Phase 2 Flashcards

Question

Subcategories of **Lung Cancer**

Answer 1

- Small Cell Lung Cancer (SCLC) - Non-Small Cell Lung Cancers (NSCLC): - Adenocarcinoma - Squamous Cell Carcinoma - Large Cell Carcinoma

Answer 2

Think- Bronchiole extras - Permanent enlargement of bronchioles - Symptoms typically involve chronic cough with mucus production - Can be due to infections - or poorly managed previous infections - or congenital causes such as CF - A high-resolution CT scan of the chest is the best investigation to diagnose bronchiectasis - It shows bronchial dilation and bronchial wall thickening (signet ring sign, tram-track sign) and lack of bronchial tapering

Answer 3

**High Anion Gap Metabolic Acidosis** KILU - KetoAcidosis - ie DKA - Intoxicants - ie methanol, ethylene glycol - Lactic Acidosis - Uraemia

Answer 4

**Normal Anion Gap Metabolic Acidosis** ABCD - *Addison's Disease* - Primary Adrenal Insufficiency - too little cortisol - *Bicarbonate Loss* - GI loss severe diarrhoea or laxative abuse - Renal loss - Renal Tubular Acidosis - *Chloride* - Hyperchlorideaemia - (Acetazolamide, IV NaCl, - *Drugs* - Acetazolamide (Diamox) - carbonic anhydrase inhibitor - inhibits resorption of bicarb by renal tubular cells

Answer 5

**Systemic Inflammatory Response Syndrome** - Inflammatory state affecting the whole body - Similar to sepsis, but caused by other factors such as large burns, etc

Answer 6

**Mild** - *Amoxicillin 1 g orally, 8-hourly*; - OR if mild nonsevere reaction to penicillin - *Cefuroxime 500 mg orally, 12-hourly* OR if not responding add: - *Doxycycline 100 mg orally, 12-hourly* 5-7 days depending on response in first 2-3 days **Moderate** 2 drug regime - *Benzylpenicillin 1.2 g intravenously, 6-hourly* - OR if sensitive to penicillins - *Ceftriaxone 1 g intravenously, daily* AND either (depending on Doxycycline tolerance) - *Doxycycline 100 mg orally, 12-hourly* - OR - *Clarithromycin 500 mg orally, 12-hourly* **Severe** 2 drug regime - *Ceftriaxone 2 g intravenously, daily;* for patients with septic shock or requiring intensive care support, use *ceftriaxone 1 g intravenously, 12-hourly*. OR - *Cefotaxime 2 g intravenously, 8-hourly*; for patients with septic shock or requiring intensive care support, use *cefotaxime 2 g intravenously, 6-hourly* PLUS - *Azithromycin 500 mg intravenously, daily;*

Answer 7

1 - Tone 2 - Power 3 - Reflexes 4 - Co-ordination 5 - Sensation Then, babinski, clonus etc if time left note - check tone first, as checking power may change tone level

Answer 8

An osmole is: - Avogadro’s number of particles in an ideal solution (6.022 × 10²³) - Units of osmolality are *mOsm/kg of solute* Calculated osmolarity = **(2 x [Na+]) + [glucose] + [urea])** **Osmolar gap = Osmolality (measured) – Osmolarity (calculated)** Normal Osmolar Gap = **< 10** A **high osmolar gap indicates presence of an abnormal solute** present in significant amounts Causes include: mannitol methanol ethylene glycol sorbitol polyethylene glycol (IV lorazepam) propylene glycol (IV lorazepam, diazepam and phenytoin)

Answer 9

**Duke Criteria** Includes: **Pathological criteria of** (if either of these is positive, diagnosis is definite): - *Microorganisms in a vegetation* -(cultute or histologic exam of veg, veg that has embolzed) - *Pathologic lesions* - (Vegetation or intracardiac abscess confirmed by histologic exam showing active endocarditis) **Major clinical criteria** (both positve, Dx is definite) - *Blood cultures +ve for endocarditis* - Typical microorgs consistent with IE from 2 separate blood cultures, microorgs consistent with IE from persistently +ve blood cultures, single +ve of Coxiella burnetii or antiphase I IgG antibody titer >1:800 - *Evidence of endocardial involvement* - Echocardiogram +ve IE, abscess, new partial dehiscience of prosthetic valve, new valvular regurg - NOTE - worsening or changing of pre-existing murmur NOT sufficient **Minor Clinical Criteria** (If all +ve, Dx is definite) - *Predisposing heart condition or injection drug use* - *Fever* - *Vascular phenomena* (major arterial emboli, septic pulmonary infarcts, mycotic aneurys,, intracranial haemorrhage, conjunctival haemorrhages, Janeway lesions - *Immunologic phenomena* (Glomerulonephritis, Osler's nodes, Roth's Spots, rheumatoid factor) - *Microbiological evidence* (+ve blood culture but does not meet major criterion above or serological evidence of active infection with organism consistent with IE)

Answer 10

**Wernicke encephalopathy** is associated with **chronic alcohol use.** If not identified and treated early, it **could lead to permanent brain damage** characterized by an **amnestic syndrome known as Korsakoff syndrome**. Wernicke Encephalopathy should be suspected if any of the following signs are present: - *Delirium* (approximately 80% of patients) - *Ataxia* (approximately 20 to 25% of patients) - *Eye signs* (nystagmus or ophthalmoplegia) (approximately 30% of patients). **TREATMENT is high level Thiamine (B1 - water soluble) supplementation** - Daily 300mg IV or IM - 3 days Folowed by - 100mg daily IV or IM - 1-2 weeks OR 100mg TDS oral 1-2 weeks Then - 100mg daily oral maintenence therapy

Answer 11

**Dihydropyridines** - Predominantly **peripheral** vasodilatory actions (Think **D**ihydros work **D**istally) - Amlodipine - Felodipine - Nifedipine - Lecarnidipine **Non-Dihydropyridines** - Significant **SA & AV node** depressant effects, as well as possible myocardial depressant effects, lesser amounts of peripheral vasodilation (Think **N**on-dihydros work on **N**odes) - Verapamil - Diltiazem

Answer 12

Any 1 of: - SBP <90 mmHg - Lactate >= 4mmol/L - Base excess < -5.0

Answer 13

Two or more Yellow Zone obs: - RR=<10/min or RR>=25/min - SpO2 <95% - SBP <100mmHg - HR =< 50 bpm or HR>= 120 bpm - Altered LOC or new onset confusion - Temp < 35.5c or Temp > 38.5c

Answer 14

**CUSHINGOID** - **C**ataracts - **U**lcers - gastric, dose dependent short term exposure - **S**kin: striae, thinning, bruising - **H**ypertension/ hyperglycemia / hirsutism (excessive abnormal dark coarse hair - **I**nfections - **N**ecrosis, avascular necrosis of the femoral head - **G**lycosuria - **O**steoporosis, obesity (central) - **I**mmunosuppression - **D**iabetes

Answer 15

- Unfractionated heparin (UFH) - **Parenteral anticoagulant** - Indirectly via antithrombin III - **inactivates thrombin (factor IIa), factor Xa** and to a lesser extent factors XIIa, XIa and IXa - Monitor Via **activated partial thromboplastin time (APTT**). - Before starting & every 4 to 6 hours. - **Protamine sulfate** reverses the effect of UFH - Can manage bleeding or an UFH overdose.

Answer 16

**PIRATES** - **P**ulmonary causes (OSA, PE, COPD, pneumonia) - **I**schemia/Infarction/CAD - **R**heumatic heart disease and Mitral Regurgitation (abnormal heart valve) - **A**lcohol / Anemia (high output failure) - **T**hyrotoxicosis / Toxins, especially stimulant medications, caffeine, tobacco or alcohol - **E**lectrolytes/Endocarditis - **S**epsis (infection) / Sick sinus syndrome.

Answer 17

ARRAPPQST * Assess quality/ Artefact * Rate * Rhythm * Axis * P-waves * PR interval - 120-200ms (3-5 mm normal)- start P to start QRS - longer is type 1 heart block * P:QRS relationship - eg 1:1 * QRS - width (<3mm normal) * QT interval - 350-450 ms men and 360-460 ms for women - Start Q to End T * ST segment - elevated, depressed? * T Wave

Answer 18

NSTEMI Typically present as: - Male patients typically present with **chest pressure/discomfort lasting at least several minutes,** at times accompanied by **sweating, dyspnoea, nausea, and/or anxiety.** - Women present more commonly with **middle/upper back pain or dyspnoea** and similar associated symptoms. - Early risk stratification and treatment with **anti-ischaemic (beta-blockers, nitrates)**, **anticoagulant (heparin),** and **dual antiplatelet agents (aspirin plus a P2Y12 receptor inhibitor - eg clopidogrel, prasugrel)** is needed.

Answer 19

- ECG - Priority! even before history! - High sensitivity troponin - CXR - FBC - UEC - LFT - BGL - CRP others to consider: - Echocardiography - Invasive Coronary Angiography (ICA)

Answer 20

- Chest pain - Dyspnoea - Pallor - periph vasoconstriction due to high symp output - Diaphoresis - again, high symp output - Cardiac risk factors Also: - Nausea/vomiting - Dizziness or light headedness - Distress and anxiety - Palpitations Don's miss atypical presentations! Women, older patients and diabetics: - Atypical chest pain - burning throbbing, tight, or trapped wind feeling - May describe indigestion rather than chest pain Pain can be: epigastric, back (interscapular), neck or jaw, arm - typically left sided

Answer 21

NAC is a glutathione precursor

Answer 22

1) Is the cancer suitable for a screening program? 2) Are there significant aetiological/ causative factors? 3) How does it present? – Symptoms, screening test, found incidentally etc. 4) How is it diagnosed? Further investigations? 5) Pathology and Staging - how do these influence prognosis and treatment? 6) What treatment modalities are appropriate for each stage. 7) What are the principles of palliative management for this cancer ie does this involve palliative radiotherapy, symptom management, pain and nausea control, treatment of constipation etc.

Answer 23

**Macrolide Indication** Broad Spectrum! - Effective against: - Both *gram Positive and Negative Cocci* - *Legionella, Mycoplasma and Chlamydia* species **MOA** - Bind 50s ribosomal subunit thus Inhibiting protein synthesis **Side effects** - QT prolongation - Inhibitors of cytochrome P450 **Examples** - "MYCINS" - - Azithromycin - Clarithromycin - Erythromycin - Roxithromycin

Answer 24

AEIOU - Acidosis - Electrolyte derangement - K+++++ - Intoxicants - Lithium, Digoxin, Ethylene Glycol, Methanol - Overload - fluid - Uraemia - Pericarditis, Encephalopathy

Answer 25

- Change in mucus - quantity, quality - Wheeze on ausc - Increased expiratory phase of breathing - Systemc red flag symptoms - Fever, weight loss, sweats, etc - Infective contacts

Answer 26

**Common** - Peptic ulcer disease (PUD) - Oesophageal Varices - Oesophagitis - Mallory-Weiss tear **Uncommon** - Boerhaave Syndrome (spontaneous oesophageal perforation) - Gastric Varices - Upper GI Tumors - AortoEnteric Fistulae (AEF) - Atriovenous Malformations (AVMs) - Dieulafoy's Lesions - Developmental vascular malformation - enlarges submucosal vessel - Coagulopathy

Answer 27

- **B**enefits - **R**isks - **A**lternatives - **I**nformation - details of the procedure - **N**atural Hx (what if we do nothing)

Answer 28

Clinical Etiological Anatomical Pathophysiological

Answer 29

**BBINDS** - Blue book - Birth Hx - Immunisations - Nutrition - Developmental Concerns - Social Hx

Answer 30

MOSCC - Menstrual Hx - Obstetric Hx - Sexual Hx - Contraception - Cervical screen - (pap smear)

Answer 31

AFP bHCG LDH Lung, Brain - Rapid haematogenous spread

Answer 32

< 100 pg/mL - Unlikely cardiac involvement > 500 pg/mL - Generally indicative of heart failure

Answer 33

- Pseudoseizures / non-epileptic seizures - Hypoxia - Hypoglycaemia - Syncope - Hyperventilation - ie hypocapnoea - Rigors - Encephalopathy

Answer 34

ENDCHHHEIM - **E**pilepsy - 1st pres, med compliance issues - **N**eoplasia - 1ry - glioma, meningioma, 2ry - breast, lung, melanoma - **D**rugs - OD, withdrawal, recreational - **C**VA - **H**ead trauma - **H**yperthermia - **H**ypoxia - **E**lectrolyte imbalance - **I**nfeciton in CNS - meningitis, encephalatis - **M**etabolic Disturbance - hypoglycaemia, hepatic encephalopathy

Answer 35

- **Airway** - monitoring, maintenence w csp protection - **Breathing** - Y/N?, RR, effort of respiration Quality - shallow, gasping, accessory muscles, indrawing, tracheal deviation, wheeze/stridor - **Circulation** - HR, BP, Fluid balance, peripheral and sternal CRT, JVP, ECG, cannula insertion - **Disability** - GCS, Pupils, neuro exam, glucose and ketones - **Exposure/Everything else** - expose patient to inspect!, hyper/hypothermia, rashes, purpura, erythema, wounds/infection, cathethers - **Fluid Status** - Skin turgor, mucous membranes, thirst, JVP

Answer 36

**P**ain **P**allor **P**aresthesia **P**aralysis **P**ulselessness **P**oikilothermia - inability to regulate body temp - ie generally very cold

Answer 37

**CRITICAL-Q** **C**alibration -Rate of x-axis **R**ate, Rhythm - P waves are key! **I**mplant - Spikes **T**ransition - R wave transition in lead V3 or V4 **I**schaemia or infarct - ST segment depression or elevation **C**onduction - - QRS complex < 120ms (3 small squares) - broad are ventricular in origin or due to bundle branch block, hyperkalaemia or sodium-channel blockade - PQ interval <0.2s (1 large square) **A**mplitude - **L**eft ventricular hypertrophy - R wave **Q** wave - check territories

Answer 38

- Tachypnoea - RR > 22/min - Tachycardia - HR > 100 bpm - Hypotension - SBP < 90mmHg - Acute-onset confusion - SpO2< 92% on RA (or lower than baseline in patients with comorbid lung disease) - Multilobar involvement on chest X-ray - Blood Lactate > 2 mmol/L

Answer 39

**Class I** - The patient is generally asymptomatic, and vital signs are within normal limits **Class II** - C/O nausea and fatigue. S&S pallor and cooling of the extremities Vital signs will start to deviate from normal **Class III** - S&S: delayed capillary refill (> two seconds) and changes in mental status. **Class IV** - Absent peripheral pulses, Anuric, Shock, Cellular aerobic metabolism, Production of lactic acid, Metabolic acidosis

Answer 40

Airway - maintain - own, or etc Breathing Circulation Disability Environment or exposure

Answer 41

* Polyps * Endometrial hyperplasia * Leiomyoma - fibroids * Adenomyosis * Adenocarcinoma * Infection * Sarcoma - Rare * Uterine arteriovenous malformation - Rare * Oestrogen secreting ovarian tumours - Rare

Answer 42

- Diabetes - Thyroid disease - Coagulation Disorders - up to 11% adults, 19% adolesc

Answer 43

**Menorrhagia** - Excessive or prolonged menstrual bleeding occurring at regular intervals. - Total > 80mL or >7 days - Studies suggest that less than 40% of women complaining of menorrhagia fulfilled the criteria of 80ml blood loss on measurement - A clinician must rely on indirect indicators: – Passage of blood clots – Iron deficiency anaemia **Medical Management** - Oral Iron - Combined oral contraceptive pill (OCP) - Progestogens - Non steroid anti-inflammatory drugs (NSAIDs) -- - - Mefenamic Acid (Ponstan) - Anti fibrinolytic drugs - *Tranexamic Acid* - Progesterone releasing IUCD (Mirena) **Surgical Management** - Resection of significant intra-cavity lesions. - Endometrial ablation. - Myomectomy. - Uterine artery embolisation. - Hysterectomy. NB: curettage is not therapeutic except in pregnancy (incomplete or induced abortion).

Answer 44

**Risk Factors** - Early Menarche and late menopause - very oestrogen dependent - Genetic - FHx - Obesity - again, very oestrogen dependent - High intake red meat and ETOH - Low Vit D levels **Symptoms** - Heavy or prolonged menstrual bleeding - menorrhagia due to increased surface area - Bulk related symptoms - such as pelvic pressure or pain - Reproductive dysfunction - ie inferetility or obstetric complications

Answer 45

- **1 minute and 5 minutes after birth for all infants** - **5-minute intervals thereafter until 20 minutes for infants < 7 scored**

Answer 46

Cervix Foetus Placenta 2 hrs - 1st Stage: From the onset of rhythmic contractions till full dilatation of the cervix - 2nd Stage: From full dilation of the cervix to complete expulsion of fetus - 3rd Stage: From full expulsion of the baby till full expulsion of the placenta. - 4th Stage: The immediate postpartum period (first 2 hours after birth)

Answer 47

- **Passage**: the birth canal - parity, fetopelvic diameters - **Passenge**r: the fetus - presentation (breech, transverse), position, size - **Power**: force/ frequency uterine contractions & maternal effort in 2nd Stage - **Psychology** of the mother - anxiety, sedation, motivation etc. - **Placenta** - site of implantation - covering cervical os? - **Position of mother**: Maintaining an upright position in early labour aids descent of fetus

Answer 48

**LATENT PHASE** * Onset of regular rhythmic contractions - Mild and short in duration (20-30secs) * Little to no descent of presenting part * Shortening of the cervix (effacement) to 0.5 cm * Cervical dilatation from 0 to 3-4 cm * Duration: – primigravida: ~6-8 hrs; should not exceed 20 hrs – multigravida: ~4.5 hrs: should not exceed 14 hr **ACTIVE PHASE** * Uterine contractions: ↑ intensity, frequency & duration (40-60 secs) * Complete cervical effacement * Rapid cervical dilatation to 7-8cm * Progressive descent of presenting part * ↑ anxiety * ↓ ability to cope * Duration: – primigravida ~4.5 hrs – multigravida ~2.5 hrs **TRANSITIONAL PHASE** * Contractions: ↑ frequency, force and intensity & duration * ↑ fetal descent * Cervical dilatation from 7-8 to 10cm * Rupture of membranes (may occur anytime in labour) * Duration: - primigravida: ~3.5 hrs - multigravida: variable

Answer 49

Chart on which salient features of labour are entered in a graphic form for early identification of deviations from normal

Answer 50

**NON-PHARMACOLOGICAL** * Movement * Massage * Hydrotherapy: shower or bath * Imagery/visualization * Hypnosis * Transcutaneous electrical nerve stimulation (TENS) * Aromatherapy * Homeopathy * Music therapy **PHARMACOLOGICAL** * Inhalational : Nitrous oxide * Parental: Pethidine or Morphine * Regional: Epidural or Spinal

Answer 51

**2ND STAGE** **Duration** – primigravida:~ 2hrs – multigravida: ~ 30 mins **Signs & symptoms** – Expulsive uterine action – ‘Show’: vaginal loss of blood stained mucous – Dilatation & gaping of anus – Urge to push – Presenting part may be visible – No cervix felt on vaginal examination (not always required for confirmation)

Answer 52

**Tone** ~70% Uterine Atony - inability of uterus to contract, leading to continuous bleeding **Trauma** ~20% Injury to the birth canal - uterus, cervix, vagina, perineum - can occur even with proper monitoring Can be - *laceration, haematoma, inversion, rupture* **Tissue** ~ 10% Retention of tissue from placenta or fetus (>30 mins post birth) Placental abnormalities such as placenta accreta and percreta **Thrombin** ~1% Failure of clotting such as coagulopathies - Pre existing - von Willebrand's - Obstetric related - HELLP syndrome (Hemolysis, Elevated Liver enzymes and Low Platelets), abruption, sepsis, drugs (aspirin)

Answer 53

**Major Causes** - Placental Abruption (30%) - Placenta Praevia (20%) **Other causes include:** - Heavy bloody show - Cervical carcinoma - Polyps - Cervical or vaginal infection - Trauma - Varicosities - Invasive placenta - Vasa Praevia Note - 6% of all pregnancies experience some type of vaginal bleeding in the 3rd trimester

Answer 54

* Marginal – lies within 2-3cm of internal os * Partial – Implants near and partially covers the os * Total – completely covers the os

Answer 55

Incidence - 1:200 pregnancies - Premature separation, partial or total of a normal implanted placenta from the decidual lining of the uterus after 20 weeks gestation - Can be: -Marginal/Apparent - Central/Concealed - Mixed/Combined Aetiology - Actual cause unknown, however strong association with HTN - both chronic and PIH (preg induced htn) - 1 x Prev abruption - 10% inc risk, 2 =25% inc risk Other causes: Abdo trauma - ie MVA Rapid uterine decompression Cocaine Smoking Uterine abnormalities - eg bicornate uterus, leiomyoma Prior cesarean

Answer 56

- Pre-eclampsia - Hypertension - Preterm rupture of membranes - Cigarette use - Cocaine use - Thrombophilias - Multifoetal gestation - Previous abruption - Uterine leiomyoma - Multiparity - Previous caesarean section delivery - Advancing age

Answer 57

**Major** Abruptio placenta Placenta praevia **Minor** Heavy blood show Ca cervix polyps trauma varicosities vasa praevia

Answer 58

Grade 1- minor-placenta in the lower uterine segment Grade 2- reached cervix Grade 3- covers the cervix Grade 4- completely over the cervix

Answer 59

- **Syntocinon** 10 units IMI, *or* 5 units IVI *or* 40 units in 1L Hartmann’s/Saline infusion - Rash, itching or hives, swelling of face, lips tongue, throat (possible angiooedema), wheezing, nausea - *High doses can cause H2O intoxication due to antidiuretic effect - Oxytocin mimics ADH* - **Ergometrine** IV 0.25mg *or* IM 0.5mg - Gangrene, hypertension, drowsiness or confusion, nausea, vomiting. - May entrap placenta if 3rd stage not complete - **Misoprostil** 800 – 1000mcg (tab per rectum) - Diarrhoea, abdo pain, hyperthermia, shivering/chills, headache, vomiting - **Prostaglandin F2 alpha** - Intramyometrium up to 3mg - Nausea, vomiting, diarrhoea, headache, flushing, pyrexia, uterine rupture, cardiac arrest

Answer 60

* Male factor — 23 percent * Ovulatory dysfunction — 18 percent * Tubal damage — 14 percent * Endometriosis — 9 percent * Coital problems — 5 percent * Cervical factor — 3 percent * Unexplained — 28 percent

Answer 61

* Seminiferous Tubule Dysfunction * 60 to 80 percent including microdeletions of the Y chromosome. * Post-testicular defects (disorders of sperm transport) * 10 to 20 percent. * Primary hypogonadism * 10 to 15 percent. * Hypothalamic pituitary disease (secondary hypogonadism) * 1 to 2 percent.

Answer 62

* Ovulatory disorders (25 percent) * Endometriosis (15 percent) * Pelvic adhesions (12 percent) * Tubal blockage (11 percent) * Other tubal abnormalities (11 percent) * Hyperprolactinemia (7 percent)

Answer 63

* **1st degree**: Injury to perineal skin only. * **2nd degree**: Injury to perineum involving perineal muscles but not involving the anal sphincter. * **3rd degree**: Injury to perineum involving the anal sphincter complex: – 3a: Less than 50% of EAS thickness torn. – 3b: More than 50% of EAS thickness torn. – 3c: Both EAS and IAS torn. * **4th degree**: Injury to perineum involving the anal sphincter complex (EAS and IAS) and anal mucosa.

Answer 64

Note: Overall risk of anal sphincter injury about 1% * Birth weight over 4 kg (up to 2%) * Persistent occipitoposterior position (up to 3%) * Nulliparity (up to 4%) * Induction of labour (up to 2%) * Epidural analgesia (up to 2%) * Second stage longer than 1 hour (up to 4%) * Shoulder dystocia (up to 4%) * Midline episiotomy (up to 3%) * Forceps delivery (up to 7%)

Answer 65

* Lose does (250iu) for 1st trimester indications * Antenatal **prophylaxis (625iu) at 28 and 34 weeks** for Rh Neg nulliparous women with no performed antibodies 1st trimester indications: - Chorionic Villus Sampling; - Miscarriage; - Abortion (medical after 10 weeks of gestation or surgical); and - Ectopic pregnancy - Molar pregnancy 2nd and 3rd Trimester Indications - Obstetric haemorrhage; - Amniocentesis or other invasive fetal intervention; - External cephalic version of a breech presentation, whether successful or not - Abdominal trauma, or any other suspected intra-uterine bleeding or sensitising event. - Abortion

Answer 66

* Iron deficiency anaemia * Delay or failure of lactation due to pituitary effects * Pituitary infarction * Exposure to blood products * Haemorrhagic shock & hypotension * Coagulopathy * Acute tubular necrosis * Coma * The need for further surgical intervention * Prolonged hospital stay

Answer 67

- Aspirin 150mg (1/2 a normal tablet) nightly from 10-12 weeks until 36 weeks - Calcium > 1000mg per day after 20 weeks - if deficient 25-50% reduction in early onset disease 14% reduction in neonatal death

Answer 68

- Pregnancy associated plasma protein - **PAPP-A** - Free ß-human chorionic gonadotropin - **Free ß -hCG** - Low PAPP-A - assoc with: - Intra-Uterine Growth Restriction (IUGR) - Small for Gestation Age (SGA) - Miscarriage - Levels expressed as Multiples of Median (MoM) Other screening test is **Nuchal Translucency Scan** - >3.0mm associated with Tri 13, 18, 21 and other anomalities - cardiac, skeletal Also look for nasal bone development Abnormal results are taken into account with maternal age as a pre/post test probability

Answer 69

A complication of pregnancy - HELLP stands for: ***H**aemolysis **E**levated **L**iver enzymes and **L**ow **P**latelet count* Usually begins in 3rd trimester or shortly postpartum Symptoms include - fatigue, headache, nausea, upper R quadrant P, epistaxis, seizures. Complications include -- Disseminated Intravascular Coagulation (DIC), placental abruption, renal failure Occurs in assoc w pre-eclampsia or eclampsia, and risk increases w mothers >25y Dx involves blood tests showing signs of haemolysis, and must include all of: - Lactate Dehydrogenase > 600 units/L - Aspartate transaminase > 70 units/L - Platelets < 100 x 10^9 / L Rx involves delivery ASAP

Answer 70

Infection Infarction Insulin - not enough Ingestion of bulk glucose Iatrogenic Infant/Insemination - ie, you’re pregnant

Answer 71

**Expectant management** - Can wait for the body to pass the products of conception on its own - Can take quite a long time (days-weeks) - Need to have follow up to track bHCG levels or an ultrasound to ensure all products have passed - Risks = pelvic infection, if fails needs medical or surgical management, associated with bleeding/cramping, can be psychologically difficult for some women **Medical management** - Uses a drug called misoprostol – placed in the vagina and it causes the uterus to contract to help remove the products. Is quicker than expectant management - Need to have follow up to track bHCG levels or an ultrasound to ensure all products have passed - Risks – can cause side effects (bleeding, pain/cramps, fever/chills, diarrhoea, vomiting), if fails may need surgical management **Surgical management** - Suction curettage (<13 weeks gestation) or dilation and evacuation (>14 weeks) - Surgery done under general anaesthetic – the surgeons will dilate the cervix and insert a tube into the uterus which will remove the products of pregnancy - Most effective method, one surgery does not have impact on fertility in future, day procedure so can go home same day - Risks – risks of surgery (anaesthesia, bleeding, infection, damage to surrounding structures)

Answer 72

**Colour** Pallor (including parent/carer report) Mottling Cyanosis Jaundice **Activity** Lethargy or decreased activity Poor Feeding Not responding normally to social cues Does not wake or only with prolonged stimulation, or if roused, does not stay awake Weak, high-pitched or continuous cry **Respiratory** Grunting Tachypnoea Increased work of breathing Hypoxia **Circulation and Hydration** Poor feeding Murmur, weak peripheral pulses Persistent tachycardia Central CRT ≥3 seconds Dry mucous membranes, reduced skin turgor, sunken fontanelle Reduced urine output / Hypotension **Neurological** Bulging fontanelle Neck stiffness Tone Focal neurological signs Focal, complex or prolonged seizures **Other** Non-blanching rash Fever for ≥5 days Swelling of a limb or joint Not using an extremity Distended abdomen

Answer 73

**Investigations** For unwell neonates and young infants: - Perform FBE, CRP, blood culture, urine (SPA), BSL, LP - Consider blood gases - Consider chest X-Ray **Treatment** All unwell neonates and young infants should receive: - early administration of empiric antibiotics (IV/IM/IO) - prompt management of sepsis - consider aciclovir - adequate analgesia and sedation Careful fluid management: - fluid resuscitation as required - maintenance fluids (account for oral intake) Treatment targeted to underlying suspected cause - Consider a nasogastric tube on free drainage if bowel obstruction is suspected - Early referral to the paediatric, surgical and/or sub-specialist teams as indicated - *In neonates with suspected duct dependent congenital cardiac condition, consider IV prostaglandin.* **Consider Consultation with local paediatric team when** Assessing any unwell neonate or young infant **Consider transfer when** - Child requiring care beyond the comfort level of the hospital - For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services **Consider discharge when** - The neonate/infant is clinically well and there is low likelihood of infection based on examination and negative infective indices - In this setting, and if cultures are negative at 48 hours, antibiotics can be ceased Note: a clinically well child (≥3 months) with normal investigations can be discharged with follow up in 12-24 hours

Answer 74

- Kawasaki disease (KD) is a **clinical diagnosis** that requires prompt recognition and management - Consider incomplete KD where there is prolonged fever and no alternative cause found - **Infants and adolescents** may present with incomplete KD and are at particularly high risk of **developing coronary artery aneurysms** - Early treatment with intravenous immunoglobulin (IVIg) has been shown to reduce morbidity and mortality KD is the second most common vasculitis in childhood after Henoch Schönlein purpura, and is the most common cause of acquired heart disease in children in high-income countries. **Lack of appropriate treatment leads to coronary artery aneurysms (CAA) in approximately 25% of cases.** Worldwide distribution, although more common in Asian children **Approximately 75% of cases occur under 5 years of age** **Less common in children < 6 months and > 5 years; however these children are more likely to develop CAA** Can present without all diagnostic criteria (see flowchart below) which can present a significant diagnostic challenge

Answer 75

Kawasaki disease: Diagnostic criteria **Fever persisting for 5 days, PLUS 4 of the 5 following criteria: CROEL** - A diagnosis earlier than 5 days can be made with a typical presentation in consultation with an experienced clinician - KD can be diagnosed with less than four of the following features if coronary artery abnormalities are present **Conjunctival Injection** Billateral, non exudative, painless. Often with limbic spating - ie zone around iris is clear **Rash** Erythematous polymorphous rash occurs in first few days, involving trunk and extremeties Variable presentations, most commonly maculopapular, erythema multiforme-like or scarlantinform Bullous, besicular or petechial rashes are not typical in KD **Oral changes** Strawberry tongue Erythema, dryness, cracking and bleeding of lips Diffuse oropharyngeal erythema Exudates are not typical of KD **Extremety changes** Hyperaemia and painful oedema of hands and feet Progresses to **desquamation** from the second week of illness **Lymphadenopathy** - Cervical, most commonly unilateral, tender - At least 1 node >1.5cm - Less common feature and seen in older children **Common findings in addition to the diagnostic criteria include:** - Neurological: irritability, aseptic meningitis - GIT symptoms: abdominal pain, vomiting, diarrhoea, gallbladder hydrops - Arthralgia / arthritis - Dysuria - Inflammation at recent (within 6 months) BCG vaccination site KD is a medium vessel vasculopathy; any organ system can be affected

Answer 76

Caused by superficial blood vessels contracting and dilating at the same time Often benign, reasons for reaction are not fully understood Can happen when skin cools Often decreases as children age

Answer 77

VINDICATE or Head to Tail! think of things which can go wrong at each place

Answer 78

PPBRRAIN - Pneumothorax - Patent Ductus Arterosis - Bronchopulmonary Dysplasia - Retinopathy of prematurity - Respiratory Distress Syndrome - Apnoea / Bradycardia of the newborn - Intra Ventricular Haemorrhage - Graded 1-4 - Necrotising Enterocolitis Also: - Sepsis - Jaundice

Answer 79

(Oxygen, Volume, Potassium, Temp) Hypoxia Hypovolaemia Hypokalaemia/hyperkalaemia Hypothermia/hyperthermia (Pneumo, Tamp, Thromb, Tox) Tension Pneumothorax Tamponade Thrombosis Toxins

Answer 80

Think - do less invasive things first, and try to auscultate heart sounds early if bub is not crying so that you can hear. This is a rough ideal order, but obviously you have to work with the bub First lot of things are only really possible to do well when bub isn't crying, and hence here they gradually get more invasive. Gradually undress bub, keep them warm and covered for as long as possible! **General appearance - tone etc** 1 - Auscultate Heart sounds - 3 areas - pulmonary, mitral, apex 2 - Auscultate lung sounds anteriorly 3 - Pupillary light reflex - abnormal can be black or white 4 - Femoral Pulses - check for patent urethra - ie has bub urinated 5 - Palpate abdomen - spleen, liver, kidney - any distentions. -Check testes in boys **These onwards, not as important for bub to be relaxed** 6 - Hands - fingers, palmar creases, grasp reflex, upper limb tone 7 - Legs and feet - toes, foot reflex 8 - Face - eyes, nose, mouth 9 - Head - Cranial sutures not lapping, Fontanelles, Bruising or lacerations from instrumental delivery 10 - Mouth - Cleft palate, Tongue tie, gum abnormalities 11 - Chest - nipples, no lumps 12 - Back - Spinous processes, no spinal lesions, patent anus, sacral dimple 13 - Walking reflex 14 - Moro's test - Startle reflex 15 - Hip dysplasia check - 1st - Barlow's - Posterior pressure in 90 degrees flexion - Test pos is dislocation - 2nd - Ortolani's - 1 leg at a time - Flex to 90, gradual abduct with simultaneous medially directed force over the greater trochanter - should relocate fem head in acetab if positive

Answer 81

Formula based on assumption of: - 100ml/kg/day fluid intake - 3mL/kg/hr urine output, - Normal stool output Thus, it must be tailored to individual situation - Lower - bronchiolitis, meningitis - cases with higher ADH secretion Higher - Diarrhoea ++ ~ 400mL/kg/day

Answer 82

Resuscitation - 0.9% NaCl Replacement - 0.9% NaCl + 5% glucose +/- KCl Maintenance - 0.9% NaCl + 5% glucose +/- KCl

Answer 83

38 c FBC (FBE) BSL Lactate CRP - as baseline Blood Culture Urine MCS +- LP +- CXR

Answer 84

Ie - Premature babies do not have fully developed alveoli, and thus often need input for respiratory support

Answer 85

RISK - female sex - breech delivery - intrauterine packaging deformities e.g. plagiocephaly, foot deformities or torticollis - family history of DDH PHYS EX - Instability with Barlow’s or Ortolani’s test - limitation of hip abduction - deep uneven gluteal crease - leg length discrepancy - waddling gait after walking age

Answer 86

**Testicular Cancer** Most common cancer in young men and is one of the most curable of all cancers. More than 95 percent of all men diagnosed with testicular cancer survive their disease. **O/E** - Typically painless swelling - Males 20-35 - Negative translumination - Dull pain or discomfort in the lower abdomen or scrotum - Metastasis to lungs or bones → SOB, cough, chest pain, bone pain - Gynaecomastia - hormonally active leydig cell tumor - Precocious puberty in preadolescent males **Risk Factors** Non-modifiable - Male sex - 20-35 - Family or personal Hx of testicular cancer - Cryptorchidism - (one or both testes fail to descend from abdomen) - Genetics – Klinefelter + Down syndrome Modifiable - Carcinogen exposure **Tumor markers include:** - Alpha-fetoprotein - AFP - Beta- Human chorionic gonadotrophin - b-HCG - Lactate Dehydrogenase - LDH **Treatment includes** - Radical inguinal orchidectomy - removal testicle and spermatic cord via inguinal canal to reduce risk of mets - Chemotherapy - Radiotherapy - Sperm banking is strongly encouraged

Answer 87

* Blood loss >=500ml during and after childbirth. * Severe PPH is defined as a blood loss of >=1000ml OR * Any amount of blood loss postpartum that causes haemodynamic compromise. NB. Blood may collect in an atonic uterus with little evidence of excessive loss but with a fundal height increase. **Primary - 0-24hr after birth** **Secondary - 24hr - 12 weeks postpartum**

Answer 88

**Antepartum** * Previous PPH/retained placenta * Grand multipara * Placenta praevia * Anaemia * Antepartum haemorrhage (praevia) * Over distension of the uterus as in; multiple pregnancy, polyhydramnios, macrosomia * Fibroids * Preeclampsia * Chorioamnionitis **Intrapartum and Postpartum** * Prolonged or Precipitate labour * Mismanaged 3rd stage of labour * Labour augmented with Syntocinon * Assisted birth – vacuum/forceps * Retained placenta * Distended bladder * Caesarean section * Lower genital tract trauma (episiotomy) * Abruption * Placenta praevia * Inversion of uterus or uterine rupture

Answer 89

Female Sexual activity Diabetes Mellitus Incontenence Recent travel - prevalence of resistant or other organisms Men - - Lack of circumcision - Functional/anatomical abnormality of urinary tract - ie obstruction

Answer 90

- Bimanual compression - Insertion of Bakri Balloon - Tamponage Then: Surgical options - Uterine compression sutures - Ligate uterine or hypogastric arteries - Peripartum hysterectomy --- LAST RESORT Radiological intervention - Uterine artery embolization

Answer 91

- Testicular cancer - Inguinal hernia - Femoral hernia - Testicular torsion - Hydrocoele - Varicocoele - Spermatocoele - Epididymitis - commonly from STIs such as chlamydia - Epididimo-Orchitis - Inflam involves teste and epididymis

Answer 92

- Chronic HTN - Pre-Eclampsia previous pregnancy - FHx Pre- Eclampsia - 1st pregnancy - Mum >40 - Kidney disease - Diabetes - Autoimmune disease - Multiple pregnancy - BMI >= 35 - IVF

Answer 93

Calcium channel blockers: Pregabalin (Lyrica) Gabapentin (Neurontin) Noradrenalline can play a part, thus SNRIs - (Duloxetine, Venlafaxine) TCAs - (Amitryptaline, Nortryptaline)

Answer 94

**Aspirin 300 mg orally**, chewed or dissolved before swallowing, for the first dose, then 100 to 150 mg daily PLUS ONE OF THE FOLLOWING **1st pref: ticagrelor 180 mg orally**, for the first dose, then 90 mg twice daily OR **1st pref: prasugrel 60 mg orally**, for the first dose, then 10 mg daily OR **2nd pref clopidogrel 600 mg orally**, for the first dose, then 75 mg daily. *The preferred P2Y12 inhibitors for a patient undergoing PCI are ticagrelor* and prasugrel; these have more rapid onset of action, less variable platelet inhibition, and *better clinical outcomes than clopidogrel.* Clopidogrel is used if ticagrelor and prasugrel are not available or are contraindicated [Note 4], including if the patient: - is being treated with thrombolytic therapy - has a separate indication for oral anticoagulation - has a high or very high bleeding risk (eg a PRECISE-DAPT score of more than 25 or a HAS-BLED score of more than 3) - has had prior intracranial haemorrhage or stroke, recent gastrointestinal bleeding or - anaemia, or has a coagulopathy - has liver failure, or severe kidney failure (estimated glomerular filtration rate [eGFR] less than 15 mL/min or requiring dialysis) - is of extreme old age or frail.

Answer 95

- Insomnia - Tremulousness - Mild anxiety - Gastrointestinal upset, anorexia - Headache - Diaphoresis - Palpitations Remember: 20% could experience more advanced manifestations such as hallucinosis, seizures, and delirium tremens Status epilepticus is very uncommon - if this presents, we must keep in mind it may be something else

Answer 96

Total Score /30 Score < 23/30 is indicative of cognitive impairment

Answer 97

8 - intubate 11 - Very close watch - may need support

Answer 98

An easy way to remember the categories is to think of the scores in a game of tennis: Love – 15 – 30 – 40 — game over (>40) **Class 1 Blood loss: up to 750 mL or 15% blood volume** Heart rate: <100/min Blood pressure: normal Pulse pressure (mmHg): normal/ increased Respiratory rate: 14-20/min Urine output: >30 mL/h CNS: slightly anxious Heart rate is minimally elevated or normal (<100) Typically, there is no change in blood pressure, pulse pressure, or respiratory rate. **Class 2 Blood loss: 750-1500 mL or 15-30% blood volume** Heart rate: 100-120/min Blood pressure: normal Pulse pressure (mmHg): decreased Respiratory rate: 20-30/min Urine output: 20-30 mL/h CNS: mildly anxious **Class 3 Blood loss: 1500-2000 mL or 30-40% blood volume** Heart rate: 120-140/min Blood pressure: decreased Pulse pressure (mmHg): decreased Respiratory rate: 30-40/min Urine output: 5-15 mL/h CNS: anxious, confused **Class 4 Blood loss: >2000 mL or >40% blood volume** Heart rate: >140/min Blood pressure: decreased Pulse pressure (mmHg): decreased Respiratory rate: >35/min Urine output: negligible CNS: confused, lethargic

Answer 99

**SCALPR** ‘Street’: scalp and external sources (especially small children) Chest Abdomen Long bones (especially femurs) Pelvis Retroperitoneum

Answer 100

- Heart blocks - Sick sinus syndrome/sinus node dysfunction - Triggered/precipitated bradycardia, e.g. - Electrolyte abnormalities - Drugs: digoxin, CCBs, beta blockers - Inferior ischaemia - Neurocardiogenic syncope - Infections, eg: aortic root abscess

Answer 101

The PR interval is the time from the onset of the P wave to the start of the QRS complex. It reflects conduction through the AV node. - The normal PR interval is between 120 – 200 ms (0.12-0.20s) in duration (three to five small squares). - If the PR interval is > 200 ms, first degree heart block is said to be present. - PR interval < 120 ms suggests pre-excitation (the presence of an accessory pathway between the atria and ventricles) or AV nodal (junctional) rhythm.

Answer 102

5mm = 0.2 seconds

Answer 103

**Second degree AV block (Mobitz I) with prolonged PR interval** - Second degree heart block, Mobitz type I (Wenckebach phenomenon). - Note how the baseline PR interval is prolonged, and then further prolongs with each successive beat, until a QRS complex is dropped. - The PR interval before the dropped beat is the longest (340ms), while the PR interval after the dropped beat is the shortest (280ms).

Answer 104

Women and men approximately 45 years old and who suffer from several complaints (at least 5 of the 16 symptoms)[26] listed below could have giant cell arteritis. - Fatigue and apathy - Stiffness in joints and/or muscles - Painful jaws when chewing - Sensitive scalp - Physical malaise and/or weakness - Bloated arteries of the temples - Headaches, migraine - Tongue problems - Bleakness, depression - Changed eyesight - Anorexia or reduced appetite - Reduced eyesight, blindness - Unusual loss of weight - Fever - Diaphoresis - Night sweats Medical emergency due to potential vision loss High dose corticosteroids - likely prednisolone 1mg/kg/day is treatment

Answer 105

Leads **I and aVF**

Answer 106

**Right Axis Deviation** - Right ventricular hypertrophy - Acute right ventricular strain, e.g. due to pulmonary embolism - Lateral STEMI - Chronic lung disease, e.g. COPD - Hyperkalaemia - Sodium-channel blockade, e.g. TCA poisoning - Wolff-Parkinson-White syndrome - Dextrocardia - Ventricular ectopy - Normal paediatric ECG - Left posterior fascicular block – diagnosis of exclusion - Vertically orientated heart – tall, thin patient - Secundum ASD – rSR’ pattern **Left Axis Deviation** - Left ventricular hypertrophy - Left bundle branch block - Inferior MI - Ventricular pacing /ectopy - Wolff-Parkinson-White Syndrome - Primum ASD – rSR’ pattern - Left anterior fascicular block – diagnosis of exclusion - Horizontally orientated heart – short, squat patient **Extreme Axis Deviation** - Ventricular rhythms – e.g.VT, AIVR, ventricular ectopy - Hyperkalaemia - Severe right ventricular hypertrophy

Answer 107

The D-dimer is a by-product of the blood clotting and break-down process that can be measured via analysis of a blood sample. - Platelets in the blood are connected to a D-subunit. - When a clot forms, the D-group between platelets form a bond - Many platelets bound together by these bonds (along with other factors like fibrin) form a clot. - As part of a healing process, clots which form begin to break down quickly, releasing D-dimers D--P--D + D--P--D → D--P--D==D--P--D → D--P + D==D + P--D **Ie- D-dimer is released when a blood clot begins to break down.** D dimers have a **high sensitivity but low specificity** for detecting PE or DVT in low-risk populations

Answer 108

**Cardiac Arrest** - 1mg adrenaline - 1:10000, 10mL IV - Flush with saline after **Anaphylaxis** - 0.5 mg adrenaline - 1:1000, 0.5mL IM

Answer 109

Can't see - Pupil dilation Can't pee - Urinaty retention Can't sweat - Flushed skin, Dry skin Can't spit - Dry mouth Can't shit - Decrease in GI motility Tachycardia

Answer 110

Remember - 1 small box = 0.04s or 40ms - 1 large box = 0.2s or 200ms QT interval should usually be measured in lead II or V5-6 - however lead with longest measurement should be used **QT is prolonged if >440ms in men or >460ms in women** ie about 22-24 mm or small boxes **Causes of prolonged QT interval:** - Hypokalaemia - Hypomagnesaemia - Hypocalcaemia - Hypothermia - Myocardial ischaemia - ROSC post cardiac arrest - Raised ICP - Meds/Drugs - Antipsychotics, antiarrythmics, Tricyclic antidepressents, antihistamines, macrolides (mycins) - Congenital long QT syndrome **Complications include** - Toursades de pontes - Ventricular Fibrilation - Sudden death

Answer 111

- Hyperkalaemia - Hyper/hypo magnesemia - Tricyclic antidepressent poisoning - BBB

Answer 112

**Intro Ax** - LL - Gait - Figure 8 - Toes/Heels if ok - UL - Pronator drift **Key Bits** 1 - *Tone* - QUICK! 5 seconds per side - check all joints together - will be obvious if increased, and won't be decreased 2 - *Power* - Keep it joint by joint - check all, at one billaterally, then move distally 3 - *Reflexes* - Joint on 1/2 stretch - Succinct 4 - *Co-Ordination* - - UL - Dysdiadochokinesis flip clap, tracking finger to nose - LL - Heel slide, toe tap 5 - *Sensation* - Sharp/dull, Proprioception **Extra** - Clonus - Babinski

Answer 113

**HIP** F - L2 L3 E - L4 L5 ADD - L2 L3 L4 - Obturator ABD - L4 L5 - Sup Gluteal **KNEE** E - L3 L4 F - L5 S1 **ANKLE** DF - L4 L5 PF - S1 S2 INV - L4 L5 EV - L5 S1 **HALLUX** E - L5 F - S1

Answer 114

**Transudative** Common - "failures" - Heart Failure, Cirrhosis - liver failure Less Common - Hypoalbuminaemia, Nephrotic Syndrome, Perotineal dialysis, Hypothyroidism **Exudative** Common - Infection (parapneumonic, tuberculosis), malignancy Less Common - Pulmonary infarction, Pancreatitis, Post MI (dressler's syndrome), post CABG Autoimmune diseases (eg Rheumatoid arthritis), Asbestosis Rare - Drugs - methotrexate, amiodarone, phenytoin **Other** Haemothorax - blood in pleural space Empyema - pus in pleural space Chylothorax - Chyle in pleural space due to disruption of thoracic duct (neoplasm, trauma, infection/inflammation)

Answer 115

MAD MoBeD SAC

Answer 116

Escherichia coli Staphylococcus aureus Streptococcus pneumoniae Neisseria meningitidis MRSA or pseudomonas aeruginosa are more common if infection associated with health care contact

Answer 117

Pharmacokinetic drug-drug interactions occur when a drug alters the **absorption, distribution or elimination** of a co-administered agent. Pharmacokinetic interactions may result in the increase or the decrease of plasma drug concentrations. Physiologic factors include: absorption, distribution, metabolism, and excretion. The main factors are disease, genetics, and age.

Answer 118

**Warfarin** is metabolised by CYP enzymes **Fluconazole** - antifungal, inhibits p450 enzymes - increases effects of warfarin **Statins** - Warfarin Inhibits statin metabolic process -increased risk of toxicity and rhabdomyolysis **St John's Wort** - Induces CYP enzymes - Can decease warfarin Effectiveness **Macrolides** - can inhibit warfarin metabolism, inhibiting CYP enzymes

Answer 119

Benign Melignant Primary Metastatic

Answer 120

Melanoma Lung Renal

Answer 121

Prostate Breast Colorectal Lung Melanoma

Answer 122

**1. Partial seizures** a. Simple partial seizures (with motor, sensory, autonomic, or psychic signs) b. Complex partial seizures c. Partial seizures with secondary generalization **2. Primarily generalized seizures** a. Absence (petit mal) b. Tonic-clonic (grand mal) c. Tonic d. Atonic e. Myoclonic **3. Unclassified seizures** a. Neonatal seizures b. Infantile spasms

Answer 123

- Exertional Dyspnoea - Angina - Syncope

Answer 124

**GI** - Appendicitis - Mechanical bowel obstruction - Perforated viscus - Bowel ischaemia - Diverticulitis - Strangulated hernia - Sigmoid volvulus **Hepatopancreaticobiliary** - Acute pancreatitis - Acute cholecystitis - Biliary colic - Obstructive jaundice +- cholangitis **Urological** - Ureteric colic - Testicular torsion **Gynaecological** - Ruptured ectopic pregnancy - Ovarian torsion - Ovarian cyst rupture - Salpingitis **Vascular** - Ruptured Abdominal Aortic Aneurysm (AAA) - Aortic dissection

Answer 125

**Disease Problem** **Treatment Problem** - Eg methotrexate - Give folinic acid **Something else** - Rando unrelated problem - eg a fall, MI, etc

Answer 126

**Where is it?** - Staging **What is it?** - Pathology (Tissue) **What are my patient factors?** - RF/Family/Genetics - Performance status - ECOG - 0 = Normal, - 1 = Strenuous exercise restriction but able to do most ADLs - 2 = Capable of most things, up and around >50% of the day - 3 = Resting > 50% of the day - 4 = Chair or bed bound - 5 = Dead - Comorbidities - Support networks - Values/beliefs - eg Jehova's Witness blood products after, Friend/family experience **What Can I Do?** - Treatment options - Chemotherapy/ Immunotherapy - Radiotherapy - Surgery - Palliative care **Do it** - Surg - where/when/recovery - Chemo - where/ when/ IV access - Radiation - Where /how /planning - Palliative - Symptom management/ Care for patient **Review it** - Evaluate treatment - Follow up - Survivorship - Manage long term living with cancer - Those who have complications from treatment or cancer & "cured" - Psychology - Return to work help with disabilities and other morbidity

Answer 127

**History and Exam** - How long - Consistency **Imaging** - Diagnostic mamogram **Biopsy**

Answer 128

SERM - Selective Oestrogen Receptor Modulator Pre and Peri menopausal breast cancer

Answer 129

DCI - Ductal Carcinoma In Situ - Not Ductal Carcinoma Pupiliary - Rarer Tubular LCS - Grade - 1-3 Margin ER/PR HER2 (human epiderman receptor 2) Sentinal Lymph Node Biopsy TNM T - 1-4, Size in breast cancer - T1 <1cm, T2 1-2cm, T3 >2cm, T4 Inflam N - 1-3, Axilliary and internal mammary number of nodes - M - Nodes, Brain, Lung Liver, PEritoneum, Ovaries

Answer 130

12 monthly U/S for 10 years post Diagnosis Clinical Exam every 3 month

Answer 131

Autosomal Dominant - Ie 50% likelyhood

Answer 132

R heart Louder on inspiration L heart louder on expiration Blood goes in before out - ie larger R filling on inspiration

Answer 133

- **S1 (1st sound)** = closure of AV (mitral and tricuspid) valves at the beginning of systole (point a). - Normally a single sound because mitral and tricuspid valve closure occurs almost simultaneously. - Clinically, S1 corresponds to the pulse. - **S2 (2nd sound)** = of semilunar (aortic and pulmonary) valves - S2 is normally split because the aortic valve (A2) closes before the pulmonary valve (P2) - due to aortic pressure > pulmonary trunk pressure - Sound split widens during inspiration, narrows during expiration - **S3 (3rd sound)** - "Sloshing In" - Can be physiological - Early diastole - Represents a transition from rapid to slow ventricular filling in early diastole. - S3 may be heard in normal children - **S4 (4th sound)** - "Stiff Wall" - Always pathological! - Abnormal late diastolic sound - Caused by atrial contraction when decreased ventricular compliance is present.

Answer 134

Systolic Ejection (early) - AS -loud /PS -quieter Pan/Holo Systolic (mid/late) - MR - loud / TR - quieter Diastolic Early - AR (loud) - PR (quieter) Mid/Late Diastolic - MS (loud) - TS (quieter)

Answer 135

According to KDIGO, AKI is defined as an: 1) Increase in serum creatinine by ≥0.3 mg/dL (26.52 µmol/L) within 48 hrs; OR, 2) Increase in serum creatinine to ≥1.5 times baseline (i.e. 50% above baseline), which is known or presumed to have occurred within the prior 7 days; OR, 3) Urine volume <0.5 mL/kg/h over a 6-hour period.

Answer 136

Dry MM Sunken eyes Reduced skin turgor Tachycardia Postural hypotension Supine hypotension only after >10% loss bodyweight - severe!!

Answer 137

Nephrotoxic drugs Prolonged and severe hypotension Tubular cells can regenerate - epithelial cells, however the glomerulus will not

Answer 138

Urinary casts are cylindrical structures that are formed from coagulated protein (Tamm-Horsfall protein) secreted by tubular cells. As their name implies, they are usually formed in the long, thin, hollow renal tubules and take their shape. Low urine flow rate, high urinary salt concentration, and low urine pH all favor protein denaturation and precipitation of Tamm-Horsfall protein, the organic matrix that cements the casts together These get decorated with other cells - ie red cells - from glomerulonephritis, white cells from pyelonephritis or

Answer 139

Glomerular bleeding! If >~ 40% RBCs are dysmorphic - 2 theories of how this works - RBC damaged as forced through glomerulus - RBC damaged as they go through huge osmolar concentration differences in the renal tubules

Answer 140

**B-U-KUS!!** **Preliminary - Key for AKI** - Blood test : Renal function test - Urine : dipstick and microscopy, cast - Kidney U/S *Follow up* - CT KUB - Vasculitic serology, Myeloma screening - Renal artery dopplar - Kidney biopsy

Answer 141

**Cardiac symptoms** - - jvp, - pulse - BP - regularly! Like even hourly **Urine output** Every 4-6 hours!! (Don't leave it 24hrs for monitoring)

Answer 142

**Preeclampsia** - New-onset of hypertension with: - SBP>= 140 mmHg and/or DBP >= 90 mmHg after 20 weeks of gestation - Proteinuria and/or end-organ dysfunction (renal dysfunction, liver dysfunction, central nervous system disturbances, pulmonary edema, and thrombocytopenia). **Eclampsia** - New onset of generalized tonic-clonic seizures in a woman with preeclampsia

Answer 143

Remember - get patient EUVOLAEMIC first priority Then, slowly uptitrate meds every 2-4 weeks, aiming for 3 months @ target or max tolerated dose - **ARNi** - Sabubitril + valsartan, 24 + 26mg BD - increase every 2-4 weeks to max 97 + 103 mg BD or - **ACE inhib** - Ramipril 2.5mg BD - inc up to max 5mg BD AND - **Beta blocker** - Bisoprolol - 1.25 mg Daily, inc to max 10mg daily - **Mineralcorticoid receptor antagonist diuretic** Spironolactone - 25mg daily, inc to max 50mg daily if required - **SGLT-2 inhib** - Dapagliflozin 10mg daily

Answer 144

**BRIAN** - Benefits - Risks - Indications - for procedure - Alternatives - for proceture - Natural history of condition - ie if we do nothing

Answer 145

**P-Glycoprotein** - Drug transporter, transmembrane efflux pump, essentially picking up substrates and transporting them outside the cell. - Located in large concentrations in the intestine (also in the BBB/kidney + others, it reduces the bioavailability of drugs that are substrates, by transporting them back into the lumen and increasing their elimination in bile and urine.

Answer 146

- **200mg/kg** or - **>= 10g in 24 hours** (use Ideal BW) **ALT and INR** are main markers for assessing hepatotoxicity Note - if taken Panadol Osteo - start NAC immediately!

Answer 147

- Anhidrosis - Anhidrotic hyperthermia - Vasodilation-induced flushing - Mydriasis - dilated pupils - Urinary retention - Neurological symptoms - delirium, agitation, and hallucinations. - Constipation - Dry mouth

Answer 148

Roughly 3-5 doses

Answer 149

- Laryngospasm - Tetany - Muscle cramps - especially with exercise - Seizure - Parasthesia - Numbness - Lengthened QTc interval >450ms - Infant feeding problems - Chvostek's sign - Trousseau's sign

Answer 150

In practice - if possible just do distal toe pressure **Record brachial pressure reading:** Can use doppler if unable to palpate - Record SBP **Record ankle pressure reading:** * Place BP cuff around leg just above the ankle. * Can use doppler if unable to palpate at Tib Post or DP - Record SBP **ABI = SBP Leg / SBP Arm**

Answer 151

Serotonin-5HT3 antagonist Think - "Setron" = Serotonin **Side effects** Constipation!! Headache

Answer 152

Ordine - morphine & Lorazepam

Answer 153

Comminuted - Many parts Compound - open/ broken skin

Answer 154

Trimethoprim - 300mg 3 days female 7 days male Not indicated during pregnancy - folic acid antagonist

Answer 155

- Urinary tract malignancy - Glomerulonephritis - Trauma - Nephrolithiasis - UTI - Cystitis, Pyelonephritis - IGA Nephropathy - Bergers disease - Pulmonary renal syndromes - Goodpastures, ANCA - Alport syndrome - genetic

Answer 156

- Smoking - Shistosomiasis - Occupational exposures - Benzene solvents, Arsenic - FHx - Chronic bladder inflammation - Chronic catheter use

Answer 157

**Presentation** - Painless Haematuria - Back pain - Frequency - Constitutional symptoms - Palpable renal mass on ballotion **Bladder** - **Urothelial carcinoma** - formally known as transitional cell carcinoma, is the most common form of bladder cancer (80-90%) and starts in the urothelial cells in the bladder wall's innermost layer - **Squamous cell carcinoma (1-2%)** begins in the thin, flat cells that line the bladder - **Adenocarcinoma is a rare form (1%)** which starts in mucus-producing cells in the bladder and is likely to be invasive. **Kidney** - Clear cell carcinoma - Non clear cell carcinoma

Answer 158

1⁄2 life of aspirin is ~ 6 hours, BUT Aspirin has an irreversible effect on platelets for the life of the platelet therefore must produce new functioning platelets. Produce 10% of platelet population /day What is the life span of a platelet? Platelets have a life span of about 10 days ∴ to achieve **safe levels of normally functioning platelets takes 5- 7 days**

Answer 159

1mg/kg twice daily or 1.5mg/kg daily, SCI ie **‘treatment dose not just VTE prophylactic dose** which is(40mg SCI daily)

Answer 160

**Clean** — an incision in which no inflammation is encountered in a surgical procedure, without a break in sterile technique, and during which the respiratory, alimentary and genitourinary tracts are not entered. **Clean-contaminated** — an incision through which the respiratory, alimentary or genitourinary tract is entered under controlled conditions but with no contamination encountered. **Contaminated** — an incision undertaken during an operation in which there is a major break in sterile technique or gross spillage from the gastrointestinal tract, or an incision in which acute, non-purulent inflammation is encountered. Open traumatic wounds that are more than 12–24 hours old also fall into this category. **Dirty or infected** — an incision undertaken during an operation in which the viscera are perforated or when acute inflammation with pus is encountered during the operation (for example, emergency surgery for faecal peritonitis), and for traumatic wounds where treatment is delayed, and there is faecal contamination or devitalised tissue present

Answer 161

- Apixaban (CrCl 25 mL/min or more) 10 mg orally, twice daily for 7 days, then decrease to 5 mg twice daily. or - Rivaroxaban (CrCl 30 mL/min or more) 15 mg orally, twice daily for 21 days, then decrease to 20 mg once daily

Answer 162

Think - generally things which increase level of circulating Oestrogen - Early menarche - Late primigravida (latin ~ first heavy life) - Late menopause - Combined oestrogen/progesterone OCP - HRT - Obesity Genes - Genetics - BRCA genes, Li fraumeni p53, cowden PTEN, - FHx Others - Previous cancer - Ionising radiation - Shift work - Alcohol - Digoxin use - Hyperthyroidism

Answer 163

**NAMES** - Aripiprazole - Olanzapine - Paliperidone - Quetiapine - Risperidone **SIDE EFFECTS** - Metabolic syndrome- weight gain, hyperlipidemia, diabetes mellitus, - Constipation - Saliorrhoea - Breast pain/growth/lactation - QTc prolongation, - Extrapyramidal side effects, - Fatigue - Headache - Cataracts - Sexual side effects - reduced libido - ***Clozapine*** - Own special issues - Agranulocytosis - Myocarditis,

Answer 164

- Antiarrythmic - Used in cardioversion

Answer 165

- muscarinic (M1), - dopaminergic (D2), - histaminergic (H1) - motion sickness involved - 5-hydroxytriptamine or 5-HT3 (serotonin), and - neurokinin NK1 (substance P)

Answer 166

- No blood clots - Clots never occur in glomerular bleeding - Dysmorphic RBCs - RBC Cast - Proteinuria >500mg/Day

Answer 167

Duration Pain? - Constant or collicky Clots? - Clots are never in glomeruluar bleeding - Clots in urine should be taken very seriously Evenly mixed, early flow, etc Prostate symptoms Constitutional symptoms - UTI, Neoplastic disease

Answer 168

Urine Dipstick Microscopy Imaging - U/S, CT IVP (intravenous pyelogram) Retrograde pyelogram with contrast FBC LFT UEC

Answer 169

If >5.5cm diameter or Expands > 0.5cm in a 6 month period Or when becomes symptomatic/ discovered with other aneurysms

Answer 170

- SCLC - Small Cell Lung Cancer - most common tumour leading to ectopic ADH production - Extrapumlonary small cell carcinomas - Non-Small cell Lung Cancer - Head and neck cancers - Mesothelioma - Lymphoma - Ewings Sarcoma - bones (pelvis, scapula, ribs, long bones like mid femur), soft tissue - Primary brain tumours

Answer 171

Note: if gent is contraindicated (terrible renal function) substitute Piperacillin/tazobactam 4.5g IV q6h

Answer 172

Weight Severity of illness Renal function - ie calcuate createnine clearance

Answer 173

*First line therapy:* - **Flucloxacillin 2g q6h** Note: Benzylpenicillin may be used but it is uncommon *Penicillin hypersensitivity:* - **Cefazolin 2g Q8h – non-severe penicillin reactions** Often used for HITH due to low risk of phlebitis in a peripheral vein - **Clindamycin IV 600mg Q8h – severe penicillin reactions** *MRSA suspected:* - **Vancomycin**

Answer 174

- Vancomycin has a **large volume of distribution** so thus requires a loading dose - Loading dose = 25-30mg/kg of ACTUAL body weight - Average loading dose = 1.5-3g - *Requires trough measurements for therapeutic monitoring* **MOA** - Glycopeptide - Bactericidal - Inhibits cell wall peptidoglycan polymerisation - Leads to leakage of intracellular components - bacterial death

Answer 175

Site -location Size Shape - roughly Contour - raised, sunken, etc Colour Consistency - firm, soft, scaly etc Tenderness Temperature Tethering

Answer 176

**SBO** - Adhesions ~ 60% - usually from post surgery - Hernia - strangulated - Neoplastic mass Small bowel obstructinmy face AHN **LBO** - Colorectal Cancer - Diverticular disease Complications - Volvulus - Sigmoid colon CDV

Answer 177

- Ductal Carcinoma (~75%) - Lobular Carcinoma (~5-15%) - Tubular carcinoma (~1-2%)

Answer 178

Donepezil Rivastigmine

Answer 179

Visual hallucinations Parkinsonism REM sleep behaviour disorder Fluctuating cognition

Answer 180

**Methotrexate** *Uses* * - Chemotherapy - leukaemia, lymphoma, breast * - Rheumatoid arthritis *MOA* * - Inhibits "Dihydrofolate reductase" * - Thus inhibits DNA synthesis - relevant to chemotherapy * - In RA - Inhibits T-cell activation & downregulation of B-cells - thus reduces cytokines driving inflammatory process *Side effects* * - Leukopaenia * - Mouth ulcers * - Teratogenic * - Nausea * - Diarrhoea * - Allopecia * - Fatigue * - Lymphoma * - Fatty liver disease

Answer 181

- Birth Hx - caesarian, induction, vaginal, instrumental, tear/episiotomy - Bleeding - periods, lochia - postpartum bleeding or discharge - Baby - gaining weight, sleeping, wet nappies - Blood pressure - Breast - issues with feeding, ,latching, pain, mastitis - Bladder - continence issues, prolapse - Bowels - continence issues, prolapse - Birth Control - MIni pill, IUD, barrier - any non oestrogen option - Brains and Blues - Baby blues vs Postnatal depression - Banging - return to sexual function - not recommended before 6 weeks

Answer 182

The prevalence reflects the number of existing cases of a disease. In contrast to the prevalence, the incidence reflects the number of new cases of disease and can be reported as a risk or as an incidence rate.

Answer 183

Answer is a table - try to remember top 4 rows

Answer 184

VANISH LITH - Vertigo - Ataxia - Nystagmus - Intention Tremor - Stupor - Hyperreflexia - Leukocytosis - Insipidus (nephrogenic diabetes insipidus) - T wave inversion - Heaviness - weight gain, Hypothyroidism, Hyperparathyroidism Also, Ebsteins Abnormality as a Teratogenic Side effect!!

Answer 185

**Tissue Hypoxia** - Severe Hypoxaemia - Circulatory Shock - Heart Failure - Severe Anaemia - Grand Mal Seizure **Other Causes** - Acute Alcoholism - Drugs and toxins - Metformin OD, Truvada (HIV anti-retroviral) - Diabetes Mellitus - Leukaemia - Deficiency Riboflavin (b2) or Niacin (b3) - Idiopathic

Answer 186

CVIS - Capacity to make the decision - Voluntary - Informed - Specific

Answer 187

- Home - Education and employment, eating and exercise - Activities and peer relationships, social media - Drug use, including prescribed medications, cigarettes, vaping, alcohol and other drugs - Sexuality and gender - Suicide, self-harm, Safety and spirituality.

Answer 188

1. Palpate all draining lymph nodes 2. Examine all remaining lymph node groups 3. Examine abdomen - particularly for hepato-spleno-megaly & ascites 4. Feel the testes 5. Examine the mouth and lungs 6. Examine all skin and nails for melanoma - also checking for hints of haematological disease such as petechiae and purpura 7. Examine breasts and axilla 8. Perform a pelvic exam - Bimanual, ovarian cancer or cervical 9. Perform a rectal exam - prostate, lower CRC

Answer 189

**Diagnosis is made when 2 out of 3 criteria are met:** - Symptoms consistent with pancreatitis (e.g. epigastric pain) - Elevation of serum amylase or lipase (to 3 times normal level) - Radiological features consistent with pancreatitis (e.g. CT or MRI) Severity ranges from mild to severe (acute necrotising pancreatitis) 15-25% of pancreatitis is severe **overall mortality of severe acute pancreatitis is about 15%**

Answer 190

MCV < 80 TAILS - Thalaseamia - Anaemia of Chronic Disease - Iron deficiency - Lead Poisoning - Sideroblastic Anaemia - no iron binding capacity

Answer 191

MCV 80-100 **Haemolytic** Congenital - G6PD deficiency (glucose-6-phosphate dehydrogenase) - Hereditary spherocytosis - Sickle cell - PKD (Pyruvate Kinease Deficiency) Non-congenital - Multiple Myeloma - Mechanical valves - Auto immune haemolytic anaemia - Malaria - Schistosomiasis **Non Haemolytic** - Bleeding - CKD - Aplastic anaemia

Answer 192

MCV > 120 - B12 deficiency - Folate deficiency - Alcoholism - Hypothyroidism - Rarely Multiple Myeloma

Answer 193

5-Fluroracil

Answer 194

Doxorubicin

Answer 195

1. Phase 1 is a sharp tapping sound and indicates the systolic blood pressure. 2. Phase 2 is a swishing sound associated with blood flow. 3. Phase 3 transitions to a softer thump 4. Phase 4 is a thump that becomes muffled. 5. Phase 5 is the diastolic blood pressure when all sound ceases

Answer 196

CRAB - Calcium - High with normal PTH - Renal impairment - without clear cause such as diabetes or autoimmune disease - Anaemia - normo or macrocytic without clear cause - Bone pain or crush #s in younger patients

Answer 197

**General Inspection** - Restlessness - Body habitus - weight loss - Goitre - Clothing/Sweating - heat intolerance - Irritability - Hair **Vitals** - Hypertension **Hands/Arms** - Warm vasodilated peripheries - Palmar erythema/sweating - Tachycardia or atrial fibrilation - Onycholysis - nail separates from nail bed - Tremor **Eyes/face** - Exopthalmos - view form front and side - H test - Look for lid lad on downward gaze - Close eyes - inability to do so is "Lagopthalmos" **Neck/Thyroid** - Inspect front and sides - scars, swelling - If swelling, ask patient to take sip of water - thyroid gland, goitre or thyroglossal cyst will rise during swalllowing - attachments to larynx - Protrude tongue - look for thyroglossal cyst when doing so - Palpate thyroid glands and isthmus from behind - Palpate whilst swallowing water - Percuss manubrium - Auscultate thyroid for thrill - Pembertons sign - retrosternal goitre **Legs** - Pretibial myxoedema **Reflexes** - Hyperreflexia **Others** - Auscultate heart for murmurs - Question - oligomenorrhoea, impotence - Inspect gynaecomastia - Check for apex beat - cardiomegaly due to heart failure

Answer 198

**General Inspection** - Tiredness/malaise - Weight gain - Cold intolerance - clothing - Arthralgia/myalgia - Constipation - Memory issues - Depression and/or poor libido **Hands** - Dry, coarse skin - Check pulse - Bradycardia - - Cold peripheries - Carpal tunnel syndrome - Ataxia - check for DDK - Peripheral oedema **Face and neck** - Periorbital oedema - Dry, brittle unmanaged hair - Loss of eyebrows - Goitre - inspect, then palpate thyroid - Auscultate thydoid - Pemberton's sign - hands up **Motor/Peripheries** - "Hung up" or slow to relax reflexes - Oedema peripherally - check dependent zones **Others** - Heart failure can occur - check apex beat, auscultate - Proximal myopathy - weakness proximal muscles

Answer 199

1. DiPeptidyl Peptidase 4 (DPP-4) inhibitors 2. Normally 2nd line treatment in T2DM - or 1st line in those who have adverse reactions to metformin 3. DPP-4 decreases circulating incretin hormones like GLP-1 (Glucagon-Like Peptide 1) and GIP (Gastric Inhibitory Peptide) - These hormones increase insulin secretion and decrease glucagon secretion. DPP-4 inhibitors thus increase circulating levels of these hormones and lower blood glucose 4. Linagliptin, Sitagliptin - "'gliptins" 5. - Anaphylaxis, Angiooedema - GI problems - nausea, diarrhoea, stomach pain - Flu like symptoms - headache, runny nose, sore thorat - Skin reactions - rashes - ? link to pancreatitis

Answer 200

**EDH - ExtraDural Haemorrhage** - Between bone and periosteal dura - 75% pterion #s involving middle meningeal artery 1. Headache 2. nausea and vomiting 3. confusion 4. LOC -> Lucid -> Deterioration **SDH - Subdural Haemorrhage** - Blood between Dura mater and arachnoid mater in "subdural space" - Acute < 3 days - - Head injury, - Shearing or deceleration - high mortality untreated - Chronic > 21 days - - Older patients, - Cerebral atrophy, - Tear in bridging veins, - Often on anticoags - May be self limiting, develops slowly over weeks Clinically - Headache, nausea and vomiting, confusion, drowsiness, poor balance, muscle weakness, parasthesia and numbness **SAH - SubArachnoid Haemorrhage** - 10% all strokes - Commonest cause rupture saccular (berry) aneurysm Presents as: - Headache, Nausea and Vom, often LOC - May have headache for days previously - "warning leaks" - Signs meningeal irritation - photophobia, neck stiffness - Mass effect prior to rupture - 3rd nerve palsy- ptosis, dilated pupil - Commonly - Anterior communicating - 30%, Internal carotid/post communicating 30% MCA - 20% **IPH - Intraparenchymal Haemorrhage**

Answer 201

ABSMATPCIJ Appearance Behaviour Speech Mood Affect Thought (Both Form and Content) Perception Cognition Insight & Judgement

Answer 202

At least 2 weeks symptoms of below: At least 5 total, including one of first 2 **Depressed mood Anhedonia** **LAGS-SCLEWP** * Low mood * Anhedonia * Guilt * Suicidal Ideation * Sleep Disturbances * Concentration Problems * Libido Diminished * Energy Decreased * Weight changes * Psychomotor agitation

Answer 203

* Healthy cell reproduction - cells born in crypts from stem cells, migrate along axis, shed into lumen several days later * DNA mutation - * Tumour suppressing gene **_APC_** (Adenomatous Polyposis Coli) turned off in stem cell → ~80% of CRCs * Polyp - aka ADENOMA - forms * Benign at this stage, non invasive * Oncogene **_K-RAS_** turned on → Cell proliferation → ~50% cases * Tumour suppressing **_p-53_** turned off → cells become resistant to apoptosis → ~70% * **_DCC_** - (Deleted in Colorectal Carcinoma) turned off → poor cell-cell adhesion, ie metastassis →~70% Growth becomes malignant → Carcinoma Local invasion, then spreads

Answer 204

**TX**: The primary tumor cannot be evaluated. **T0** (T zero): There is no evidence of cancer in the colon or rectum. **Tis**: Refers to carcinoma in situ (also called cancer in situ). Cancer cells are found only in the epithelium or lamina propria, which are the top layers lining the inside of the colon or rectum. **T1**: The tumor has grown into the submucosa, which is the layer of tissue underneath the mucosa or lining of the colon. **T2**: The tumor has grown into the muscularis propria, a deeper, thick layer of muscle that contracts to force along the contents of the intestines. **T3**: The tumor has grown through the muscularis propria and into the subserosa, which is a thin layer of connective tissue beneath the outer layer of some parts of the large intestine, or it has grown into tissues surrounding the colon or rectum. **T4a**: The tumor has grown into the surface of the visceral peritoneum, which means it has grown through all layers of the colon. **T4b**: The tumor has grown into or has attached to other organs or structures.

Answer 205

* **Histaminic effects** – sedation and weight gain * **Anticholinergic effects** – dry mouth, blurred vision and constipation * **A1 adrenergic effects** – postural hypotension * **Effects on the heart** – arrhythmias (either directly or through electrolyte disturbances) * **Electrolyte disturbances** – particularly hyponatraemia * **A lowering of the seizure threshold** * **Serotonergic effects** – GIT dysfunction, appetite disturbances, sexual dysfunction or serotonin syndrome

Answer 206

**FINISH** - **Flu-like symptoms** (lethargy, fatigue, headache, achiness, sweating), - **Insomnia** (with vivid dreams or nightmares), - **Nausea** (sometimes vomiting), - **Imbalance** (dizziness, vertigo, light-headedness), - **Sensory disturbances** (“burning,” “tingling,” “electric-like” or “shock-like” sensations) - **Hyperarousal** (anxiety, irritability, agitation, aggression, mania, jerkiness)

Answer 207

Inability to sit still Sensation of motor restlessness in entire body An extrapyramidal side effect - EPSE Can be treated with Benzattropine - an anticholinergic

Answer 208

- A rare idiosyncratic response to an antipsychotic drug Characterised by: - Muscular rigidity - Hyperthermia - Sweating - Dysphagia - Hypertension, - Tremor - Elevated CK. - NMS may lead to changes in level of consciousness, and in its most extreme, can be lethal. Management is mainly supportive (cooling, fluids and ceasing antipsychotics), but D2 agonists (bromocriptine) may also be used.

Answer 209

- Full blood examination - Iron studies - Blood group & Rh Antibody screen, - Haemoglobinopathies screen - Random blood glucose - Screening for infections: - Rubella - Syphilis, Hep B and C, - HIV - Midstream urine test Other investigations based on patient previous medical conditions (i.e. thyroid - thyroid function test), family history (i.e. gestational diabetes - early OGTT) and risk factors (chlamydia, gonorrhoea).

Answer 210

- Random blood glucose >11mmol/L requires an early OGTT at 12-16 weeks. - Random blood glucose <11mmol/L requires an OGTT at 24-28 weeks. - If patients do have gestational diabetes mellitus this will require further management with diet modification and medication as indicated.

Answer 211

DIME - Distress tolerance skills/effectiveness - (emotional control) - Interpersonal skills/effectiveness - (learning boundaries and expressing needs) - Mindfulness - (being present rather than preoccupied with past and future) - Emotional regulation - (being more aware of emotions)

Answer 212

- Erratic relationships - Frequent changes in partner, employment - Fluctuant changes in emotion - Fear of abandonment

Answer 213

- Major depressive disorder - Anxiety disorder - PTSD - Substance abuse

Answer 214

For VTE prophylaxis: **LMWH** - Enoxaparin - 40mg subcutaneous, 1 x daily (for CrCl >30 mL/min - 1/2 dose for worse than this **DOAC** - Rivaroxabain - 10 mg oral, 1 x daily (CrCl>15mL/min) Dose is given for 28-35 days

Answer 215

- Loss of Cortical Bone thickness and density - Loss of bone Trabeculae

Answer 216

- Infiltration of inflammatory cells - Goblet cell loss - Crypt abscesses

Answer 217

- Infiltration of inflammatory cells - Presence of granulomas

Answer 218

Rare, but potentially deadly complication of colonic inflammation Described as: - Nonobstructive dilation of the colon, - Which can be total or segmental - Usually associated with systemic toxicity Most commonly associated with IBD, especially UC Other causes: - Inflammatory - Crohn's - Infectious - Clostridium difficile, Salmonella, Shigella, Campylobacter colitis, CMV in HIV/AIDs patients - Ischaemia Factors that can precipatate include: - Hypokalemia - Medications (antimotility agents, opiates, anticholinergics, antidepressants) - Barium enema - Colonoscopy & bowel preparations

Answer 219

MSK - Enteropathic arthritis - Osteoporosis Dermatologic - Erythema nodosum - shin inflam subcut fat - Pyoderma gangrenosum - painful rapidly enlarging ulcer - Hair loss & brittle nails - Associated psoriasis & amyloidosis Mucosa - Apthous ulcers - Fissures Haemotological - Iron deficiency anaemia - microcytic - B12 deficiency (crohns) - macrocytic anaemia Hepatopancreatobiliary - Primary sclerosing cholangitis - Bile duct carcinoma - NAFLD - Autoimmune chronic hepatitis - Cirrhosis Ocular - Uveitis/iritis, retinal vascular disease Renal - Calcium oxalate stones

Answer 220

- **Levodopa** (*dopamine precursor*) + **Carbidopa** (*peripheral dopamine decarboxylase inhibitor*) - Most effective symptomatic treatment which is typically very effective in the early phase of treatment but is associated with inevitable development of dyskinesia -First line treatment in patients > 65 years - **Dopamine agonists** – *pramipexole, ropinirole, apomorphine* - first line in patients < 65 years, - may be combined with levodopa/carbidopa - **MAO-B inhibitors** e.g. *selegiline* - **COMT inhibitiors** e.g. *entacapone* - **Anticholinergics and muscarinic antagonists** such as benztropine or biperiden are indicated in patients < 65 years with tremor as a chief concern

Answer 221

Think RIPE - Rifampicin - Isoniazid - Pyrazinamide - Ethambutol

Answer 222

**Baby check features suggestive of Down’s Syndrome:** * Dysmorphic facies – brachycephaly, epicanthic folds, upslanting palpebral fissures, Brushfield spots (white dots in a ring round the edge of the iris), large tongue, small poorly formed ears * Hands and feet – broad hands, simian crease (single palmar crease), gap between first and second toes * Hypotonia * Check heart for murmur (AVSD/ASD/VSD) * Check for imperforate anus **Later complications include** * Cardiac defects eg. AVSD, VSD, ASD * Gastrointestinal abnormalities eg. intestinal atresia, Hirschsprung’s disease, coeliac disease * Opthalmologic disorders eg. cataract, nystagmus, strabismus * Hearing difficulties, most commonly due to otitis media * Endocrine disorders eg. thyroid disease * Neurological disorders eg. atlantoaxial instability * Intellectual disability and behavioural problems * Short stature and obesity * Haematologic disorders eg. leukaemia * Sleep disorders eg. obstructive sleep apnoea

Answer 223

**Positive signs and symptoms** - hallucinations (eg hearing voices) - delusions (eg persecutory, bizarre, grandiose) - impaired insight - disorganised thinking and speech **Negative signs and symptoms** - lack of motivation - poor self-care - blunted affect - reduced speech - social withdrawal **Cognitive signs and symptoms** - impaired planning - reduced mental flexibility - impaired memory and concentration - impaired social cognition [NB2] **Excitement** - disorganised behaviour - aggression - hostility - catatonia

Answer 224

**SSRIs** - Citalopram, - Escitalopram, - Fluoxetine - adolescent population - Fluvoxamine, - Paroxetine, - Sertraline - older population Common Adverse effects: Gi upset, reduced libido, weight gain, drowsiness **SNRIs** - Venlafaxine - difficulties in weaning off - Desvenlafaxine - Duloxetine, Common Adverse effects - nausea, GI upset, loss of appetite, dry mouth, dizziness, discontinuation syndrome **TCAs** - Nortriptyline, - Amitriptyline, - Clomipramine Adverse effects: - Anticholinergic affects can be problematic: dry mouth, blurred vision, constipation, urinary retention , drowsiness - Toxicity in OD - Contraindicated Hx heartblock, arrythmia **MAOIs** - Phenelzine - Moclobemide - hypertensive crisis- need to avoid dietary tyramine **NASSA** - Noradrenergic and specific serotonergic antidepressant - Mirtazepine Then: **ECT** - Electroconvulsive trial - at least 2 medicaitons trialed for > 2 weeks at an adequate dosage

Answer 225

**History** - HOPC - Premorbid State - Collateral from family - Meds Hx - including: polypharmacy, Allergies & Toxicity - Social Hx - Living Situation, ADLs - Risk Assessment - Self, others, vulnerability, financial, reputational - Forensic Hx - Sexual Hx - Developmental Hx - Family Hx **Investigations** - Vit B12 / Folate /Vit D - TSH - UA/MCS - CT Brain - FBC/UEC/CMP/LFT - BSL - UDS - urinary drug screen - CXR/AXR - ECG **Differential Diagnosis** *Organic Causes* - Hypo/per thyroidism - Delirium - Metastatic Disease - Dementia - B12/Folate/VitD Deficiency - Constipation/UTI *Substance/Iatrogenic* *Then psych differentials:* - MDD - Adjustment Disorder - Grief

Answer 226

**Lithium** - Acute treatment option - Teratogenic side effect - Ebstein Anomaly (cardiac, incorrectly formed and lower located tricuspid valve) - Renally excreted - need EUCs before commencing **Valproate** - Teratogenic effect: Neural tube defect - Steven Johnson Syndrome - Dermatological emergency **Lamotrigine** - Teratogenic effect: Cleft Palate

Answer 227

*Typicals/ 1st Gen* - **Chlorpromazine** - EPSE - **Droperidol** - Used in ED for sedating effects - **Haloperidol** - EPSE *Atypicals* ^ = availabile in depot form - **Aripiprazole** ^ - Akathesia - **Olanzapine** ^ - Weight gain - depot but difficult to source - **Paliperadone** ^ - Hyperprolactinaemia - baseline prolacin level , repeat 3/12 - **Quetiapine** - sedative - **Risperidone** -# depot as well older/adolescents - **Zuclopenthixol** ^ - (Clopixol) - *Treatment resistant - must have tried at least 2 other for at least 6 weeks* **Clozapine** - Initiation first 4-5 weeks can be done in hospital - Then in community monitored weekly for 4-5 weeks - Then Monitored 4 weekly Baseline ECG, ECHOs, All the bloods - Myocarditis - Agranulocytosis - wcc monitor - Constipation - monitor, bowel obstruction biggest killer in those on cloz - QTC prolongation - 3-6 monthly ECG -

Answer 228

**Neurological** - Tremor - Ataxia - Hyperreflexia - Nystagmus - Altered consciousness - ranging from mild confusion to delerium **Renal** - Nephrogenic Diabetes Insipidus - Nephrotic syndrome **GI** - Common with acute overdose settings within 1 hr of digestion - Nausea, vomiting etc **Cardiovascular** - T wave flattening - QT prolongation **Endocrine** - Hypothyroidism

Answer 229

**Cluster A - Mad** - Bizarre - Paranoid - thinks others out to get them - Schizoid - does not desire close relationships - Schizotypal - odd beliefs / magical thinking **Cluster B - Bad** Jerks - Antisocial - assholes - Histrionic - wants constant attention & praise - Narcissistic - probably politicians - Borderline - emotionally unstable **Cluster C - Sad** - Stressed/Anxious - Avoidant - avoids risks, relationships, fear - Obsessive Compulsive - details - Dependent - needs others for decisions

Answer 230

- **Groans**: - Gastrointestinal symptoms such as: - Pain, - Nausea - Vomiting. - Hypercalcemia can lead to peptic ulcer disease and pancreatitis. - **Bones**: - Bone pain. - Osteoporosis, - Osteomalacia, - Arthritis - Pathological fractures. - **Stones**: - Renal stones - **Moans**: - Fatigue - Malaise. - **Thrones**: - Polyuria, - Polydipsia, - Constipation - **Psychic overtones**: - Lethargy, - Confusion, - Depression - Memory loss.

Answer 231

Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated). At least one of these must be (1), (2), or (3): - Delusions. - Hallucinations. - Disorganized speech (e.g., frequent derailment or incoherence). - Grossly disorganized or catatonic behavior. - Negative symptoms (i.e., diminished emotional expression or avolition). Further: - Impact to function - Continuous signs of disturbance > 6months - Schizoaffective, depressive or bipolar with psychotic features is ruled out - Not attributable to substances

Answer 232

5/9 of the below 1. Frantic efforts to avoid real or imagined abandonment. 2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. 3. Identity disturbance: markedly and persistently unstable self-image or sense of self. 4. Impulsivity in at least two potentially self-damaging areas (e.g., spending, sex, substance abuse, reckless driving, binge eating). 5. Recurrent suicidal behavior, gestures or threats, or self-mutilating behavior. 6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and rarely more than a few days). 7. Chronic feelings of emptiness. 8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights). 9. Transient, stress-related paranoid ideation or severe dissociative symptoms. Note too: Median population prevalence ~1.6% Primary care ~6% Outpatient mental health 10% Mental health inpatients 20% M:F ratio roughly 1:3 - Aus/western soci-cultural factors and expression vs genetic factors - eg blokes may more likely have antisocial personality disorder Dx

Answer 233

Most effective generally is Dialectical behaviour therapy, but: - People with BPD are not immune to depression and anxiety - Clonadine (alpha 2 agonist) - lower level of agitation throughout the day - Prazosin (alpha 1 receptor antagonist + depress baroreceptor reflex) - used to help people not remember PTSD nightmares as reduces sympathetic arousal and people stay in deeper level of sleep

Answer 234

*Rate* - Pressured > Rapid > Regular > Slowed *Rhythm* - Spontaneity - able to make smalltalk - Latency - pauses before speaking - Prosody - patterns of rhythm used in poetry *Articulation* - Dysarthria - slurred at times - Stuttering

Answer 235

*Affect*: physical expression of a person's immediate feeling state, typically focussed on facial expression *Type* - Euthymic - Normal display of emotion - Hyperthymic - Intense display of emotion - Elevated/Euphoric - In an excited state of intense happiness - Dysphoric - In a profound state of unease or disssatisfaction - Irritable - Easily annoyed or angry - Anxious - Feeling worried ir nervous - typically over an uncertain future outcome *Quality/range* - depth and range of feelings shown - Intense > Full > Constricted > Blunted > Flat *Motility* - Labile > Supple/Stable > Sluggish *Appropriateness to content* - Appropriate or not appropriate

Answer 236

- *Goal directed / Logical* - Linear progression without veering from subject at hand - *Circumstantial* - unable to answer a question without giving excessive, unnessecary detail - *Tangential* - Wandering from the topic and never returning to it or providing info required - *Overinclusiveness* - Irrelevant over detail - *Flight of ideas* - Rapid shift from one topic ot another - *Thought Blocking* - Abrupt cessation of speech without explanation in the middle of a sentence - *Perseveration* - Repetition of a particular response regardless of the absence or cessation of stimulus

Answer 237

***Attitude*** - Co-operative / unco-operative - Seductive - Flattering - Charming - Eager to please - Entitled - Controlling - Hostile - Guarded - Critical - Antagonistic **Behaviour** - Posture - Eyecontact - Mannerisms - Tics - Activity level - Psychomotor retardation/ activation **Terms** - Akathesia - Inner restlessness with inability ot sit still - Automatism - Spontaneous verbal or motor behaviour without patient awareness - Catatonia - Extreme motor inactivity or hyperactivity - Athetosis - Twisting / writhing - Chorea - Irregular migrating contractions - Dystonia - Twisting/ repetitive movement or abnormal fixed posturing - Tremor - Resting or Intention

Answer 238

DELUSIONS!! - *Somatic* - Ones bodily function/sensation/appearance is abnormal - *Grandeur* - Possessing superior qualities such as fame, wealth, or supernatural qualities - *Persecutory* - People are out to get me, speaking behind my back - *Reference* - Otherwise insignificant event is misconstrued - *Thought Insertion* - Believes thought internalle placed by outside party - *Thought Control* - Belief being controlled by outside party/parties - *Thought Broadcasting* - Thoughts are made known to everyone in the outside world - *Control* - Ie neighbour is making me take drugs - *Erotomanic* - Prominent figures or superstars are in love with or in relationship with onesself - *Nihlistic* - Nothing is real. Or they are going to die or are rotting away inside despite all medical evidence to the contrary

Answer 239

Perception can be considered as processed sensation: **Hallucinations** - Ie "Do you ever...." - Auditory - "Hear voices when no one is in the room" - 3rd person most common in schizophrenia - Visual - "See things that other people can't" - More common in Delirium - Somatic - "Feel things that don't make sense" - Thermal, tactile, viceral

Answer 240

Risk of: - Self Harm - Harm to others - Misadventure - Vulnerability - Reputation - Financial

Answer 241

Charcot's Triad - RUQ Pain - Fever - Jaundice And Raynalds Pentad - Shock - Altered Mental Status

Answer 242

**Toddler 0-4y** - Transient hip synovitis - Acute myositis - Toddler's fracture - Developmental dysplasia of hip **All ages not to forget** - Infections: osteomyelitis/septic arthritis, bursitis, discitis, epidural collection - Trauma (see Fractures) - Non accidental or inflicted injury - Malignancy: haematological, bone, soft tissue - Rheumatological/immunological disorders: reactive arthritis, autoimmune arthritis, - Henoch Schonlein Purpura, vasculitis, serum sickness, post infectious arthritis, Guillain-Barre syndrome - Intra-abdominal pathology or genitourinary conditions eg appendicitis, ovarian or testicular torsion - Haematological: vaso-occlusive crisis (sickle cell), haemophilia - Functional limp

Answer 243

**Child 5-10y** - Transient hip synovitis - Acute myositis - Developmental dysplasia of hip - Perthes disease **All ages not to forget** - Infections: osteomyelitis/septic arthritis, bursitis, discitis, epidural collection - Trauma (see Fractures) - Non accidental or inflicted injury - Malignancy: haematological, bone, soft tissue - Rheumatological/immunological disorders: reactive arthritis, autoimmune arthritis, - Henoch Schonlein Purpura, vasculitis, serum sickness, post infectious arthritis, Guillain-Barre syndrome - Intra-abdominal pathology or genitourinary conditions eg appendicitis, ovarian or testicular torsion - Haematological: vaso-occlusive crisis (sickle cell), haemophilia - Functional limp

Answer 244

**Age Specific - Adolescent 10y+** - Stress fractures & sprains - Traction apophysitis (Osgood Schlatter – tibial tuberosity, Severs – calcaneus) - Slipped Upper Femoral Epiphysis - SUFE **All ages not to forget** - Infections: osteomyelitis/septic arthritis, bursitis, discitis, epidural collection - Trauma (see Fractures) - Non accidental or inflicted injury - Malignancy: haematological, bone, soft tissue - Rheumatological/immunological disorders: reactive arthritis, autoimmune arthritis, - Henoch Schonlein Purpura, vasculitis, serum sickness, post infectious arthritis, Guillain-Barre syndrome - Intra-abdominal pathology or genitourinary conditions eg appendicitis, ovarian or testicular torsion - Haematological: vaso-occlusive crisis (sickle cell), haemophilia - Functional limp

Answer 245

Schizophreniform disorder: - Same symptoms as people with schizophrenia. - Illness episodes do not last as long (from 1 to 6 months) - May not have as many problems getting along with other people.

Answer 246

- 3rd person auditory hallucinations - Thought echo - Running commentary - Thought withdrawal - Thought insertion - Thought broadcasting

Answer 247

Schizoaffective disorder - Periods in which manic and major depressive episodes are concurrent with the active phase symptoms of schizophrenia - Periods in which delusions or hallucinations occur for at least 2 weeks in the absence of a manic or major depressive episode. - The diagnosis is “bipolar I disorder, with psychotic features” if the psychotic symptoms have occurred exclusively during manic and major depressive episodes.

Answer 248

* Urinalysis to exclude drug induced psychosis or urinary tract infection * UEC to exclude electrolyte imbalance, * Thyroid function test to exclude hyper/hypothyroidism * Imaging studies to rule out intracranial pathology * Cognitive functions assessment to look for indication of delirium/dementia

Answer 249

- CNS disorder due to deficiency of THIAMINE (B1) in the brain - Typically associated with prolonged, excessive consumption of alcohol - (but also Beriberi) Symptoms include - Reterograde Amnesia - Anterograde Amnesia - Confabulation - fabricated, distorted or misinterpreted memories - Explicit memory defecits

Answer 250

* At risk mental status – hopelessness, despair, agitation, shame, guilt, anger, psychosis * Recent interpersonal crisis – rejection, humiliation * Recent suicide attempt, major loss or trauma * Alcohol intoxication, or drug withdrawal state * Chronic pain or illness * Financial difficulties or unemployed status * Impending legal prosecution or child custody issues * Lack of social support network * Unwillingness to accept help

Answer 251

Triad of: - Confusion - Opthalmoplegia / Nystagmus - Ataxia - Thiamine (B1) deficiency (cause)

Answer 252

**DRCBRAVADO** **DR: Define risk** - High or Low - Maternal medical illness - GDM, HTN, Asthma - Obstetric complications - Multiple gestation, post date gestation, previous caesarian section, IUGR, premature rupture membranes, congenital malformations, Induction/Augmentation labour, pre-eclampsia - Other risk factors - Absence of prenatal care, Smoking, Drug abuse **C: Contractions** - Duration of each - Intensity - via palpation - Frequency - "X in 10" **BRa: Baseline rate** - Average HR in 10 minute window - 110-160 bpm normal - Severe bradycardia - ie Below 80 for > 3 mins indicates severe foetal hypoxia **V: Variability** - Normal variability = 5-25 bpm = Reassuring - Non reassuring - < 5 bpm for 30-50 minutes - > 25 bpm for 15-25 minutes - Abnormal - More extreme than above - Sinusoidal **A: Accelerations** - Abrupt increase in foetal HR > 15 bpm for > 15 seconds - Reassuring - When occuring alongside contractions - indications healthy foetus **D: Decelerations** - Abrupt decrease foetal HR < 15 bpm for >15 seconds - *Early Decels* - In time with uterine contractions - deemed physiological - *Variable Decels* - No clear sync with contractions - Accompanied by "shoulders" of acceleration - recovering - Thought to be due to cord compression - *Late Decels* - Begin peak contraction - recover after contraction ends - Uteroplacental insufficiency - Maternal hypotension, pre-eclampsia, uterine hyperstimulation - *Prolonged Decels* - > 2 minutes - 2-3 minutes = Nonreassuring - >3 minutes = Immediately abnormal **O: Overall impression** - Reassuring - Non-reassuring - Abnormal

Answer 253

DRSABCDE **Details** - - Name, DOB, AP/PA/Transverse, Time/Date, L/R marker **RIPE** - - Rotation - SC joints equal - Inspiration - 8-10 ribs posterior above diaphragm - Picture - ?entire lung fields, scapulae outside lung fields - Exposure - IV discs & spinous processes thru cardiac silohette **Soft Tissue** - Swelling - Masses - Calcification of arteries **Air** - Trachea - Hilum - Lung field outlines **Bones** - Ribs - Scapulae - Sternum - Vertebrae **Circulation** - Heart 2/3 L, 1/3 R - Measure Ratio on PA film - Aortic arch **Diaphragm** - R higher by 1 intercostal space - Shape & contour **Everything Else** - Tubes - NG, ETT, Permacath, CVC - ECG

Answer 254

PMOSC * * Pap smear * * Menstural Hx * * Obstetric * * Sexual/STI * * Contraception

Answer 255

- Pelvic Inflammatory disease - Polycystic Ovarian Syndrome - Endometriosis - Pelvic adhesions - Tubal blockages

Answer 256

- Fetal sleeping: this should last no longer than 40 minutes (this is the most common cause) - Fetal acidosis (due to hypoxia): more likely if late decelerations are also present - Fetal tachycardia - Drugs: opiates, benzodiazepines, methyldopa and magnesium sulphate - Prematurity: variability is reduced at earlier gestation (<28 weeks) - Congenital heart abnormalities

Answer 257

1-5y - 2-6 puffs salbutamol 6+ y - 12 puffs salbutamol ReAx after 20 minutes If not improving, treat as moderate

Answer 258

1-5 - 6 puffs salbutamol every 20 mins for 3 doses Avoid steroids If not responding well - 4 puffs ipatropium every 20 mins 6+ - 12 puffs every 20 minutes for 3 doses Oral prednisolone - 1mg/kg to max 50mg If not responding well - 8 puffs ipatropium every 20 mins If not responding here, treat as severe Otherwise if needs Burst more frequently than 3 hourly after this, admit

Answer 259

**For all - Admit to resus, notify senior staff** O2 via NP - titrate to SpO2 > 90% IV access Methyprednisolone 1mg/kg - max 60mg IV 6hrly Continue 20 minute burst therapy Salbutamol and Ipatropium via spacer 1-5 - 6 puffs salbutamol, 4 ipatropium 6+ - 12 puffs salbutamol, 8 ipatropium If not responding, this is **LIFE THREATENING** We give IV MgSO4 and Aminophylline

Phase 2 Flashcards

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