GP 22 Flashcards

Question

Ortho Trauma

Answer 1

**Comminuted** = broken in several places **Angular/oblique** = curved or at angle **AD** - dislocates forward . . . maybe deltoid parastheisis (axilliary neve damage) **Montegia and Galleazzi** **Humerus #** AX w radial nerve damage (wrist drop) **Colles**- fall on outstretched wrist - damage to median nerve leads to loss of thumb abduction **Scaphoid -** all proximal scaphoid fractures req surgical fixation **Knee** - not swollen? probs hip **Hip-** Garden classification for neck of femur fractures iliofascial nerve block is effective pain relief **MCL/CCL** - Vu**L**gar Stress = **L**ateral stress = MCL injury - vargus is the other **Tib/Fib** - if tib breaks then probs fi also **Ankle** - surgery as casting ankle weird and they don't usually break well. **Compartment Syndrome** - *on repurfusion, after crush injury, very tense, check compartment pressure, tx - fasciotomy* **Ottawa Rules** Xray if: pain in malleolar zone **and** one of bony tenderness at the lateral malleolar zone (from the tip of the lateral malleolus to include the lower 6 cm of posterior border of the fibular) bony tenderness at the medial malleolar zone (from the tip of the medial malleolus to the lower 6 cm of the posterior border of the tibia) inability to walk four weight bearing steps immediately after the injury and in the emergency department **Subluxation of the radial head** Pulled Elbow MC upper limb injury in \>6 elbow pain with limited supination and extension of the elbow MX: analgesia and passively supination of the elbow joint whilst the elbow is flexed to 90 degrees **Iliotibial band syndrome (not trauma)** a common cause of lateral knee pain in runners. Athletes commonly present with a sharp or burning pain around the lateral knee joint line. **Plantar Fasciitis (not trauma)** Plantar fasciitis is the most common cause of heel pain seen in adults. The pain is usually worse around the medial calcaneal tuberosity. Management rest the feet where possible wear shoes with good arch support and cushioned heels insoles and heel pads may be helpful **trochanteric bursitis (non trauma)** aka Greater trochanteric pain syndrom MC women 50-70 from repeated movement of the fibroelastic iliotibial band pain over the lateral side of hip/thigh tenderness on palpation of the greater trochanter

Answer 2

**Key Approach** Relationship of p waves to QRS Width of QRS **Sinus Arrhythmia** changes in rate associated with respiration normally seen in young sUpraventricular rhytms have narrow QRSs and ventricular are wide (except supraventricular with bbb or WPW syndrome) **Escape Rhythms** normal sinus then SAN fails to discharge. you then get: atrial escape (abnormal p wave followed by qrs then back to normal) junctional escape (no p waves and normal qrs ventricular escape (larger delay then abnormal qrs . . . t wave often inverted) **Extrasystoles** This is the same as escape rhythms but occur early rather than late) again have atrial, junctional and ventricular. extrasystoles rarely require mx **Supraventricular Tachicardias** **Atrial Tachicardia (subtype)** atria depolorise faster than 150bpm if \>200 then av block occurs preventing higher rates in ventricles **Atrial Flutter (subtype)** atrial rate \>250 (no flat baseline between p waves) often associated with 2:1 block a narrow complex tachicardia with a ventricular rate of 125-150 should always alert you to possibility of atrial flutter with 2:1 block **Junctional Tachicardia (subtype)** P waves v close or not seen at all with normal QRSs **Carotid Sinus Massage** Do in SVT to tx but also make nature of arrythmia more obvious rub along one carotid artery at the point of maximal pulsation for 5-10s do not attempt in pts with known carotid artery stenosis or in those with recent TIAs or strokes because of risk of dislodging emboli **Diagnostic use:** sinus tachicardia = temporary slowing of HR atria or junctional tachicardia = may terminate or have no effect atrial flutter = usually causes temporary increase in block atrial fibrillation or ventricular tachicardia = no effect **Ventricular Tachicardia** = very tidy wide abnormal QRSs **Atrial Fibrillation** No p waves, irregular baseline, irregular QRS, Normal QRS morphology **Ventricular Fibrillation** = very fuzzy (ecg totally disorganised) pt will quickly lose conciousness **Bundle branch block complications** compare to sinus rhythm if qrs\> 4 squares its probs ventricular origin in context of MI invariably ventricular tachicardia LAD indicates ventricular origin very irregular may have AF on top **Wolff-parkinson-white syndrome** short PR interval with slurred upstroke on QRS complex **What to do:** 1. For fast or slow sinus rhytm treat the underlying cause, not the rhythm itself 2. extrasystoles rarely need treatment 3. in patients with acute HF or low BP due to rachycardia, DC cardioversion should be considered early on 4. Patients with any bradycardia that is affecting the circulation can be treated with atropin, but if this is innefective they will need temporaty or permanent pacing 5. Consider Vagal manouvres such as CSM, valsalva or eyeball compression in abnormal narrow wave tachycardia

Answer 3

**Key Approach** Relationship of p waves to QRS Width of QRS **Sinus Arrhythmia** changes in rate associated with respiration normally seen in young sUpraventricular rhytms have narrow QRSs and ventricular are wide (except supraventricular with bbb or WPW syndrome) **Escape Rhythms** normal sinus then SAN fails to discharge. you then get: atrial escape (abnormal p wave followed by qrs then back to normal) junctional escape (no p waves and normal qrs ventricular escape (larger delay then abnormal qrs . . . t wave often inverted) **Extrasystoles** This is the same as escape rhythms but occur early rather than late) again have atrial, junctional and ventricular. extrasystoles rarely require mx **Supraventricular Tachicardias** **Atrial Tachicardia (subtype)** atria depolorise faster than 150bpm if \>200 then av block occurs preventing higher rates in ventricles **Atrial Flutter (subtype)** atrial rate \>250 (no flat baseline between p waves) often associated with 2:1 block a narrow complex tachicardia with a ventricular rate of 125-150 should always alert you to possibility of atrial flutter with 2:1 block **Junctional Tachicardia (subtype)** P waves v close or not seen at all with normal QRSs **Carotid Sinus Massage** Do in SVT to tx but also make nature of arrythmia more obvious rub along one carotid artery at the point of maximal pulsation for 5-10s do not attempt in pts with known carotid artery stenosis or in those with recent TIAs or strokes because of risk of dislodging emboli **Diagnostic use:** sinus tachicardia = temporary slowing of HR atria or junctional tachicardia = may terminate or have no effect atrial flutter = usually causes temporary increase in block atrial fibrillation or ventricular tachicardia = no effect **Ventricular Tachicardia** = very tidy wide abnormal QRSs **Atrial Fibrillation** No p waves, irregular baseline, irregular QRS, Normal QRS morphology **Ventricular Fibrillation** = very fuzzy (ecg totally disorganised) pt will quickly lose conciousness **Bundle branch block complications** compare to sinus rhythm if qrs\> 4 squares its probs ventricular origin in context of MI invariably ventricular tachicardia LAD indicates ventricular origin very irregular may have AF on top **Wolff-parkinson-white syndrome** short PR interval with slurred upstroke on QRS complex **What to do:** 1. For fast or slow sinus rhytm treat the underlying cause, not the rhythm itself 2. extrasystoles rarely need treatment 3. in patients with acute HF or low BP due to rachycardia, DC cardioversion should be considered early on 4. Patients with any bradycardia that is affecting the circulation can be treated with atropin, but if this is innefective they will need temporaty or permanent pacing 5. Consider Vagal manouvres such as CSM, valsalva or eyeball compression in abnormal narrow wave tachycardia

Answer 4

**CF**: shortened, externally rotated flexed leg **IX**: AP pelvis and lateral xray MX : **Pre-operatively** Analgesia including a fascia iliaca block, stop anticoagulants/anti-platelets & early surgery. **Post operatively** Thromboprophylaxis, early mobilisation Beware of delirium! Garden Classification ( for intracapsular fractures)

Answer 5

**Resuscitate \> Reduce \> Hold \> Rehabilitate** **Reduce** Reduction in the taction of soft tissues (to reduce swelling) of transversing nerves ( to reduce neuropraxia) and reduction of pressures on blood vessels (restoring blood supply). Some use an initial exaggeration of fraction to uncouple distal and proximal fragments can be done open or closed Requires analgesia e.g. local/regional blockade or conscious sedation requires at least two people (one apply reduction force and another counter reduction . . . . often 3rd for casting) **Hold** immonilising fracture consider need of traction where strong muscles pull across facture sites eg femur fractures most commonly simple splints or casts casts non circumferential in first 2 weeks due to risk of compartment syndrome axial instability: casts need to cross both the joint above and below if # able to rotate along axis eg combined tibia/fibula metaphyseal # or radius/ula metaphyseal # weight bear? always let pt know if they can Thromboprophylaxis: common if immobilised and non-weight bearing safety net pt on sx of compartment syndrome. **Rehabilitate** Intensive period of physiotherapy as pts stiff after immobilisation encourage movement of non-immobilised unaffected joints from outset Frailty a significant risk factor so therapists essential to making sure suitable adaptions implemented for their recovery

Answer 6

**Projection** * -2 views generally AP and lateral * -if shaft of long bone image joint above and below * -Comment on skeletal maturity (fused epiphyses/growth plates) **Patient Details** -name, DOB, date taken **Technical Adequacy** * -Penetrance? – make out bones and soft tissue * -rotation/? * Obvious Abnormalities? * -fractures, subluxations/dislocations **Systemic r/v of the xray** * -look at disruption of smooth continuous cortex (fractures) * -then medulla for fracturs (trabecular disruption and sclerotic/lucent lines) * -soft tissue swelling and join effusion * -joint surfaces for subluxation or dislocation * - assess joints for degenerative changes (loss of joint space, subchondral sclerosis, subchondral cysts and osteophytes) * -assess joints for inflammatory changes (periarticular osteoporosis, soft tissue swelling and bony erosions) * -r/v bone densitiy for lucent and sclerotic areas. **Summary** * -State key findings (description or findings) * -differential diagnosis * - further relevant imaging * - appropriate initial mx **Fracture Description** * What bone involved * What part of bone (proximal/middle/distal third, intraarticular) * Fracture pattern (simple/open, comminuted (\>2 fragments), impacted (fragments driven into eacchother)) * Type of fracture (Transverse(perpendicular), oblique(\<90degrees), vertical (parallel), spiral, greenstick (break in once cortex but not other) * Subluxation (some contact between articular surfaces) vs dislocation (no contact) * Translational Displacement (relation of distal to proximal fragment . . . . anterior/posterior/medial/lateral displacement) . . . AP view displacement = medial/lateral and lateral view displament = anterior/posterior * Angulation (movement of distal fragment relative to proximal in degrees * Rotation (internal or external, measured along long axis – might be easier on examination) * Shortening * Joint space (smaller/larger, asymmetrical, fragments/foreign bodies) * Joint cartilage (symmetrical outline of cartilage?) * Bone texture * Mostly radiolucent with thin cortices = osteopenia * Radiolucent around joint = inflammation/infected joint * Focal lucent areas indicate lesion (tumour/infection) * Sclerotic lesions (rarer – paget’s, osteochondritis, sclerotic bone mets)

Answer 7

**End of bed o gram** look at patient look at obs speak to nurse then . . . .

Answer 8

**Ottowa rules** General mx Closed reduction with propafol (try in A&E) RICE = Rest, Ice, Compression, Elevation **Webber Classification** lateral malleolus classification based on level of fracture of fubual compared to syndesmosis **Extra** Trimalleolar includes posterior malleolus Lauge-Hansen classification used in orthopaedics. . . . depends on position at time of fracture immobilised with below knee backslab Any signs of NV compromise requires immediate surgical review (check pulses) lightbulb sign on xray is aposterior shluder dislocation

Answer 9

1. Cord Compression? 2. Non-specific = MSK 3. can jump to others if you do not think msk (XRAY/MRI) 4. If not MSK then tx is surgery based on sx and lifestyle Thoracic back pain is a red flag symptom acute = \<6w, subacute = 6-12 and chronic \>12 **MSK** lower backpain first line NSAID (ibuprofen/naproxen) + ppi if \>45 encourage exercise ( print excercise sheet) but physiotherapy only if sx no resolving or likely to become disabled. after 2-4 weeks encourage graded return to work even if pain . . .. won't make worse **Spinal cord compression -** *seems the same as cauda equina syndrome (this can be caused by massive disk herniation) - surgical emergency* - sensory loss, lowe limb weaknes - urinary incontinence/retention - reduced sensationin perianal area - reduced anal tone MRI spine WHOLE spine in 24hr urgent oncology referal high dose dex **Cauda Equina vs cord compression** Cauda equina = flaccid paralysis + loss of reflexes Cord compression = spastic paralysis + brisk reflexes. Both = sensory + power loss. **Sciatica** = shooting pain from bottom down back of legs to toes Do **not offer X-ray in UK** - MRI only if you suspec someting sinister - red flag symptoms **pseudoclaudication (spinal stenosins** - only upper thigh and buttocks - don't get climbing stairs or bent over on bike - resolves on sitting down **Herniation-** AKA prolapsed disk Leg pain usually worse than back pain worse on sitting pain ins dermantological according to which level affected NSAIDs/exercise/physiotherapy . . MRI if no imporovement after 4-6 weeks nerve route compression unlikely if SLR not limited or pain does not extend below knee on slr look for L5/S1 compression (loss of sensatino of lateral border of lower leg and foot, weakness of dorsiflexion and plantarflexion of foot or impaired ankle reflex) **Compression fracture** - dont forget f/u dexa scanand osteoporosis tx **Ankylosing Spondylitis** should be here: Typically a young man who presents with lower back pain and stiffness Stiffness is usually worse in morning and improves with activity Peripheral arthritis (25%, more common if female) **NSAIDS** - remember PPI if over 45 **psoas abscess** Back/flank pain worse which is worse when the hip is flexed, with associated fever and raised inflammatory markers in an IVDU. ix CT Abdo TX = IV abx and percutaneous drainage **EXTRAS** Previous hx of Ca? - always orthopaedic referal **Discitis** CF backpain, fever, sepsis, lower limb neurological sx RF: IVDU MC Staph Aureus . . . may present with endocarditis Dx: MRI Tx: 6-8w abx

Answer 10

QRISK2 score calculated for \>40y and \<84y to assess CVD risk More specific guidlines or DM, CKD and Familial hyperlipidaemia Safetynet for muscle pain and weakness .. .. check cK if the complain of it. \>10 times upper limit stop immediatelly (rhabdo). \<5 times rarely significant. Might underestimate for HIV, NICE suggest QRISK2 may underestimate CVD risk in the following population groups: people treated for HIV, SLE, antipsychotics, steroids and immunosuppresent drugs Measuring lipid levels A full lipid profile should also be checked (i.e. including triglycerides) before starting a statin. The samples does not need to be fasting. Can feed lipid measurements into QRISK score. Consider familial hyperlipidaemia if very high If \>10% statin indicated (offer period of lifestyle modification first) also offer statin for DM as above and CKD **Other tests** TFTs - can be caused by hypothyroidsim Bloood Glucose: DM can cause Anorexia nervosa can also cause **Secondary prevention** All patients with CVD should be taking a statin in the absence of any contraindication. Atorvastatin 80mg should be offered first-line. Follow-up of people started on statins (asthenia (physical weakness), flatulance, headaches) NICE recommend we follow-up patients at 3 months repeat a full lipid profile if the non-HDL cholesterol has not fallen by at least 40% concordance and lifestyle changes should be discussed with the patient NICE recommend we consider increasing the dose of atorvastatin up to 80mg **Familial Hyperlipidaemia** Ezetimibe inhibits the absorption of cholesterol Bezafibrate reduce serum triglycerides. **Lifestyle modifications** These are in many ways predictable but NICE make a number of specific points: **Cardioprotective diet** total fat intake should be \<= 30% of total energy intake saturated fats should be \<= 7% of total energy intake intake of dietary cholesterol should be \< 300 mg/day saturated fats should be replaced by monounsaturated and polyunsaturated fats where possible replace saturated and monounsaturated fat intake with olive oil, rapeseed oil or spreads based on these oils choose wholegrain varieties of starchy food reduce their intake of sugar and food products containing refined sugars including fructose eat at least 5 portions of fruit and vegetables per day eat at least 2 portions of fish per week, including a portion of oily fish eat at least 4 to 5 portions of unsalted nuts, seeds and legumes per week **Physical activity** each week aim for at least 150 minutes of moderate intensity aerobic activity or 75 minutes of vigorous intensity aerobic activity or a mix of moderate and vigorous aerobic activity do musclestrengthening activities on 2 or more days a week that work all major muscle groups (legs, hips, back, abdomen, chest, shoulders and arms) in line with national guidance for the general population **Weight management** no specific advice is given, overweight patients should be managed in keeping with relevant NICE guidance **Alcohol intake** again no specific advice, other than the general recommendation that males drink no more than 3-4 units/day and females no more than 2-3 units/day **Smoking cessation** smokers should be encouraged to quit

Answer 11

can ix primarty hyperaldosteronism after two drugs if suspected (aldo:renin ratio) **Stage 1 hypertension** * Clinic BP \>= 140/90 mmHg **and** subsequent ABPM daytime average or HBPM average BP \>= 135/85 mmHg* * lifestyle changes + consider antihypertensives* * *Stage 2 hypertension** * Clinic BP \>= 160/100 mmHg **and** subsequent ABPM daytime average **or** HBPM average BP \>= 150/95 mmHg* *Antihypertensives regardless* **Severe hypertension** * Clinic systolic BP \>= 180 mmHg, **or** clinic diastolic BP \>= 110 mmHg* * immediate tx* admit if worryig signs (pappilodema, retnal haemorhages, confusion) if no worry signs do urgent ECG, urine tests and bloods lookinf for end-organ damage **Clinic BP** Take readings in both arms (if \>20 dif recheck then go with highest if persistent) Take two readings in consultation and use lowest **Ambulatory blood pressure monitoring (ABPM)** at least 2 measurements per hour during the person's usual waking hours (for example, between 08:00 and 22:00) use the average value of at least 14 measurements If ABPM is not tolerated or declined HBPM should be offered. **Home blood pressure monitoring (HBPM)** for each BP recording, two consecutive measurements need to be taken, at least 1 minute apart and with the person seated BP should be recorded twice daily, ideally in the morning and evening BP should be recorded for at least 4 days, ideally for 7 days discard the measurements taken on the first day and use the average value of all the remaining measurements **If however the blood pressure is \>= 180/110 mmHg:** immediate treatment should be considered if there are signs of papilloedema or retinal haemorrhages NICE recommend same day assessment by a specialist NICE also recommend referral if a phaeochromocytoma is suspected (labile or postural hypotension, headache, palpitations, pallor and diaphoresis)

Answer 12

**ACEi** - *enalapril, lisinopril, perindopril and ramipril.* **ARBs** - *candesartan, irbesartan, losartan, valsatan* **CCBs** - *amlodipine, felodipine and nifedipine.* **Diuretics** - *indapamide and bendroflumethiazide.* Bendroflumethiazide **first, check for:** * confirm elevated clinic BP with ABPM or HBPM* * assess for postural hypotension.* * discuss adherence* **Step 1 treatment** patients \< 55-years-old or a background of type 2 diabetes mellitus: ACE inhibitor or a Angiotension receptor blocker (ACE-i or ARB): (A) angiotensin receptor blockers should be used where ACE inhibitors are not tolerated (e.g. due to a cough) patients \>= 55-years-old or of Afro-Caribbean origin: Calcium channel blocker (C) ACE inhibitors have reduced efficacy in patients of Afro-Caribbean origin are therefore not used first-line If CCB give peripheral oedema it can be switched for 2nd line indapamide to relieve symptoms **Step 2 treatment** if already taking an ACE-i or ARB add a Calcium channel blocker or a thiazide-like Diuretic if already taking a Calcium channel blocker add an ACE-i or ARB for patients of Afro-Caribbean origin taking a *calcium channel blocker for hypertension, if they require a second agent consider an ARB in preference to an ACE inhibitor* (A + C) or (A + D) **Step 3 treatment** add a third drug to make, i.e.: if already taking an (A + C) then add a D if already (A + D) then add a C (A + C + D) **Step 4 treatment** NICE define step 4 as resistant hypertension and suggest either adding a 4th drug (as below) or seeking specialist advice if potassium \< 4.5 mmol/l add low-dose spironolactone if potassium \> 4.5 mmol/l add an alpha- or beta-blocker

Answer 13

Acid base balance not a Dx but a catch all Bad blood = carboxyhaemoglobin/ Methemoglobinemia Anaemia - don't worry about the type at first. Just Dx - SOB, fatigue, tiredness, pale skin, dizziness Same w CHF - exacerbation the same whichever type -SOB, Orthopnoea, PND, Crackles, chest pain Pleuritic Pain + SOB narrows it - pneumothorx, pneumonia, PE, pulmonary effusion, CA - Obstructive and restrictive - DAH = diffuse alveolar Haemorhage IX Always these (BNP debatable) ABG - covers top two CXR - covers bottoms two ECG - arythmia/MI BNP- CHF SATS - also do these. generally want \>92% order all before you get there and cancel if you don't need **Pneumothroax** \<2cm rim and not SOB discharge if \<2cm SOB then aspiration if \>2cm and \>50 or SOB after aspiration then instert chest drain

Answer 14

Type + Location = Shortlist Somatic Pain = pinpoint pain (correct target) Neuropathic pain (tingling/burning) - not frome target Visceral organs = no innvervation . . hijack somatic overlay from EMBRYOLOGICAL origin Feel obstruction/stretch/inflammation (not stabbing/buring) **Obstructive** Hollow organs -increase pain as peristalsis approachs obstruction Restless trying to find position of comfort **Inflammatory** Constant and restlesss with inflammatory markers **Perforation** Peritoneal does have innvervations and very sensitve so SAS , very paifull, motionless peritoneal pain will illicit rebound tenderness (percuss non tende area and tender area will hurt) hollow viscous to perf - PUD/ Diverticulitis **Ischaemic** POOP - ie very painful but not at all tender to touch . . . . lactate gives it away Some sort of vascular history (AF/CAD/PVD) or ischaemic colits? **Functional** Reffered pain - can have pain from bad constipation or bloating from periods **ANGRY ROBOT** **PM BAD BRUNG** = randos . . .NOT periumbilical Epigastric Chest and Epigastric Abdo (remember Qs for both) RUQ = US Everwhere else use CT **O/E** not very useful except peritoneal pain/ absent bowel sounds Rovsing's Sign = pain in LIF when palpation of RIF boas' sign = hyperaesthesia below right scapula in Cholecystitis PM BAD LUNCH: * *Porphyria** * *Mediterranean** Fever (Familial Mediterranean Fever): Armenian heritage; FHx of FMF. History paroxsymal fever/abdominal pain x 72 hrs. * *Black Widow** Spider bite * *Addison’s:** Associated hypotension; history of steroid use, auto-immune disease, or tuberculosis (the most common causes of Addison’s disease) * *Diabetic Ketoacidosis** * *Lead** poisoning * *Uremia** * *Narrow angle glaucoma**: Red, painful eye. * *Calcium:** Hypercalcemia causes chronic constipation due to chronic bowel contraction. * *Herpes Zoste**r: Dermatomal pain may precede vesicular rash by 1-2 days.

Answer 15

**Acute** = always infection **subacute** = alwasys post infection dex/benz = sx releief don't worry in practice if \<8weeks **ACEi/Cigs** = stop -smoking cessation initial worsening for 8 weeks CXR to see if primary pathology (resp referal if +ve) - empirit tx if not (8 weeks each) Further ix if not primary pathology missed by CXR if still nothing then idiopathic and tx symptoms

Answer 16

**OM** URTIs - S. pneumoniae, H. influenzae, M. catarrhalis erythromycin or clarithromycin if pen allergy Antibiotics should be prescribed immediately if: * Symptoms lasting more than 4 days or not improving* * Systemically unwell but not requiring admission* * Immunocompromise or high risk of complications secondary to significant heart, lung, kidney, liver, or neuromuscular disease* * Younger than 2 years with bilateral otitis media* * Otitis media with perforation and/or discharge in the canal* If an antibiotic is given, a **5-day course of amoxicillin** is first-line. In patients with penicillin allergy, erythromycin or clarithromycin should be given. **OE** swimmers ear from not drying after - pseudomonas digital - cotton buds Tx - usully resolves spontaneously 1st line - topical abx or topical abx/steroid combo **cipro** topical if bad **Flucloxacillin** if sreading Ref to ENT if toical abx not working Consider malignant OE in diabetes and immunocompromised -CT and emergerncy ent ref + IV antiseudomonal **Mastoiditis** hx of OE/OM CT often not needed **Sinusitis** vral v bacterial purulent thick bilateral discage don't really need imaging **TX** - analgesia + nasal decongestants maybe steroids if \>10 days phenoxymethylpenicillin first-line, co-amoxiclav if very unwell Consider causes of poor drainage (predisposes) eg polyps Double sickening indicates bacterial sinusitis (initial recovery before worsening **Nasal virla - coryzal** bilateral copius and clear supportive **Pharyngitis** viral vs strep A tx strep A to avoid rhematic fever EBV? - do the monospot centor criteria (3 or 4 = more likely to benefit from antibiotics); * presence of tonsillar exudate* * tender anterior cervical lymphadenopathy or lymphadenitis* * history of fever* ***absence** of cough* Tx: Penicillin V (erythromycin/clarithromycin in pennicilln allergy) **epistaxis** normal = unilateral for \<30mins if posterior bleed then pack + prophylactic Abx for toxic shock anterior = 1st silver nitrite cautery and 2nd line rapid rhino for 24hrs (tampon thigng . . . . different ones for anterior and posterior bleed **Choanal atresia** = blockage from nose to throat blue on feeding dx - fail to cathetarise tx surgery **foreign body** remove it and tx infection with abx homeless may be insect -- do not use light - lidocaine to parylise first. **Perforated Tympanic membrane** ENT referal if does not heal in 6-8 weeks abx if caused by acute OM **Infectious Mononucleosis** EBV aka HVV-4 Classic triad = sore throat, pyrexia, lymphadenopathy Also: palatial petechiae, splenomegaly, hepatitis, lymphocytosis, haemolytic anaemia, maculopapular rash with amoxicilin/ampicillin Ix: Monospot tests and FBC in second week of illness (NICE) Tx: rest/fluids/avoid alcohol, simple analgesia for aches and pains, avoid contact sports for 8 weeks

Answer 17

Diffulculty swallowing (not pain) often desribed as getting stuck - ask where they feel its getting stuck (above or below clavicle **Oropharyngeal** - ENT laryngoscope - usually a neuro problem - problem with initiating (cough/choke/gag) **Vagus nerve** MS - multiple sclerosis TM = transverse myolitis Stroke is most common SALT referal (automatic if stroke) Pharyngogram = radiolabel different cosistencies If NBM then NG tube PEG you would still need to get gastro involved **OESOPHAGEAL** GI referall and endoscope **Motility** funcitional (muscle fine) liquid and food problems from get go **Mechanicl** obstructive worsening and progessive food then liquid BOTH - barium swallow and OGD monometry - maybe in the community but wont as OGD in hospital if admitted **IX UK** All OGD, FBC maybe barium ambulatory oesophageal ph and monometry for GORD and achalesia **causes** oesophageal cancer oesophagitis oesophageal candidasis achalasia pharyngeal pouch systemic sclerosis myasthesia gravis globus hystericus

Answer 18

**EI** Slapped cheek syndrome is giveaway . . .but can be on arms and legs Aplastic crisis if Sicle Cell disease Keep away from pregnacy **M** the 4 Cs giveaway remember subacute sclerosing Panencephalitis later in life ( brain problems) Maccular otitis media = MC complication **Rubella** Genralised Tender Lymphadenopathy is the giveway. Maccular **Roseola** High spiking fever THEN rash paracetamol for high temperature febrile seizures more likely as higher temperature v quickly **Varicella** Rash w/o fever? Adults - never croses midline can be painfull before and after (gabapentin/ pregabalin) Can give varicella vaccine in old too acyclavir to reduce length in elderly *exclude from school until all lesions dry and crusted over* **Mumps** pretty obvious **Hand foot and mouth disease** Like Varicella but on the hands, feet and face no need to stay away from school if feels well

Answer 19

**WIPE** chaperone if intimate area **General Inspection (Distribution)** Check for meds, bandages etc Acral = distal areas eg hands and feet Extensor = elbows and knees (psoriasis) Flexural = axillae, genital region, cubital fossa (eczema) Follicular = areas with increased sebaceous glands eg face, chest and axillae (acne) Dermatomal = dermatomes don't cross the midline (herpes zoster) Seborrhoeic= increased density of sebaceous glands eg face and sculp (seborrhoeic dermatitis) Stocking distribution = status **Close Inspection** Assess size **Configuration** Discrete lesions = seperate (normal mole) Confluent = merging together (urticaria) Linear = in a line (excoriations) Discoid lesion = coin shaped (discoid eczema/ discoid lupus) Target Lesion = rigns of varying coloure eg bullseye annular = ring like (tinea corporis) **Colour** Erythematous: red and blanches Purpuric: red/purple don't blanche pertechiae(\<2mm) and purpura (\>2mm- bruise) Hyperpigmented lesion: diffuse (addison's) or discrete (linea nigra) Depigmentation = white due to absent melanin (vitiligo) **Morphology (flat raised or depressed)** Macule= altered colour \< 1.5cm Patch = altered coloure \>1.5cm Papulle = raised palpable nodule = raised and \>0.5cm diametre Plaque = palpable flat lesion \>1cm vesicle: fluid filled \<0.5 cm bulla = fluid filled \> 0.5cm pustule = pus filled \< 0.5cm abscess = localised accululation of ppus Wheal = oedematous papulae or plaque Boil/furuncle = staph within a hair follicle Carbuncle = staph in adjacent follicles (multiple boils/furuncles) **Secondary Lesions (modification of primary)** Excoriation Lichenification (thickening of normal skin 2ary to scratching) Scales = shedding skin Crust = rough surface from dried fluid Scar (atrophic, hypertrophic and keloidal) Ulcer = dermis lost Fissure = sharp linear wedge Striae (stretch marks) purple lines from rapid growth/ stretch (pink then white) **Pigmented lesion** ABCDE regional lymph nodes if malignancy suspected **Palpate** Don gloves surface characteristics = texture elevation, crust and temperature) Deep characteristics = consistency, fluctuance, mobility, tenderness) Systemic Consideration Nails (pitting, onycholysis, or klilonychia) Elbows (plaques, xanthomas and rheumatoid nodules) Hair: loss (alopecia areata/totalis) excess (hirsutism, hypertrichhosis) Scalp: psoriasis/seborhoeic dermatitis Mucous (hyperpigmented macules (ppeutz jeghers) or bullae (blisters) **Complete** Thank patient dispose of ppe wash hands summarise **Consider** relevent systems examinations swabs and scrapings dermatoscopy Biopsy

Answer 20

REMEMBER THESE ARE GENERAL RULES First differentiate by numbers then acuity/ toxicity High acuity/toxicity you admit - low one harder to spot Ser -ve = PAIR Poly = VIRUSSSSS SLEs like big joints. RA likes small joints AP = lower back OA = weight bearing joints (shoulder/hip) or joints with previous trauma/surgery Acute = red hot swollen tender and immobile Reactive = ive got gonorhoea and my joint hurts. Infective = I have gonourhea in my joint The (A)s are for acute toxicity Abs most important to learn from top to bottom

Answer 21

Not all wheezing asthma but should always consider Ominous = lots of air trapping and not much room for air movement PFTS = spirometry ach agonist = Methacholine Negavite Spirometry does not exclude asthma: ix further with fractional exhaled nitric oxide (FeNO) testing **Tx** Bronchoconstricion with bronchodilators Inflammation with anti-inflammatories Stabalisers can be used for athletic asthma as you can take pre-emptivly (cromolyn/ nedocromil) short course of prednisolone for acute episodes (eg 5day hx of wheeze and cough and already on medicaiton) **Adult Tx** 2- jump in here if Newly-diagnosed asthma with symptoms \>= 3 / week or night-time waking Salmeterol = LABA aka a 'controller' **Child 5-16 tx** The same as adult but stop LRTA at 4 Jump to 2 if Newly-diagnosed asthma with symptoms \>= 3 / week or night-time waking 8 week trial: After 8-weeks stop the ICS and monitor the child's symptoms: if symptoms did not resolve during the trial period, review whether an alternative diagnosis is likely if symptoms resolved then reoccurred within 4 weeks of stopping ICS treatment, restart the ICS at a paediatric low dose as first-line maintenance therapy if symptoms resolved but reoccurred beyond 4 weeks after stopping ICS treatment, repeat the 8‑week trial of a paediatric moderate dose of ICS **Exacerbation** Life threatening: *SpO2 \<92% PEF \<33% best or predicted Silent chest Poor respiratory effort Agitation Altered consciousness Cyanosis* Nebs = Ipratropium (muscarinic antagonist)/ salbutamol PEFR = peak espiratory flow rate ( they should know their best) All patients to receive PO prednisolone Oxygen through non rebreath MDI = metered dose inhalors Rescue medication : Racemic adrenaline neb, subq adrenaline, IV magnesium all used to try and prevent intubation **Grades** 1 - intermitent 2/3/4 = intermittent 2. mild 3. moderate 4. severe Refractory = tx not working **Adult Corticosteroid Doses** \<= 400 micrograms budesonide or equivalent = low dose 400 micrograms - 800 micrograms budesonide or equivalent = moderate dose \> 800 micrograms budesonide or equivalent= high dose. **Paeds Corticosteroid Doses** \<= 200 micrograms budesonide or equivalent = paediatric low dose 200 micrograms - 400 micrograms budesonide or equivalent = paediatric moderate dose \> 400 micrograms budesonide or equivalent= paediatric high dose. **Maintenance and reliever therapy (MART)** a form of combined ICS and LABA treatment in which a single inhaler, containing both ICS and a fast-acting LABA, is used for both daily maintenance therapy and the relief of symptoms as required MART is only available for ICS and LABA combinations in which the LABA has a fast-acting component (for example, formoterol) **Criteria for discharge** been stable on their discharge medication (i.e. no nebulisers or oxygen) for 12–24 hours inhaler technique checked and recorded PEF \>75% of best or predicted

Answer 22

**Oesophagitis in general** As you often have to do a biopsy and take a **PIECE** E for GORD and everything else MC presents with odynophagia but sometimes just dysphagia Give some sort of antacid for all as if its not the cause it can make it worse **Pill induced** Gets stuck and inflames surface Non-entric coated NSAIDs notorious for it Pill often not still there but remove if it is Should recover with PPI PPX but taking pills with a whole glass of water adn not when lying down **Infectious** Pretty much anything can cause but remember these four Candida - oral candidasis with oesophagitis symptoms (tx with fluconazol HSV = herpes = painful prodrome, vesicles on erythematous base and ulcers at multiple stages of healing cal or acyclavir CMV - wont see anything HIV - opportunitstic infections and to remind you infectious oesophagitis often in immunosuppressed **Eosinophilic** allergic reaction in oesophagus EGD with \>15eos per high powered field then you trial PPI as GORD often causes . . .. if they were origionally tx for GORD before biopsy then they now get oral aerosolised steroids **Caustic** Kid eg drinking drain cleaner Aduld = suicide attempt Touches all on way down inc larynx OGD to determine severity Low = trial liquid diet and monitor High severity = strictures with necrotic black looking oesophagus Never neutralise pH as it can cause a exothermic reaction and burn again . .. .. or expose again on induced emesis NGT and flush and suck multiple tiems

Answer 23

**Initial IX in general** bladder diaries should be completed for a minimum of 3 days vaginal examination to exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles ('Kegel' exercises) urine dipstick and culture urodynamic studies **Stress** have to have given birth cardinal ligament hlds uterus/bladder/vagina in place Leads to cystocel and IAP thne only increases bladder pressure and not sphincter anything that IAP (coughing, laughing, running) no nocturnal as no IAP Q-tip test = apply q tip to urethra and IAP .. . . if it rotates \>30 degress then you have urethral mobility Strengthen pelvic floor with kegal exerises then use pessaries if fails surgery MC calposuspension (NICE = retropubic mid-urethral tape procedures) Duloxetine 2nd life if decline surgical procedures ALL the following applicable to men and women **Hyertonic** random spasms of detrussor (not predictable) nocturnal (as random) U/A to ro infection Cystometry = empty and then allow to fill . . . random detrusor activity throughout Too much antispasmotics can lead to hypotonic Bladder training by graduall increasing intervals oxybutynin (avoid in old frail women), tolterodine or darifenacin mirabegron (a beta-3 agonist) if concern anticholinergic burden **Hypotonic (neurogenic bladder)]** leak before you explode (bladder pressure intermittently exceeds sphincter pressure) nocturnal (if bladder full) Physical might also find underlying FND (eg multiple in MS) Bethanacol induces spasms but in chronic irreversibele conditions consider intermittent/indwelling catheters Cystometry shows no activity **Irritated** FUD = frequency/urgency/dysuria not neccessarily incontinence might wake up with bladder symptoms but not incontinence U/A gives the answer (use in other to r/o) WBC = infection and RBC = stones, Ca UTI abx (amoxicillin, nitrofurentoin, trimethrorim sulphate) **Fistula** Epithelial line tract between bladder and anything from inflammation/radiation (so look for hx of Surgery, Ca, IBD-crohns) Physical . ..look for fistula Tampton test = put tampon where you think it is and inject dye up urethra Vagina = vaginal leak skin = they might have ad to catch it rectum = air/stool in urin (or urin in rectum) tx with fistulotomy

Answer 24

**Differentiate by age** **Most common causes** foreign body mc inserted by herself vaginal atrophy esp after sex **What you most worry about** sexual abuse if trauma or STI Pregnancy = PAD DUB (dysfunctional uterine bleeding) = AUB (abdnormal uterine bleeding) **also be aware of** = precocious puberty/HRT **what to do** speculum can be traumatising in young so under GA UPT = urinary pregnancy test post menopausal = Ca until proved otherwise **Bleeding a lot** ABC including two peripheral cannulae, 14 gauge IV syntocinon (oxytocin) 10 units or IV ergometrine 500 micrograms IM carboprost 1. for access 2. support BP until blood 3. crossmatch and transfuse as needed 4. IV oestrogen to stop bleeding 5. if above fail some sort of surgical intervention **Assess** Hb key but assess after IVF as before normal \<7 = absolute transfusion indicaiton orthostatics to assess haemodynamic stablity **surgical intervention** Intracavitary Tamponade = absolute tamponade Dilattion and cuterage = get at source to stop bleeding and preserve fertility Uteine arter embolisation reserved for AVM and fibroids (by intervential radiology) TAH = definitive tx for unrelenting haemorhage ( does not preserve fertility)

Answer 25

**Secondary** want to first consider secondary and ask RED FLAGS SAH = worst HA Tumour = FND with progressive N/V Abscess = fever/HA/FND Meningitis = Fever and HA will proabbly follow up with one or more of those IX **Primary HA** **Tension** Common one that people usualy tx themselves Bilateral vice like pain that starts in the front and radiates backt to the neck might be exacerbated by loud noise and exercise but no photo/phonophobia **If they have \> 2 days a week consider prophylaxis (10 sessions of accupuncture or amitriptyline 25mg-150mg ON). trail of prphylaxis after 4-6 months.** **Analgesic Rebound or medication overuse** most at risk are those using triptans barbituates and opiates \>10/month to tx HA can also be caused by withdrawl from NSAIDS/Paracetamol and even caffeine tx = push through withdrawl ***consider if HA 15 days a month for three months*** ***advised to stop abruptly, not gradually and push through at least a month (but can also do naproxen 250mg TDS for 4 weeks first?!)- give antiemetics*** **Cluster HA** Asx for months and then a cluster of HAs increased duration means decreased frequence and vice versa same each time unilateral eye pain associated with horner's syndrome: rhinorhea, lacrimation, conjunctival injection and lid sags 2nd line triptans MRI to r/o 2are HA ***give parenteral triptan (IN zomitriptam 5-10mg or SC sumatriptan 6mg to terminate or 100% oxygen no rebreath 12l/min for 10-20 mins to terminate in ED) no paracetamol, nsaids, opioids, ergots or oral triptans*** **Migraine** **do dual treatment of NSAID and triptan straight away** **nsal triptan in 12-17yo** **give antiemetic if naeusea eg prcholorperazine3-6mg bucacal tablets or domperidone 10mg po** **prophylaxs with topiramate or propanaol** vascular . . .generally vasodilation Aura can be any FND Trigger : eg MSG, menstrule cycle, chocolate, caffeine Sleep usually aborts but 'hangover' following day NSAIDs best if you get in early Triptans (can cause vasospasm in CAD) Idiopathic Intracranial Hten increased ICP w/o cause ICP sx esp papiilloedema associated OCPs CT scan will be -ve LP has high opening pressure and releives sx tx = acetazolamide refractory tx = serial LPs last resort = VP shunt Migraine triggers include the mnemonic **CHOCOLATE**: chocolate, hangovers, orgasms, cheese/caffeine, oral contraceptives, lie-ins, alcohol, travel, exercise **Menstrual Migraine** **ID relationhip with period for at least two cycles. give triptans or nsaids a couple of days before and after expected HA** **Trigeminal Neuralgia** ear to chin shooting pain on eating or cold liquids tx with carbamazapine **Temporal arteritis** Typically patient \> 60 years old Usually rapid onset (e.g. \< 1 month) of unilateral headache Jaw claudication (65%) Tender, palpable temporal artery Raised ESR Asoociated with polymyalgia **Low Pressure Headache** post lumbar puncture worse on standing up tx with caffeine and fluids

Answer 26

r/o syncope and disequilibrium (syncope can pose immediate risk) Vestibular system begins in semi circular canal of ears and connected to brainstem by CN8 **Central** NS = neighbourhoods sx, esp FND FND usually cerebellar MC MS, CVA and tumour IX: MRI head looking at posterior Fossa **Peripheral** **Benign paroxysmal positional vertigo** lasts \<1min, eg every time i lie on my left side Dx: Hallpike manouvre looking for rotary nystagmas Tx: Epley Manouvre **Labrynthitis and vestibular neuritis** the same but labrynthitis has hearing loss vertigo lasts 1-10 mins horizontal nystagmus can confuse for central but will be negative scan can tx with steroids if get straght awau but mosly wait it out with antivertigo meds URI = URTI tx: prochlorperazine for sx mx but only for 3 days (vertigo and nausea sx) Vestibular neuronitis urgernt referal to balance specialist for rehabilitation in the first week **Menier's** Triad of . . . last for life so prescribe anti vertigo meds Stop driving until sx under control sx tx with prochlorperazine ppx with betahistine

Answer 27

**Anxiety** Feeling + Physical Individual experience Bad experience so risk of mood disorders and to self medicate **Generalised Anxiery Disorder** At least 6 months somatic sx ie impairs normal fxn chronic problem so psychotherapy best **Panic Disorder** Presents like physical problem so r/o others Benzos to abort attack SSRIs can be used to decrease frequency CBT can be used to get out of panic attack agoraphobia = fear of leaving home alone **Phobias** Irrational or/and irrational fear Flooding = medicate then rapid exposure to stimulus Desensitisation = gradual exposure (floor by floor analagy **Social Phobia** non selective BB eg propanalol

Answer 28

A) 6 months of worry/anxiety about most things, most days - can justify several weeks B) At least 4 of: (including at least 1 from STAM) Sweating Trembling (shaking) Accelerated HR (palpitations) Mouth = dry Sx think brain, chest, abdo, muscles, nerves or think apprehension + motor tension + autonomic overactivity A) A period of at least six months with prominent tension, worry, and feelings of apprehension, about everyday events and problems. B) At least four symptoms out of the following list of items must be present, of which at least one from items (1) to (4). **Autonomic arousal symptoms** (1) Palpitations or pounding heart, or accelerated heart rate. (2) Sweating. (3) Trembling or shaking. (4) Dry mouth (not due to medication or dehydration). **Symptoms concerning chest and abdomen** (5) Difficulty breathing. (6) Feeling of choking. (7) Chest pain or discomfort. (8) Nausea or abdominal distress (e.g. churning in the stomach). **Symptoms concerning brain and mind** (9) Feeling dizzy, unsteady, faint or light-headed. (10) Feelings that objects are unreal (derealization), or that one's self is distant or "not really here" (depersonalization). (11) Fear of losing control, going crazy, or passing out. (12) Fear of dying. **General symptoms** (13) Hot flashes or cold chills. (14) Numbness or tingling sensations. **Symptoms of tension** (15) Muscle tension or aches and pains. (16) Restlessness and inability to relax. (17) Feeling keyed up, or on edge, or of mental tension. (18) A sensation of a lump in the throat or difficulty with swallowing. **Other non-specific symptoms** (19) Exaggerated response to minor surprises or being startled. (20) Difficulty in concentrating or mind going blank, because of worrying or anxiety. (21) Persistent irritability. (22) Difficulty getting to sleep because of worrying.

Answer 29

**WIPE** **LOOK** pt standing From back: muscle wasting, assymetry, scoliosis of spine, scars, skin changes, hairy patches Frome side: Cervical lordosis, thoracic kyphosis and lumbar lordosis Front: head, shoulders, hands level and no lower limb abnormality Gait: four phases present? normal armswing? symetricle, smooth, stable and good speed? **MOVE**  Assess lumbar flexion and extension by placing two or three fingers over the lumbar spine. Ask the patient to bend to touch their toes. Your fingers should move apart during flexion and back together during extension.  lateral flexion: run leg down side of legs- extent/quality/pain?  Cervical spine: lateral flexion (ear to soulder), rotation, extention (back and forwards). Extent/quality/pain?  Thoracic Rotation: sit, cross arms and rotate. extent/quality/pain?  With the patient lying as flat as possible, perform straight leg raising (see Figure 20). Dorsiflexion of the foot with the leg raised may exacerbate the pain from a nerve root entrapment or irritation such as that caused by a prolapsed intervertebral disc.  Assess limb reflexes (upper and lower) and dorsiflexion of the big toe. **FEEL** lying face down (sitting if this is not possible) feel spinal process for tenderness, pain, swelling and stiffness (and steps indicating possible subluxation) feel paraspinal mucles for tenderness/spasm Compress sacroiliac joint for tenderness **SPECIAL TESTS** Dermatomes, Myotomes and reflexes of the upper and lower limbs Femoral Nerve Stretch: face down, flex at knee, extend hip while compresses SI joint. reproduce anterior thigh pain = maybe compression of upper lumbar spinal nerve routes SLR: lift until symptoms reproduced, then lower a for degrees, then passive dorsiflexion = maybe compression of lower lumbar pinal nerve route or sciatic nerve SI joint Distraction test: +ve if reproduces pain Hip to shoulder test (assess SI joint also) - flex knee up to oppostie shoulder . .+ve test reproduces pain Hoffman's Sign (for UMN lesion eg Cervical cord compression): tap middle finger, +ve if involuntary contraction of thumb and index finger flexures Can also examine pulses if indicated. **Complete** Thank pt, ask to redress and summarise **Summary** “Today I examined Mr Smith, a 32-year-old male. On general inspection, the patient appeared comfortable at rest, with no stigmata of musculoskeletal disease. There were no objects or medical equipment around the bed of relevance.” "General inspection of the spine revealed normal spinal curveture, no scars or muscle wasting and symetrical alignment of back and joits" "No tenderness, swelling, stiffness was noted on palpating the spinous processess and no tenderness or spasms on palpation of paraspinal muscles. No tenderness of Sacroiliact joint was ilicited" “Movement ofcervical, thoracic and lumbar spine was normal.” “In summary, these findings are consistent with a normal examination of the spine.” “For completeness, I would like to perform an upper and lower limb neurological examination, examine hips and shoulder joints and consider imaging of the spine.”

Answer 30

**Normal Ranges** pH: 7.35 – 7.45 PaCO2: 4.7 – 6.0 kPa || 35.2 – 45 mmHg PaO2: 11 – 13 kPa || 82.5 – 97.5 mmHg HCO3–: 22 – 26 mEq/L Base excess (BE): -2 to +2 mmol/L **Hypoxic?** \<10 kPa on air = hypoxaemic \<8 kPa on air = severely hypoxaemic **Type 1 or 2?** **Type 1 respiratory** failure involves hypoxaemia (PaO2 \<8 kPa) with normocapnia (PaCO2 \<6.0 kPa). V/Q (ventilation/perfusion) mismatch\>hypoxia + hypercapnaei \> increased RR then blows off CO2 causes: alveolar hypoventilation (pneumonia, ARDS, pulmonary oedema), distribution/diffusion) (pulmonary fibrosis), perfusion (pulmonary embolism) **Type 2 respiratory** failure involves hypoxaemia (PaO2 \<8 kPa) with hypercapnia (PaCO2 \>6.0 kPa). Alveolar hypoventilation: Central (coma, intracerebral haemorhage), Neuromuscular (muscular dystrophy), obstruction (COPD/ Asthma), restriction (pulmonary fibroisis, pneumothorax) -airway obstruction (COPD) -reduced compliance (pneumonia/rib fracturs/ obesity - reduced respiratory muscle strength (Guilian-barre/MND) -Drugs reducing resp rate (opiates) **pH?** Acidotic: pH \<7.35 Normal: pH 7.35 – 7.45 Alkalotic: pH \>7.45 imbalance in the CO2 (respiratory) or HCO3– (metabolic). **PaCO2?** Does it correlate or not\> **Bicarbonate?** Does this correlate? **(Base Excess)** High base excess = \> +2mmol/L = high HCO3- = primary metabolic alkalosis or compensated respiratory alkalosis Low base excess = \< -2mmol/L = low HCO3- = primary metabolic acidosis or compensated respiratory alkalosis respiratory compensation is quicker than metabolic (days) **Compensation?** Assess compared to primary disturbance **Anion Gap?** Normal = 4-12 mmol/L Anion gap formula: Anion gap = Na+ – (Cl- + HCO3-) An increased anion gap indicates increased acid production or ingestion: Diabetic ketoacidosis (↑ production) Lactic acidosis (↑ production) Aspirin overdose (ingestion of acid) A decreased anion gap indicates decreased acid excretion or loss of HCO3–: Gastrointestinal loss of HCO3– (e.g. diarrhoea, ileostomy, proximal colostomy) Renal tubular acidosis (retaining H+) Addison’s disease (retaining H+) **Mixed acidosis/alkalsosis** CO2 and HCO3- will be moving in oppositie directions tx each primary acid/base disturbance **Context** A ‘normal’ PaO2 in a patient on high flow oxygen: this is abnormal as you would expect the patient to have a PaO2 well above the normal range with this level of oxygen therapy. A ‘normal’ PaCO2 in a hypoxic asthmatic patient: a sign they are tiring and need ITU intervention. A ‘very low’ PaO2 in a patient who looks completely well, is not short of breath and has normal O2 saturations: this is likely a venous sample.

Answer 31

**WIPE** **Visual Acuity** 6metres from snellen chart one eye to the lowest possible line improvement through pin-hole indicates refractive component 6 (distance read)/ 6(lowest line read) -2 (two letters wrong) if more than two letters wrong go to previous line U/A = unnaided, PH = pinhole 3metres \>1 metres \> fingers holding up Can assess near vision with fine print reading **Decreased accuity differentials** Refractive errors Amblyopia Ocular media opacities such as cataract or corneal scarring Retinal diseases such as age-related macular degeneration Optic nerve (CN II) pathology such as optic neuritis Lesions higher in the visual pathways **Colour Vision** Ischihara plates wear reading glasses if they have number of plates corrctly idied = x/13 **Visual fields** Bitemporal Hemianopia (optic chiasm pressure) Homonymous Field defects = same side of visual field in each eye Scotoma = area of reduced vision surrounded by normal Monocular vision loss = total loss of one eye . . . secondary to optic nerve pathology (vascular neuropathy) or occular diseae (retinal detachment or retinal artery/vein problems) **External Eye Inspection** Eyelids (lumps/oumps/ ectropions) Eyelashes diffuse conjunctival injection (whole conjunctive: viral, bacterial , allergic) Cicumcilliary injection (circular around cornea suggesting intraocular inflammation Discharge: watery (corneal abraisn/foreign body/ viral/allergic) or purulent (bacterial) Hyphema = blood in anterior chamber eg trauma Hypopyon (pus in anterior chamber) Periorbital erythema and swelling (preseptal cellulitis or orbital cellulitis foreign bodies corneal abrasion corneal ulcer Inspect pupil (size, shape, symmetry) **Pupil reflexes** Direct Consensual accommodation swinging light test (relative afferent pupillary defect) * normally both constrict same amount on shining light in either eye* * if efferent damage then when light shone in affect eye both constrict a reduced amount* * shining light in swinging eye test gives the effect of relative dilation* * either significant retinal damage (retinal vein/artery occlusion or large retinal detachment) or optic neuropathy (optic neuritis, unilaterlal advanced glaucoma, compression of secondary tumour or abscess and ischaemic optic neuropathy)* **Strabismus** * Light reflex test/ corneal reflex test/ hirschbeg test:* * focus on half a metre away and shine light in both eyes . .. should reflect equally* Cover test *If contralateral eye does not move then orthotropic (normal alignment) if it does then heterotropia . .. see diagram for specifics* **Eye movments** H pattern restricted movement or nystagmus? **Fundoscopy** darkened room, ideal with short acting mydriatic eye drops (tropicamide 1%) ask to look straight ahead for duration of test **Red light reflex** about arms length absent in adults :cataracts vitreous haemorrhage and retinal detachment absent in children = congenital cataracts, retinla detachment, vitreous haemorrhage and retinoblastoma white reflex (lekocoria) in any age can be above pathologies **Anterior segment** use green 10 or 15 hand on forehead to prevent colision idealy with dye . .. white opacities can be coreanl ulcer **Fundus** **Optic disk** 45 degree angle slighlt temportal follow vessels to optiv disc comment on 3 Cs: Contour (clear and well defined . . .blurrred = papilloedema secondary to raised ICP) Colour: disc should be orange pink doughnut with pale centre . .. pale disc = aptiv atrophy (optic neuritis, advanced glaucoma and ischamic vascular events) Cup: cup to disc ratio should be around 3 Iie cup occupies 3rd of disc) . .. . if increaseed ratio reduced neural teinal tissue (glaucoma) **Retina** clockwise/anticlockwise: superior temportal, superior nalsa, inferior nasal, inferior temportal Look for arteriolar narrowing, arteriovenous nipping.bicking, dot and blot haemorhages, flame haemorrhages, cotton wool spots, hard exudates, neovascularisation, pan retinal photocoagulation, branch retinal vein occlusion **assess macula** fovea should be same size as optiv disk look for haed exudates, drusen, cheery red spot **Complete** thank patient remind can't drive if had mdriatic drops for 3-4 hours till wear off for completeness : slit lamp exam, cranial nerve examination, blod pressure, capilliary blood glucose, retinal photography

Answer 32

**Prehepatic** Haematoma (reabsorption of it) Conjugation = bilirubin rate limiting step (2,3 UDP gluconyltransferase) **Intrahepatic** Liver three main steps (entry, conjugation, excretion (genetic rotors, duben johnson etc) **Post hepatic** = obstruction **Gallstones** choledocholithiasis = stone from GB stuck in biliary tree sudden so only mild dilation of tree but inflammation of biliary tree and gallbladder (cholecystitis) Inflammation = mild fever, leukocytosis, pain and maybe murphy's sign US first, MRCP best (ERCP w/o ro complication) ERCP usually opted for as faster than cholecystectomy with retrogrrade cholangiopancreatography **Stricture/cancer** Slowly obstruction so system has time to adapt massivly dilated and thin walled distended gallbladder courvoisier sign = painless jaundice and enlarged gallbladder **Flow** all three things point ot obstructive jaundice Bili levels higher (20-26 as opposed to single digits of gallstones) Workup = CT first in test if not sure? **Pacnreatic** grows in peritenium so asx till large or mets (terrible prognosis) Migratory thrombophlebitis = clot moves around body (eg leg) = pancreatic cancer (or maybe lung cancer?) Endoscopic US with biopsy as outside the biliary tree Double duct sign on CT (dilated common bile duct and dilated pancreatic duct) Monitor with Ca 19-9 **Cholangiocarcinoma** biliary tree mass associated with primary sclerosing cholangitis which would have beeds on a string sign ERCP as in biliary tree **Ampulla of Vater** as too small on CT but entrance to biliary tree so can cause significant obstruction FOBT would be positive but nothing on colonoscopy as too far up ERCP as in biliary tree

Answer 33

**Cholelithiasis** means gallstones in gallbladder stones in two forms: cholesterol = green and haemolysis = black does't really matter as present the same Fat makes GB squeeze out bile but squeezes stones US great as solid against liquid Ursodoxycholic acid if not surgical candidate **Cholecystitis** inflammation US to look for 1,2,3 Murphy's sign (hand on ribs and thumb on GB . . . big breath in and out and then put thumb in. . . will stop breathing out in positive) HIDA san if US not all 1,2,3 (gallbladder won't fill with ijected isotope) tx with urgent (\<72hrs) cholecystectomy as could perforate Cholecystotomy in non surgical candidate Boas sign refers to this hyperaesthesia (increased sensitivity). It occurs because the abdominal wall innervation of this region is from the spinal roots that lie at this level. (beneath right scapula) **Choledocolithiasis** Gallstones in CBD presents with painful jaundice (consider everyting else a maybe) might have gallstone pancreatitis or hepatitis too US looks for dilated CBD Want ERCP (but ok to NP,E VF, IVabx as don't know if infective and can progress to cholangitis) tx with urgent ERCP and can do cholecystectomy at a later date (can do straight away but ERCP quicker) Ball-valve . . . .painful and deranged LFTs correct then come back as its acting as a valve **Cholangitis** Dilated ducts with stagnant fluid is ready for infection . . .. SAS GNR = gram -ve rods Don't bother with MRCP and ERCP as this is emergency tx (ERCP diagnostic) can give IVF, IV abx and NPO when prepping for surgery Cholecystectiomy still urgent after ABX p cipro (GNR) and metronidazole (anaerobe) - pip tazo wastes the +ve coverage **Extra** Pigmented Stones associated with Sickel Cell Anaemia

Answer 34

**Who** CVD RFs : old fat and hypertensive Thrush: sore itchy foreskin in men polyuria, polydipsia, blurred vision **How** The randam blood glucose is useful for the T1DM who comes in with all the sx The tests are better as they go down. HbA1C measures glycosylated end products so is therefore an average over 90 days But cannot r/o diabetes as haemaglobinopathies affect levels **IFG/IGT** Impaired fasting glucose = FPG \>6.1 but \<7.0 mmol/L and should be offered OGTT to r/o DM Impaired glucose tolerace = Pre-diabetes **T1 DM** AI desruction of pancrease old person with normal BMs last year presenting with polydisia, polyuria and very high BMs is same as young anti-GAD (anti-glutamic acid decarboxylase) and IA-2 are antibodies (to differentiate from T2DM in older patients) **Tx** with insulin Monitor at least 4 times a day, including before each meal and before bed **Pre-Diabetes** **Mx** lifestyle modification = weight loss, increase exercise, change diet At least yearly F/U blood tests Metformin for their FPG or HbA1c is progressing towards T2DM **T2DM** **Mx** Check HbA1c q3-6 months then every 6 months when stable 1. Lifestyle: target = 48 mmol/mol 2. Add metformin: target = 48mmol/mol 3. If \>58 add another drug: target = 53 mmol/mol 4. If still \>58 add another or consider Insulin Keep metformin when starting insulin and consider the others **If metformin not initially tolerated then:** First try modified release meformin 1. Lifestyle: target = 48 mmol/mol 2. Add another drug: target = 48mmol/mol 3. If \>58 add another drug: target = 53 mmol/mol 4. If still \>58 consider Insulin Drugs **Metformin**: the diarhoea will go away **Sulfonylureas** (pick as cheap and been around ages): watch out for the hypoglycaemia esp in CKD pts- increases insulin expression **TZD** = thiazolidinedione = pioglitazone : can cause CHF **GLP1 mimetic** (exenatide) criteria = BMI\>35 and unable to lose weight or \<35 but insulin would have significant occupational implicatons . . . only continue if a 1% HbA1c reduction or weight loss of 3% in 6 months SGLT-2i can cause DKA so avoid **Alpha Glucosidase** inhibitors mean that glucose not absorbed so dirahoea and smeel flatulance **RF modification** **Htn:** 1st line ACEi \<80 target 140/90 clinic (135/85) \>80 target 150/90 (145/85) **Antiolatelets** offered **Lipids** = QRISK2 score = atorvastatin 20mg ON **Retinopathy -** sudden vision loss = vitrious haemorhage **Nephropathy** All diabetic patients require annual screening for albumin:creatinine ratio (ACR) in early morning specimens ACR \> 2.5 = microalbuminuria Mx: Start ACEi diet restrict protein gd control of BP, BM, Lipids **Neuropathy** 1st line: amitriptyline, duloxetine, gabapentin or pregabalin 2nd- try another one of the drugs 3. tramadol can be used as rescue therapy 4 - refer to pain mx clinic] **Charcot Foot** Mild pain considering of joint dysruption swollen, red and warm **DM sick day rules** increase frequency of BG monitoring drink at least 3 litres/24hrs have sugary drinks if struggling to eat keep phone on you **MODY** maturity onset diabetes of the young (MODY) - type Hepatic Nuclear Factor 1 Alpha (HNF1A). HNF1A accounts for 70% of MODY cases. Sulfonylureas (e.g. gliclazide) are the optimal treatment in HNF1A-MODY. **Small bowel bacterial overgrowth syndrome (SBBOS)** DM at ro this excessive gut bateria sx: chronic diarhoea, bloating, flatulance, abdo pain dx: hyrodogen breath test tx: rifaximin and DM control **Dietary advice** encourage high fibre, low glycaemic index sources of carbohydrates include low-fat dairy products and oily fish control the intake of foods containing saturated fats and trans fatty acids limited substitution of sucrose-containing foods for other carbohydrates is allowable, but care should be taken to avoid excess energy intake discourage use of foods marketed specifically at people with diabetes initial target weight loss in an overweight person is 5-10%

Answer 35

Gastric usully H pylori Duodenal always H pylori H. pylori usually single ulcer (malignancy can start like this though) Malignancy - necrotic as outgrowing blood supply (can present with gastric outlet obstruction) Curling irons burn and cushions are squishy **Presentation** 20% asx so present with the complications: GI bleed, perforation, G/O obstruction Sx worsened by eating in gastric and improve with duodenal (this is unreliable in life though) Almost always OGD **TX for everyone** stop smoking and drinking (not direct RF but inhibit healing) PPI almost everyone **Flow** if its NSAIDs presentation don't need to bx but probs will (tx with high dose PPI then lower dose ppx if you restart NSAID) if bx shows normal then PPI tx **H-pylori** often present with complications as Asx OGD best: rapid urease, histology (expensive and time consuming), histology (best . ..actually see it) Stool ag: check it eradicated serology - will be positive if had once (Tx if +ve + sx + not previously dx) Urea breath test need to be off PPI so not that much in practice (good for initial dx though) Tripple therapy; use metro if pennicillin allergy **ZE** gastrin stimulates parietal cells to produce acid . .. acid inhibits gastrin production Gastrinoma produces gastrin regardless OGD will see lots . .. high dose PPI doesn't work. . . .. repeat OGD and still loads . . . suspect gastrinoma Gastrin in triple digits diagnostic if in between secretin stim test will lead to increased gastrin Locate with CT but best is somatostatin receptor scintography resect for ulcers but also it can induce gastric carcinoma

Answer 36

Consider in pt with \>6months of ABC (abdo pain/discomfort, bloating or change in bowel habit) ROME III diagnostic criteria = ≥ 3 days/month of abdo pain/discomfort in last 3 months with ≥ 2 of - improvement with defectation - onset associated with change in stool frequency - onset assciated with change in form (appearance) sx onset should be at least 6 months before diagnosis refer to secondary care for any red flag symptoms including family hx of bowel or ovarian cancer **IX:** FBC, ESR, CRP tTG (tissue transglutaminase) faecal calprotectin to differentiate between IBD and IBS if Ca not suspected **mx** bda ibs factsheet pdf dietician referal for FODMAP diet may help peppermint oil (antispasmodid) laxative (but not lactulose aas can make bloating worse) loperamide best for antispasmodic for diarhoea predominent consider TCA if above measures unseuccessful (then ssri)

Answer 37

**Tx:** W- BB O- IVF or stockings if ANS - (Volume down from th e4 Ds (dehydration, diarhoea, diuresis or haemorage) - **LOOK AT MEDS)** M- Surgery **LOC?** - How long did it take them to come round? - 2010 rule for shakes- - the rest ask for sake of OSCE but pretty useless **WOMAN 3-2-1 PE** (321 for first three sub categories) W- acetylcholline released by cagus leads to bradycardia and vasodilation Orhostatics - Volume down from th e4 Ds (dehydration, diarhoea, diuresis or haemorage) - **LOOK AT MEDS** **- sitting/standing** BP 5 minutes lying down, then in 1st minute standing, then after 3 minutes standing ANS - old, PD, DM . . . if IVF does not help its this . . . stockings MA - admit as heart ones . . . . M usually valvular and old eg aortic stenosis (old man shovling ice) could be Hypertrophic obstruct cardiomyopathy in young. N - very rare- . . . only consider if focal deficit P = psych . . . faking it . . . arm drop test E= electrolytes Na and ca for altered mental staus and K and mg for weakness If you suspect cardiac, admit and do echo and ecg (inc 24hr) PE - different as if they fall to the floor it won't help them

Answer 38

Only work up if diastolic or systolic 3+ **MS** aortic dilation thereofre af Only one you can do ballo valvuloplasty as not calcified. Want ot avoid valve replacement until older **AI (aka aortic regurgitation)** May have chest pain as less blood coronary artery ostia Acute and chronic both need replacement Floppy valve leads to floppy heart **AS** atherosclerosis leads ot calcium deposition also leads to ventricuolar dilation Mostly old men but bicuspic valve in younger tx as soon as symptomatic (syncope) Nitrates contraindicated due to theoretical hypotension narrow pulse pressure **MI** aortic dilation therefore af holosystolic so may not hear s1 or s2 * all above improve worsen with increase venous return (squatting/leg lift increase and valsalvar decreases)* * Following are opposite* * Pansystolic murmur can also be caused by ventricular septal defect following an MI* **HCM** less blood and ventricle smaller so ventricle outlet closes (can kill) you won't see the sudden deaths Like Aortic stenosis but more blood makes better beta blockers increase preload **MVP (mitral valve prolapse)** Like MS but better with more blood valve too big so ends don't touch . . .more blood means they can **Endocarditis** The most common valvular abnormality in infective endocarditis is tricuspid regurgitation. Combined with the fact that this man is showing sings of right sided heart failure (peripheral oedema) Holosystolic murmur louder during inspiratio **Replacement for all 1st four but can medically manage by afterload reduction and diuresis** **Patterns of the 4** Left diastolic/ right systolic up is heart apex+aortic dilation/ down is base +VD Insufficiency = more acute/ stenotic = more insidius **Extra** Venous hum is a benign murmur heard in children and sounds like a continuous blowing noise heard below the clavicles A pansystolic murmur is associated with mitral regurgitation. An ejection systolic murmur is associated with aortic stenosis. A continuous 'machinery' murmur is associated with a patent ductus arteriosus. A late diastolic murmur is associated with mitral stenosis.

Answer 39

**What it represents** P wave = depolorisation of atrial muscle PR interval = time for electricle impulse to spread from atria to ventricles (3-5 small squares) QRS = depolorisation of the ventricles (\<3 squares) ST segment = period when ventricles are completely activated T wave = repolorisation of ventricular muscle U wave = repolorisation of pappilary muscles (abnormal if after flattened T wave) **Context** note BP/HR consciouness when taking ECG **RRPWQST** RATE: 300, 150, 100, 75, 60, 50 (small = 4ms and large = 200ms RHYTHM: regular = equal distance between QRS complexes P WAVES: P wave before every QRS = sinus (impulse from SAN to ventricles) - no P = abnormal rhythm. \>1 P = heart block (abnormal coduction to the ventricles) WIDTH: QRS \>3 squares = slow ventricle conduction (abnormal conduction or eronously starting in ventricular tissue) Q WAVE: if QRS starts with deep downward deflection could be old MI ST segment: should be level with baseline. elevated = MI and depressed = MC Ischaemia T wave: normally upside down in VR and V1 .. in other leads could be ischamie or ventricular hyertrohy QT interval: varies with heart rate, prolonged with some drugs (\>12 small squares) Calibration: 1 square wide and two high . . .. . should be included on every record (25mm/s) **AXIS** serves to alert of other pathology eg PE/ conudction abnormality Normal = +ve I and II Left leaving = positive in I and Negative in II Right reaching = -ve in 1 and +ve in 2 90 degrees from isoelectric lead, see if +ve at +90 or -90 RAD ax Right ventricluar hypertrophy (2ary pulmoary conditions causeing right heart strain) LAD ax wtih conduction abnormalities **V leads** V1,V2 look at right ventricle V3/V4 look at septum V5/V6 look at left ventricle V leads QRS - first septal depolorisation from left to right (intial R wave in V1/V2 but q wave in V5/V6) then ventricular depolorisation RS trasition point represents the position of interventricular septum (normal V3/V4), right ventricle hypertrophy pushes to V4/V5/V6 Reporting ECG Always: 1. rhythm 2. conduction intervals 3. cardiac axis 4. description of QRS complexes 5. description of ST segments and T waves eg: 1. Simus rhythm, rate 50bpm 2. normal PR interval (100ms) 3. Normal QRS complex duration (120ms) 4. Normal Cardiac Axis 5. Normal QRS complexes 6. Normal T waves (inverted in VR is normal) **Setup** attache electrodes to correct limbs ensure ggod elecrical contact check the calibrationand speed settings make patient comfortable and relaxed

Answer 40

**Systems Review** **Head** – History of injury, headaches or infection? **Eyes** – Visual acuity/glasses? History of injury, headaches or surgery? **Nervous system** – Fits, faints, or funny turns? History of hearing concerns, seizures (febrile or afebrile), abnormal or impaired movements, tremors or change in behaviour? School performance? History of hyperactivity? **ENT** – Earache, throat infections, snoring or noisy breathing (stridor)? **Chest** – Cough, wheeze, breathing problems? Smokers in the family? Exposure to smoke? **Heart** – Cyanosis, exercise tolerance, chest pain, fainting episodes? History of heart murmurs or rheumatic fever in the child or the family? **GIT** – Vomiting, diarrhoea/constipation, abdominal pain? Rectal bleeding? **Genitourinary** – Dysuria, frequency, wetting/accidents, toilet training? **Joints/Limbs** – Gait, limb pain or swelling, other functional abnormalities? **Skin** – General rashes? Birthmarks or unusual marks? Pubertal development – Age of menarche? **HEEADSSS** **Home and relationships** Who lives at home with you? Do you have your own room? Who do you get on with best and/or fight with most? Who do you turn to when you’re feeling down? **Education and employment** Are you in school/college at the moment? Which year are you in? What do you like the best/least at school/college? How are you doing at school? What do you want to do when you finish? Do you have friends at school? How do you get along with others at school? Do you work? How much? **Eating** Are you worried about your weight or body shape? Have you noticed any change in your weight recently? Have you been on a diet? Do you mind telling me, how? **Activities and hobbies** How do you spend your spare time? What do you do to relax? What kind of physical activities do you do? **Drugs, alcohol and tobacco** At this stage – reassure about confidentiality Does anyone smoke at home? Lots of people your age smoke. Have you been offered cigarettes? How many do you smoke each day? Many people start drinking alcohol around your age. Have you tried or been offered alcohol? How much/how often? Some young people use cannabis. Have you tried it? How much/how often? What about other drugs, such as ecstasy and cocaine? **Sex and relationships** Are you seeing anyone at the moment? Are they a boy or a girl? Young people are often starting to develop intimate relationships? How have you handled that part of your relationship? Have you ever had sex? What contraception do you use? **Self-harm, depression and self-image** How is life going in general? Are you worried about your weight? What do you do when you feel stressed? Do you ever feel sad and tearful? Have you ever felt so sad that life isn’t worth living? Do you think about hurting or killing yourself? Have you ever tried to harm yourself? **Safety and abuse** Do you feel safe at school/at home? Is anyone harming you? Is anyone making you do things that you don’t want to? Have you ever felt unsafe when you’re online or using your phone?

Answer 41

WIPE Postion/Exposure General Inspection General Examination Chext examination: Inspection Palpation Auscultation Special Manouvres Additional Examination Bedside Investigations Proffesionalism **Presentation** Name and Age 5 things of general inspection/ exam: warm peripheries, pulse rate was xxx, regular rhythm and normal volume, CRT \<2s, non cyanotic and no appreviable JVP On Inspection of the chest there were not notable scars On Palpation . . . . On auscultation . . .. There was no eveidence of peripheral oedema My THREE top differentials are: For further Ix I would like . .. **WIPE** **Correct position and adequate exposure** **General Inspection** **General Examination (vital signs)** Hands and anils radial pulse BP Eyes Face/mouth Neck Carotid pulse **Inspection** **Palapation** Apex Beat Heaves and thrills Auscultation Mitral Aortic Tricuspid Pulmonary **Special Manouvres** Mitral stenosis Aortic Regurgitation Mitral regurgitation Aortic stenosis **Additional Examination** Lung bases periperal pulses Peripheral odema Abdominal Examination **Bedside Investication** **Professionalism** Look, point and touch everything you exam eg scars/marks Ankle oedema Hold for 10s, look at face to see if painful, then check how pitted Anaemia Remove glasses and pulldown eyelids yourself. get patint to look dows and check for icterus JVP 'No appreciatable JVP' **Extra** Collapsing pulse is a feature of aortic regurgitation, PDA, and hyperdynamic states (anaemia, thyrotoxicosis, fever, exercise/pregnancy) A pansystolic murmur is associated with mitral regurgitation. An ejection systolic murmur is associated with aortic stenosis. A continuous 'machinery' murmur is associated with a patent ductus arteriosus. A late diastolic murmur is associated with mitral stenosis.

Answer 42

**Projection** PA = best (check scaulae are lateral AP = crAP (for haemodynamically unstable) **Patient details** Name, gender, DOB, date of xray (check previous xrays) **technical Adequacy** Nothing imortant cut off/ RIP **Obvious Abnormalities** Where, size, texture, density **Systemic r/v of xray** Zoom out first then close up for subtle abnormalities ABCDD ***Airway*** Trachea Central? check not rotation deviates towards lobar/lung collapse Deviates away from pleural effusion/mediastinal mass ***Breathing/Borders*** Apices down to costrophrenic angles comparing both sides left hilum should never be lower than right (look for volum pulling right u or or pulling left down) Hila should be same density with no lumbs or convex margins look at edge of lung for pneumotharaces (if you dont look for it you wont see it ***Cardiac and Mediastinum*** Heart size - cardiomegally = heart \>50% maximal internal thoracic diametre (on technically adequate PA . . . but if not enlarge on AP then won't on PA) Mediastinal borders should be clearly visible (look for lung pathology if not) heart/mediastinum should be positioned over thoracix vertebra . . . . assess volume change in lungs if not Mediastinal weidnicg (technical factors, masses or haemorhage) Heart should have uniform density (consider retrocardiac pathology if not) linear lucencies in suerior mediastinum = pneumomediastinum ***Diaphragm*** Both hemidiaphragms should be seen Upwardly convex (flattened in COPD) Righ should be slightly higher due to liver lungs can distend beyone diaphragm so look behind look for free air under diaphragm (stomach bubble would have thicker membrane and on the left) costrophrenic angles should be sharp (fluid if not) ***Delicates*** Ax for fracturs intercostal spaces should be equal soft tissues - gas = surgical emphysaema ***Lines*** Endotracheal tube must have tip b4 carina ( if goes down a bronchi the other can collapse) Tip of NG tube well below diaphragm Central lines in midlower SVC **review areas** Apices, Hila, Behind the heart, Costrophrenic Angles, Under diaphragm **summary** Maind finding with differentialss state will r/v any previous suggest further investigations suggest mx plan **Presenting** This is a PA chest radiograph which has been anomynised - i would like to confirm date and patient details No important areas have been excluded, there is no rotation, there is adequate inspiration and penetrance therefore the chest radiograph is technically adequate What strikes me about the xray is . . . . on review airway is central, lung fields are clear, there a clear cardiac borders w/o evidence of cardiomegally, diaphragms are bilaterally convex with no free air below, there are no discernable abnormalities of bony or soft tissue. HEART FAILURE A - alveolar oedema (bat wing opacities) B - Kerley B lines. C - cardiomegaly. D - dilated upper lobe vessels. E - pleural effusion.

Answer 43

PULSE In practice not may options - its about team managment Sinus bradycardia is kind of an arythmia Stable is not emergency management Unstable = they will die unlesss you do something CP = chest pain AMS = altered mental status (same time as arythmia Shock = synchronised cardioversion (not during T wave) F+W = likely VTAC - amiodarone F+N = likely SVT - adenosine Slow get atropine to prepare pace Only pattern you need to know is Afib/flutter -but even if you missed this you still go to BB/CCB after adenosine **NO PULSE (if in doubt always CPR)** Shockable (120-150j then same or higher in subsequent) CPR = 30:2 (2mins) Ventilation = supraglottic airway continuous 10/min if excessive leak then do breaths very 30 compressions Rhythm check should be \<5s (only check at appropriate time unles signs of ROSC (ie not if normal rhythm on defib) - 1mg IV adrenaline (1mg/10mls, 1:10,000) after 3rd shock (then alternate) - flush with 20ml for 10-20s after every drug) - 300mg amiodarone after 3rd shock (consider 150mg after 5th) **Non shockable** - adrenaline IV asap and then every 3-5m (2 CPR cycles) **ALL THIS ONLY WORKS IF YOU TREAT THE CAUSE** **4 Hs and 4Ts** * Hypoxia (ensure ventilation with 100% o2, equal expansion, correct tracheal placement)* * Hypovolaemia (most common severe haemorhagh . . obvious (trauma) or occult (GI, ruptured AAA)* * Hyperkalaemia, hypokalaemia, hypoglycaemia, hypocalcaemia, acidaemia and other metabolic disorders (blood tests)* * Hypothermia/ Hyperthermia (suspec in drowning and low thermometre reading)* * Thrombosis (coronary or pulmonary)* * Tension pneumothorax* * Tamponade – cardiac* * Toxins* **Airway Managment** choking without efffective cough = 5 back blows and 5 abdominal thrusts back to back simple airway manouvres = head tilt + chin lif or jaw thrust guedel = from incisors to angle of mandible. too big\>too small. if suspect cervical spine injury then maintain immobilisation of head and neck oxygen: max possible ie non-rebreath suction: caution in gag reflex. fine bor flexible suction tubes if limited mouth opening **EXTRAS** Precordal thump: if no interuption and no defib immediately available (VT/VF) If you see person go into VT/VF in before any ALS intiiated call for help and deliver 3 shocks back to back (check for ROSC each time) ?true asystole: check for p waves . . . . if present pacing may be effective Waveform capnography helps with: esure tarcheal tube placement, monitoring ventilation rate, monitoring quality of chest compressions, identifying ROSC and ? prognostication during CPR Intraosseous access: requires training, prox tibial, prox humerus and distal tibia, contraindicated if trauma, infection or prosthesus at site, withdraw blood to confirm position and flush to conifrm patency. inspiratory wheeze = laryngeal level or above snoring = phaynx parially occluded by tongue or palate blood oxygen (on blood gas) shoud be about 10 less that fio2

Answer 44

-aemia not -osi as you can have lots of osi but eventually something wins Look at PH to see what it is Look at CO2 to determine type **Hypoventilation** Look for air trapping disease osa = obstructive slee anoea muscle strenght eg intubated too long **Hyperventilation** look for high RR (could be tidal volume related though) **Metabolic Alkalosis** Do a urine chloride to determine if volume resonsive or not (Volume down means activated RAS and increased aldo which means retention of Na AND Cl- ) . . . tx with colume Emesis especialy bad as volume down and acid lost Not low see if hypertensive or not hyperaldo = Conn's or RAS/MDS **Metabolic acidosis** Calculate anion gap (Na - Cl - Bicarb) Non Gap do a Urine anion gap (Na + k - Cl) - \>20 think RTA, normal/-ve think diarhoea/vom positive is renal tubular acidosis and -ve = diarhoea (yes volume down but loses bicarb) MUDPILERS (rhabdomyolysis)

Answer 45

Angina is Demand ischaemia - reducing load will help **ANGINA** Tx: GTN spray, BB or CCB (titrate up till max tolerated) \> BB + CCB **Diagnosis** Work from STEMI back **Troponins** only for initial presentation as they do not go back down **Stable chest pain** : Contrast-enhanced CT coronary angiogram is the first line investigation for stable chest pain of suspected coronary artery disease aetiology **Types of MI** Type 1 = acute palaque rupture (ischaemia/infarction) Type 2 = supply and demand (whole body problem - sepsis/hypoxia) **Cath lab** \>3 or big and proximal = surgery (stents for everything else) stop metformin 24hr (contrast media decreased renal clearance and along with metformin can cause lactic acidosis) **General ACS** Aspirin 300mg Nitrates (sublinguinal glyceryl trinitrate - avoid if hypotensive though) and morphine to relieve pain Anti-emetic eg metoclopromide 02 if sats \<94% **STEMI** above and: P2Y12-receptor antagonist = Prasugrel\>Ticagrelor\>Clopidogrel Unfractionated heparin if PIC (LMWH is an alternative) tPA (Alteplase/Tenecteplase) if PCI \<120mins of presentation not possible (perform ECG 90 mins after and if ST elevation not reduced by 50% then rescue PCI better than repeat tPA) - give antithrombin (fonadparinux) at same time and ticagrelor after Blood glucose \< 11.0 mmol/L **NSTEMI** Unstable = immediate coronary angiography Fondaparinux (antithrombin) - if no immediate PCI planned Estimate 6 month mortalitly (GRACE) if low risk (\<3%) then give Ticagrelor If intermediate/high (.3%) : PCI immediate if unstable and within 72hrs if stable give prasugrel/ticagrelor give unfractionated heparin drug elucidating stents prefered. Ticagrelor and prasugrel antiplatelets prefered to clopidogral. continue for at least 12m Prasugrel if going to have PCI (also 12m if stented. **Complications** DARTH VADER Death Arrythmia/Heart block Ruptured Aneurysm Thrombus Heart Failure VSD Another MI Dressler's Syndrome Embolus Regurgitant Valve **RIGHT SIDED INFRACTS = PRELOAD DEPENDENT** RS = V1\>V2 ST eleveation in V1 and depression in V2 is highly specific to RSHF Lead III \> Lead II Give IV fluids and do not give nitrates as they cause hypotension **Extra** Diclofenac Contraindicated deeply inverted or biphasic waves in V2-3 in a person with the previous history of angina is characteristic of Wellen's syndrome. This is highly specific for a critical stenosis of the left anterior descending artery

Answer 46

aspirin a second antiplatelet if appropriate (e.g. clopidogrel) a beta-blocker an ACE inhibitor a statin

Answer 47

**Croup** Classic Presentation Racemic Adrenaline is the diagnositc step Steelple sign (subglottic narrowing not sensitive or specific so don't bother with xray) *CKS recommend giving a single dose of oral **dexamethasone (0.15mg/kg)** to all children regardless of severity* adrenaline/ O2 for emergency **Bacterial Tracheaitis** Almost always S.aureus following viral prodrome presents like not improving croup (esp Racemic adrenaline) IX- ENT scope eg laryngoscopy (purulent = abx + culuture) **Epiglotitis** quirte rare - SAS classic presentation - check if had HIB vaccine if not straight to ER (diagnosis will be on scoping to secure airway) **Retropharyngeal Abscess** Pretty much the same but lump on neck CT instead of OR **PT (quinsy)** going to be older - mainly adolescents deviated uvela = key urgent ent referal (maybe tonsillectomy) trismus = dificullty opening mouth **Laryngomalacia** Congenital abnormality of the larynx. Infants typical present at 4 weeks of age with: stridor Noisy breathing . . . worse on eating

Answer 48

Four seperate entities here as opposed to upper airway **Foreign body Airway obstruction** Intrathoracic location + stridor as airways narrow on exhalation Extrathoracic = oposite true Coin sign +ve lateral as floppy bit is at back Depending on these clues it tells you who to contact for help **Asthma (high yield summary)** OLD = obstructive lung disease Dx on spirometry (reversible on bronchodilator) - if normal can induce with Methacholine GET PARENTS TO STOP SMOKNIG **Bronchiolitis** Beta agonists don't do anything as its not bronchoconstriction but cells sloughing off. non of the investigations or Tx really help even o2 and IVF is just so they are well enough to eat so they don't FTT BUT not a nonsense illness as can lead to acute hypoxic respiratory failure and ARDS **Immediate hospital referal** \>70 breaths per min central cyanosis looks SAS persistent \<92% O2 saturation Grunting **Consider hospital referal** \>60 breaths per minute dehydration feeding \<50% normal **TX** O2, consider NGT, consider suction (upper airway secretions) **CF** Triad of; Typical pulmonary and/or gastrointestinal tract manifestations A family history A positive result on ‘sweat-test’ (based on Cl-ion concentration). (pilocarpine given to induce sweating. . \>60 diagnostic and \>30 in infant is highly suggestive Common infections: S.aureus Klebsiella Pneumoniae Pseudeomonas Aeruginosa Burkholderia Cepacia 50-55y life expectancy

Answer 49

**VW Happens** **Viral** Needs to be chronic infection both transmitted via blood (eg transfusions) Hep C can now be treated with Direct acting antogonists and cured (no longer year long SEs of rubavirin and interferon) **Wilson's** sx depending where Cu deposited also speach, behaviour and psychiatric problems IX ceulopkasmin or urinary cu pencillamine to bridge to transplant (which cures the disease as well as cirhosis) **Haemochromatosis** iron deposition in skin, pancreas, liver and heart usually switch in gut to stop absorbing Fe Ix Ferritin \>1000 w/o inflammation or hepatic necrosis transferin is a better test tx with phlebotomy deferoxamine is a chelator transplant treats the cirhosis but not the disease asa its in the gut **Alpha-1 anti-trypsin deficiency** look for the young non smokers iwth COPD and Cirhosis this enzyme opposies elastase in the lungs it can't get out of liver so causes cirhosis elastase unchecked in lungs so causes COPD transplant stops further lung damage **Primary Sclerosing Cholangitis** (S for son's of bitches) manly and overt so extrahepatic and dx on imaging painless jaundice Don't need ERCP if beads on a string on MRCP tx with transplant and bridge with ursodeoxycholic acid don't stent as althought provides relief makes transplant harder **Primary Billiary CIrhosis** B is for bitches coy therefore intrahepatic and have to dx with imaging (AMA not always detectable) the **M** rule = Ig**M**, anti-**M**itochondrial antibodies, **M**2 subtype ,**M**iddle aged females Sicca Syndrome: 70% cases : dry moyth (xerostomia) **ETOH** long alc hx stop drinking or can't get transplant **NASH** = non alcoholic steatohepatitis **NAFLD** = non alcoholic fatty liver disease

Answer 50

TP = total proptein tp - alb = protein gap TB = total bili. d bili = direct thinks in black form hpuse. . .stuff liver makes therefore an assessment of chronic liver disease t - direct = unconjugated d bili and alp green as linked and post hepatic TAKE 2 blue are things you should order alb made by liver but used and lost elsewhere (think ossi) nephrosis = nephropathy gastrosis = protein losing enteropathy or probs malnutritianb pre albumin = tells if its just nutritional statis u/a or u proteinm tells us if its coming from kidney protein gap over 4 tells us something is wrong (lots of immunoglobulins eg hiv hep c , mm) but can also be sepsis ast also made in muscle (check cpk or ck to see if from mjscle) alt can be from bone (check ggt) but rarely need to do these extra steps as can tell from patterns/context 2:1 ratio esp if not that elevated if get into 1000s then think of the 6 as aflatoxin = mushrooms bud chiari you can check with doppler Hepatocellular = 1ary intrahepatic (large increase ast and alt). ALP/ Bili also a little as has portal triads etc alk phos and d bili = post . . . painful almost always gallstones (at lwat choledocolithiasis to be affecting liver) small numbers as acute small alt/ast as back up to liver jaundive haemolysis needed to generate haemoglobin pre = mostly from haemolysis intra = 3 steps (uptake, conjucation, release) . .. mix probs intra infiltrative (islolated alp not from bone do a liver bx). . . more for completedness

Answer 51

**PC** When (time and what they were doing) Where (inside/outside) What (before, during and after) * Before: any warning/ dizziness/chest pain/ palpitations* * During: LOC/incontinence/ tongue biting/ palor/ what hit the floor* * After: Got up/ long lie/ how long till back to normal/ weakness/numbness/ speach/ confusion* Why: why do you think? (trip/medication) How: How many over the last month (seriousness of problem) Sysyems Review (inc joint pain/muscle weakness) **PMH** **Dhx** Beta-blockers (bradycardia) Diabetic medications (hypoglycaemia) Antihypertensives (hypotension) Benzodiazepines (sedation) Antibiotics (intercurrent infection) **SHx** Alcohol Support at home: friends/family/.carers Mobility: aids and when they are used **ICE** **DDx** WOMAN PE, also strokes, vertigo **IX** **Exams**: AtoE (murmurs, stenosis, injuries, eyes and ears, , timed up and go test, BP) **Bedside**: obs, sitting/standing BP, urine dip (infxn/abdo), ECG, cognitive screening, blood glucose **Bloods**: FBC (infxn/anaemia), U&Es (hydration, electrolytes, abdo), LFTs (chronic alcohol), Bone profile (malignancy/over supplementation) **Imaging**: CXR, CT Head, Echo(valvular) **Specialist**: Tilt table test, epley, cardiac monitoring (48hr tape) **Management** Get your ears and eyes checked, good light, good shoes, review medication and reduce alchohol 1Gait Physiotherapy 2Visual problems Eye test and ensure wears glasses 3Hearing difficulties Remove earwax Hearing assessment 4Medications review Reduce unnecessary medication 5Alcohol intake Alcohol cessation advice Alcohol service referral 6Cognitive impairment Referral to a psychiatric team 7Postural hypotension Review medication Improve hydration 8Continence Treat or rule out infections Continence assessment 9Footwear Ensure good fitting footwear 10Environmental hazards Turn on lights Take up rugs

GP 22 Flashcards

(76 cards)