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Medicine year 4 CDM > Mosler investigations and management > Flashcards

Mosler investigations and management Flashcards

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1
Q

Hypertension Symptoms and investigations

A

Symptoms: palpitation, chest pain, SOB, N+V, headache, muscle cramos, fatigue, heat intolerance, polyuria/polydipsia

  • Bedside: BP, obs, fundoscopy, urine dip, ECG, 24 hour ambulatory blood pressure
  • Bloods: FBC, U&E, LFT, glucose, lipids
    Investigations: renal US
  • Secondary: Dexamethasone suppression test (crushings), Metanephrenes (phaemochromatoma), Urine albumine:creatinine ratio (addisons)
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2
Q

Hypertension management

A
  • Conservative: lifestyle, DASH diet, avoid caffeine stress, QRISK2
  • Medical: ACEi )<55, diabetic), CCB (>55, afro-carribean), statins, regular monitory. A+C. then A+C+T
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3
Q

Diabetes symptoms and investigations

A

Symptoms: polyuria/polydipsia, fatigue, weight loss, dizziness, leg ulcer, slow wound healing, loss of sensation, eyes (flashers, floateers, visual loss), thrush, erectile dysfunction, darkening skin in armpits

  • Bedside: urine dip, ECG, fundoscopy, peripheral pulses
  • Bloods: glucose, HBA1c, FBC, U&E, LFT, lipid
  • Investigations: OCT
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4
Q

Diabetes management and complications:

A
  • Conservative: pneumococcal, flue vaccine, lifestyle
  • Medication: metformin + SGLT2 (of cardiovascular risk). Titrate metformin first. Then add DDP4, sitagliptan or sulfonylurea

Complications: infections (thrush), diabetic retinopathy, peripheral neuropathy, autonomic neuropathy CKD, diabetic foot, gastroparesis

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5
Q

Heart failure symptoms and investigations

A

Symptoms: SOB (rest, orthopnoea, walking distance, pillows), chest pain, palpitations, ankle swelling, pink frithy sputum, cough, wheeze, fatigue, weight loss

  • Bedside: ECG, urine dip, glucose, sputum culture
  • Bloods: FBC, U&E, LFT pro-BNP, TFT, lipid screen
    -Imaging: CXR, echocardiogram
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6
Q

Management of Heart failure

A
  • Conservative: encourage to sleep lying up, smoking, diet, exercise, alcohol, vaccines (pneumococcal, flu), cardiac rehabilitation
  • Medication: ACEi, SGLT2, Beta blocker, MRA, Furosemide
  • Surgery: pacemaker + defib, Cardiac resynchronisation therapy (severe heart failure, EF <35%), heart transplant- severe disease
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7
Q

Myasthenia gravis investigations

A
  • Bedside: obs, BM, ECG, Ice test, FVC
  • Blood: ABG, anti-AChR, anti-MuSK, TFT, FBC, UE, LFT, CRP
  • Imaging: MRI brain, thymus CT/MRI
  • Special: Nerve stimulation, edrophonium test
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8
Q

Myasthenia-gravis management

A

Urgent admission
Assessment and management of crisis: respiratory support (NIV- BiPAP/intubation), IVIg, Plasma exchange

Long term:
· AChI- pyridostigmine/neostigmine
· Immunosuppression- prednisolone/azathioprine
· Thymectomy
· Mab: rituximab

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9
Q

Sickle cell disease investigations

A

Bedside: peak flow – essential in chest crises

· Bloods: FBC, U+Es, LFTs, coag, iron studies, b12 and folate

· Imaging: blood film (sickle cells, target cells, reticulocytosis with polychromasia. Also may show features of hyposplenism – Howell-Jolly bodies, nucleated RBCs)

· Special: haemoglobin electrophoresis +/- genetic testing, newborn heel pric

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10
Q

Sickle cell disease management

A

Conservative:
o Good hydration to try and prevent crises
o Avoid triggers – cold weather, intense exercise, dehydration, high altitudes, alcohol, smoking
o Discussion around family planning e.g. is husband a carrier if planning on pregnancy

· Medical
o High flow oxygen
o IV fluids and analgesia
o Blood transfusions, especially if also anaemic
o Hydroxycarbamide if frequent crises
o Vaccinations including pneumococcal
o Antibiotic prophylaxis – typically penV

  • Surgical: Bone marrow transplant further down the line
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11
Q

Causes of nephritic syndrome

A
  • IgA nephropathy
  • Post streptocococal nephropathy
  • Ant GBM disease
  • Small vessel vasculitis
  • Granulomatosis with polyangitis
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12
Q

Causes of nephrotic syndrome

A
  • Minimal change disease
  • Focal segmental glomerulosclerosis
  • Membraneous glomerulonephropathy
  • Amyloidosis
  • Lupus nephritis
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13
Q

Angina symptoms and investigations

A

Symptoms: chest pain (exertion, rest, after eating), SOB, palpitation, syncope, ankle swelling, fever, weight loss, cough, wheeze

-Bedside: ECG, BP, obs
- Bloods: FBC, U&E, LFT, TFTL HBA1C, fasting glucose
- Imaging: CT angiogram, cardiac stress test

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14
Q

Angina management

A
  • Conservative: lifestyle, vaccines, QRISK score
  • Medical: BB, CCB, GTN spray- take with symptoms then every 5 minutes. Asprin, statin
  • Surgery: PCI, coronary artery bypass graft (CABG)
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15
Q

PAD symptoms and investigations

A

Symptoms: pins and needles, tingling, numbness, pain (with heat, movement), diarrhoea, incontinence, skin changes, heat, swelling, feels cold, paraysis

  • Bedside: peripheral pulses, BP, obs, ABPI, ECG, culture, lipids, Buergers test
  • Bloods: FBC, U&E, LFT, HBA1C, fasting glucose
  • Investigations: duplex ultrasound for pulses, angiography (CT or MRI)
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16
Q

PAD management

A
  • Conservative: lifestyle, foot care (keep foot dry, have well fitting shoes), exercise training
  • Medical: give gabapentin/amitriptyline for pain. Statin, clopidogrel, Naftidroforyl oxilate
  • Surgery: emergency amputation, bypass surgery, endovascular angioplasty and stenting
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17
Q

CKD symptoms and investigations

A

CKD: fatigue, N+V, muscle cramps, bony pain, urine (oligouria/haematuria), oedema, SOB, confusion, itch, weight loss, loss of appetite

-Bedside: urine dip, albumin:creatinine ratio,, fluid balance chart, 24 hour urine collection, obs
- Bloods: FBC, U&E, LFT, calcium, phosphate, bone profile, ABG
- Investigations: renal US, CT KUB, post void residual volume, renal biopsy

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18
Q

CKD management

A
  • Conservative: flu and pneumococcal vaccine, low phosphate and sodium diet, maintain fluid intake
  • Medical: optimise comorbidities. Statin and antiplatelet. ACEi if ACR >3 with diabetes, >30 with hypertension or just above >70.
    For complications: phosphate binders, EPO + iron, bicarbonate in metabolic acidosis, calcitonin
    RRT: peritoneal dialysis, Haemodialysis, kidney transplant
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19
Q

Liver failure symptoms

A

Increased bruising, N+V, abdo swelling, vomiting blood, weight loss, pale stool, dark urine, itch, colour change to skin or eyes, confusion, blood in stools

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20
Q

Liver failure investigations

A
  • Bedside: BP, obs, FIB4 score (NAFLD), AUDIT score, Child-pugh score
  • Bloods: FBC, U&E, LFT, CRP, HBA1C, fasting glucose, AFP, ELF (NAFLD)
  • Investigations: Fibro scan, abdo US, Paracentesis (in ascites), endoscopy (varices), liver biopsy
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21
Q

Liver failure management

A
  • Conservative: lifestyle (stop drinking, improve diet), flu and pneumococcal vaccine, regular meals to avoid malnutrition
  • Meds: Vitamin E (if not diabetic), Liraglutide and Pioglutide (if diabetic), Spironolactone (ascites), B12, folate, stop hepatotoxic drugs
  • Surgery: TIPS (ascites), liver transplant (if decompensated)

MELD/UKELD score: if cirrhosis
HE: lactulose, rifaximine
Maddrey score: alcoholic hepatitis
Refer to specialist

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22
Q

COPD symptoms and investigations

A

Symptoms: SOB, wheeze, haemoptysis, weight loss, cough, sputum, chest pain, oedema, skin changes. Ask about work, pets, smoking

  • Bedside: BP, spirometry, sputum culture, ECG (heart failure), TLCO, calculate MRC breathlessness scale
  • Bloods: FBC, U&E, CRP, alpha 1-antitrypsinogen
  • Investigations: CXR
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23
Q

COPD: Management

A
  • Conservative: stop smoking, lifestyle, pulmonary rehab, flu and pneumococcal vaccine
  • Medicine: SABA or SAMA -> add LABA and LAMA. If asthmatic LABA + ICS
  • Surgery: lung transplant
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24
Q

A-fib symptoms and investigations

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A

Symptoms: palpitation (coffee and alcohol), chest pain, SOB (on exertion at night), ankle swelling, haemoptysis, syncope, dizziness, heat intolerance, muscle pains, cramping, anxiety

  • Bedside: ECG, BP, obs
  • Bloods: FBC, U&E, LFT, coag, TFT, Pro-BNP, calcium, magnesium , glucose
  • Special: CXR, 24 hour ECG, exercise stress ECG
25
A-fib management
- Conservative: lifestyle (recreational drugs, smoking), refer to cardiology - Medical: CCB, BB, Digoxin. If present within 48 hours can electrically cardiovert them. Do CHAD-VISK score for anticoagulation - Surgery: ICD, pacemaker, Left atrial ablation, atrioventricular node ablation with permanent pacemaker Pharmacological cardioversion: Flecainide, Amiodarone Long term rhythm control: Beta blockers, Dronedarone, Amiodarone
26
Investigations for breast cancer
bedside: full set of obs bloods: - FBC to look for anaemia - U+Es for baseline - LFTs to look for liver mets - calcium to look for hypercalcaemia of malignancy imaging: - mammogram (ultrasound if under 35) - ultrasound of axilla to look for lymph node spread special tests: - fine needle aspiration - ultrasound guided biopsy of abnormal lymph nodes
27
Management of breast cancer
conservative: MDT involvement from surgeon, oncologist and breast care nurse medical: - chemo - radiotherapy - hormonal therapy with tamoxifen (pre-menopausal) or aromatase inhibitors (post-menopausal) surgical: - breast conserving surgery - mastectomy with breast reconstruction - axillary clearance
28
Investigations of Osteoarthritis
bloods: CRP/ ESR to rule out inflammatory cause imaging: joint XR
29
Management of osteoarthritis
conservative: - weight loss - exercise and physio - walking aids medical: - regular paracetamol and topical NSAID gel (move up pain ladder as needed) - intra-articular steroid injections surgical: joint replacement
30
Investigations for RA
bedside: urinalysis as baseline and to exclude other differentials bloods: - FBC to look for anaemia - ESR/ CRP to look for inflammation - rheumatoid factor and anti CCP - LFTs and U+Es for baseline before DMARDs - TFTs to rule out hypothyroidism imaging: - joint ultrasound (sensitive for synovitis) - joint XR - CXR to exclude lung disease before DMARDs special tests: joint aspiration if uncertainty
31
Management of RA
conservative: - physio - patient education - lifestyle change to reduce CVD risk - vaccines to decrease risk of infection on immunosuppressive drugs medical: - paracetamol and weak opioids - steroid injections - DMARDs - biologics - treat osteoporosis surgical: joint replacement
32
Investigations for back pain
bedside: - digital rectal examination to assess for reduced peri anal sensation and loss of anal tone - urinalysis if associated urinary symptoms bloods: - FBC to look for normocytic anaemia seen in AS - CRP/ ESR raised in AS - LFTs to look for raised ALP seen in AS imaging: - XR if suspected spinal fracture or AS - urgent MRI if suspected caudal equine syndrome - post void bladder scan to assess urinary retention if associated urinary symptoms
33
Management of back pain
conservative: - physio - consider CBT if functional - spinal brace if fracture medical: - NSAIDs are 1st line analgesia surgical: - urgent decompression for cauda equine syndrome - consider surgery for fracture - vertebral osteotomy to correct deformities due to AS
34
Investigations for osteoporosis
bedside: FRAX to assess fracture risk bloods: - FBC, ESR/ CRP to rule out inflammatory causes - bone profile to look for calcium deficiency which can contribute to osteoporosis - U+Es and LFTs to look for renal or liver failure which can cause osteoporosis - TFTs to look for hyperthyroidism which can cause osteoporosis imaging: - DEXA scan at vertebrae and femoral neck - XR
35
Management of osteoporosis
conservative: - stop smoking and reduce alcohol - physio - OT medical: - bisphosphonates - calcium and vitamin D - HRT surgical: management of NOF fracture
36
Asthma investigations
bedside: PEFR imaging: CXR to rule out other causes special tests: - spirometry with reversibility testing - fractional exhaled nitric oxide
37
Management of asthma
conservative: - avoid triggers (consider symptom diary) - teach inhaler technique - annual flu vaccine - smoking cessation medical: - SABA reliever -> ICS -> montelukast -> LABA
38
Epilepsy investigations
bedside: - capillary blood glucose to rule out non-epileptic seizure - ECG to rule out cardiac cause bloods: - U+Es to rule out non-epileptic seizure - serum drug levels if appropriate to rule out non-epileptic seizure - FBC and LFTs for baseline before commencing anti epileptics imaging: - MRI or CT lead to localise cause of focal seizure and rule out other causes e.g. tumour/ stroke special tests: EEG
39
Management of epilepsy
conservative: - in acute seizure: remove obstacles, call ambulance, place in recovery position after - review annually - counsel about driving (can't drive until seizure free for 1 year) - avoid triggers e.g. alcohol and poor sleep - discuss drug side effects esp relating to contraception and pregnancy medical: - in acute seizure: buccal midazolam, PR diazepam or IV lorazepam - long term anti epileptics
40
Stroke investigations
bedside: - capillary blood glucose to rule out hypoglycaemia as a cause - ROSIER to distinguish stroke and TIA bloods: - FBC, U+Es and LFTs as baseline imaging: - non-contrast CT head - contrast CT angiography if considering thrombectomy - carotid doppler to assess for stenosis
41
Management of stroke
conservative: - secondary prevention with lifestyle advice medical: - 300mg aspirin - consider thrombolysis with alteplase if within 4.5hrs - secondary prevention with ACEi, statin and clopidogrel surgical: - carotid endarterectomy if stenosis above 70% - thrombectomy if within 6hrs and confirmed proximal anterior circulation occlusion
42
Management of migraines
conservative: - avoid triggers - ensure good sleep, hydration, regular meals and reduce stress medical: - acute treatment with paracetamol/ NSAID and triptan - consider anti emetic even in absence of nausea - prophylaxis with propanolol or topiramate
43
Management of Parkinsons
conservative: - physio - OT - SALT - contact DVLA medical: - levodopa, dopamine agonists, MAO-B inhibitors, COMT inhibitors - symptomatic management: midodrine (postural hypotension), melatonin (REM sleep), modanafil (daytime sleepiness), glycopyronium bromide (drooling), quetiapine (hallucinations) - best medical therapy is intermittent apomorphine injections or continuous infusion surgical: deep brain stimulation
44
Investigations for macular degeneration
bedside: - visual acuity and visual field testing - slit lamp examination imaging: - optical coherence tomography - fluorescein angiography
45
Management of macular degeneration
conservative: - stop smoking to slow progression - inform DVLA - help with access to aids - advise to officially register as visually impaired to access benefits - correct refractive errors at optician medical: - anti VEGF agents for wet AMD - vitamin supplementation for dry AMD to slow progression
46
Investigations for glaucoma
bedside: - visual acuity and visual field testing - slit lamp examination imaging: optical coherence tomography special tests: - tonometry (measure IOP) - gonioscopy (measure drainage angle) - pachymetry (measure corneal thickness)
47
Management for glaucoma
conservative: - inform DVLA - help with access to aids - advise to officially register as visually impaired to access benefits - correct refractive errors at optician medical: - topical eye drops: prostaglandin analogues, beta blockers, a2 agonists, carbonic anhydrase inhibitors surgical: laser or surgical trabeculoplasty
48
Cataracts investigations
bedside: - visual acuity and visual field testing - slit lamp examination
49
Cataracts management
conservative: - inform DVLA - help with access to aids - advise to officially register as visually impaired to access benefits - correct refractive errors at optician surgical: cataract surgery
50
MS investigations
Bedside– consider BP, slit lamp, fundoscopy, Bloods- consider FBCs, U+Es, LFTs Lumbar puncture- Oligoclonal bands I – MRI head and spine (T2 and gadolinium contrast) McDonald- must show dissemination in time and space
51
Management of MS
Conservative – physiotherapy, support groups, home adaptations, patient and carer education, when appropriate DNACPR/EHCP M Medical– acute flare; steroids long-term remission maintenance; pegylated interferons, natalizumab/other specialist mabs symptom management; baclofen (spasticity), SSRIs, pregabalin/gabapentin (pain), oxybutynin (urge incontinence)
52
Controlled medication and which you use brand names
- Controlled: Methadone, ketamine, Morphine, Codeine, Fentanyl, Oxycodone, Anabolic steroids, Lorazepam - Brand names: Insulin, antiepileptics, inhalers, Lithium, Opioids, Mesalazine, Diltazem, Tacrolimus, Contraception + HRT, Nifedipine
53
Heart attack symptoms and investigations
Symptoms= Event (chest pain, palpitations, sense of dread, N+V, sweating), N+V After event: recovery, weight loss, mood, chest pain, SOB, palpitations, oedema, syncope - Bedside: ECG, urine dip, BMI, BP, obs, grace score - Bloods: FBC, U&E, LFT, Troponin, pro-BNP, lipid, glucose - Imaging: CXR, echocardiogram
54
Heart attack management
- Conservative: lifestyle, flu and pneumococcal vaccine, cardiac counselling, counselling - Medicine: Dual antiplatelet (Asprin + Tricregalor (low bleed risk) or Clopidogrel (high bleed risk)), ACEi/ARB, BB, statin, GTN
55
Cardiomyopathy symptoms and investigations
Symptoms: chest pain, SOB (rest, exertion, night), palpitations, oedema, syncope, reduced exercise tolerance, fatigue, weight loss, dizziness - Bedside: ECG - Bloods: FBC, U&E, LFT, pro-BNP, lipid - Investigations: CXR, echocardiogram, genetic testing, Cardiac MRI, exercise stress test
56
Cardiomyopathy management
- Conservative: flu and pneumococcal vaccine, lifestyle (less important as genetic). If Hypertrophic dont take part in competitive sports - Medicine: BB, CCB, Disoporamide, diuretics - Surgery: Heart transplant if severe heart failure, IDF Hypertrophic: Surgical myectomy, alcohol septal ablation. Avoid nitrates and ACEi
57
IPF symptoms and investigations
Symptoms: cough (type, sputum), wheeze, SOB (rest, on exertion, how far can you walk), reduced exercise tolerance, weight loss, fever, work, pets - Bedside: BP, obs ,spirometry, sputum, culture, TLCO - Bloods: FBC, U&E, LFT, CRP, ANA, RHF - Imaging: CXR (granulomatosis), CT thorax (HRCT)- ground glass, Lung biopsy, Broncheoalveolar lavage
58
IPF management
- Conservative: avoid triggers (keep trigger diary), lifestyle (stop smoking), flu and pneumococcal vaccine, pulmonary rehab, home oxygen - Medicine: Ani-fibrotics (Pirferidone, Nintedanib) - Surgery: Lung transplant

Medicine year 4 CDM (44 decks)

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