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Medicine year 4 CDM > Mosler investigations and management > Flashcards

Mosler investigations and management Flashcards

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

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
Q

A-fib management

A
  • 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
Q

Investigations for breast cancer

A

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
Q

Management of breast cancer

A

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
Q

Investigations of Osteoarthritis

A

bloods: CRP/ ESR to rule out inflammatory cause

imaging: joint XR

29
Q

Management of osteoarthritis

A

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
Q

Investigations for RA

A

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
Q

Management of RA

A

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
Q

Investigations for back pain

A

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
Q

Management of back pain

A

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
Q

Investigations for osteoporosis

A

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
Q

Management of osteoporosis

A

conservative:
- stop smoking and reduce alcohol
- physio
- OT

medical:
- bisphosphonates
- calcium and vitamin D
- HRT

surgical: management of NOF fracture

36
Q

Asthma investigations

A

bedside: PEFR

imaging: CXR to rule out other causes

special tests:
- spirometry with reversibility testing
- fractional exhaled nitric oxide

37
Q

Management of asthma

A

conservative:
- avoid triggers (consider symptom diary)
- teach inhaler technique
- annual flu vaccine
- smoking cessation

medical:
- SABA reliever -> ICS -> montelukast -> LABA

38
Q

Epilepsy investigations

A

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
Q

Management of epilepsy

A

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
Q

Stroke investigations

A

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
Q

Management of stroke

A

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
Q

Management of migraines

A

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
Q

Management of Parkinsons

A

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
Q

Investigations for macular degeneration

A

bedside:
- visual acuity and visual field testing
- slit lamp examination

imaging:
- optical coherence tomography
- fluorescein angiography

45
Q

Management of macular degeneration

A

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
Q

Investigations for glaucoma

A

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
Q

Management for glaucoma

A

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
Q

Cataracts investigations

A

bedside:
- visual acuity and visual field testing
- slit lamp examination

49
Q

Cataracts management

A

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
Q

MS investigations

A

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
Q

Management of MS

A

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
Q

Controlled medication and which you use brand names

A
  • Controlled: Methadone, ketamine, Morphine, Codeine, Fentanyl, Oxycodone, Anabolic steroids, Lorazepam
  • Brand names: Insulin, antiepileptics, inhalers, Lithium, Opioids, Mesalazine, Diltazem, Tacrolimus, Contraception + HRT, Nifedipine
53
Q

Heart attack symptoms and investigations

A

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
Q

Heart attack management

A
  • 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
Q

Cardiomyopathy symptoms and investigations

A

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
Q

Cardiomyopathy management

A
  • 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
Q

IPF symptoms and investigations

A

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
Q

IPF management

A
  • 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 (41 decks)

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