Eyes response 
     - eyes open spontaneously  (4 points)
     - eyes open to verbal command 
     - eyes open to pain 
     - no eyes opening (1 point)
Voice response
     -  orientated  - 5 points 
     - confused conversation but able to answer Qs
     - inappropriate responses 
     - incomprehensible sounds/ speech 
      - no verbal response  - 1 point 
Motor response:
     - obeys commands for movement - 6 points 
     - purposeful movement to painful stimulus
     - withdraws from pain 
     - abnormal flexion (decorticate)
     - abnormal extension (decerebrate) 
     - no motor response - 1 point

score from 3- 15

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3
Q

describe the causes of reduced GCS

A

head injury - basal skull fracture, epidural haemorrhage, subarachnoid haemorrhage, subdural haemorrhage, concussion and contusion

neoplasm - e.g. glioblastoma or mets

infection - meningitis, encephalitis

seizures

metabolic - electrolytes, cerebral oedema, hepatic encephalopathy, wernickes , hypoglycaemia, hypoxia, uraemia, acidosis

drugs - opioids, intoxication.

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4
Q

describe overall presentation of a head injury?

A 
laceration 
obvious skull deformity 
C spine tenderness deformity
signs of basal skull fracture 
      - racoon eyes, battle sign, rhinorrhoea/ottorrhoea, haemotypanum (blood on tympanic membrane)

signs of raised ICP - headache, papilloedema, vomiting, focal neurological signs (cranial nerves, weakness in certain area)

hearing and visual problems
confusion/ drowsiness/ low GCS , amnesia
seizures
decorticate/ decerebrate positioning
cushings triad - high BP, low HR, irregular breathing (late sign)

unequal pupils

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5
Q

what is coup and contra coup injury?

A

coup injury is bruising at the site of head trauma

contra coup is injury on the opposite site due to transmission of forces.

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6
Q

what is an epidural haemorrhage ?

A

between skull and dura
often caused by blow to side of head (at pterion) where the skull fracture can rupture middle meningeal artery.
presents with immediate unconsciousness, lucid interval and then slow loss of consciousness. features of raised ICP too.

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7
Q

what is a subdural haemorrhage ?

A

between dura and arachnoid
caused by lacerations of bridging veins.
most commonly at frontal and parietal lobes.
risk factors include old age, alcoholism, anticoagulation

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8
Q

what is a subarachnoid haemorrhage?

A

between pia and arachnoid
sudden occipital headache (thunderclap), worst headache ever, neck pain, photophobia, vomiting
can be caused by ruptured cerebral aneurysm

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9
Q

what is monro kellie Doctrine hypothesis?

A

volume in the brain is fixed and made up of 3 components: brain, blood and CSF. so if any of these increases the others will reduce to compensate until the displacement has reached its maximum and there will be a sharp rise in ICP and brain can herniate.

for example increased brain tissue will result in raise in ICP which will reduce cerebral perfusion to lower ICP. however this can cause brain ischaemia.

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10
Q

what is the cerebral perfusion pressure ? and what happens to MAP if ICP rises?

A

Mean arterial pressure - ICP

if ICP rises, then MAP needs to increase to maintain cerebral perfusion pressure otherwise brain ischaemia.

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11
Q

When ICP is high enough, MAP cant compensate and cerebral perfusion pressure drops and results in brain ischaemia. what is the physiological response after this?

A

sympathetic NS stimulation - vasoconstriction to increase resistance and thus HTN. also by increased HR and CO initially.

parasympathetic stimulation: baroreceptors in aortic arch detect the rise in BP and trigger parasympathetic response via the vagus nerve. this leads to bradycardia

raised ICP also puts pressure on brainstem and respiratory centre in medulla oblongata. this results in an irregular respiratory pattern.

overall = cushings reflex = hypertension, bradycardia, irregular respiration .

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12
Q

what causes raised ICP (categorise into blood, brain , CSF)?

A

blood - haematoma
CSF - hydrocephalus, cerebral oedema, infection
brain - tumour, abscess, infarct and resulting oedema.

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13
Q

what are the NICE indications for a CT head scan within 1 hour ? (adults)

A 
GCS <13 initially after injury
GCS <15 - 2 hours after injury 
post traumatic seizure
>1 episode of vomiting 
neurological deficit 
suspected open skull fracture or depression 
signs of basal skull fracture

although not indicated by NICE, may emergency departments consider anticoagulation as an absolute indication for CT scan in context of head trauma.

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14
Q

what are the NICE indications for CT head scan within 8 hours?

A

loss of conscious/ amnesia + one of following:

  • age >65
  • dangerous mechanism of injury e.g. motorcyclist
  • amnesia retrograde >30 mins
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15
Q

what are the indication for CT scanning of head in under 16s?

A 
known loss of consciousness >5 mins
amnesia >5 mins 
GCS <14 in >1yrs 
GCS <15 in <1yrs 
drowsiness

suspected open fracture
signs of basal skull fracture
<1yrs and laceration of >5cm on head or bruising/ swelling

seizure (in non epileptics)
3 or more episodes of vomiting
focal neurological deficit

dangerous mechanism of injury
suspicion of non accidental injury

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16
Q

how is a head injury managed?

A

A to E

  • C spine immobilisation if head injury and GCS <15, neck pain/ tenderness or focal neurology
    - intubate if GCS = 8
    - avoid hypoxia, low BP (can maintain cerebral perfusion pressure), hypothermia/hyperthermia and hypoglycaemia

treat seizure
treat raised ICP
analgesia (to avoid rise in ICP)

contact neurosurgery if required
wound management
may need Abx and tetanus

frequent neurological observations

discharge advice for patient.

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17
Q

how is raised ICP treated?

A

elevate head of bed to 30 degrees to promote venous drainage
hyperventilate to keep CO2 low and promote vasoconstriction of cerebral vessels. (not used anymore)
mannitol - 0.5-1mg/kg over 10-15mins
fluid resus - maintain systemic pressure to help MAP and cerebral perfusion.
treat the cause
last resort - Burr holes to relieve pressure.

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18
Q

how often should GCS be recorded post head trauma?

A

half hourly GCS until GCS is 15, then half hourly for 2 hours, then hourly for 4 hours and then 2 hourly.

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19
Q

what discharge advice would you give someone post head injury?

A

advised to return if any of the following develop:

  • unconsciousness, confusion, drowsiness
  • problems with understanding, speaking, balance, weakness
  • blurred vision, headache, vomiting
  • seizures
  • clear straw coloured fluid from nose/ ears
  • bleeding from ears.

written and verbal advice should be given

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20
Q

what is the outcome after a head trauma?

A

death
complete heal after 2 years

ataxia
seizures

speech disorder
tinnitus
CN palsies

personality change - emotional disturbance, irritable
headaches
dizziness, fatigue, depression
poor memory/ concentration

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21
Q

what are the causes of seizures?

A 
genetic - abnormalities in ion channels
metabolic 
space occupying lesion - tumour 
drugs/ ilicit substance use
withdrawal from: Alcohol, benzodiazepine, barbiturates, anti epileptics (ABBA)
trauma
stroke
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22
Q

what is meant by focal neurological deficit?

A

signs of impaired neurology that affect one region of the body and thus relate to a specific brain location.

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23
Q

what causes focal neurological deficit?

A

trauma, tumour, strokes, infections/ abscess, haemorrhage

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24
Q

what focal neurological signs would you see in damage to the:

a) temporal lobe
b) frontal lobe
c) parietal lobe
d) occipital lobe
e) cerebellum

A

a) emotional and behavioural change, dysphasia
b) personality change (disinhibition), dysphasia (brocas area), anosmia, hemiparesis
c) hemisensory loss, decreased 2 point discrimination, inability to recognise familiar objects, sensory inattention (ignore one side of world)
d) visual loss of one side of vision e.g. left eye temporal loss and right eye nasal loss.
e) DANISH - dysdiadokinesia, ataxia, nystagmus, intention tremor, slurred speech and hypotonia.

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25
what are the characteristics of migraines?
recurrent severe headaches: unilateral and throbbing associated with: aura, nausea and photosensitivity aggravated by routine activities of daily living. in women it may be aggravated by menstruation
26
what are the characteristics of a tension headache?
recurrent, non disabling, bilateral headache, described as a tight band not aggravated by routine activities of daily living.
27
what are the characteristics of cluster headaches?
pain typically occurs once - twice a day: - each episode lasts 15mins to 2 hours - clusters typically last 4-12 weeks intense pain around one eye and patient is restless during attack (always affects same eye) accompanied by: redness, lacrimation, lid swelling more common in men and smokers.
28
what are the causes of headaches?
primary - tension, migraine, cluster secondary - medication overuse, meningitis, encephalitis, subarachnoid haemorrhage, head injury, sinusitis, glaucoma, psychological / anxiety. substance missuse/ withdrawal , metabolic (hypoglycaemia, hypoxia, hypercapnia, CO poisoning)
29
how would you investigate someone who presents to A+E with a headache?
detailed history - how did it start? worst headache ever? associated symptoms? examination - rashes? Kernigs sign? papilloedema, neurological examination. palpate sinuses for tenderness. full set of obs bloods - rule out metabolic cause (electrolytes, LFTs, glucose), FBC and CRP (infection), if pyrexic (blood cultures) ``` imaging: CT/ MRI brain - once stable CSF analysis (lumbar puncture) ```
30
how do you treat someone who presents with headache
after serious causes are ruled out | analgesia, fluids, IV metoclopramide with IV fluids.
31
what is the emergency management for meningitis?
cefotaxime 2g IV if >55yrs add ampicillin to cover listeria IV dexamethasone fluids and analgesia
32
what is the management of a subarachnoid haemorrhage?
A to E Ix: clotting, FBC, U+Es, CT head, ECG, admit for lumbar puncture (carried out >12 hours after headache onset use hunt and less scale to grade analgesia and antiemetic contact neurosurgery may require mannitol IV if evidence of raised IC
33
what is the hunt and hess scale?
scale used for subarachnoid haemorrhage grade 1 - asymptomatic, mild headache, slight nuchal (neck) rigidity grade 2 - moderate to severe headache, nuchal rigidity, no neurological deficit other than cranial nerve palsy grade 3 - drowsiness/confusion, mild focal neurology grade 4 - stupor, moderate - severe hemiparesis grade 5 - coma, decerebrate posturing
34
how is an acute migraine attack managed?
analgesia and antiemetic | may give sumatriptan (contraindicated in ischaemic heart disease)
35
what does CSF show in: a) viral meningitis, b) bacterial meningitis c) fungal meningitis d) TB meningitis
a) clear , slightly raised WCC, mainly lymphocytes, pressure slightly raised b) cloudy/turbid, very high WCC, neutrophils, raised protein, low glucose, high pressure c) fibrin webs seen, slightly high white cell, mainly lymphocytes , very high pressure. d) cloudy/viscous, slightly raised WCC, mainly lymphocytes, raised protein, very low glucose, high note: mumps is unusually associated with low glucose (also herpes too sometimes)
36
what tests can be done to analyse CSF fluid?
``` colour, WCC, Red cells, protein, glucose culture and sensitivity PCR for virology acid fast/ zeihl nelson stain xanthochromia - subarachnoid haemorrhage electrophoresis - oligoclonal bands in MS cytology - tumour ```
37
what are the clinical features of poisoning?
fast irregular pulse - salbutamol, antimuscarinics, tricyclics, quinine respiratory depression - opiate, benzos hypothermia - barbiturates hyperthermia - amphetamines, MAOIs, cocaine, ecstasy seizures - recreational drugs, hypoglycaemic agents, tricyclics, theophylline constricted pupils - opiates, insecticide dilated pupils - amphetamines, cocaine, quinine, tricyclics hyperglycaemia - MAOIs, theophylline hypoglycaemia - insulin, oral hypoglycaemics, alcohol, salicyclates metabolic acidosis - alcohol, methanol, paracetamol, CO poisoning renal impairment - salicyclates, paracetamol high osmolality - alcohol coma - benzos, alcohol, opiates, tricyclics, barbiturates
38
how do we manage acute poisoning?
A to E - consider ventilation if resp rate <8 or GCS <8 - resuscitate any shock / fluids/ catheterise - if unconscious nurse in semi prone position to protect against aspiration assess patient to find cause of poisoning: - history, speak to family - plasma toxology screen - all unconscious patients should have paracetamol, salicylates and glucose levels checked. - urine toxology - good for recreational drugs - glucose, FBC, INR, UEs, LFTs, ABG - ECG - monitor vitals definitive treatment for toxin e.g. activated charcoal, gastric lavage, haemodialysis, antidote psychiatric assessment
39
what is activated charcoal used for
It reduces the absorption of many drugs from the gut when repeated doses are given it can increase elimination from blood too. not useful in - petroleum, corrosives, alcohols, clofenotane, malathion, metal salts (lithium, iron) give lower dose in children
40
what is gastric levage?
rarely used now process of cleaning out stomach contents done in <30 mins of ingestion don't use with petroleum/ corrosives
41
which toxins can haemodialysis be used for in poisoning?
lithium, methanol, salicyclates, sodium valproate, ethylene glycol
42
how is paracetamol overdose managed?
use paracetamol treatment curve to decide if treatment needed. if unsure when tablets were taken, treat anyway. activated charcoal if ingested (ideally within 1 hour but can be given up to <4 hour ago) N-acetylcysteine (NAC) liver transplantation monitor INR, UEs, LFTs
43
how is salicylate poisoning managed?
usually straight to haemodialysis | used to use urinary alkalisation - however rarely used and contraindicated in pulmonary/ cerebral oedema
44
how is opioid overdose managed? | how is benzodiazepine overdose managed?
naloxone | flumazenil
45
how are tricyclic antidepressant overdoses managed?
IV bicarbonate may reduce risk of seizures and arrhythmias in severe toxicity. don't treat arrhythmias with antiarrhythmics dialysis
46
how is lithium overdose managed?
mild/moderate toxicity may respond to fluid resus with normal saline haemodialysis in severe toxicity
47
how is warfarin toxicity and heparin toxicity treated?
warfarin - stop warfarin, vitamin K, prothrombin complex heparin: protamine sulphate
48
how is ethylene glycol/ methanol toxicity treated?
alcohol - competes for alcohol dehydrogenase to reduce production of toxic metabolites. fomepizole - competitive inhibitor of alcohol dehydrogenase - now first line haemodialysis
49
how is digoxin toxicity treated?
digoxin specific antibody fragments
50
how are insecticide poisoning treated?
atropine
51
how is carbon monoxide poisoning treated?
100% oxygen in hyperbaric chamber
52
how is iron and lead poisoning treated?
iron - desferrioxamine (chelating agent) lead - dimercaprol, calcium edetate
53
how is cyanide poisoning treated?
hydroxocobalamin | also combination of amyl nitrite, sodium nitrite and sodium thiosulphate
54
what are the signs of paracetamol poisoning?
``` RUQ pain vomiting jaundice encephalopathy organ failure ```
55
what amount of paracetamol can be fatal?
12g
56
how is b blockers toxicity treated?
if bradycardic - give atropine | in resistant cases can give glucagon
57
what are the features of illness in older people?
present differently cause greater morbidity/ mortality co-morbidity is common lack of physiological reserve so deteriorate quickly polypharmacy social problems - poor housing, live alone, lack of care
58
what should be taken into account when assessing the older patient?
be aware of cognitive impairment clarify what support they have - family, neighbours etc screen for problems with hearing, vision, gait/ balance, continence assess their nutrition assess their mental health - are they lonely/depressed assess their level of independence/ activity level ask if they have advancd care directive/ nominated proxy healthcare decision maker assess their compliance to medication
59
what are the different specialities that work in MDT for care of old people?
``` dietician OT physio psychiatrist GP geriatrician carers ``` elderly have problems in many aspects e.g. health (eye, ears, cardio, resp, arthritis etc), social (live alone), psychological (lonely, dementia) so need MDT approach
60
how can syncope be classified?
reflex syncope: - vasovagal: due to reflex bradycardia and peripheral vasodilation provoked by pain, emotion, standing too long. syncope last 2 mins and there may be brief jerking of limbs due to cerebral hypoperfusion - situational: with coughing, sneezing - carotid sinus syncope - hypersensitive baroreceptors orthostatic syncope: - primary autonomic failure - parkinsons, MSA - secondary autonomic failure - diabetes, amyloidosis, uraemia - drug induced - diuretics, alcohol, vasodilators - volume depletion - dehydration, haemorrhage, addisons cardiac syncope: - arrhythmias - valvular (aortic stenosis), MI, hypertrophic cardiomyopathy (HOCM) - P.E, tamponade, acute aortic dissection other: anxiety, panic attack, hyperventilation
61
what features would indicate a cardiac cause of syncope?
syncope in supine syncope during/after exercise syncope without warning family history of sudden death
62
how can we investigate syncope?
acutely: A to E, ECG, FBC (anaemia), glucose (hypoglycaemia) , ECHO history - when was the black out, what happened, loose awareness, vision? movements? injury? incontinence? what were they doing before? what happened after? later: postural BP reading, tilt table test
63
how can postural BP readings help us diagnose syncope?
diagnostic if fall in systolic >20mmHg or diasytolic >10mmg or drop in systolic <90mmHg
64
what factors increase old persons risk of falling?
``` poor vision poor balance poor proprioception poor muscle mass poor central processing of sensory and motor info ```
65
what defines hypothermia?
core (rectal) body temperature of <35 degrees
66
what are the causes of hypothermia?
impaired homeostatic mechanisms - age related low room temperature - poor housing impaired thermoregulation - pneumonia, MI, heart failure, MS, sepsis, pancreatitis reduced metabolism - hypothyroidism, DM, hypopituitarism autonomic neuropathy - Parkinson's, diabetes excessive heat loss - psoriasis , burns reduced cold awareness - dementia drugs - alcohol trauma patients are more susceptible to hypothermia neuromuscular disorder.
67
what are the risk factors to becoming hypothermic?
``` very old/ young chronic illness malnourished intoxication cognitive impairment ```
68
how does someone with hypothermia present?
low temperature recorded other signs - shivering, slurred speech, slow breathing rate, cold pale skin, lethargy, low GCS, agitation, bradycardia, hypotension, arrhythmias if patient is not shivering despite <35 degrees = severe hypothermia
69
where can core body temperature be recorded from?
axilla oral rectal infra-red ear thermometer last 2 are the best.
70
what tests should be done in hypothermic patients?
UEs, plasma glucose, amylase, TFTs, FBC, blood cultures, ABG/VBG, ECG, coagulation studies (DIC may occur)
71
what ECG changes are seen in hypothermia?
J waves , increased PR and QT
72
how do we treat hypothermia?
A to E all patients should receive warm humidified O2 remove any wet clothing and slowly rewarm using blankets vital signs every 30 mins warm IV fluids keep ECG on - arrhythmia can occur during re-warming give prophylactic Abx for those >65 and T<32 do not warm too quickly - aim for 1-2 degrees / hour (rewarming too quickly can cause peripheral vasodilation and shock)
73
what are the complications of hypothermia?
arrhythmia, pneumonia, pancreatitis, AKI, DIC
74
what is pyrexia?
temperature >37 degrees
75
what are the causes of pyrexia?
``` infection inflammatory conditions - RA, SLE, AS malignancy drugs - malignant hyperthermia vaccination heat exhaustion tissue destruction - rhabdomyolysis , surgery ```
76
what investigations would you do in someone with pyrexia?
look for infection with basic bloods - FBC, CRP/ESR, blood cultures, UEs, LFTs urine - culture and microscopy analysis of CSF - lumbar puncture imaging of suspected source e.g. CXR, CT/MRI head etc
77
when should Abx be given in infection?
after microbiology samples are taken | then ASAP
78
what should be considered before Abx are prescribed?
``` allergies dose renal function medication interaction pregnant/ lactating? ```
79
what Abx should be given for: a) exacerbation of chronic bronchitis b) community acquired pneumonia c) atypical pneumonia d) hospital acquired pneumonia ?
a) amoxicillin or tetracycline or clarithromycin b) amoxicillin (doxycycline or clarithromycin if pen allergy. add flucoxacillin if staphylococcus suspected) c) clarithromycin d) <5 days of admission:Co -Amoxiclav or cefuroxime > 5 days of admission: piperacillin with tazobactam OR broad spec cephalosporin or quinolone (ciprofloxacin)
80
what antibiotics are used to treat a) lower Urinary tract infections b) acute pyelonephritis c) Acute prostatitis ?
a) nitrofurantoin or trimethroprim b) cephalosporin or quinolone c) quinolone or trimethroprim
81
what antibiotics are used to treat: a) gonorrhoea? b) chlamydia? c) syphilis? d) PID? e) bacterial vaginosis ?
a) IM ceftriaxone and oral azithromycin b) doxycycline or azithromycin c) benzathine benzylpenicillin or doxycycline or erythromycin d) oral ofloxacin and oral metronidazole OR IM ceftriaxone + oral metronidazole and doxycycline e) oral or topical metronidazole or topical clindamycin
82
what antibiotics are used to treat: a) clostridium difficile b) campylobacter enteritis? c) salmonella (non typhi) d) shigellosis
a) metronidazole or vancomycin b) clarithromycin c) ciprofloxacin d) ciprofloxacin
83
what Abx are used to treat: a) impetigo? b) cellulitis? c) erysipelas d) animal/ human bite e) mastitis during breast feeding?
a) topical fusidic acid/ oral flucoxacillin or erythromycin b) floxacillin (clarithromycin if pen allergy) c) phenoxymethylpenicillin (erythromycin if pen allergy) d) co-amoxiclav (doxy + metronidazole if pen allergy) e) flucloxacillin
84
what Abx should be used to treat: a) throat infections b) sinusitis c) otitis media d) otitis externa
a) phenoxymethylpenicillin (erythromycin if pen allergy) b) amoxicillin or doxycycline or erythromycin c) amoxicillin (erythromycin if pen allergy) d) flucloxacillin (erythromycin if pen allergy)
85
list the main notifiable disease
brain: acute meningitis, acute encephalitis, meningococcal septicaemia GIT: cholera, enteric fever, typhus, haemolytic uraemic syndrome, food poisoning, infectious bloody diarrhoea blood borne: malaria, yellow fever, haemorrhagic fever (e.g caused by virus's ebola, Marburg, yellow fever), respiratory/ rashes: TB, whooping cough, SARS neuro: polio, anthrax, botulism, diphtheria, leprosy, rabies, tetanus rash: measles, mumps, rubella, scarlet fever, plaque, small pox other: brucellosis , invasive group A streptococcus and acute infectious hepatitis
86
what are the different types of burns?
thermal chemical electrical radiation
87
how can we assess a burn?
history - how it happened, material they were burnt with? any smoke inhalation? examination: any airway burn? some extensive burns can constrict chest movement? hypovolaemic shock? hypothermia? assess extent - use lund and browder chart to map out surface area assess depth overall assessing severity so we can triage correctly
88
how can the depth of a burn be categorised?
superficial: minor erythema, painful with blistering (first degree), epidermis only second degree burns: do not blanch on pressure. epidermis and part of dermis third degree/ full thickness: white, brown or black and look leathery, no sensation, no blister. through dermis and into subdermal structures.
89
how are major burns managed?
A to E - high flow O2 , consider early intubation - fluid resuscitation - 0.9% saline (calculated based on weight and body surface area burnt) + catheterise and fluid balance monitored. - may require blood transfusion take bloods - Xmatch FBC, UEs, glucose, coagulation, COHb levels irrigate chemical burns with water (for 20-30mins cool running water (be aware of hypothermia) cover burns in clean sheets - clingfilm, wet dressings, gel dressings remove clothes that are burnt analgesia and anti-emetic tetanus and Abx prophylaxis check urine for myoglobinuria (high risk of renal failure) get a burn specialist treat specific problems: - CO poisoning - may need hyperbaric chamber
90
what is the parkland formula?
used to calculate the amount of volume needed for fluid resuscitation... volume in ml = body surface area % x weight kg x 4 first half of fluid over 8 hours, second half over 16 hours
91
how are smaller burns managed?
cool the burn - cool pack but NOT ice simple saline/ paraffin gauze analgesia tetanus/ Abx prophylaxis
92
what burns are more serious out of acid and alkali?
alkali tend to be deeper and more serious
93
how long should alkali burns to the eye be irrigated for?
8 hours
94
what is a complication of an electrical burn?
rhabdomyolysis - resulting in AKI | should increase fluids in this case
95
how are wounds managed?
assessment: - history - what caused it ? when? what has been done since? - examination - site, depth, contamination, test neurology, tendons and vascular injury, look for fractured bones, signs of infection? - imaging - may need X ray management: - cleaning- remove any foreign body and irrigate with saline - lignocaine may be needed - closure - sutures, steristrips, skin glue, staples (cant be closed if >12 hours ago - dressing on top - document - tetanus/ Abx - follow up and after care advice

A+E (4 decks)

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