PACES revision Flashcards
1
Q
GI history?
A
Blood/mucus in stool
Abdo pain
Diarrhoea/constipation
Bloating
Frequency of passing stools
Dark urine/pale stools
Ask about previous surgeries
FLAWS
2
Q
Diverticulitis presentation
A
acute left iliac fossa pain +/- diarrhoea and fever
3
Q
Peptic ulcer disease presentation
A
chronic epigastric pain +/- reflux symptoms
4
Q
Important to remember?
A
ICE!!!
5
Q
MSK history?
A
Pattern of joint involvement
Any history of trauma?
Fever, skin rash, weight loss, eye signs, bowel symptoms, scalp tenderness, red eyes, chest pain
Pain, swelling, stiffness, muscle pain, deformity
FLAWS
ICE
6
Q
Cardiac histories?
A
Chest pain - SOCRATES
SOB
Swelling, orthopnoea, pink frothy sputum
Palpitations
Dizziness, syncope, claudication
7
Q
Cardiac RF?
A
Hypertension (high blood pressure)
Hypercholesterolaemia (high cholesterol)
Family history (heart attack < 60 years old in biological relative)
Smoking
Diabetes
8
Q
Resp history?
A
SOB
Wheeze
Cough +- productive
chest pain
Sputum
Haemoptysis
FLAWS
Smoking, pets, occupation, allergens
Recent travel
ICE
9
Q
Differentiating COPD and asthma?
A
10
Q
foot drop and a peripheral neuropathy
A
CMT, GBS, CIDP, diabetes, alcohol, B12 deficiency,
11
Q
Side effects of cushing’s syndrome?
A
Osteoporosis, dyslipidaemia, HTN, T2DM
12
Q
Causes of Cushing’s
A
C – Cushing’s disease (a pituitary adenoma releasing excessive ACTH)
A – Adrenal adenoma (an adrenal tumour secreting excess cortisol)
P – Paraneoplastic syndrome
E – Exogenous steroids (patients taking long-term corticosteroids)
13
Q
Ix for cushing’s
A
Low dose dexamethasone suppression test
High dose dexamethasone suppression test
24-hour urinary free cortisol
Full blood count may show a high white blood cell count
U&Es may show low potassium if an adrenal adenoma is also secreting aldosterone
MRI brain for a pituitary adenoma
CT chest for small cell lung cancer
CT abdomen for adrenal tumours
14
Q
Nelson’s syndrome
A
Involves the development of an ACTH-producing pituitary tumour after the surgical removal of both adrenal glands due to a lack of cortisol and negative feedback. It causes skin pigmentation (high ACTH), bitemporal hemianopia and a lack of other pituitary hormones.
15
Q
Diagnosing addison’s disease
A
Short synacthen test
16
Q
Secondary adrenal insufficiency?
A
caused by a reduction in adrenocorticotropic hormone release. May be seen as part of panhypopituitarism, an isolated deficiency, following brain injury or secondary to medications.
17
Q
Tertiary adrenal insufficiency
A
caused by a reduction in corticotropin-releasing hormone, most commonly seen following chronic glucocorticoid steroid use.
18
Q
Causes of acromegaly?
A
Pituitary adenoma
19
Q
DI treatment?
A
desmopressin
Fluid restrict
20
Q
Prolactinoma sx?
A
Visual field problems, headaches, lethargy, galactorrhoea, hair growth, decreased libido, gynaecomastia, infertility, irregular menstruation, painful breasts, impotence
21
Q
Treatment of prolactinoma?
A
1st line = Bromocriptine/cabergoline
2nd line = transphenoidal surgery
22
Q
SIADH?
A
Body weakness
Fatigue, dizziness, confusion, lethargy
Muscle cramps
Seizures
Ix: Urine analysis, hyponatraemia, low plasma osmolarity
Tx: Water restriction
23
Q
splenomegaly and keloid scars
A
Sickle cell disease
24
Q
Hypogonadotrophic hypogonadism
A
(low LH and FSH resulting in low testosterone), can be due to:
Pathology of the pituitary gland or hypothalamus
Suppression due to stress, chronic conditions or hyperprolactinaemia
Kallman syndrome
Steroid use
25
Anabolic steroids and endo?
Anabolic steroids cause secondary hypogonadism by suppressing the hypothalamic–pituitary axis.
26
Hypogonadism
Hypogonadotropic hypogonadism: a deficiency of LH and FSH
Hypergonadotropic hypogonadism: a lack of response to LH and FSH by the gonads (the testes and ovaries)
27
Endo causes of secondary amenorrhoea?
Pituitary tumours, such as a prolactin-secreting prolactinoma
Pituitary failure due to trauma, radiotherapy, surgery or Sheehan syndrome
28
PCOS sx?
Oligomenorrhoea, hirstuism, weight gain, infertility, acne, hair loss
29
PCOS Ix?
Total testosterone: tends to be normal or moderately elevated in PCOS.
Sex hormone-binding globulin (SHBG): tends to be normal or low in patients with PCOS. Low levels are associated with an increase in free testosterone and more severe disease.
LH/FSH: LH is elevated in around 40% of patients with PCOS, resulting in an increased LH/FSH ratio. Of note, the LH/FSH ratio is not used in the diagnostic criteria. FSH is normally elevated in those affected by premature ovarian failure (another cause of oligo/amenorrhoea).
Prolactin: hyperprolactinaemia can cause oligomenorrhoea and should be excluded. Levels can be mildly elevated in PCOS.
Thyroid profile: thyroid dysfunction commonly results in menstrual irregularity and should be excluded.
USS
Rotterdam criteria
30
Thoracotomy scar?
A thoracotomy is the first step in thoracic surgeries including lobectomy or pneumonectomy for lung cancer or to gain thoracic access in major trauma.
31
Erb palsy,
paralysis of the arm caused by the injury to the upper group of the main nerves supplying it, specifically the upper trunk C5-C6 of the brachial plexus.
Waiter's tip arm
32
Poliomyositis?
Patient had one smaller, atrophied leg with power 1/5 in all regions of the leg and absent reflexes. Lower motor neurone, no signs on the other side. It was Polio,
33
Types of hip replacement?
total hip replacement.
partial hip replacement.
hip resurfacing.
34
Non-rebreather mask
asked how it worked (basically just wanted to talk about the valves)
The mask has a one-way valve system that prevents exhaled oxygen from mixing with the oxygen in the reservoir bag.
35
Central line kit
36
Incisional hernia
Hernia over incision site
37
Failed hernia operation: next steps?
I said you give the patient a choice but if you’re going to operate again laparoscopic would be better
38
Incarceration, strangulation, hernia, reducible
39
Peripheral signs of fibrosis?
Clubbing
40
Extra-pulmonary manefestations?
Erythrema nodosum,
41
Treatment of ILD?
Steroids acutely, supportive otherwise
42
Sepsis pneumonics?
qSOFA (quick Sepsis Related Failure Assessment): aims to identify patients at increased risk of poor outcomes outside the ITU environment. It consists of three components:
Mental status (score 1 if altered mental status)
Respiratory rate (score 1 if ≥ 22)
Systolic BP (score 1 if ≤ 100)
NEWS (National Early Warning Score): a score derived from a patients' observations (RR, O2 sats, HR, BP, GCS, Temperature) that alerts healthcare staff to early deterioration that warrants a review.
42
What is sepsis?
Sepsis is a dysregulated host response to infection leading to life-threatening organ dysfunction. sepsis is organ dysfunction secondary to an infection.
43
Sepsis six?
Fluids, antibiotics, oxygen
Urine output, lactate, blood cultures
Don't forget clotting screen
44
Hernia types?
Inguinal hernias are typically located above and medial to the pubic tubercle.
Femoral hernias are typically located below and lateral to the pubic tubercle.
45
Reducible hernia
A reducible hernia is one which can be flattened out with changes in position (e.g. lying supine) or the application of pressure.
46
Incarcerated hernia?
as by definition the hernia is trapped and immovable)
47
Strangulated hernia?
A strangulated hernia occurs when the hernia contents are ischemic due to a compromised blood supply.
48
Pleural effusion
Pleural effusion is the accumulation of fluid in between the parietal and visceral pleura, called the pleural cavity. It can occur by itself or can be the result of surrounding parenchymal disease like infection, malignancy, or inflammatory conditions
49
Pleural effusion findings?
Reduced tactile vocal fremitus, stony dullness on percussion, shifting dullness, and diminished or absent breath sounds.
50
4th nerve palsy muscle?
Superior oblique
51
6th nerve palsy muscle?
Lateral rectus
52
Leriche Syndrome
claudication, impotence, and absence of femoral pulses.
53
Hyperkalaemia treatment?
AE assessment
12-ECG monitoring
Alert seniors of patient
10 ml of 10% IV calcium gluconate over 10 minutes
10 units of a short-acting insulin (e.g. ACTRAPID) alongside dextrose (e.g. 50 ml 50% or 100 ml 20%) over 30 minutes.
You may also give nebulised salbutamol: 5mg nebulised
-Loop diuretics (e.g. furosemide)
-Potassium-binding resins (e.g. Patiromer or sodium zirconium cyclosilicate)
-Haemodialysis
Once initial management has been completed, the patient will require repeated 12-lead ECGs, and U&Es checked 4-6 hourly.
54
What to look for in pneumothorax?
Check for rib fracture if you say pneumothorax.
55
Indications for central line insertion?
Key indications include: parenteral nutrition, emergency venous access, fluid resuscitation, infusion of irritant drugs, vasopressors, inotropes.
Complications on insertion include: pneumothorax, sepsis, thrombosis and misplacement.
56
Colloids
Useful in cases of shock e.g. due to sepsis or hypovolaemia.
57
Hickman line indications?
long-term parenteral nutrition, long-term intravenous antibiotic therapy and chemotherapy.
58
Hickman line insertion?
This is a an example of a long term central venous line which is inserted in a similar way to a central line (usually subclavian).
The remnant of the line is tunnelled subcutaneously, which decreases the incidence of line infection.
59
IM femoral nail?
This is an intramedullary femoral nail which is used to internally fix femoral shaft fractures.
Interlocking screws are used to fix the nail. They are usually removed after 12 / 18 months.
60
LMAs?
Excellent choice of airway management, however they do not eliminate aspiration risk. Inflation of the device can also cause pressure lesions and nerve palsies.
61
iGels?
Has high esophageal sealing pressure and esophageal drainage tube, effective in preventing gastric aspiration.
The i-gel®, from Intersurgical, is ideal for use in emergency medicine and difficult airway management as it provides high seal pressures and reduced trauma, plus incorporates a gastric channel to give additional protection against aspiration.
62
Mannitol
osmotic diuretic which can be used to lower raised intracranial pressure or drive the urine output in a patient with obstructive jaundice to prevent hepato renal syndrome.
63
Nylon Suture
This an example of a synthetic non absorbable monofilament suture. This suture can be used to close skin wounds.
64
PICC line
A commonly used IV access option is the peripheral IV central catheter, or PICC line, which shares features of both central and peripheral venous access. PICC lines are suitable for long-term vascular access for blood sampling, chemotherapy administration, and infusion of hyperosmolar solutions such as those used for total parenteral nutrition. A PICC line is composed of a thin tube of biocompatible material and an attachment hub that is inserted percutaneously into peripheral veins and advanced into a large central vein.
65
Ryles NG tube
Primarily used for decompression (drip and suck) in bowel obstruction, but can also be used to insert drugs or contrast into the GI tract.
After explaining what you are about to do to the patient, you will require a NG tube which has been in the fridge as it is stiffer, some lubricant, a bladder syringe, a drainage bag and pH dipstick.
The correct position of the tube is checked by aspirating gastric contents and checking for acidity on pH dipstick, if this is unavailable then air can be inserted to the tube and the epigastrium auscultated for bubbling. Finally, an x-ray can be taken to identify the tube.
Once the tube is in the correct position a bag is attached and it is taped to the patients face.
66
Central venous cannulas?
inserted in the superior vena can usually via either the internal jugular or subclavian veins.
They can be single or triple lumen lines. They are primarily used to measure the central venous pressure. They can also be used for the insertion of drugs e.g. amiodarone, dopamine or chemotherapy.
66
Bowel obstruction management?
Make the patient nil-by-mouth (NBM) and insert a nasogastric tube to decompress the bowel (“suck”)
Start intravenous fluids and correct any electrolyte disturbances (“drip”)
Urinary catheter and fluid balance
Analgesia as required with suitable anti-emetics
66
Silastic catheters
Silastic catheters are made of silicone and are more appropriate than latex one for long term catheterization.
67
MI/arrhythmia: who to call?
Cardiology registrar
67
upper GI bleeding: who to call?
Endoscopist on call
68
Coarse crackles
aspiration, pulmonary oedema from chronic heart disease, chronic bronchitis, pneumonia
69
Emergency hypoglycaemia?
Glucose 20% 100ml over 15 minutes
70
Splenomegaly causes?
Non-massive:
Congestive: cirrhosis, splenic vein obstruction
Increased function: haemolytic anaemia, infection (HIV, glandular fever, malaria)
Massive:
CML, AML, myelofibrosis, polycythaemia, essential thrombocythaemia
71
Hepatomegaly?
Infiltration: Metastatic disease
Congestion: RHF, hepatic vein thrombosis
Infection: Viral hepatitis
Inflammation: NAFLD, alcoholic liver disease, sarcoid, amyloid
72
Hepatosplenomegaly?
Portal hypertension with chronic liver disease
Viral hepatitis, malaria
Sarcoid, amyloid, myeloproliferative
73
Renomegaly?
Polycystic kidney disease, simple cyst, renal cancer, infiltration, hydronephrosis
74
Subtotal colectomy?
Acute severe UC
75
Abdominoperineal resection of the rectum?
End colostomy (LIF)
76
Anterior resection?
Loop
Ileostomy RIF
77
Panproctolectomy stoma?
End colostomy
LIF
78
Subdural haematoma?
Torn bridging veins: elderly, alcoholics, trauma
Crescenteric shaped
79
SAH?
Aneurysmal, traumatic or idiopathic; thunderclap headache
CT head, LP
Patients are given nimodipine 60mg every 4 hours for 21 days
80
Hydrocephalus ct?
ventriculomegaly with compression of the brain parenchyma
81
Ring Enhancing Lesion
demyelinating disease R: radiation
M: metastasis
A: abscess
G: glioblastoma
I: infarct (subacute phase) or inflammatory (tuberculoma) C: contusion
A: AIDS-related CNS disease (e.g. toxoplasmosis, cryptococcosis)
L: lymphoma
82
Causes of end stage renal failure?
diabetic nephropathy, hypertensive nephropathy, polycystic kidney disease, autoimmune disease e.g. SLE, vasculitis, renovascular disease
83
Steal syndrome: fistula?
Signs of ischaemia (vascular insufficiency due to bypassing)
84
Examining fistulas?
Look: radiocephalic if at wrist, brachiocephalic if at elbow
o Infection: rash, warmth, swelling
o Venousstenosis:collateralveins
o Steal syndrome: signs of ischaemia (vascular insufficiency due to bypassing)
- Feel: should be soft, compressible and with a thrill that is not pulsatile
- Listen: soft machinery rumble normal (high pitched = stenosis)
85
Complications of fistulas?
- Aneurysm
- Infection
- Thrombosis
- Stenosis
- Steal syndrome (inadequate flow distal to fistula, leading to ischaemia)
- High output heart failure (rapid flow from arterial to venous system, increasing pre-load and
causing hypertrophy and failure)
86
Complications of renal transplant?
Complications:
- Immediate: haemorrhage, infection, damage to nearby structures, VTE
- Rejection:
o Hyperacute:withinhours–immediateremoval
o Acute:within6months;risingcreatinineandsterilepyuria–treatwithsteroids o Chronic:beyond6months
- Failure: stenosis, recurrence original disease
- Immunosuppression:
o Ischaemic heart disease
o Diabetes / cushing’s syndrome if steroids used
o Increased infection risk +/- atypical infections
o Increased cancer risk e.g. SqCC skin / EBV lymphoma
87
plexopathy
injury to the nerves in the lumbar and/or sacral plexus
Plexopathy is a disorder of the network of nerves in the brachial or lumbosacral plexus. Symptoms include pain, muscle weakness, and sensory deficits (numbness).[1]
88
Mx of CMT?
PT/OT, podiatrist, analgesia
89
Proximal myopathy causes?
Dystrophy e.g. Becker’s / Duchenne Endocrine e.g. Cushing’s / steroid use Neuromuscular e.g. MG / LEMS Inflammatory e.g. myositis / PMR Metabolic / mitochondrial
90
Cerebellar signs?
- Dysdiadochokinesia
- Ataxia (wide based gait, Romberg’s negative)
- Nystagmus
- Intention tremor
- Slurred speech
- Hypotonia
91
Causes of cerebellar disease?
Unilateral:
- Demyelination (MS)
- Posterior stroke / SOL
Bilateral:
- Demyelination (MS)
- Posterior stroke / SOL
- Metabolic (e.g. Wilson’s)
- Infective (e.g. HIV / toxo)
- Inflammatory (e.g. Miller Fischer GBS
92
Neurological histories
General
Fits/falls/LOC
Headache
Dizziness
Vision/hearing
Memory loss
Neck stiffness/photophobia
Motor
Weakness
Incontinence
Sensory
Pain
Numbness
Tingling
93
