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Question

What to consider when prescribing IV fluids to replace

Answer 1

**Which one** - 0.9% NaCl (crystalloid) UNLESS-\> ascites= HAS hypernatramia or hypoglycaemia = 5% dex bleeding = blood or colloid ( gelofusine) first **How much/how fast** - if hypotensive or tachycardic = 500ml stat (250ml if heart failure) - then reasses if only oliguric give 1L over 2-4 hrs - then reasses

Answer 2

**S**tomach Ulcers **T**hin Skin o**E**dema **R**ight and left heart failure **O**steoporosis **I**nfection (including candida) **D**iabetes ( commonly causes hyperglycaemia and uncommonly pregresses to diabetes) Cushing's **S**yndrome **Extra** Proximal myopathy (weakness) in longer term use

Answer 3

Cyclazine good firt line treatmet except cardiac cases Metoclopramide is contraindicated in PD (worsenign of sx) and young women (dyskinesia)

Answer 4

Oxycodonoe MR 10mg BD (can titrate up to max of 400mg per day) PRN oxynorm 5mg q4-6hrs po Morphine breakthrough dose, do 1/6 of total daily dose conversion of weak opiods to morphine you divide by 10 never increase background by more than 50% po morphine to po oxycodone = divide by 2 po morphine to sc morphine = divide by 2 po oxycodone to sc oxycodone = divide by 1.5 Patches if they don't want to be hooked up (buprenorphine or fentanyl - convert using NICE chart) NSAID - any stage Neuropathic: Amytriptyline 10mg nightly or pregabalin 75mg 12 hrly Diabetic Neuropathy: Duloxetine 60mg PO daily An NSAID (e.g, ibuprofen 400 mg 8-hourly may be introduced at any stage regularly or 'as required' if not contraindicated (as discussed earlier under Contraindications). With neuropathic pain (t.e. pain arising from nerve damage or disease and usually described as 'shooting', stabbing' or 'burning) the first line of treatment is amitriptyline (10mg oral nightly) or pregabalin (75 mg oral 12-hourly): duloxetine (60 mg oral daily) is indicated in painful diabetic neuropathy

Answer 5

Eosinophils = allergic reaction, paracites or coxi, Monocytes think TB(and lymphocytes) Infection vs Steroids infection = increase in band neutrophils (steroids you don't get this shift as its not new WCC but WCC moving more into the bloods) Very High Increase in WCC think CDIFF

Answer 6

Hypovolemic tx = stop relevent drugs, IV nacl, 100mg IV hydrocortison if clincial suspician of adrenal insufficiency euvolemic tx= stop relevent drugs, water restric 1 L/day, oral sodium chloride (slow sodium) +/- low dose furesemide, consider demeclocycline hypervolemic tx = tx underlying cause, sodium restrict, fluid restrict 1l/day Monitoring: CNS observations and reassess every 6 hrs till stablised? SIADH Small cell lung tumours Infection Abscess Drugs (esp. carbamazepine and antipsychotics) Head Injury

Answer 7

Oliguric =500ml Oliguric + tachycardia = 1L Oliguric + Tachycardia + shocked = \>2L * reduced urine output (oliguric if \<30 mL/h; anuric if 0 mL/h) indicates 500 mL of fluid depletion * reduced urine output plus tachycardia indicates 1 L of fluid depletion reduced * urine output plus tachycardia plus shocked indicates \>2L of fluid depletion. As a general rule never prescribe more than 2L of IV fluid for a sick patient. The effect on the patient and thus the rate of subsequent fluids should be reviewed regularly.

Answer 8

Maintenance: which fluids and how much? Adults: 1 salty, 2 sweet over 24hrs Elderly : 2 litres over 24hrs K+ determined by U&Es • As a general rule, adults require 3 L IV fluid per 24 hours and the elderly require 2L Adequate electrolytes are provided by 1 of 0.9% saline and 2L of 5% dextrose (1 salty and 2 sweet). To provide potassium, bags of 5% dextrose or 0.9% saline containing potassium chloride (KCL) can be used but this should be guided by urea and electrolyte (U&E) results, with a normal potassium level, patients require roughly 40 mmol KCI per day (so put 20 mmol KCL in two bags)

Answer 9

Adults: 8hrly bags Elderly 12 hrly Check: * U&Es * Overload signs * Bladder NOT palpable (fluids due to decreased output) Maintenance: how fast to give fluids • if giving 3 L per day = 8-hourly bags (24 3). giving 2L per day = 12 hourly bags (24 2). * If In the PSA it will not be possible to assess the patient; however, every time you prescribe fluids in real life, you must: * Check the patient's U&E to confirm what to give them. Check that the patient is not fluid overloaded (e.g. increased jugular venous pressure (JVP), peripheral and pulmonary oedema). • Ensure that the patient's bladder is not palpable (signifying urinary obstruction) if giving replacement fluids because of reduced urine output'.

Answer 10

To prevent thromboembolism pretty much everyone receives : **Remember LMW heparin eg enoxaparin** **and** **Compression Stockings** But remember the contraindications

Answer 11

Urea better marker for dehydration than Cr

Answer 12

Urea:Cr = Urea/ (creatine/1000)

Answer 13

1. Situation: reason for the bleep 2. Background 3. Assessment: Observations and relevent clinical information. If EWS is high then inform senior. 4. Recommendation: What do they want you to do? 5. Preparation: ask for nurses to prepare for you arrival .. - notes, nursing file, free computer, equipment for bloods etc. or ask nurses to do the bloods etc - prepare yourself by going over notes and information on the system 6. Instructions: specific things eg cultures, bloods, lactate for patient spiking a temperature 7. Where does this patient lie in your list of priorities?

Answer 14

1. ABCDE 2. Document initial Ax and Mx 3. R/v nursing file for obs chart, fluid balance, warfarin charts, fluid prescriptions 4. review medical notes and clerking then summarise 5. r/v prescription chart 6. Problem list 7. Working Diagnosis 8. Action plan : use tick boxes for Ix you have ordered 9. Keep thier details eg sticker on handover sheet . . . .what are YOU going to do later or what do you need to handover?

Answer 15

**Normal Ranges** pH: 7.35 – 7.45 PaCO2: 4.7 – 6.0 kPa || 35.2 – 45 mmHg PaO2: 11 – 13 kPa || 82.5 – 97.5 mmHg HCO3–: 22 – 26 mEq/L Base excess (BE): -2 to +2 mmol/L **Hypoxic?** \<10 kPa on air = hypoxaemic \<8 kPa on air = severely hypoxaemic **Type 1 or 2?** **Type 1 respiratory** failure involves hypoxaemia (PaO2 \<8 kPa) with normocapnia (PaCO2 \<6.0 kPa). V/Q (ventilation/perfusion) mismatch\>hypoxia + hypercapnaei \> increased RR then blows off CO2 causes: alveolar hypoventilation (pneumonia, ARDS, pulmonary oedema), distribution/diffusion) (pulmonary fibrosis), perfusion (pulmonary embolism) **Type 2 respiratory** failure involves hypoxaemia (PaO2 \<8 kPa) with hypercapnia (PaCO2 \>6.0 kPa). Alveolar hypoventilation: Central (coma, intracerebral haemorhage), Neuromuscular (muscular dystrophy), obstruction (COPD/ Asthma), restriction (pulmonary fibroisis, pneumothorax) -airway obstruction (COPD) -reduced compliance (pneumonia/rib fracturs/ obesity - reduced respiratory muscle strength (Guilian-barre/MND) -Drugs reducing resp rate (opiates) **pH?** Acidotic: pH \<7.35 Normal: pH 7.35 – 7.45 Alkalotic: pH \>7.45 imbalance in the CO2 (respiratory) or HCO3– (metabolic). **PaCO2?** Does it correlate or not\> **Bicarbonate?** Does this correlate? **(Base Excess)** High base excess = \> +2mmol/L = high HCO3- = primary metabolic alkalosis or compensated respiratory alkalosis Low base excess = \< -2mmol/L = low HCO3- = primary metabolic acidosis or compensated respiratory alkalosis respiratory compensation is quicker than metabolic (days) **Compensation?** Assess compared to primary disturbance **Anion Gap?** Normal = 4-12 mmol/L Anion gap formula: Anion gap = Na+ – (Cl- + HCO3-) An increased anion gap indicates increased acid production or ingestion: Diabetic ketoacidosis (↑ production) Lactic acidosis (↑ production) Aspirin overdose (ingestion of acid) A decreased anion gap indicates decreased acid excretion or loss of HCO3–: Gastrointestinal loss of HCO3– (e.g. diarrhoea, ileostomy, proximal colostomy) Renal tubular acidosis (retaining H+) Addison’s disease (retaining H+) **Mixed acidosis/alkalsosis** CO2 and HCO3- will be moving in oppositie directions tx each primary acid/base disturbance **Context** A ‘normal’ PaO2 in a patient on high flow oxygen: this is abnormal as you would expect the patient to have a PaO2 well above the normal range with this level of oxygen therapy. A ‘normal’ PaCO2 in a hypoxic asthmatic patient: a sign they are tiring and need ITU intervention. A ‘very low’ PaO2 in a patient who looks completely well, is not short of breath and has normal O2 saturations: this is likely a venous sample.

Answer 16

Glasgow coma scale (GCS) scores are generally expressed in the following format 'GCS = 13, M5 V4 E4 at 21:30'.7 Intubate if GCS \<8 (eg cuffed endotracheal tube)

Answer 17

Abbreviated Mental Test AMT-4: (\<4 = abnormal cognition) Age DoB Place Year AMT-10 (7-8 cut off to ix further for dementia) Time (nearest hour) Address to recall later (42 west street) Identification of two persons (eg doctor/nurse) Year of First world war ended Name of The Monarch Prime Minister Count backwards from 20 -1 Recall the address 8-10 = no cognitive impairement, 4-7 =impaired and 0-3 = severely impaired

Answer 18

IMPOTENCE **Introduction** * What surgery & when?* * How many days post op? Anaesthetic type? +/- sedation* * Intra-operative complications?* **Mental State** Alert & orientated? GCS/AVPU? Consider AMT10 **Pain** Where is the pain?- SOCRATES Is analgesia effective? PONV - antiemetic Laxatives **Observations** EWS - BP/HR/SPOZ/RESPS/TEMP +/- CVS/RESP EXAM +/- glucose measurement **Thromboprophylaxis** Calves soft & non-tender?-DVT Compression stockings Foot pumps LMWH Consider chest - PE Mobile ASAP **Eating and Drinking** Diet & fluids IV fluids / oral input fluid chart PU/catheter - why catheterised? Colour/amount? Bowels open? Passed flatus/bowel sounds/Abdo SNT **Neurovascular** Check distal neurovascular status & document - take into consideration, surgical positioning/anaesthetic /surgery **Cut** Surgical wound site - is it clean dry & intact? Why has the dressing been changed? Any drains? **Exercise** Has the patient been up & mobilising? Walking aids used?

Answer 19

Moderate symptoms: nausea, confusion, headache Severe symptoms: vomiting, cardiorespiratory distress, severe somnolence, seizures, coma (GCS = 8)

Answer 20

Does the patient need oxygen? Fluid balance: IV fluids? Urinary catheter? Drugs: Analgesia, Anti-emetic, Antibiotics VTE prophylaxis Escalation

Answer 21

Bedside tests Blood tests Microbiology Imaging Specialist tests

Answer 22

**REEDA** **Redness** **oEdema** **Ecchymosis** **Drainage** Serous Sanguineous serosanguineous Purulent **Approximation** well or poorly approximated?

Answer 23

Pain, stiffness in joints ? circadian rhythm  Pain, stiffness in muscles  Tingling/weakness in hand eg CTS  Falls, difficulty walking or dressing or ADL  Any skin lesions: rash, ulcer, blisters, heat bruising, itching, bleeding, colour change Rash specific: itching/pain

Answer 24

**Pain** SOCRATES **Rashes**, skin lesions and nail changes : noticed any **Immune**: think systemic sclerosis, SLE and Sjojens **Stiffness**: when is it worse, what ADLS does it affect (RA, Alk Spond, SLE and reactive arthritis) **Malignancy**: weight loss, night sweats, appetite and tiredness **Swelling and sweats**: when, painful, redness, what ADLs does it affect

Answer 25

Have they been eating and drinkning normaly? Have they been having the normal amount of wet and dirty nappies for them? Any nausea or vommitting? Any Fevers? Any Rahes? Any coughs or runny noses? any changes in weight? Any pain? Have you felt they've not been their normal self in any other way? Dietary intake: clarify what the child’s baseline dietary intake is and, if relevant, how this has changed recently. Fluid intake: calculate the child’s fluid intake over the last 24 hours. Urine output: ask if there has been any change in the child’s urine output (in younger children, ask if there has been a change in the number of wet nappies). Stool: ask about the recent frequency and form of the child’s stools. Vomiting: if the child has been vomiting, determine the frequency, volume and consistency of the vomit (e.g. bilious, haematemesis). Ask specifically about projectile vomiting if considering pyloric stenosis as an underlying diagnosis. Fever: ask if the child has had a fever recently and if this was confirmed with a thermometer. Rash: ask if the child currently has a rash, including its location, whether it appears to be spreading and if it appears to be itchy. Coryzal symptoms: ask if the child has recently had a runny nose, or sounded ‘sniffly’. Cough: ask if the child has a cough and if they are bringing up any sputum with it. Gain further details about the frequency of the cough, including associations with particular triggers or times of the day (e.g. nocturnal cough). Work of breathing: ask if the child’s breathing has appeared more laboured recently. Weight change: ask if the child appears to be gaining weight at an appropriate rate and review growth charts if available. Behaviour: ask if the child appears to be their usual self, including their level of activity, mood and social interaction. Pain: ask if the child appears to be in pain and further explore this using the SOCRATES acronym.

Answer 26

vision changes/ double vision Flashes/Floaters Photophobia Eye pain Jaw/Temporal Pain Headache/neuro changes Trauma/Wear Contacts

Answer 27

**Ears** Hearing changes? Muffled? Uni/Bi? Titinis Discharge (ottorhea/purulent) Blood per ear Pain? - where? pulling/swallowing? Vertigo facial weakness **NOSE (unilateral things worse!)** Discharge? clear/purulent Blood? Breathing problems? snoring? Pain/ Headaches(sinisitis) Facial Pain Buccal Swelling Visual disturbances (cancer growth **Throat (ALARMS 55)** Anaemia Loss of weight Anorexia Recent onset/rapid progression Malaena Swallowing difficulty \>55

Answer 28

THREE QUESTIONS ## Footnote In the last month: have you had difficulty sleeping because of your asthma symptoms (including cough)? (662P) have you had your usual asthma symptoms during the day (cough, wheeze, chest tightness, or breathlessness)? (662Q) has your asthma interfered with your usual activities (e.g. housework, work/school, etc)? (662N).c then address: -rv diagnosis check twchnique address adherence treat rhinitis with nasal steroids assess smoking status then adjust meds

Answer 29

Fever FND Age \>50 Thunderclap Headache progressivly worseining N+V

Answer 30

Hypovolaemia Hypoxia Hypercapnia Metabolic disturbance (hypoglycaemia) Seizure Raised intracranial pressure/other neurological insults Drug overdose Iatrogenic causes (e.g. administration of opiates for pain relief)

Answer 31

Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for melanoma if they have a suspicious pigmented skin lesion with a weighted 7-point checklist score of 3 or more. Weighted 7-point checklist: Major features of the lesions (scoring 2 points each): Change in size. Irregular shape. Irregular colour. Minor features of the lesions (scoring 1 point each): Largest diameter 7 mm or more. Inflammation. Oozing. Change in sensation.

Answer 32

Higher centres = GABA + H1 comitting centre = ach, h1, nk1 chemotactic trigger zone = d2, 5ht3, nk1 vestibular apparatus = ach, h1 GI tracT = 5HT3, 5HT4, d2 all feed into vomitting centre regular \> prn syringe drive = xcellent not po if comitting dont give cyclazine and metoclopramide togetheer levomepromazine a good choice in last days of life as broad-spectrum.

Answer 33

Abdo Or Pelvic Pain? PCB? IMB? PMB? Discharge?: Volume/ Coluor/ Consistency/ Smell Dyspareunia?: Duration/ location (deep or superficial)/ character Vulval skin changes or itching? Systemic: sytems r/v (esp water works)

Answer 34

Severe Asthma = any of a. PEFR 33%–50% best or predicted value b. Respiratory rate ≥25/min c. Heart rate ≥110/min d. Inability to complete sentences in one full breath Life Threatening = any of : a. Clinical – altered consciousness, signs of exhaustion, poor respiratory effort, hypotension, cyanosis, silent chest or evidence of arrhythmia b. Objective parameters – PEFR \<33% predicted, O2 saturations \<92%, pO2 \<8 kPa or a ‘normal’ pCO2 (4.5–6 kPa, indicating respiratory fatigue with inability to maintain hyperventilation as a mechanism to boost oxygenation)

Answer 35

Aim 94%-98% in most 88%-92% in known T2 resp failure Nasal cannula 2l-6l = 24-50% FIO2 Simple face mask for low to moderate o2 requirement . . . . hard to know how much o2 delivered. ventri adapter tells specific flow rate and associated fio2 (24- 60% fio2) usually used when specific amounts need to be delivered such as copd with t2rf non-rebreath mask = 60-80% fio2. . . . uses 12litre-15litres . . . .. must hold valve to fill up bagmask at start

Answer 36

<4 hours symptom onset?(think FAST, Rosier Score, BM) - AtoE (ensure stable or take to resus), hx, time onset, neurological assessment, - Fast +ve > Rosier +ve > bleep stroke team ?999 ambulance transfer - In the meantime: NBM, 2 cannulas, stroke/tia bloods (fbc, u+e, glu, coag, lipids , G+S, ECG, no aspirin >4hrs, consider bm, fast, rosier and contact stroke for advice. NIHSS (national institue of health and stroke score) - more in depth score predictive of outcomes Image considerations are ROH specific (?avoid CT if going to send to Stroke anyway)

Answer 37

A to and oxygen 2 large bore cannulas : FBC, U+Es, LFRs, Clotting, VBG, crossmatch 6 units arrange blood transfusion/ give crystalloid vs major haemorhage protocol correct coagulopathy (plts \> 50, vit/ffp, reverse anti-coags) Varicell bleed + 2mg IV terlipressin, 4.5g pip-tazo, metoclopromide 10mg escalate to med reg or GI consultant discontinue NSAIDs, aspirin and antiplatelets

Answer 38

provide analgesia for mod-servere pain within 15 mins of arrival Elderly and pregnant paracetamol good, avoid NSAIDs codeine/mophine if neccessary ton pregnant NSAIDs ibuprophen 400mg po TDS naproxen 500mg po initially then 250mg every 6-8hrs Diclofenac 50mg po TDS or 100mg PR (renal colic but contraindicated in iHD, PVD, CVD and HF avoid nhsaids in peptic ulcer disease, elderly , pregnancy and woman with fertility issues codeine phosphate 30-60mg qds (lower in elderly) oral morphine not generaly recomended in ED due to slow onset unless already on background. IV morphine: 0.1- 0.2mg/kg = normal adult dose.. . . . but titrate to desired response entonox: quick . . .in acute assessment/trauma . . . contraindicated for head/chest injuries penthrox (methyoxyflurane): mod-severe pain in trauma setting (quick onset) contraindicated in renal/hepatic failure, cardiac insufficiency, resp depression or malignant hyperthermia ketamine alagesia. 0.1-0.3mg/kg iv. bolus over 5 mins (15mins to avoid sedation/neuropsychiatric SEs_ Alternatives relaxation esp paeds local /regional anaesthesia immobilisation early reduction of fracture/dislocations

Answer 39

apply pressure to soft part of nose, lean forward, ice pack to forehead or neck. only seek medical attention after 20 mins Box 1: 1st Aid Sit patient with upper body tilted forward and mouth open. Pinch the soft cartilaginous part of the nose firmly and hold for 10-20 minutes Box 2: History  Estimated blood loss/severity of bleeding  Recurrent bleeding?  History of trauma/surgery?  Symptoms of hypovolaemia  Symptoms of underlying causes of causes of epistaxis  Past medical history  Drug history (esp anticoagulants)  1 st aid already received Box 3: Cautery  Clear clots by blowing nose  Use topical LA spray with vasoconstrictor  Wait 3-4 minutes  Identify bleeding point and lightly apply silver nitrate stick for 3-10 seconds  Only cauterise one side of nasal septum to avoid perforation  Avoid touching areas which do not need treatment Box 4: Nasal Packing  Ensure topical LA with vasoconstrictor  Wait 3-4 minutes  Insert nasal pack (eg rapid rhino) as per manufacturers instructions

Answer 40

mild: < 4 stools/day, only a small amount of blood moderate: 4-6 stools/day, varying amounts of blood, no systemic upset severe: >6 bloody stools per day + features of systemic upset (pyrexia, tachycardia, anaemia, raised inflammatory markers) severe = admit for IV steroids

Answer 41

Complaint (presenting) History of presenting complaint Allergies Medications Past medical history Social history

Answer 42

5 ps Precipitant Prodrome Position Palpitations Post-event phenomena

Answer 43

Signs and symptoms Allergies Medication Past medical history Last oral intake Events leading up to the illness or injury

Answer 44

“Is The Physician Really So Cool?” Inspection Tone Power Reflexes Sensation Co-ordination

Answer 45

Appearance (colour, pain, breathlessness etc) Behaviour (calm, agitated etc) Connections (oxygen, catheters, cannulas, surgical drains etc)

Answer 46

Pulmonary embolism Ischaemia Respiratory disease Atrial enlargement or myxoma Thyroid disease Ethanol Sepsis/sleep apnoea

Answer 47

SAD Syncope (exertional) Angina Dyspnoea

Answer 48

Airway: trachea, carina, bronchi and hilar structures. Breathing: lungs and pleura. Cardiac: heart size and borders. Diaphragm: including assessment of costophrenic angles. Everything else: mediastinal contours, bones, soft tissues, tubes, valves, pacemakers and review areas.

Answer 49

“The 5 Is” Infection Ischaemia Infarction Ignorance (poor diabetic control) Intoxication

Answer 50

BINDS Birth Immunisations Nutrition Development Social history

Answer 51

TUNA FISH Trauma Unexplained weight loss Neurological symptoms / signs Age > 50 Fever Intravenous drug use Steroid use History of cancer

Answer 52

RBBB + RAD/LAD (suggesting a hemiblock) - can lead to complete block. Bifascicular block involves conduction delay below the atrioventricular node in two of the three fascicles: Conduction to the ventricles is via the single remaining fascicle. The ECG will show typical features of RBBB plus either left or right axis deviation. RBBB + LAFB is the most common of the two patterns.

Answer 53

Cushings triad

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