Lecture Notes COPY Flashcards
1
Q
3 step Mx to high BMs in T2DM
A
- Review drug chart + oral hypoglycaemics
- Check ketones if BM >12 (more than 2x in 24hrs)
- Ask diabetes specialist nurse
2
Q
Mx of T2DM on steroids
A
Causes hyperglycaemia
May have high BM pattern
Double dose oral hypoglycaemics
OR
add 2nd agent
3
Q
Target BM in hospital
A
6-10 (4-12 acceptable)
4
Q
Insulin dependent T2DM
A
Usually 2x daily regime Increased insulin by 10%
Monitor BMs
5
Q
T1DM -Mx if hypos overnight?
A
Reduce basal insulin (night dose) - Decrease by 20%
6
Q
Short Acting Insulin
- Examples
- Mode of Action
- Use?
A
Act-rapid, Humilin-S
Onset: 30mins
Peak: 2-4 hours
Lasts: 8 hours
Use: IV in variable rate insulin
Mx of DKA, high K+
7
Q
Rapid Acting Insulin
- Examples
- Mode of Action
- Use?
A
Novarapid/humalog
Onset: 15 mins Peak: 40 mins
Lasts: 4 hours
Use: bolus insulin in T1DM (before meals/correction)
8
Q
Mixed Insulin
- Examples
- Mode of Action
- Use
A
Rapid + Intermediate Number = percentage of rapid acting insulin e.g. Novomix 30
Used in BD dosing (e.g. T2DM)
9
Q
Long Acting Insulin
- Examples
- Mode of Action
- Use?
A
Lantus, glargine, degludec
Onset: 2 hours Offset: 24-42 hours (brand dependent)
Often no real peak
Usually OD basal dose
10
Q
Emergency Op in T1DM Mx
BM Target?
A
NBM
Continue basal insulin
Stop rapid acting
Start VR infusion using table
BM target = 6-10mmol
11
Q
Indications for VR infusion
A
T1 DM - If missing 1 meal due to fasting - No background insulin
T2DM
- If missing 1 meal and BM >12
- Poor control with HbA1c >49
- Emergency surgery
12
Q
What is a VR infusion?
A
50 units act rapid in 49.5 ml normal saline
Run alongside Dex/sal infusion
Continue basal insulin in T1DM (at 80%)
13
Q
T1DM Pre-Op
A
Admit night before
First on list
Stop short acting insulin
Start on VR infusion
80% basal insulin (DO NOT STOP)
14
Q
T2DM Pre-Op
A
Omit oral hypoglycaemics (day before)
VR infusion if BM >12
If insulin dependent: - Stop insulin, give VR
15
Q
VR infusion? Post Op
A
Stop VR 30 mins after giving short acting insulin
Increase basal dose to 100% when E+D
16
Q
Mnemonic for Venturi’s
A
Barry White Yearns for Right-wing Government
17
Q
Colour, % and L of venturi’s
A
Blue = 24% = 2L White = 28% = 4L Yellow = 35% = 8L Red = 40% = 10L Green = 60% = 15L
18
Q
Right Hemicolectomy
A
Ascending colon removed
19
Q
Anterior Resection
A
Sigmoid colon removed
Proximal Rectum removed
20
Q
Abdominal-Perineal resection
A
Sigmoid colon
Rectum and anal canal removed
Anus is closed, colostomy created
21
Q
Hartmann’s
A
Emergency - Sigmoid and rectum removed
Colostomy made
Can be reversed at a later date
22
Q
Sub-total colectomy
A
Asc, trans, desc and sigmoid colon removed
Anastamosis with rectal stump to create storage pouch
Good as avoids stoma
23
Q
Intra Op Complications
A
Bleeding
Damage to tissue
Anaesthetic risk
Allergy
24
Q
Post Op Complications 1-3 days
A
Bleeding
Atelectasis
MI/Stroke
25
Post Op Complications 3-7 days
Infection - Wound, chest, urine
Anastamotic Leak
VTE
26
Post Op Complications >1 month
Hernia
Chronic Pain
Recurrence
27
Requesting Scans?
| - Criteria
What question are we asking?
How will that change management?
28
MRI Scans
| - Co-morbidities to bear in mind?
MRI - pacemaker, metal fragments (eye)
Orthopaedic plates/replacements ETC ok as not magnetic material
29
CT/AXR
| - Co-morbidities to bear in mind?
Do PT in woman of childbearing age
30
CT with Contrast
| - Co-morbidities to bear in mind?
Check eGFR
Review Meds e.g. metformin
May need to run IV fluids.
31
PRN Meds for Acute Abdo patient
Paracetamol
Weak opiate - codeine
Strong Opiate - Oramorph
Anti-emetic - cyclazine
32
Acute Abdo Bloods
FBC, UEs, LFTs, Clotting, G+S, VBG
CRP, Amylase
PT
ABG or cultures if indicated.
33
Gallbladder disease and Charcot's Triad
Biliary Colic = RUQ pain
Cholecystitis = RUQ and fever (low grade)
Cholangitis = RUQ, high fever and jaundice
34
Amylase in acute Abdo
Double normal = diagnostic of pancreatitis
Raised <2x = PUD, AAA, gastritis
35
Glasgow Scoring
| PANCREAS
```
PaO2 <8
Age >55
Neutrophils >15
Ca <2
Renal: urea >16
Enzymes: LDH>600, AST >2000
Albumin <32
Sugar >10
```
Score 3+ in first 48 hours = significant pancreatitis
36
Examination in Surgery
- Heart
- Lungs
- Testicular
Heart
- Murmur = need ECHO
- AF= think bowel infarct
Lungs
- Decreased air entry: effusion or infection
Testicular
- In all men with lower abdo pain: must rule out torsion!
37
Acute Indications for Dialysis
A = Acidosis pH <7.2
E = Electrolyte e.g. refractory high K+
I = intoxication = lithium, anti-freeze, barbituates
O = overload, fluid not responding to meds
U = Uraemia = pericarditis/encephalopathy
OR lethargy, decreased appetite, metallic taste
38
Acute Mx of Hyperkalaemia
30ml of 10% calcium gluconate
10U actrapid in 50ml 50% glucose
Salbutamol 5mg neb
39
Follow Up Mx of high K+
Treat cause
Give fluids
Review Nephrotoxics
40
Pre-Renal AKI
Decreased intake
| Fluid loss
41
Renal AKI
IV Contrast
Toxins
Vasculitis
Do Urine Dip for BLOOD and PROTEIN
42
Post-Renal AKI
Usually urological cause
- obstruction, UTI
Urine Dip
Bladder scan
Refer urology
43
Fluid Status Assessment
BP, HR, CRT, JVP
Urine output
Mucous membranes and skin turgor
FLUID BALANCE CHART
44
STOP AKI
treat SEPSIS
avoid TOXINS
OPTIMISE BP
PREVENT harm
45
Haematemesis Hx
When they last ate or drank (for endoscopy)
BG sx:
Weight loss/dysphagia/change of bowel habit = cancer
Dyspepia = gastritis, GORD
Abdo pain
46
SHOCK: what impairs physiological response?
Age
Drugs e.g. beta blockers
CV co-morbidity
leads to organ failure as cannot increase HR or BP
47
Drug Hx in Haematemesis
NSAIDS? ulcer
Antiplatelets: clopidogrel, aspirin, ticagrelor, dipyridamole
Anticoagulants: warfarin, DOAC
48
Post GI Bleed Complications
MI
Stroke
Renal Failure
Intestinal/liver ischaemia
49
Glasgow Blatchford
Do they need endoscopy?
Used in A+E to discharge patients
Score 0-1 = OGD endoscopy
50
Rockall Score
Post endoscopy, with diagnosis
Co-morbidities = very high scoring e,g, organ failure, malignancy
51
Hb and Blood transfusion in GI bleed
Hb >100 = do not transfuse
Hb <70 = aim for 70-90 Hb, unless anginal sx (can give more)
52
Pharmacotherapy for ulcer vs variceal bleed
Ulcer:
- IV PPI post endoscopy
Varicieal
- Terlipressin, can be given in A+E
- Gastro would give to any pt with stigmata of liver disease O/E, as likely to be hepatic cause for bleed
53
Chronic Liver Disease Definitions
Comp vs De-Comp
Compensated
- peripheral stigmata of liver disease, functioning well, normal synthetic function
Decompensated
- Ascites, encephalopathy, jaundice, varices
54
Acute Liver Failure Definition
Jaundice, encephalopathy +/- ascites
NO peripheral stigmata of liver disease
55
Causes of Acute Liver Failure
Drugs: Paracetamol OD
Pregnancy (HELLP)
Budd-chiari (hepatic vein thrombus)
Virus
56
Ix in Acute Liver Failure
Pro-thrombin time
- PT MOST IMPORTANT IN LIVER FAILURE
If >30 secs, contact gastro
>50 secs = liver unit
AST may be in 1000s, irrelevant
57
Causes of Chronic Liver Failure
Alcohol
Fatty liver disease
Viral hepatitis (IVDU, abroad = Hep C)
Rare
58
Fluids in Liver failure
Avoid normal saline as will follow osmotic gradient and go straight to abdomen, increase ascites
Only give in resus scenario
Give 5% dex
59
Why do liver patients decompensate?
Infection
- UTI, chest, SBP
Medications
- opiates, diuretics
AKI
- Hepato-renal syndrome
Disease progression
- Increased alcohol intake, do not cease drinking
GI bleed
60
Child Pugh Score
Albumin
PT
Bilirubin
Ascites
Encephalopathy
Grade A, B, C (most serious)
61
Viral causes Acute LF
Serology for Hep B and C
62
USS and Dopplers in Acute LF
Rule out hepatic vein thrombus (budd chiari)
63
Immune Causes Acute LF
IgA
- Alcohol
IgG
- Autoimmune hepatitis
- ASMA
IgM (M disease)
- Primary biliary cirrhosis
- Anti- mitochondrial antibody
64
Genetic Causes Acute LF
Wilson's disease
Haemochromotosis
Alpha a1 antitrypsin
65
Causes of Metabolic Acidosis
1. Lactic = tissue hypoxia
2. Keto = DKA
3. Renal = high urea and creatinine
66
BTS Oxygen Guidelines
| - Critically ill?
15L NRB Mask, 60% 02
67
BTS O2
| - Seriously ill
Mod O2 if hypoxic
2-6L via Nasal canula/face mask
68
BTS O2
- COPD/scholiosis/obesity hypoventilation
- Risk of loss of resp drive if oxygen toxicity
CONTROLLED O2 THERAPY
Venturi mask and titrate
69
Judgement of PaO2
Below 8 = RESP FAILURE
Work out if low
% of oxgen inspired -10
Therefore:
if patient on 15L NRB mask (60%)
- PaO2 should be at least 50
70
PE: ECG
Sinus tachy, fast af
RBBB (right heart strain)
S1Q3T3
71
PE: ABG
Low PaO2
Low CO2
- due to increased work of breathing
72
PE: CXR
May be normal
| May have small pleural effusion
73
Causes of COPD in a young person?
Heroin smoking
| Alpha A1 anti tripsin
74
Secondary pneumothorax
Known resp. disease
>50 with smoking hx
75
What is the Management?
COPD patient on 15L NRB Mask
```
ph 7.29
PaCO2 7.1
PaO2 8.9
HCO3 28
Base Excess +1
```
Oxygen toxicity
TRY ON CONTROLLED O2 Therapy
e.g. venturi mask
76
What is the management?
COPD patient on 28% venturi mask
```
ph 7.29
PaCO2 7.1
PaO2 8.9
HCO3 28
Base Excess +1
```
Need NIV!
Indication for NIV = resp acidosis NOT hypoxia
77
NIV Principles
Biphasic pressure
Inspiratory (IPAP) and expiratory (EPAP)
Difference between IPAP and EPAP
= increase tidal volume and decreased CO2
78
Indications for NIV
Resp Acidosis
On controlled O2 therapy
Recieved medical rx
79
Contraindications for NIV
Pneumothorax
| - Will cause tension
80
CPAP
Continuous Positive airway pressure
Used to splint open upper airway in
Obstructive sleep apnoea
81
Life-Threatening Asthma
33 92 CHEST
<33 Peak flow
<92 O2 sats
```
Cyanosis
Hypotension
Exhaustion
Silent Chest
Tachycardia
```
82
Near Fatal Asthma
33 92 CHEST
+++ HIGH CO2 LEVELS
Need ICU involvement and potentially ventilation
83
Criteria for Asthma discharge
Off Nebs
Peak flow >75% best
Check
- Inhaler technique
- PEFR meter and diary
- Self management plan
84
RED FLAGS Headache
Thunderclap - SAH
Positional = raised ICP
Malaise = meningitis
Weight loss = Cancer
85
SNOOP 4Ps
Systemic features
Neuro: arm weakness
Onset? sudden - bleed
Older: >50 years
Pattern
- Getting worse
- Precipitated by valsalver
- Papilloedema
86
Migraine Criteria
>5 episodes with 2 of:
- unilateral
- pulsating
- worsened by moving
- N+V
- photophobia
87
Seizures? What medications cause?
Meds that cause long QT
- Anti-histamines
- Anti-psychotics
- Anti-depressants
- Anti-microbials
- Anti-emetics
- Anti-arrhythmics
Not taking normal Anti-Epileptics
88
Epilepsy: Psychiatric
Ask re mental health problems
Psychogenic seizures more common
89
Epilepsy: Lifestyle
DRIVING, alcohol, relationships, occupation
90
Epilepsy: Pregnancy
DO NOT PRESCRIBE SODIUM VALPROATE
if Female <50 years
91
Epilepsy: Ix
DO AN ECG (look for long QT)
MRI for mesotemporal sclerosis
EEG only if primary generalised seizures (usually children)
92
Tests for Bradykinesia
Touch each finger to thumb in turn
Finger tapping together (slower and smaller)
Foot tapping on floor
93
SE Levo-dopa
Reduced efficacy
Freezing
Disinhibition - gambling etc.
94
Differences between Myesthenia Gravis and Guillain Barre
GB = Sensory loss, myesthenia does not
GB = progressive, Myesthenia = worse with fatigue
```
GB = demyelination after viral illness
Myesthenia = autoimmune to Ach Receptor
```
95
Causes of Pancreatitis
I GET SMASHHHED
I - Idiopathic
G - Gallstones
E - Ethanol (alcohol)
T - Trauma
```
S - Steroids
M - Mumps
A - Autoimmune
S - Scorpion/Spider bite
H - High PTH
H - High Lipids
H - High Calcium
E - ERCP
D - Drugs
```
96
Ewing's Sarcoma
Rare, 5-15 years
lytic bone lesion with periosteal rxn
'onion skinning'
97
Chrondrosarcoma
Middle aged
bone destruction and calcification
rx with excision and chemo
98
Osteosarcoma
Young people
| Comomn
99
Direct inguinal Hernia
Through abdo wall, not ing. canal
Medial to inguinal ligament
Alway acquired
RF: smoking, obesity, heavy lifting
Rarely strangulates
100
Indirect Inguinal Hernia
Through canal inyo scotum
Young active men and prem babies
Hernia above and medial to pubic tubercle
Descent into scrotum on standing or coughinh
101
Hydrocele
Fluid in tunica vaginalis
Tense, painless, fluctuant
Transilluminates
In adult, USS to rule out pathology
102
Varicocele
Left sided
Bag of worms, heavy and dragging
Harmless, supportive underwear
103
Hashimoto Goitre
Enlarged, firm, non-tender
104
MEN T1
Pituitary
pancreas
parathyroid
105
MEN T2 + T3
Pheochromocytoma
parathyroid
thyroid ca
Type 3 = with marfans as well
106
Cystic Hygroma
benign lymph proliferation in post. triangle
Transillumates brightly
107
Ant. Cord Syndrome
Loss of pain temp and motor
Lower and upper limbs (worse in lower)
Bad prognosis
108
Central Cord Syndrome
Weakness of upper limbs, not lower
Good prognosis
Older people with cervical spondylosis
109
Jones Fracture
5th metatarsal
110
Lis-Franc Fracture
2-4th metatarsal with dislocation
111
March Fracture
Stress/hairline fracture
Callus on Xray
112
Snellen Test?
Visual Acuity
113
Pupillary light reflex
| RAPD
Damaged optic nerve e.g. optic neuritis
114
Ischihara Plates
Colour vision
115
Amsler Grid
Straight lines = curved
Sign of macular degeneration
116
Schirmer's Test
Tear production
<5mm = abnormal e.g. dry eyes in sjrogens
117
Fluroscein Dye
Corneal ulcer,
Dendritic shows green
118
H Test
CN III, IV and VI
119
Tonometry
Raised intra-ocular pressure (IOP) in glaucoma
120
Daily Na2+ requirements
1-2mmol/kg
121
Daily K+ requirements
0.5-1mmol/kg
122
Daily Fluid requirements
25-30ml/kg
123
Daily Fluid requirements
- CCF
- Small
20-25ml/kg
