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Medicine Flashcards

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1
Q

Indications and relative indications for NIV

A

Indications:
Respiratory failure APO, COPD

Relative:
Asthma
ARDD
Pneumonia
Children
Pre-oxygenation

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2
Q

Physiological benefits of BiPAP in COPD

A

Reduces WOB
increases end inspiratory volume
EPAP prevents atelectasis
Improved CO2 elimination
Closed circuit (consistent FiO2)
Allows spontaneous ventilation
Alerts available

In COPD, reduces death, LOS & intubations

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3
Q

Advantages and disadvantages of NIV in asthma

A

Adv:
Extrinsic PEEP reduces WOB
IPAP improves TV
Reduce intubations (allow drugs to work)

Disadv:
Delay intubation (further deterioration)
Increased WOB if inappropriate settings
Barotrauma (pneumothorax)
Difficult to clear secretions

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4
Q

What constitutes massive PE

A

Sustained SBP <90
Requiring inotropes
Pulseless
Unstable sustained bradycardia

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5
Q

Thrombolysis in PE

A

Alteplase 1.5mg/kg (10mg over 2 minutes then rest over 2 hours)

50mg bolus if arrested

UFH 80u/kg load IV then IV 18u/kg/hr adjusted to aPTT

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6
Q

ECG changes in PE suggestive of RV strain

A

RAD
RBBB
S1Q3T3
Non-specific ST changes
Dominant R wave in early precordial leads

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7
Q

ECHO changes in PE

A

RV dilation (bigger than LV in apical view)
Dilated non-collapsing IVC
RV wall hypokinesis
McConnell sign (apex spared)

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8
Q

CXR changes in PE

A

Cardiomegaly
Elevated hemi diaphragm
Wedge infarct
Westermark sign (oligaemia)
Hamptons Hump (domed pleural opacity)
Fliesher sign (prominent PA)

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9
Q

Diagnosing exudate on pleural tap

A

Pleural protein:serum >0.5
Pleural LDH:serum >0.6
Pleural LDH >2/3 normal limit
Total protein >30g
pH <7.35

If pH <7.2 implies empyema and needs complete drainage

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10
Q

Pleural exudate vs transudate causes

A

Exudate:
Cancer
Empyema
Para-pneumonic
RA/SLE
Haemothorax / Chylo

Transudate:
Failures
Meig syndrome
Sarcoidosis

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11
Q

RF for re-expansion pulmonary oedema

A

Young <30
Collapse >1 week
>3L pleural fluid
Suction use
Rapid drainage (1.5L/hr)

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12
Q

2 pneumonia scoring systems

A

CORB (more specific)
Confusion
O2 <90%
RR >30
BP <90

SMART-COP (more sensitive)
SBP <90
Multilobar
Alb <35
RR 30 (25 if over 50yrs)
Tachycardia 125bpm
Confusion
O2 <90% (93% if over 50yrs)
pH <7.35

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13
Q

Distinguish mild, moderate and severe non-proliferative DM retinopathy

A

Mild: some micro-aneurysms

Mod:
<20 micro-aneurysms
Hard exudates
Cotton wool spots
Venous beading

Severe:
Micro-aneurysms in all 4 quadrants
Venous beading in 2 quadrants
AVM

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14
Q

Why pregnancy increased RF for DKA

A

Vomiting and nausea
Baseline metabolic alkalosis
Lower fasting BSL (relative reduced insulin)
Higher glucagon levels

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15
Q

Skin changes with DM

A

Necrobiosis lipoidica (yellow with red border)
Acrochordans (skin tags)
Carotenoderma (yellow deposits hands)
Scleroderma Adultorum (thick skin)

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16
Q

Diagnostic criteria for HHS

A

BSL >30 with ketones <3
Dehydration
Osmolality >320

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17
Q

Management HHS

A

NSaline 1L/hr and adjust
Aiming fall BSL <5 per hour
Replace 50% losses in 12 hours (200ml/kg)
If Na rising greater than 2.5 per 5.5 BSL, increase fluids
0.45% saline if BSL or osmolality not falling
VTE prophylaxis
Insulin 0.05units per kg only if raised ketones

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18
Q

T1DM diagnostic bloods

A

Insulin antibody
GAD antibody
Islet cell antibody
Fasting C-peptide
TFT
Coeliac screen
ZnT8 antibody

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19
Q

Risk factors for cerebral oedema in DKA

A

<5 years
Long standing poor control
First presentation
Received sodium bicarbonate

Tx:
Head up
Reduce fluids by 1/3
Empirical mannitol 1g/kg (0.5g/kg kids)

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20
Q

What classifies severe DKA

A

GCS <12
Ketones >6
Unstable
Bicarb <5
Hypokalaemic to start
pH <7
RAGMA

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21
Q

Insulin in DKA & target

Study These Flashcards
A

0.1u/kg/hr actrapid
(Increase in ketones not clearing 0.5 per hour)

Lantus 0.25units/kg daily (or regular)

Half insulin regime if under 5yrs, hospital transfer or starting BSL <15

When BSL <14, 10% dextrose 8hrly

22
Q

Thyroid storm treatment

Study These Flashcards
A

Cooling, paracetamol
Empirical antibiotics
Propanolol 40-80mg PO QID
(IV version esmolol or metoprolol)
Propylthiouracil 200mg QID PO/NG/PR
(Can give carbimazole 20mg TDS)
Hydrocortisone 100mg TDS
Lugol’s iodine 0.5mls TDS (1hour after drugs)
Early ICU & Endocrine involvement

23
Q

Myoedema crisis symptoms

Study These Flashcards
A

Menorrhoea
Drowsy
Reduced RR
Fluid overload (pericardial effusion, ascites, pleural effusion, hyponatraemia, hypoglycaemia)

24
Q

Myxoedema crisis management

Study These Flashcards
A

Delirium work up
Consider IV antibiotics
Hydrocortisone IV
Replace electrolytes (BSL)
Levothyroxine 500mcg PO then 100mcg OD
IV liothyronine 20mcg BD

25
NINDS stroke study 1995
Alteplase versus placebo 300 patients each arm No blinding (less severe in tPA group) No difference in mortality (3%) 13% improved disability 6% ICH vs 0.6% in placebo (1/2 died) Led to FDA approval of Alteplase In study given <3hrs from onset
26
ECASS III 2008 Stroke Study
Alteplase vs placebo 3-4.5hrs Placebo group worse stroke Modified Rankin score 0-1 as endpoint 2-6 all grouped together Showed improvement with Alteplase Again high bleeding No mortality difference If endpoint was 0-2 & 3-6: no difference
27
IST3 Stroke Study 2012
Alteplase up to 6hr vs placebo Poorly done study No blinding and no significant results No change in disability or mortality
28
When to consider decompressive craniectomy in ischaemia stroke
Young Reduced GCS Raised ICP Centre with no stroke/Thrombolysis facilities Within 48hrs stroke onset Malignant MCA infarct (>50%)
29
Reversing Thrombolysis And other anticoagulants and anti platelets used in STEMI
Alteplase reversal: FFP 2 units Q6h for 24 hours Cryoprecipitate 10 units Tranexamic acid 1g Consider aminocaproic acid Anti-platelets: 1 bag of platelets (4 pools/bag) DDAVP 0.3microg/kg Heparin: 1mg protamine for 100u UFH in last 4hrs 1mg protamine for 1mg enoxaparin in last 8hrs Half dose if >1hr since last UFH 1/4 dose if >2hr since last UFH Given slowly 5mg/min max (usually 50mg) If ICH, above plus usual ICH management: Raised head 30 degrees BP control SBP <160; MAP <110 Neurosurgery / palliative services
30
Acute transfusion reaction immediate management
Stop transfusion Give fluid bolus via another IVC Don’t flush line used for transfusion Check blood and patient details Contact pathology and send blood, line, new group and hold to them
31
Informing patient after wrong transfusion / scan
Apologise Open disclosure Opportunity for patients to relate concerns, experience, adverse effects Discussion of potential consequences Explain further steps going to be taken to investigate and prevent in future
32
Use of USS in hypotension (5 different)
Lung: pneumothorax TTE: pericardial effusion, LV fxn FAST: haemoperitoneum AAA Proximal LL Veins for DVT
33
Roper-Hall classification for chemical injury to eye (3 examination findings for severity)
Visual acuity Degree of kimball ischaemia Degree of corneal opacity
34
Petechiae/Purpura rash divided into: Sick: palpable and non-palpable Well: palpable and non-palpable
Febrile/Sick Palpable - meningococcal, IE, RMSF, HSP Non-palpable: TTP, DIC, HUS Well: Palpable: autoimmune vasculitis Non-palpable: ITP
35
Vesicles/Bullae Sick: diffuse vs local Well: diffuse vs local
Sick: Diffuse: varicella, disseminated gonococcal Local: Nec Fasc, HF&M Well: Diffuse: pemphigoid disease Local: Zoster, contact dermatitis, dyshidrotic eczema (bubbles on hands)
36
Complications of GCA
CVA Aortic aneurysm Limb ischaemia Cognitive impairment Scalp necrosis Ischaemic Optic Neuropathy
37
Erythema Nodosum causes and investigations
IBD, TB, Sarcoidosis, Pregnancy, OCP, Lymphoma, Salmonella, Strep infections Ix: ASOT, Quantiferon, stool M,C&S, blood film, BHCG, CXR (sarcoid/TB)
38
5 drug rashes
Fixed drug reaction Urticaria Acute generalised exanthematous pustulosis DRESS (eosinophilia, liver, LN, mouth, renal) EM/TEN/SJS
39
Drugs worst for drug skin reactions
Anticonvulsants (phenytoin) Antibiotics Allopurinol NSAIDS
40
Difference in EM/SJS/TEN and causes
EM major (mucosa) SJS (2 mucosa and <10%) TEN (2 mucosa and >30%) Causes: Mycoplasma HSV Lymphoma Drugs (anticonvulsants, allopurinol, antibiotics, NSAIDS)
41
Scorten Criteria
SCUBA 10 Sugar >14 Cancer Urea >10 Bicarb <20 Age >40 10% BSA at Day 1 HR >120
42
Dental Fracture Classification
Ellis 1: Enamel (white, not sensitive) 2: + dentin (yellow & sensitive) 3: + pulp (red dot, blood, pain) 4: devitalized (no sensation) 5: Tooth fell out Pulp involved: GIC to area
43
Rash and painful joint
Gonococcal Viral (HIV) Leukaemia Psoriasis Sarcoid SLE Vasculitis Serum sickness (antivenom)
44
Gout vs Pseudogout
Gout: Needle, negative birefringent Monosodium urate Raised uric acid Acute (hours) Tophi and soft tissue involvement Assoc with thiazides and aspirin Pseudogout: Rhomboid, positive birefringent CPP (calcium pyrophosphate) Normal uric acid Subacute (days) Usually knee and wrist (no tophi/ST) Assoc with loop diuretics & bisphosphonates
45
GCA
50: Over 50 years ESR >50 50% have PMR PMR symptoms (weight loss, neck and shoulder pain), limb ischaemia, valvular disease on top of usual shit Methylpred if eyes (15mg/kg) max 1g Aspirin 100mg daily
46
Takayuso
F: < 40 Fainting with Flu Female (Asian) Similar symptoms to dissection
47
HSP Dx Severe factors (admit) Complications Investigations Tx
Rash and 1 of: Arthralgia (migratory poly) Nephritis Abdominal pain Usually recent viral, GAS or gastro Severe: can’t walk, HTN, Neuro/Pulm, abdominal (intussusception/perf/testicle), urine PCR abnormal Note can also get oedema Complications: HTN Renal failure (nephrotic syndrome) Intussusception / Perforation Orchitis Ix: BP, urine blood and protein, U&E, LFT (albumin), cultures if unclear, abdominal imaging, ASOT Tx: NSAIDS in mild, steroids severe (Helps pain but not complications) Follow-up GP: Weekly for 1 month Fortnightly 1-3 months Then at 6 and 12 months
48
Triad of Behçet’s disease
Ocular lesions Genital lesions Aphthous mouth ulcers
49
Complications of RA
Felty syndrome (splenomegaly) Accelerated atherosclerosis Iritis/Scleritis Pericardial & Pleural effusions Immunosuppression from meds
50
Reye’s syndrome and stages
Aspirin in viral illness Liver and brain 1: palmar erythema, GI, confusion 2: drowsy, hyperventilate 3: coma, cerebral oedema 4: fixed dilated pupils 5: seizures, MOF, high ammonia Think of alcoholic for stages

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