Newest Flashcards
1
Q
Ascites evaluation and management
A
Issue
- Spontaneous bacterial peritonitis
- > medical emergency
- > mortality in 1/3rd
- Secondary bacterial peritonitis
- > perforation
- > polymicrobial stain/culture + PMNs + LDH
- > surgical emergency
- Haemoperitoneum
- > half of HCC with ascites
Hx
- SBP
- > abdo pain
- > vomiting/diarrhoea
- > obstipation
- Liver
- > change in bowel habits/dark urine/pale stools/pruritus
- HF
- > orthopnoea/PND/palpitations
- Ovarian
- > bloating/early satiety/post prandial fullness
- Pancreatitis
- > pain/steatorrhoea
- Malignancy
- > fatigue/weight loss/anorexia
- Past
- > liver (cirrhosis/hepatitis)
- > heart
- > malignancy
- > diabetes/HTN/hypercholesterolaemia
- OnG
- > menarche/menopause
- > parity
- > pill
- Family
- > malignancy
- > BRCA
- > lynch
- > haemochromatosis
- Medications
- > non compliance
- > paracetamol
- Social
- > diet + exercise
- > alcohol
- > IVDU
- > transfusions
- > tattoos
- > travel/country of birth
Exam
- Vitals
- > fever
- > haemodynamically stable
- Volume status
- > urine output
- Mental status
- > encephalopathy
- Chronic liver disease
- HF
- > JVP
- > crackles/effusion
- Abdo
- > peritonism
- > ovarian mass (consider bi-manual)
Investigations
- VBG
- > lactate
- > glucose
- US
- > ascites
- > cirrhosis
- > splenomegaly
- > portal/hepatic vein patency
- Triple phase CT
- > malignancy
- Amniocentesis
- > total albumin (serum:ascites <11g/L is non cirrhotic)
- > cell count + differential (SBP = polymorphs)
- > gram stain
- > culture
- > glucose
- > LDL
- > amylase
- FBC
- > Hb (haemoperitoneum)
- > thrombocytopenia
- Ferritin
- > haemochromatosis
- LFTs
- Synthetic function
- > albumin
- > PT/INR
- EUCs
- > hepatorenal
- Hepatitis serology
- Anti-smooth muscle antibody
- > autoimmune hepatitis
- Anti-mitochondrial antibody
- > primary sclerosing cholangitis
Management
- Risk score
- > Child Pugh
- > MELD score
- Hepatorenal syndrome
- > albumin + midodrine
- Haemoperitoneum
- > endovascular embolisation
- Refractory ascites
- > transjugular intraphepatic portovenous shunt (TIPS)
- Hepatic encephalopthy
- > lactulose
- > rifaximin
2
Q
Hyponatraemia evaluation and management
A
Review
- Cognition
- > establish baseline
- > dementia/neurological disorder/stroke
- Comorbidities
- > HF
- > cirrhosis
- > CKD
- > thyroid
- > diabetes
- Medications
- > SSRI
- > opioids
- > thiazides
- Admission
- > antibiotics + sensitivities
- > fluids given + previous electrolytes
- Fluid balance
- > vomiting/diarrhoea
- > fluids chart
Initial investigations
- Serum osmolality
- > isotonic = check glucose for hyperglycaemia
- > hypertonic = check protein + lipids for pseudo
- > hypotonic = consider urine osmolality
- Urine osmolality
- > low in ADH independent (CKD/AKI/potomania/polydipsia)
- > high in ADH dependent (check volume status)
Exam
- Vitals
- > sepsis
- > hypotension
- Hypervolaemia
- > HF
- > cirrhosis
- > nephrotic syndrome
- Hypovolaemia
- > GI losses
- > renal losses
- > third spacing
- Euvolaemia
- > hypothyroid
- > adrenal insufficiency
- > SIADH
Further investigations
- Urine Na
- > low in non renal hyper/hypovolaemia
- > high in renal hyper/hypovolaemia and SIADH
- EUCs
- > high urea in hypervolaemia and hypovolaemia
- > suppressed urea in SIADH
- Electrolyte free water excretion
- Euvolaemic
- > TSH
- > free cortisol
Management
- General
- > correct slowly
- > treat underlying cause
- > manage delirium
- > insert catheter
- > monitor
- Acute onset + severe symptoms
- > ICU
- > hypertonic (3% saline)
- > caution osmotic demyelination syndrome
- Hypovolaemic
- > normal saline or LR bolus for BP
- > infusion at 0.5mL/kg/hr
- Hypervolaemic or Euvolaemic
- > fluid restrict <1L per day
- > guided by electrolyte free water excretion (lower)
- > frurosemide 20mg IV and increase
3
Q
Alcohol withdrawal evaluation and management
A
Issues
- Sepsis
- Withdrawal
- > life threatening DTs
- Response
- > vitals
- > primary survey
- > call for help in unstable
Hx
- PC
- > agitation
- > anxiety
- > nausea/vomiting
- > insomnia
- > hallucinations
- > seizures (generalised tonic clonic)
- Past
- > establish baseline cognition
- > comorbid psychiatric illness
- > liver disease
- Medications
- > opioids
- Social
- > alcohol intake + past withdrawal
- > other substances
- > IVDU/tattoos
Exam
- Vitals
- > sepsis (fever/tachycardia/hypotension)
- > DTs (fever/HTN/tachycardia)
- Cognition
- > time
- > person
- > place
- > hallucinations
- Inspection
- > tremor
- > sweating
- Wernickes
- > ataxia
- > nystagmus
- > confusion
Investigations
- ECG
- > tachyarrhythmia
- Blood cultures
- VBG
- > glucose
- > electrolytes
- > lactate
- FBC
- EUCs
- LFTs
- > GGT
- > AST:ALT >2
- Coags
- > INR/PT (chronic liver disease)
- Thiamine
Management
- Assess capacity
- > high risk of absconding
- Consult
- > drug and alcohol
- > psychiatry
- Supportive
- > education
- > low stimulus environment
- > fluids + electrolyte replacement
- > monitoring
- Thiamine (before glucose)
- > 300mg IV TDS for 3 days
- > 300mg oral for several weeks
- Glasgow modified withdrawal scale score
- Severe
- > senior help
- > consider ICU
- > IV high dose lorazepam
- > consider holoperidol oral/IM
- Mild
- > oral diazepam 20mg every 2hrs until effect (up to 100)
- > use lorazepam/oxazepam/timazepam in liver disease
- Monitoring
- > benzo overdose
- > 1-4 hrly
- > GCS/RR/BP/sats
- Long term
- > consider inpatient detox
- > group or individual psychotherapy
- > disulfiram in young fit and motivated
- > acamprosate not useful in acute phase (reduces craving)
- > naltrexone (reduces high)
4
Q
Substance overdose/withdrawal
A
Opioids
- Overdose
- > respiratory depression
- > stupor
- > constricted pupils
- > treated with naloxone
- Withdrawal
- > onset after 2 days
- > agitation
- > goose flesh
- > sweating
- > abdo cramping/vomiting/diarrhoea
- > seizures
- Withdrawal treatment
- > bupenorphine subling in acute
- > delay for 6hrs or signs evident (causes withdrawal)
- > long term management = bupenorphine or methadone
Benzo
- Overdose
- > not life threatening on its own
- > combination with alcohol or opioids
- > treated with flumazenil (antagonist)
- Withdrawal
- > anxiety
- > insomnia
- > myoclonus
- > palpitations
- > hallucinations
- > seizures
- Treatment
- > stabilise total daily dose with diazepam
- > after a few days, dose reduce 10% per day
Stimulants
- Withdrawal
- > hypersomnia
- > hyperphagia
- > depression
- > aggression
- Treatment
- > SSRI’s for depression
- > benzos for aggression
5
Q
Hypercalcaemia evaluation and management
A
Hx
- PC
- > weakness/malaise
- > nausea/vomiting
- > constipation
- > cramps
- > change in mood
- DDx
- > bone pain/weight loss/fatigue/anorexia (malignancy)
- > dry cough (sarcoid)
- > sweats/fevers/dyspnoea/bleeding/bruising (leukaemia)
- Past
- > malignancy
- > pathological fractures
- > osteoporosis/osteopaenia
- > CKD
- > kidney stones
- > psychiatric illness
- Family hx
- > inherited PHP
- Medications
- > thiazides
- > lithium
- > antacids
- Social
- > diet
- > vitamin D + calcium supplementation
Exam
- Neck
- > hard/dense mass = carcinoma
- Weakness
- Hypo-reflexia
- Lymphadenopathy
- Hepatosplenomegaly
- Bone tenderness
- Lungs
- > wheeze
Investigations
- ECG
- > bradycardia
- > heart block
- > short QT
- Calcium
- > corrected for albumin
- PTH
- > high in PHP
- Phosphorus
- > low in PHP
- Al phos
- Low PTH
- > PTHrP raised in humoral hypercalcaemia of malignancy
- Low PTHrP
- > 1,25 dihydroxvitamin D (calcitriol) raised in sarcoid
- Low calcitriol
- > 25 hydroxyvitamin D (calcidiol) elevated with supplements
- Low calcidiol
- > SPEP + UPEP
Management
- Further investigations
- > 24 urinary calcium (low in familial hypocalciuric hypercalcaemia)
- > DXA scan (osteoporosis/osteopaenia)
- > neck imaging for surgical planning
- Parathyroidectomy
- > pathological fracture/stones/neurological disease
- > minimally invasive directed parathyoidectomy in single adenoma
- > bilateral exploration and subtotal in multiple gland disease
- Bisphosphonates
- > poor surgical candidates
- > zoledronic acid IV once yearly
- Supportive
- > Ca + Cr + DXA + vitamin D every 12 months
- > avoid thiazides/lithium
- > egocalciferol or colecalciferol
6
Q
Palliation management
A
Communication
- Family meeting
- Inform
- > patient will die soon
- > overview of what may happen
- > overview of what can be done
- > ensure they can recognise death and what to do
- Explore concerns
- > noisey secretions normal and not harmful
- > irregular breathing/apnoea/agonal common
- > agitation and confusion common
- > medications do not speed up death
- Patient wishes
- > advanced care directive/guardian
- > cares
- > location of death
- Written instructions
- > visible do not resuscitate order
- > prevent unwanted interventions
- Speaking to patient
- > assume still aware of surroundings
- > explain cares
- Carer supports
- > religious or community supports
- > need for rest
- > psychological services
Medications
- Stop any
- > unnecessary regular medications
- > cease oral route
- Subcut
- > catheter
- Prescribe
- > in advance for expected issues
- > PRN for breakthrough symptoms
General care
- Consult palliative care
- Incontinence
- > pads or pan
- > catheter
- Skin
- > moisten mouth
- > prevent pressure sores
- Pain
- > manifest as agitation
- > 2.5-5mg morphine hourly
- Dyspnoea
- > oxygen ineffective
- > morphine
- > clonazepam
- Secretions
- > suction + repositioning
- > glycopyrronium
- Nausea/vomiting
- > haloperidol
- > metaclopromide
- Agitation
- > clonazepam
After death
- Cultural practices
- Saying goodbye
- Family support
- Duties
- > verify death
- > death certificate
- > inform relevant health care providers
7
Q
Pseudomembranous colitis evaluation and management
A
Hx
- PC
- > diarrhoea
- > fever
- > abdo pain
- > nausea/vomiting
- > recent antibiotic exposure
- > recent health care exposure
- Past
- > IBD
- > CKD
- > HIV
- > immunosuppression
- > transplants
- Meds
- > PPI
Exam
- Vitals
- > febrile
- > haemodynamically stable
- Volume status
- Acute abdomen
- > fulminant disease
Investigations
- FBC
- > leukocytosis
- FOBT
- > occult blood
- Stool MCS
- > ova
- > paracites
- > cysts
- > c diff toxin
- Abo xray
- > dilated colon
- CT
- > if signs of obstruction
- Colonoscopy
- > if negative with high suspicion or treatment resistant
Management
- Infection control
- > contact precautions
- > hand hygiene
- > private room with own toilet
- Cease causative antibiotic
- Antibiotics
- > vancomycin oral for 10 days
- > add metronidazole IV if fulminant
- > consider IvIg or subtotal colectomy for fulminant
8
Q
MM evaluation and management
A
Hx
- PC
- > bone pain
- > fatigue/dyspnoea
- > weight loss
- > fevers/night sweats
Exam
- Unremarkable
- > pallor
- > bone pain
Investigations
- FBC
- > normocytic normochromic anaemia
- Smear
- > rouleaux
- EUCs
- > impairment
- CMP
- > hypercalcaemia
- Prognostic
- > albumin
- > beta 2 microglobulin
- Serum eletrophoresis + immunofixation
- > IgA/IgG M spike
- > hypogammoglobinaemia
- > urinary free light chains
- Serum free light chains
- > raised
- Skeletal survey (whole body low dose CT preferred)
- > lytic lesions
- Bone marrow biopsy
- > monoclonal plasma cells >10%
Management
- Good functional status
- > chemo +- radiation
- > corticosteroids
- > autologous stem cell transplant
- Poor functional status
- > chemo +- radiation
- > corticosteroids
- Bone disease
- > zoledronic acid or denosumab
- Prognosis
- > stage 1 = 5 years
- > stage 3 = 2 years
