ISCE High Yield Flashcards
If a patient in the ISCE presents with delirium, what must you consider?
it is temporary so rule out:
infection
nutrition
constipation
change of scenery
What would a whirlpool sign indicate on an ultrasound and explain it?
ovarian torsion (adnexal torsion)
-fallopian tubes twist on the tissues that support them
-usually one sided
-sudden, intense pain and vomiting
-can cause an infection (peritonitis) in the abdominal cavity
Remember to perform PREG TEST
-emergency surgery is needed
-prophylaxtic abx
When is routine anti-D given and why? When is it also given?
28 and 34 weeks
To prevent haemolytic disease of the newborn:
Anaemia
Oedema and heart failure
Jaundice
Hepatosplenomegaly
Given when:
-termination
-miscarriage >12 weeks
-surgical management of ectopic
-trauma
-CVS/amniocentesis
When are UK abortions legal and how does it happen and what are the risks?
Up to 24 weeks
Less than 9 = mifepristone FOLLOWED 48hrs later by prostaglandins (misoprostol)
less than 13 = surgical dilation and suction
more than 15 = surgical dilation and evacuation of uterine contents
Heavy bleeding, sepsis, PID
What is a molar pregnancy (hydatidiform mole)?
A molar pregnancy (hydatidiform mole) is a tumor that develops in the uterus. The placenta doesn’t form correctly. Instead it develops into a mass of cysts and can’t supply the baby with food and oxygen like it does in a healthy
pregnancy
Bleeding in first or early second trimester
hyperemesis
big uterus size
‘snow storm’ on ultrasound
high hCG
Almost always ends in pregnancy loss
What can be an unusual sign that presents with an ectopic pregnancy and how do you treat it?
abdo pain that radiated to the left shoulder
expectant: <35mm and no pain: monitor B-hCG over 48hrs
medical: <35mm and minimal pain: methotrexate
surgical: >35mm and pain: salpingectomy
Consider a major haemorrhage protocol
Give VTE prophylaxis
Blood transfusion potentially?
How do you investigate and treat pre-eclampsia?
Abdo exam
Fundoscopy
Obs
Urinalysis
FBC, U&Es, LFTs, coag, glucose, electrolytes, clotting
PLGF (placental growth factor- will be low)
ECG
CTG/ultrasound
-Labetalol unless they have asthma then give nifedipine
-aspirin from 12 weeks until birth
-deliver baby if severe
How do you treat eclampsia in pregnancy?
Magnesium sulphate
(Can cause resp depression)
What is preterm prelabour rupture of the membranes (PPROM)?
amniotic sac ruptures early <37 weeks- can be like normal gush of water or just gradual damp pads/underwear
Speculum exam!!
High vaginal swab!!!- group B strep
-admit + observe
-oral erythromycin for 10 days (broad spectrum abx like tazocin if emergency)
-antenatal steroids
-IOL and delivery if at term
-If not at term CTG monitoring twice a week
How do you treat umbilical cord prolapse?
FETUS pushed back in if out
kept warm and moist if left out
get patient on all 4
stocolytics- slow pregnancy using drugs
retrofilling the bladder
What features would suggest an amniotic fluid embolism in pregnancy?
usually during or within 30mins of labour
cyanosis
respiratory distress
hypoxia
hypotension
–> oxygen, supportive care, ITU, intubation
If a pregnant woman IN LABOUR presents with pyrexia (>38 degrees), what should be given?
most likely GBS (group B strep) –> benzylpenicillin
and if goes on to have another baby prophylaxis IV abx should be given during labour
What is post-partum haemorrhage (PPH)?
blood loss of more than 500ml
primary = within 24hrs of birth
secondary = 24hrs-6weeks
causes: 4T’s
Tone-uterine atony
Trauma- perineal tear
Tissue- retained placenta
Thrombin
lie flat, palpate fundus and catheterise
give fluids
IV oxytocin
IM carboprost (unless asthmatic)
IV/IM ergometrine (unless hypertension)
intrauterine balloon tamponade
hysterectomy
What is intrahepatic cholestasis of pregnancy (obstetric cholestasis)?
Give differentials.
build up of bile acids during pregnancy
itchy palms, soles and abdomen
jaundice
raised bilirubin (ALT is raised in acute fatty liver of pregnancy)
raised bile salts
-histamine to stop itch if not contraindicated in pregnancy
-increased risk of stillbirth so have an induction of labour
-give Ursodeoxycholic acid
-give vit k
Differentials:
Fatty liver disease of pregnancy
Pre-eclampsia
How do you manage a miscarriage?
Expectant = wait 7-14 days for it to complete
if this ^ doesn’t work or there is increased risk of haemorrhage or infection:
Medical = vaginal misoprotol
Surgical = vacuum aspiration
Preg test 3 weeks after MEDICAL management
How do you investigate and treat placental abruption?
Abdominal exam
AVOID Speculum until ruled out
Obs
Urine dip
Glucose
ECG
Transvaginal ultrasound
High vaginal swab
FBC, U+Es, LFTs, CRP, bHCG
Clotting screen
Rhesus status
Group and save
ACTIVATE MAJOR HAEMORRHAGE PROTOCOL
SENIOR HELP
A-E
Alive and <36 weeks:
-foetal distress = C section
-no distress = observe and steroids
Alive and >36 weeks:
-distress = C section
-no distress = vaginal delivery
Dead:
-induce vaginal delivery
How do you investigate and treat placental praevia?
Abdominal exam
AVOID SPECULUM until ruled out
Obs
Urine dip
Glucose
ECG
Transvaginal ultrasound
High vaginal swab
FBC, U+Es, LFTs, CRP, bHCG
Clotting screen
Rhesus status
Group and save
ACTIVATE MAJOR HAEMORRHAGE PROTOCOL
SENIOR HELP
A-E
If low lying at 16-20 week scan:
-rescan at 34 weeks
-no need to limit sex/exercise
At 34 weeks if low lying/reaches internal OS:
-rescan every 2 weeks
-C section at 37 weeks
Presenting with bleeding:
-admit
-Vaginal delivery if grade 1
-C section at 37 weeks if grade 3/4 (placenta covers OS)
How do you treat and manage vasa praevia?
Same investigations as placental abruption
URGENT C-SECTION
if going to deliver then give 2 doses of dexamethasone
What is the treatment for acute asthma?
- inhalers- nebulized salbutamol (SABA) USE A SPACER IN CHILDREN
- nebulized ipratropium bromide (M3 antagonist- SAMA)
- predisolone - steroids
- if these don’t work then IV magnesium sulphate
- IV aminophylline
- intubation and ventilation
What is the treatment for a pneumothorax?
If asymptomatic:
Conservative care regardless of size and reviewed every 2-4 days
If symptomatic:
-High risk = chest drain
-low risk = conservative (reviewed every 2-4 days. If secondary pneumothorax then admit or if stable review in 2-4 weeks), needle aspiration or ambulatory care = patient choice
High risk = tension, hypoxia, bilateral, underlying lung disease, >50 and smokes, haemopneumothorax
If it’s a TENSION pneumothorax (deviated trachea) –> urgent needle aspiration —> DO NOT wait for an x-ray
How would you treat an acute exacerbation of COPD?
-increase the frequency of bronchodilator use and consider giving via a nebuliser
-give prednisolone 30 mg daily for 5 days
-amoxicillin or clarithromycin or doxycycline ONLY if sputum of pneumonia signs
-NIV or BIPAP
How do you investigate and treat interstitial lung disease?
most common type is idiopathic pulmonary fibrosis
other causes: sarcoidosis, SLE, asbetosis, drug induced (methotrexate), rheumatoid arthritis
-Bilateral fine end-inspiratory creps
-pleural effusion
-Finger clubbing
-Raynaud’s phenomenon
-Arthritis
obs
urine dipstick
lung function: restrictive pattern
FBC, U+Es, CRP
Autoimmune antibodies: anti-CCP suggests rheumatoid arthritis, ANA suggests SLE
chest x-ray
High resolution CT
conservative: smoking cessation, vaccines, pulmonary rehab
medical: depends on the cause
long term oxygen
lung transplant (very severe)
How do you treat acute atrial fibrillation?
A
IN THIS ORDER:
rhythm control = DC cardioversion (first line only if symptoms less than 48 hrs or on anticoags)
Stroke control = DOAC’s !!! e.g. apixaban if CHADVASC score 2 for 4 weeks or for a minimum of 3 weeks before the cardioversion or transoesophageal echo instead of the 3 weeks anti-coag
rate control = beta blocker OR calcium channel blocker e.g. diltiazem, digoxin
if already on a beta blocker and need another rate control:
-Amiodarone (especially if they have heart disease)
-Flecainide
What is endocarditis/criteria to diagnose?
DUKE’s CRITERIA
infection of the inner lining of the heart (the endocardium)–> flu/infection like symptoms, chest pain when breathing
fever and a new murmur
janeway lesions
THREE sets of blood cultures
treatment:
normal valve—> amox +/- gent
prosthetic —> vanc + rifampicin + gent
How do you treat acute and chronic heart failure?
ACUTE:
1) IV furosemide
2) oxygen
3) nitrates (with caution)
4) CPAP for patients with respiratory failure
5) inotropes if have hypotension e.g. dobutamine
CHRONIC:
1) ACE-inhib
2) beta blocker
3) spironolactone
4) SGLT-2 inhibs e.g. dapagliflozin
5) ivabradine if sinus rhythm
6) valsartan
7) digoxin if in AF
8) annual influenza and one off pneumococcal
What is an aortic dissection?
aortic aneurysm (abdominal or mediastinal) is painless until it dissects
-weak carotid, brachial and femoral pulses
-variation in arm BP
-pulsating feeling in your stomach
-persistent back pain
-persistent abdominal pain
-clammy, tachy, SOB, dizzy, TLOC
-In men, the pain can also radiate down into the scrotum
diagnose with ultrasound or if a dissection use a CT angiography
May see mediastinal widening on chest x-ray
-if tear is bigger than or 5.5cm then surgery and see specialist in 2 weeks if clinically well otherwise
-if not then regular scans to keep an eye on it-surgery if it is rapidly enlarging
-rescan in 3months if enlarging slowly
-rescan once a year if 3-4.4cm
-medications to reduce BP and cholesterol level
Acute management:
-ABCDE assessment
-Call senior
-2222- call
-2 large bore cannulas- Fluid/blood resus
-high flow oxygen
-labetalol
-analgesia
-anti-emetic
-take bloods: FBC, CRP, CK, troponin, U+Es (renal failure), glucose, Lactate- end organ damage, blood gas, group and save
How do you treat a STEMI? acute and long term?
MONA
-oxygen if less than 94%
-don’t give GTA if hypotensive
1) always give 300mg aspirin
2) PCI (or fibrinolysis if PCI not possible in 2hrs)
3) give prasugrel with aspirin if not already taking oral anticoagulants or clopidogrel with aspirin if taking an oral anticoag
4) Give unfractionated heparin with bailout GPI for radial access
5) if did fibrinolytic give anti-thrombin at same time and then give ticagrelor and repeat ECG 60-90mins later
6) if no PCI then give ticagrelor
Long term:
Aspirin
ACE-inhibitor
Beta-blocker
Statin
How do you treat stable angina?
episodes of angina attacks = GTN spray or isosorbide mononitrate (IM)
- use asymmetric dosing interval for IM
treating stable angina = beta blocker (CANNOT USE THIS IF PATIENT HAS ASTHMA) or a calcium channel blocker and combine the two if monotherapy doesn’t work
CC monotherapy: verapamil
CC combination: amlodipine, nifedipine
prevention of stable angina (LONG TERM)= aspirin and statin OR aspirin + statin with an ACE-inhib if also have diabetes
if drugs do not work = CABG or PCI
How do you treat SVT (supraventricular tachycardia), acute and chronic?
acute management:
-vasovagal maneouvre but if systolic BP<90 then shock first
-IV 6mg adenosine (can cause chest pain)–> 12mg –> 18 mg UNLESS have asthma then use verapamil
Prevention of episodes:
beta-blockers
radio-frequency ablation
How do treat an NSTEMI and unstable angina?
1) aspirin 300mg and fondaparinux if no immediate PCI
2) calculate GRACE score
3) if GRACE > 3% = PCI, heparin, prasugrel or ticagrelor
4) if GRACE < 3% = ticagrelor
How do you treat bradycardia?
1) atropine 500mcg (up to 6 times)
2) transcutaneous pacing
3) adrenaline infusion
How do you treat atrial flutter?
radiofrequency ablation of the tricuspid valve
What would be the most likely diagnosis if someone had breathlessness and PALPITATIONS with pain worse when lying down? and what would be seen on an ECG? How do you treat?
acute pericarditis
PR depression and saddle shaped ST elevation
management:
-NSAID AND colchicine
What are the features of cardiac tamponade and how do you manage it?
accumulation of pericardial fluid under pressure
-Beck’s triad = hypotension, raised JVP and muffled heart sounds
-can also be worse when lying down like pericarditis
-pulsus paradoxus = an abnormally large drop in BP during inspiration
-ECG: electrical alternans: QRS height varies
management: ugrent pericardiocentesis
What are the features of a PE and how do you manage it?
tachypnea
tachycardia
crackles
fever
chest pain
Calculate Well’s score and follow below: can also order ECG and chest x-ray
If a PE is ‘likely’ (more than 4 points) = CTPA/VQ scan and give a DOAC if delay in imaging
if the CTPA is positive then a PE is diagnosed
if the CTPA is negative then consider a proximal leg vein ultrasound scan if DVT is suspected
If a PE is ‘unlikely’ (4 points or less) = D-dimer test
if positive follow above steps
Management:
-DOACs for 3 months if there was a cause or for 6 months if there was no known cause
-If renal impairment/anti phospholipid syndrome/pregnancy give LMW heparin
-Thrombolysis for hypotensive PE
How do you treat the different types of heart block?
AV blocking drugs stopped: beta-blockers, calcium channel blockers, antiarrhythmics, and digoxin
Pacemaker if symptomatic
Atropine, transcutaneous pacing, adrenaline (for complete block)
How would a patient present if they had alcohol withdrawal and how would you treat this?
Calculate CIWA score
6-12 hours: tremor, sweating, tachy, anxiety
36 hours: seizures
48-72 hours: delirium tremens –> coarse tremor, confusion, delusions, auditory and visual hallucinations, fever, tachy
treat with TAPERING chloradiazepoxide or diazepam
pabrinex
How do you assess risk?
1) risk to self:
-self harm (if so then take a history on this)
-look after themselves (hygiene, substances, physical health)
2) risk from others:
-do they feel safe at home?
-has anyone hurt you?
3) risk to others:
-sometimes when people are going through difficult things, they might have thoughts to harm other people. Have you ever thought about this?
-is anyone telling you to harm other people
How do you sedate an agitated patient who is at risk to self or others?
-Try to camp patient down and moved to a safe place
-Call security
-Turn on the lights and explain where they are and the time and ask if a relative is near to come in to the room
LORAZEPAM 1-2mg PO/IM
OR HALOPERIDOL 2-5mg PO/IM
Repeat at 30-60mins up to 3 times
If this fails call anaesthetist
-half doses in elderly or renal failure
-haloperidol is contraindicated in Parkinson’s, Lewy body dementia, alcohol withdrawal, heart problems
-ensure procyclidine is available if using haloperidol to counteract
-REMEMBER TO DOCUMENT WHY
What is the management for small bower obstruction caused by adhesions?
smALL bowel obstruction = bowel lines cross ALL the way across
No surgery needed–> insert NG tube to allow bowel rest, give fluids, anti-emetics and pain relief
What is Coeliac’s disease, symptoms, investigations and management?
Autoimmune disorder where gluten is not broken down fully and leads to chronic inflammation and malabsorption
Symptoms:
rash, change in bowel habits, fatigue, iron and B12 deficiency, osteomalacia
Investigations:
-TTG (tissue transglutaminase) Antibodies
-IgA anti-endomysial antibody (EMA)
-duodenal endoscopy biopsy which shows:
villous atrophy, raised intra-epithelial lymphocytes and crypt hyperplasia
Management:
Gluten free diet
Pneumococcal vaccine every 5 years
Correct anaemia
Refer to dietician
What is Hirschbrungs disease?
Poo is sticky and sticks to walls of intestine —> no passage of poo
should be seen when they are born- failure to pass meconium!!
persistent constipation, swollen tummy, failure to pass poo in 48hrs, vomiting green bile
Rectal washouts and bowel irrigation
rectal biopsy + surgery is a must
How is DKA diagnosed and treated?
Hyperglycaemia (>11), ketonaemia (>3 and urine), acidosis (ph low <7.3)
treatment in this order:
-fluids (slowly to prevent cerebral oedema)
-insulin: 0.1 /kg/hour
-potassium
-if diabetic: continue long acting insulin but stop short acting
Hourly check of blood sugar
2hr check of potassium + HCO3
What is Addison’s disease?
not enough cortisol and aldosterone—> synacthen test
FATIGUE
ABDO PAIN
VOMITING
LOW BP
LOW SODIUM
hyperpigmentation- darkened skin
low mood
loss of appetite and unintentional weight loss
increased thirst
replace hormones + adrenal crisis/”Addisonian crisis” = give hydrocortisone
hydrocortisone (most of it given in morning) and fludrocortisone
