Passmedicine Notes PDF

Preview

Summary

Passmedicine Notes...

Description

PASSMEDICINE NOTES Fluid Therapy The prescription of intravenous fluids is one of the most common tasks that junior doctors need to do.

In the 2013 guidelines NICE recommend the following requirements for maintenance fluids: 25-30 ml/kg/day of water and approximately 1 mmol/kg/day of potassium, sodium and chloride and approximately 50-100 g/day of glucose to limit starvation ketosis So, for an 80kg patient, for a 24 hour period, this would translate to: 2 litres of water 80mmol potassium For the first 24 hours NICE recommend the following: When prescribing for routine maintenance alone, consider using 25-30 ml/kg/day sodium chloride 0.18% in 4% glucose with 27 mmol/l potassium on day 1 (there are other regimens to achieve this). The amount of fluid patients require obviously varies according to their recent and past medical history. For example a patient who is post-op and is having significant losses from drains will require more fluid whereas a patient with heart failure should be given less fluid to avoid precipitating pulmonary oedema. The table below shows the electrolyte concentrations (in millimoles/litre) of plasma and the most commonly used fluids:

Raynaud’s Phenomenon Raynaud's phenomena may be primary (Raynaud's disease) or secondary (Raynaud's phenomenon). Raynaud's disease typically presents in young women (e.g. 30 years old) with bilateral symptoms. Factors suggesting underlying connective tissue disease       

onset after 40 years unilateral symptoms rashes presence of autoantibodies features which may suggest rheumatoid arthritis or SLE, for example arthritis or recurrent miscarriages digital ulcers, calcinosis very rarely: chilblains

Secondary causes      

connective tissue disorders: scleroderma (most common), rheumatoid arthritis, SLE leukaemia type I cryoglobulinaemia, cold agglutinins use of vibrating tools drugs: oral contraceptive pill, ergot cervical rib

Management  

first-line: calcium channel blockers e.g. nifedipine IV prostacyclin (epoprostenol) infusions: effects may last several weeks/months

Nifedipine is the first line drug treatment, other treatments that may be useful according to NICE include evening primrose oil, sildenafil and prostacyclin (for severe attacks/digital gangrene). Chemical or surgical sympathectomy may help in those who have severe disease.

Degenerative cervical myelopathy Degenerative cervical myelopathy (DCM) has a number of risk factors, which include smoking due to its effects on the intervertebral discs, genetics and occupation - those exposing patients to high axial loading [1]. The presentation of DCM is very variable. Early symptoms are often subtle and can vary in severity day to day, making the disease difficult to detect initially. However as a progressive condition, worsening, deteriorating or new symptoms should be a warning sign. DCM symptoms can include any combination of [1]:  

 



Pain (affecting the neck, upper or lower limbs) Loss of motor function (loss of digital dexterity, preventing simple tasks such as holding a fork or doing up their shirt buttons, arm or leg weakness/stiffness leading to impaired gait and imbalance Loss of sensory function causing numbness Loss of autonomic function (urinary or faecal incontinence and/or impotence) - these can occur and do not necessarily suggest cauda equina syndrome in the absence of other hallmarks of that condition Hoffman's sign: is a reflex test to assess for cervical myelopathy. It is performed by gently flicking one finger on a patient's hand. A positive test results in reflex twitching of the other fingers on the same hand in response to the flick.

The most common symptoms at presentation of DCM are unknown, but in one series 50% of patients were initially incorrectly diagnosed and sometimes treated for carpal tunnel syndrome [2]. An MRI of the cervical spine is the gold standard test where cervical myelopathy is suspected. It may reveal disc degeneration and ligament hypertrophy, with accompanying cord signal change. All patients with degenerative cervical myelopathy should be urgently referred for assessment by specialist spinal services (neurosurgery or orthopaedic spinal surgery). This is due to the importance of early treatment. The timing of surgery is important, as any existing spinal cord damage can be permanent. Early treatment (within 6 months of diagnosis) offers the best chance of a full recovery but at present, most patients are presenting too late. In one study, patients averaged over 5 appointments before diagnosis, representing >2 years. Currently, decompressive surgery is the only effective treatment. It has been shown to prevent disease progression. Close observation is an option for mild stable disease, but anything progressive or more severe requires surgery to prevent further deterioration. Physiotherapy should only be initiated by specialist services, as manipulation can cause more spinal cord damage.

Acute Confusional State Acute confusional state is also known as delirium or acute organic brain syndrome. It affects up to 30% of elderly patients admitted to hospital. Features - wide variety of presentations       

memory disturbances (loss of short term > long term) may be very agitated or withdrawn disorientation mood change visual hallucinations disturbed sleep cycle poor attention

Management   



treatment of underlying cause modification of environment the 2006 Royal College of Physicians publication 'The prevention, diagnosis and management of delirium in older people: concise guidelines' recommended haloperidol 0.5 mg as the firstline sedative the 2010 NICE delirium guidelines advocate the use of haloperidol or olanzapine

Rheumatoid Arthritis The clinical features are suggestive of rheumatoid arthritis (RA). It is important to remember that Anti-CCP (cyclic citrullinated peptide) antibody is positive in approximately 40% of patients who test negative for Rheumatoid Factor. Therefore, Anti-CCP is an important diagnostic test for RA. NICE have stated that clinical diagnosis is more important than criteria such as those defined by the American College of Rheumatology. 2010 American College of Rheumatology criteria Target population. Patients who 1) have at least 1 joint with definite clinical synovitis 2) with the synovitis not better explained by another disease Classification criteria for rheumatoid arthritis (add score of categories A-D; a score of 6/10 is needed definite rheumatoid arthritis) Key  

RF = rheumatoid factor ACPA = anti-cyclic citrullinated peptide antibody

Anal Fissure Pain on passing faeces accompanied by bleeding post-defaecation is suggestive of a diagnosis of fissure in ano. Thrombosed haemorrhoids may also present with painful PR bleeding but in this scenario a fissure is more likely. This young lady has a background of Crohn's disease and that patients with Crohn's disease are more susceptible to fissure formation. Rectal cancer can present with rectal bleeding but would be unlikely in a 36-year-old. Recto-uterine fistulas typically cause faecal incontinence rather than bleeding. A perianal abscess would cause perianal pain and may be accompanied by pyrexia. Anal fissures are longitudinal or elliptical tears of the squamous lining of the distal anal canal. If present for less than 6 weeks they are defined as acute, and chronic if present for more than 6 weeks. Around 90% of anal fissures occur on the posterior midline Risk factors   

constipation inflammatory bowel disease sexually transmitted infections e.g. HIV, syphilis, herpes

Features 

painful, bright red, rectal bleeding

Management of an acute anal fissure (< 6 weeks)      

dietary advice: high-fibre diet with high fluid intake bulk-forming laxatives are first line - if not tolerated then lactulose should be tried lubricants such as petroleum jelly may be tried before defecation topical anaesthetics -analgesia topical steroids do not provide significant relief

Management of a chronic anal fissure (> 6 weeks)   

the above techniques should be continued topical glyceryl trinitrate (GTN) is first line treatment for a chronic anal fissure if topical GTN is not effective after 8 weeks then secondary referral should be considered for surgery or botulinum toxin

Cardiology

Cardiologist taught me to remember the 3 D's for Beck's triad: - Drop in BP - Distant heart sounds (muffled) - Distended neck veins (Raised JVP)

Situation Major bleeding

Management

Stop warfarin Give intravenous vitamin K 5mg Prothrombin complex concentrate - if not available then FFP* INR > 8.0 Stop warfarin Minor Give intravenous vitamin K 1-3mg bleeding Repeat dose of vitamin K if INR still too high after 24 hours Restart warfarin when INR < 5.0 INR > 8.0 Stop warfarin No bleeding Give vitamin K 1-5mg by mouth, using the intravenous preparation orally Repeat dose of vitamin K if INR still too high after 24 hours Restart when INR < 5.0 INR 5.0-8.0 Stop warfarin Minor Give intravenous vitamin K 1-3mg bleeding Restart when INR < 5.0 INR 5.0-8.0 Withhold 1 or 2 doses of warfarin No bleeding Reduce subsequent maintenance dose

Poorly controlled hypertension, already taking an ACE inhibitor, calcium channel blocker and a thiazide diuretic. K+ < 4.5mmol/l - add spironolactone Massive PE + hypotension - thrombolyse DOACs such as apixaban or rivaroxaban should now be offered as first-line treatments for PE. If neither of these are suitable then LMWH followed by another DOAC such as dabigatran or edoxaban OR LMWH followed by a vitamin K antagonist (e.g. warfarin) may be used. Bisoprolol is used in rate control of longstanding tachycardias If angina is not controlled with a beta-blocker, a calcium channel blocker should be added

Angina Pectoris Management

Rate-limiting (non-dihydropyridine) ca channel blockers (Verapamil, more specifically as it's effect is more pronounced than Diltiazem) shouldn't be used with beta-blockers as there is risk of complete heart block. However, dihydropyridine ca channel blockers(e.g. amlodipine, nifedipine) can be used with beta blockers as they act on blood vessels rather than the heart, so the risk of heart block isn't there.

   

all patients should receive aspirin and a statin in the absence of any contraindication sublingual glyceryl trinitrate to abort angina attacks NICE recommend using either a beta-blocker or a calcium channel blocker first-line based on 'comorbidities, contraindications and the person's preference' if a calcium channel blocker is used as monotherapy a rate-limiting one such as verapamil or diltiazem should be used. If used in combination with a beta-blocker then use a long-acting dihydropyridine calcium-channel blocker (e.g. modified-release nifedipine). Remember that beta-blockers should not be prescribed concurrently with verapamil (risk of complete heart block)

Common side effects of amiodarone:

      

Bradycardia Hyper/hypothyroidism pulmonary fibrosis/pneumonitis liver fibrosis/hepatitis jaundice taste disturbance persistent slate grey skin discolouration

Aortic regurgitation - early diastolic murmur, high-pitched and 'blowing' in character IVDU are more prone to tricuspid valve vegetations exactly due to your explanation. The most classic is tricuspid syndrome in IVDU with persistent fever associated with pulmonary events, anemia, and microscopic hematuria. The recommended dose of adrenaline to give during advanced ALS is 1mg

If it was his first episode of AF and he was now in sinus he wouldn't be classed as having AF (you need 2 or more episodes) so you wouldn't need to anticoagulate. In paroxysmal treat with flecainide, and persistent you attempt to cardiovert, so I'm not sure if they require anticoagulation, logic would dictate that they wouldn't but this question definitely isn't continuous (permanent) AF yet it says anticoagulation (or at least consideration of via CHADS VASc) is indicated it is important to recognize that Beta Blockers can cause the following in overdose: Hypotension Bradycardia HYPOGLYCEMIA Hypothermia This is why we treat BB overdose with Atropine, Glucagon, and high dose insulin in 10% dextrose Verapamil has been shown to be effective for prophylaxis of cluster headaches Pulmonary embolism and renal impairment → V/Q scan is the investigation of choice ^^ due to contrast – renal AKI

Cardiovascular disease: atorvastatin 20mg for primary prevention, 80mg for secondary prevention Heart Failure Management:

1st line: ACEi + beta blocker (bisoprolol) 2nd line: Aldosterone antagonist/ARBs/Hydralazine (particularly if African) + nitrate eg isosorbide dinitrate 3rd line: cardiac resynchronisation therapy (biventricular pacemaker) OR digoxin (strongly recommended if coexistent Afib).   

offer annual influenza vaccine offer one-off pneumococcal vaccine CHA2DS2-VASc, I find SADCHAVS easier to remember. The top two in the list are the 2 point scores, and the rest 1. Stroke 2 Age >75 2 Diabetes 1 Congestive Heart Failure 1

HTN 1 Age >65 1 Vascular Hx 1 Sex Female 1 VT - Very Tidy. VF - Very Funny. An inferior myocardial infarction and AR murmur should raise suspicions of an ascending aorta dissection rather than an inferior myocardial infarction alone. Bendroflumethiazdie = Hypokalaemia - U waves on ECG

Day 1-2: 'Wind' - Pneumonia, aspiration, Pulmonary Embolism Day 3-5: 'Water' - Urinary tract infection (esp. if catheterised) Day 5-7: 'Wound' - Infection at the surgical site or abscess formation Day 5+: 'Walking' - Deep vein thrombosis or Pulmonary embolism Any time: 'Wonder Drugs’, transfusion reactions, sepsis, line contamination. Sydenham’s chorea is a late complication of rheumatic fever The main ECG abnormality seen with hypercalcaemia is shortening of the QT interval Colchicine should be used to treat acute gout if NSAIDs are contraindicated for example a peptic ulcer Guidelines have advised that patients with fragility fractures and if their age is >= 75y years old, treatment for presumed osteoporosis should be commenced without the need for a DEXA scan. CLOT – Coagulation defect e.g. APTT, Liverdo reticularis, Obstetric complications (i.e. miscarriages), Thrombocytopenia De Quervain's tenosynovitis is caused by inflammation of the extensor pollicis brevis and abductor pollicis longus tendon sheath causing radial styloid process pain and painful abduction of the thumb against resistance. It is also known colloquially as 'texter's thumb' as repetitive texting motions have been associated with causing this inflammatory response. Ultrasound is the initial imaging modality of choice for suspected Achilles tendon rupture

Chondrocalcinosis helps to distinguish pseudogout from gout Direct trauma to the knee can result in patella dislocation. Patella dislocation is associated with a positive patellar apprehension test Twisting knee injury can result in a meniscal tear (with potential medial collateral ligament sprain). The knee would be swollen and painful to palpate. McMurray’s test would also be positive (painful click). Back pain with previous history of cancer is a red flag Galeazzi fractures occur after a fall on the hand with a rotational force superimposed on it. On examination, there is bruising, swelling and tenderness over the lower end of the forearm. X- Rays reveal a displaced fracture of the radius and a prominent ulnar head due to dislocation of the inferior radio-ulnar joint.

Rheumatic fever

Monday 14 Dec – 100 Neuro Qs Passmed, Resp teaching Tuesday 15 Dec – 100 Cardio Passmed Qs, 40 SBAs, Cardio Valvular teaching, cardio flashcards Wednesday 16 Dec – 40 MSK Passmed Qs, Rheum flashcards, Rheum Teaching, 35 SBAs 01204576691 capital windows quote from us Serial number...