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1

Causes of raised JVP (>4cm)

Heart Failure
Cardiac Temponade
Restrictive pericarditis
Fluid overload e.g. renal disease
Superior vena cava obstruction

2

Interpret the following CSF results. Given are the tests and normal ranges.

Appearance (clear), White cells (<5), predominant white cell (all mononuclear), protein (0.2-0.4), glucose (>60%)

a)
cloudy & viscous
900
mononuclear
5
<30%

b)
- Clear
- 100
- Mononuclear
- 0.6
- >60%

c)
- Cloudy and Turbid
- 5,000
- Polymorphs
- 8
- 35%

d)
Fibrin web
400
Mononuclear
0.4
30%

a) Is TB meningitis
- WCC Less high than normal bacterial men but raised 50-1000
- High protein
- Low glucose

b) Viral
Clear, raised white cells (10-1000),
- normal/high protein
- normal glucose

c) bacterial: cloudy & think, very high white cell count, polymorphs and very high protein

d)
Fibrin web, high WCC (not as high as bacterial)
- Low protein
- Normal/low protein

3

Bacteria in Newborns

group B strep
E. coli
listeria monocytogenes

4

Bacteria in young children

N. meningitidis
Strep pneumonia
Haemophilus influenza

5

Bacteria in teens/adults

N. meningitides
Strep pneumonia

6

Virus

VZV, enterovirus, HSV, HIV, mumps

7

Fungal

Cryptococcus neoformans

8

Additional Tests after LP

- culture: grow bacteria
- PCR for virus
- Electrophoresis: oligoclonal bands (MS)
- Acid-fast stain TB
- Xanthochromia/bilirubin: subarachnoid
- Cytology: malignant cells

9

Subarachnoid Haemorrhage in LP

Usually blood stained, normal white blood cells,
Red cells high, normal or high protein, glucose normal or high

10

Treatment for TB

RIPE

Rifampicin: 600-900mg
Isoniazid: 15mg/kg
Pyrazinamide: 2.5g
Ethambutol 30mg/kg

All PO 3 times a week

11

What cause of large bowel obstruction appears as a large coffee bean on AXR?

Sigmoid Volvulus

12

What width should the large and small bowel be on AXR

Large= 5cm (except the caecum which is 8cm)

Small= 3cm

13

Name 3 ways of identifying pneumoperitoneum on XR

CXR: air under diaphragm (gastric air bubble under left is normal)
Rigler's sign: see both sides of bowel wall (normally only inner wall is viable) contrast of air inside bowel
Football sign: round area of air, mostly found in neonates.

14

Causes of perforation

obstruction
gallstone disease
inflammatory conditions (Crohn's)
Appendicitis
Trauma

15

What does thumb printing of the bowel on AXR suggest?

Oedema of the bowel wall, occurs in inflammatory bowel disease and ischaemic colitis

If you see an enlarged colon, question if it inflammatory bowel disease-related toxic megacolon (particularly UC)

16

Talk through how to interperate an abdo x ray

1. Projection
2. Patient details
3. Technical Adequacy (entire abdo)
4. Obvious abnormalities
5. Systematic review
- Foreign bodies
- Assess bowel (large then small, size, abnormalities, extra or intraluminal content (air is black, faeces are mottled grey
- Liver, spleen, gallbladder (size, gallstones (most radiolucent))
- Abdominal aorta (calcifications, aneurysm, if suspecting dissection look for psoas muscle shadow (normally present)
-Kidney stones
-Bones (pelvic & hip& spine)
6. Summary: key findings, diagnosis, management plan * differentials

17

Example of describing AXR for small bowel obstruction in OSCE.

This is an AP supine abdominal radiograph. From the identifying markers, I would like ensure it is the correct patient and check the date. A view of the entire abdomen are included in this film.

There are multiple loops of small bowel obstruction. It is the small bowel due to the central distribution & valvulae commiventes.

There is no evidence of hernia or previous surgery. There is no evidence of extraluminal air. The abdominal aorta is not visible and the bladder seems a normal size. There are no apparent bony abnormalities.

In summary, this is an abdominal radiograph showing small bowel obstruction with no evidence of perforation. I would like to arrange an erect chest X-ray to look for free air under the diaphragm.

Differentials for the cause of small bowel obstruction would be adhesions, neoplasia, incarcerated hernias and strictures.

18

Management of small bowel obstruction

-NBM
- Drip & Suck IV access for IV fluids & NG tube
- Bloods: FBC, U&E, LFT, CRP, clotting, group & save (prepare for theatre)
- Erect CXR
- Urgent surgical review for further imaging to surgical intervention

19

Causes of blood on urinalysis

Haematuria or in women form menstrual peroid

20

Ketones

↑DKA & starvation

NB:↑Glucose, metabolic acidosis & ↑ketones for DKA
If no ketones with high glucose = HONK hyperosmolar non ketotic state

- ask patient if they are deliberately trying to lose weight & when they last ate

21

Nitrites & leukocytes

↑ suggest bacterial infection

leukocytes are non-specific
Nitrites only produced by gram negative bacteria. Some infections will be negative.

22

protein

↑renovascular, glomerular, tubulointersitial disease, pre-eclampsia & hypertension

Can be benign (exercise, postal)

In nephrotic syndrome (low albumin, oedema, raised cholesterol & proteinuria) must measure protein loss in 24 hours

23

Glucose

↑diabetes: especially HONK or DKA
can be raised in pregnancy

24

Specific gravity

Concentrating and diluting status of the kidney
↑dehydration, HF, liver failure, syndrome of inappropriate ADH (SIADH)
↓diabetes insipidus & ↑fluid intake

25

Urine pH

useful for UTI & calculi (stones)

- UTI symtoms + alkaline = infection with urea splitting organism
- Acidic calculi made of uric acid & cystine. Alkalinisation of the urine is an important part of the management of these patients (potassium citrate)

26

Management of renal stones

-Diclofenac (NSAID)
- IV fluids
- Antibotics (cefuroxime)

Refer to urology

27

What other test can you do on urine

pregnancy test
microscopy, culture & sensitivity (UTI)
Protein electrophoresis
test for microalbuminuria (DM)

28

ABG interpretation

1. Ask about patients current clinical status. On oxygen, two
2. Is the patient hypoxia
- >10kpa on air
- 10kpa< that FiO2
- <10kpa= hypoxic
<8kpa =severely hypoxic-
- Type 1 or 2 RF: look at pCo2. If >6kpa= Type 2
3. pH. Metabolic (abnormal HCO3-)or Resp (abnormal CO2)??
4. PaCO2: does it fit with pH (high=lowpH) If doesn't make sense (↓CO ↓PH) then think metabolic
- compensation
5. HCO3- (mops H+): low pH= low (acidosis)
6. Base Excess:
- high= ↑level of HCO3, metabolic alkalosis or compensated respiratory acidosis
-Low= metabolic acidosis or compensated respiratory alkalosis

29

Respiratory acidosis

inadequate ventilation = CO2 retention
↓pH ↑ CO2

Respiratory depression (e.g. opiates)
Guillain-Barre – paralysis leads to an inability to adequately ventilate
Asthma
Chronic obstructive pulmonary disease (COPD)
Iatrogenic (incorrect mechanical ventilation settings)

30

Respiratory Alkalosis

hyperventilation
↑pH ↓CO2

Anxiety – often referred to as a panic attack
Pain – causing increased respiratory rate
Hypoxia – resulting in increased alveolar ventilation in an attempt to compensate
Pulmonary embolism
Pneumothorax
Iatrogenic (excessive mechanical ventilation)