1
Q
5 things to consider with new undifferentiated patient - Murtaugh
A
2
Q
When to refer for a cardiac murmur in paeds:
Who to refer to:
A
Refer to a Paediatric Cardiologist when:
- Murmur in neonates - higher chance of pathologic murmur vs older kids
Older children with murmurs that include:
- Diastolic
- Holosystolic
- Harsh or loud sounding
- Radiation to back or neck
- Signs of cardiac disease
- FHx cardiac disease
Note - ECG, CXR and other tests should not be reflexively performed, as they aren’t cost effective!
3
Q
Differential Diagnosis of Systolic Murmurs - Table
Note:
- Common Diseases
- Site and Radiation
- Accentuation and Dynamic maneuvres
- Other Features
A
4
Q
Three main presentations of
unstable angina
A
- Angina at rest—Also prolonged, usually > 20 minutes
- Angina of new onset—At least CCS class III in severity
- Angina increasing—Previously diagnosed angina that has become more frequent, longer in duration, or lower in threshold (change in severity by >1 CCS
class to at least CCS class III)
CCS=Canadian Cardiovascular Society
5
Q
Complications of Myocardial Infarction
A
Darth Vader
- Death
- Arrhythmia
- Rupture (free ventricular wall/ ventricular septum/ papillary muscles)
- Tamponade
- Heart failure (acute or chronic)
- Valve disease
- Aneurysm of ventricle
- Dressler’s syndrome
- ThromboEmbolism (mural thrombus)
- Recurrence/ mitral Regurgitation
6
Q
Indications for coronary reperfusion therapy:
A
- Persistent ST elevation ≥1mm in 2 contiguous limb leads; or
- ST elevation ≥2mm in 2 contiguous chest leads
7
Q
How to classify risk factors for NSTEACS - (Non ST-Elevation Acute Coronary Syndrome)
Note - High/Med/Low Risk
A
8
Q
Overview of STEMI management
A
For patients with a STEMI undergoing primary percutaneous coronary intervention (PCI) or in whom PCI is planned, give aspirin plus a P2Y12 inhibitor; use:
Note:
- Aspirin 300mg oral 1st day,
- then 150mg/daily after
- Ticagrelor 180mg oral 1st day,
- then 90mg BD after
9
Q
- For patients with a STEMI undergoing primary percutaneous coronary intervention (PCI) or in whom PCI is planned, give aspirin plus a P2Y12 inhibitor
- Indications for use of Clopidogrel over Ticagrelor or Prasuragrel in DAPT therapy
A
Clopidogrel is used if ticagrelor and prasugrel are not available or are contraindicated 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.
10
Q
Contraindications to thrombolytic therapy in ST elevation myocardial infarction
A
Absolute contraindications
- any prior intracranial haemorrhage
- known structural cerebral vascular lesion (eg arteriovenous malformation)
- known malignant intracranial neoplasm (primary or metastatic)
- ischaemic stroke within 3 months, except acute ischaemic stroke within 4.5 hours
- suspected aortic dissection
- active bleeding or bleeding diathesis (excluding menses)
- significant closed head or facial trauma within 3 months
Relative contraindications
- history of chronic, severe, poorly controlled elevated blood pressure
- severely elevated blood pressure on presentation (more than 180 mmHg systolic or more than 110 mmHg diastolic)
- ischaemic stroke more than 3 months ago, dementia, or known intracranial abnormality not covered as an absolute contraindication
- traumatic or prolonged (more than 10 minutes) cardiopulmonary resuscitation
- recent (within 3 weeks) major surgery
- recent (within 4 weeks) internal bleeding (eg gastrointestinal or urinary tract haemorrhage)
- noncompressible vascular punctures in the past 24 hours (eg liver biopsy, lumbar puncture)
- pregnancy or within 1 week postpartum
- active peptic ulcer disease
- current use of anticoagulants
- advanced liver disease
- infective endocarditis
- transient ischaemic attack in the preceding 6 months
11
Q
Contraindications to Thrombolysis
A
ABSOLUTE
* Allergy
* Aortic Dissection
* Acute Pericarditis
* Active Bleeding
* Known intracranial vascular abnormality.
RELATIVE
* CVA (embolic < 2 months, Haemorrhagic ever)
* Surgery to Brain/ Back /eye (< 2months)
* Acute Haemorrhage‐ GIT/Non compressible site (< 2months)
* HT diastolic>110 (uncontrolled despite analgesia and nitrates).
* Major Trauma (< 2weeks)
* Recent major surgery ( < 2 weeks ‐discuss with surgeon).
* Pregnancy
* Unable to get consent
* CPR
* Streptokinase if STK > 6 days ago.
12
Q
Red flags LBP
When to refer
A
ED
- Cauda equina syndrome
- Suspicion spinal # - Trauma, sudden onset severe P relieves lying down
Radiation Oncologist
- Aged 50 or older, gradual onset of symptoms
- Severe unremitting pain that remains when the person is supine, night pain
- Localised spinal tenderness
- No symptomatic improvement after 4-6 weeks of therapy
- Unexplained weight loss, past history of cancer — breast, lung, gastrointestinal,
prostate, renal, and thyroid cancers are more likely to metastasise to the spine
ED/ID specialist
- Fever
- Tuberculosis, or recent urinary tract infection
- Diabetes
- History of intravenous drug use
- HIV infection/ immunosuppression
Rheumatology
- AS suspicion
- Morning stiffness
- Improvement with exercise
- Alternating buttock pain
- Awakening due to back pain at night
- Younger age, male
13
Q
LBP Diagnostic Triage
A
– non-specific LBP (NSLBP) 90% - mechanical/ muscular and spondylosis
– radicular syndrome <10%
– specific spinal pathology <1%
– Look for diagnostic triads
– Consider red flags, yellow flags and masquerades
14
Q
A
15
Q
8 minute OSCE LBP
A
- Introduce yourself , confirm patient details, explain the need to take a history, wash hands
- Hx Site – where is the pain?
- Onset -When did the pain first start/ triggers/ acute/ gradual
- Character - dull/spasm/tingling
- Radiation
- Associated symptoms – fever/ weight loss/ existing ca
- Time course
- Exacerbating or relieving factors
- Phx, Fhx, Shx, Rx
- CONSIDER RED FLAGS/YELLOW FLAGS
- OE (Obx BP P T BMI)
- Look, palpate vertebrae and musculature, ROM flexion/ ext, lat flexion, rotation
- Power – leg lift, leg kick, plantarflexion and dorsiflexion
- Sensation L4-S1
- Reflex L4 and S1
- Consider diagnosis – diagnostic triage
- Rx – (Stratify risk) First line: Patient education, physical therapy, simple analgesia, judicious use of complex
medication - Ix Second line - Refer for imaging at 6 weeks as per guidelines, scheduled review
- Third line: specialist referral
16
Q
What are Co-Factors in regards to anaphylaxis?
A
Cofactors are sometimes required before an allergen will provoke a reaction - Not everyone with allergies get anaphylaxis - Duh
Such cofactors may include:
- Intercurrent infection
- Concomitant medication(particularly α-blockers, β- blockers, angiotensin-converting enzyme [ACE] inhibitors,
non-steroidal anti-inflammatory drugs [NSAIDS]. - Alcohol or spicy food ingestion
- High ambient temperatures
- Exercise.
“Summation anaphylaxis” may explain intermittent anaphylaxis despite frequent allergen exposure.
17
Q
Risk Factors for Sudden Cardiac Death
(Many - think of some, and some protective!)
A
Demographics
– Increasing age
– Male gender
– African-American or non-Asian ethnicity
Coronary heart disease risk factors
– Hypertension
– Diabetes
– Dyslipidaemia
– Cigarette smoking
– Obesity
Electrocardiographic parameters
– Heart rate
– QRS duration or fragmentation
– Q waves or dynamic ST segment changes
– QTc interval
– QRS-T angle
– QRS transition zone
– T-peak-to-T-end interval
– Increased R wave voltage
– Specific abnormalities associated with primary arrhythmic disorders
Lifestyle/psychosocial factors
– Depression and anxiety
– Diet (greater fish, n-3 fatty polyunsaturated acids, Mediterranean diet protective)
– Heavy alcohol use
– Limited physical activity
Genetics
– Family history of sudden cardiac death
– Specific mutations/polymorphisms
Specific conditions
– Coronary heart disease
– Atrial fibrillation
– Chronic kidney disease
– Obstructive sleep apnoea
– Dilated cardiomyopathies
– Hypertrophic cardiomyopathy
– Arrhythmogenic right ventricular dysplasia
– Infiltrative diseases (e.g. sarcoidosis, amyloidosis)
– Valvular heart disease
– Congenital abnormalities
Inherited arrhythmic syndromes
– Long and short QT syndromes
– Brugada syndrome
– Catecholaminergic polymorphic ventricular tachycardia
– Early repolarisation syndrome
18
Q
SOBOE DDXs
A
Acute
- Acute myocardial ischemia
- Heart failure
- Cardiac tamponade
- Pulmonary embolism
- Pneumothorax
- Pulmonary infection in the form of bronchitis or pneumonia
- Upper airway obstruction by aspiration or anaphylaxis
Chronic
- Asthma
- Chronic obstructive pulmonary disease
- Congestive heart failure
- Interstitial lung disease
- Myocardial dysfunction
- Anaemia
- Obesity
- Deconditioning
19
Q
Parameters and causes of Type 2 respiratory failure
A
PaCO2 > 45mmHg
- Respiratory pump failure
- Decreased central drive - neurological (stroke, tumour, encephalitis)
- Decreased central drive - intoxicants - etoh, benzos, opioids
- Impaired neuromuscular transmission - Guillian barre, SCI, tetanus poison - organophosphate
- Chest wall and pleural disorders - flail, kyphoscoliosis, obesity, large pleural effusions
- Dead space ventilation > 50% - ARDS, PE, emphysema
- Muscle abnormalities - DMD, ruptured diaphragm
- Increased dead space
- Tachypnoea - high dead space/ tidal volume ratio
- Increased CO2 production
- Fever
- Exercise
- Sepsis
- Thyrotoxicosis
Alveolar hypoventilation
20
Q
Red flags for monoarthritis
A
- Weight loss
- Worst attack
- Not responded to usual NSAID Rx
- Fever
- Generally unwell
21
Q
Systemic causes of Oedema and MOA
A
22
Q
Localised causes of Oedema and MOA
A
23
Q
Key concussion signs and symptoms are:
(heaps - try to remember 10!)
A
- Headache
- Sensitivity to light
- Nervous or anxious
- “Pressure in head”
- Sensitivity to noise
- Neck pain
- Balance problems
- Fatigue or low energy
- Difficulty concentrating
- Nausea or vomiting
- “Don’t feel right”
- Difficulty remembering
- Drowsiness
- More emotional
- Feeling slowed down
- Dizziness
- More irritable
- Feeling like “in a fog”
- Blurred vision
- Sadness
24
Q
Red flags in concussion
A
- Neck pain
- Increasing confusion, agitation or
irritability - Repeated vomiting
- Seizure or convulsion
- Weakness or tingling/burning in the
arms or legs - Deteriorating conscious state
- Severe or increasing headache
- Unusual behavioural change
- Loss of vision or double vision
- Visible deformity of the skull
- Loss of consciousness
25
Return to activity steps in concussion management
26
Symptoms for Major Depressive Disorder
SIGECAPS
- Sleep disturbance,
- Interest (diminished),
- Guilt or feeling worthless,
- Energy (loss),
- Concentration difficulties or indecisiveness,
- Appetite abnormality or weight change,
- Psychomotor retardation or agitation
- Suicide or death (acts or thoughts of)
27
Melanoma removal for diagnosis
- Excision biopsy 2mm margin
- other biopsy types - risk misdiagnosis - as you may just punch an area of dysplastic naevus vs other areas may have melanoma
- Definitive wide excision
- Breslow thickness - gives depth of growth - helps to plan surgery
- Clark level
- For wide local excision - 2cm border and sentinal lymph node biopsy
28
Non-Melanocytic skin Cancers
**Biopsy**
- Depends on shape and size
**Elliptical excision**
- Mark boundaries
- 3-4mm margin
- To subcut fat
- (You'll know you aren't deep enough if you have to work hard - you're still in the dermis)
**Other options**
- Cutterage and diathermy
- Liquid nitrogen
- Moh's - for clinically significant lesions such as infiltrative BCCs - Live time excision and pathology review - continue to take - if you don't get it all, it will just come back - high 90% cure rate vs large wide local excision ~80%
- Moh's also relative where need tissue conservation - only private, can be very exxy if plastic surgeon is needed to be called in
29
Contraindications to Thrombolysis
Absolute and Relative
**Absolute**
- Prior intracranial hemorrhage
- Known structural cerebral vascular lesion
- Known malignant intracranial neoplasm
- Ischemic stroke within 3 months (excluding stroke within 3 hours)
- Suspected aortic dissection
- Active bleeding or bleeding diathesis (excluding menses)
- Significant closed-head trauma or facial trauma within 3 months
**Relative**
- History of chronic, severe, poorly controlled hypertension
- Severe uncontrolled hypertension on presentation (SBP >180 mmHg or DBP > 110mmHg)
- History of ischemic stroke >3 months prior
- Traumatic or prolonged (>10 minutes) CPR or major surgery <3 weeks
- Recent (within 2 to 4 weeks) internal bleeding
- Noncompressible vascular punctures
- Recent invasive procedure
- For streptokinase/anistreplase – Prior exposure (>5 days ago) or prior allergic reaction to these agents
- Pregnancy
- Active peptic ulcer
- Pericarditis or pericardial fluid
- Current use of anticoagulant (eg, warfarin sodium) that has produced an elevated
- INR >1.7 or PT >15 seconds
- Age >75 years
- Diabetic retinopathy
30
On an ECG -
- What if a PR interval > 0.2s (5 mm)
- What are some causes
- What is the clinical significance?
**First degree heart block**
**Causes**
- Increased vagal tone
- Athletic training
- Inferior MI
- Mitral valve surgery
- Myocarditis (e.g. Lyme disease)
- Electrolyte disturbances (e.g. Hyperkalaemia)
- AV nodal blocking drugs (beta-blockers, calcium channel blockers, digoxin, amiodarone)
- May be a normal variant
**Clinical Significance**
- As an isolated finding this is a benign entity that does not cause haemodynamic instability
- No specific treatment is required
31
On an ECG with progressively longer PR interval until reset
- Whats it called?
- Mechanism
- Other features
- What are some causes?
- What is the clinical significance?
AV block 2nd degree, Mobitz I (Wenckebach Phenomenon)
**Other features**
- The P-P interval remains relatively constant
- The greatest increase in PR interval duration is typically between the first and second beats of the cycle
- The RR interval progressively shortens with each beat of the cycle
- The Wenckebach pattern tends to repeat in P:QRS groups with ratios of 3:2, 4:3 or 5:4
**Mechanism**
- Mobitz I is usually due to reversible conduction block at the level of the AV node
- Malfunctioning AV nodal cells tend to progressively fatigue until they fail to conduct an impulse. This is different to cells of the His-Purkinje system which tend to fail suddenly and unexpectedly (i.e. producing a Mobitz II block)
**Causes**
- Drugs: beta-blockers, calcium channel blockers, digoxin, amiodarone
- Increased vagal tone (e.g. athletes)
- Inferior MI
- Myocarditis
- Following cardiac surgery (mitral valve repair, Tetralogy of Fallot repair)
**Clinical Significance**
- Mobitz I is usually a benign rhythm, causing minimal haemodynamic disturbance and with low risk of progression to third degree heart block
- Asymptomatic patients do not require treatment
- Symptomatic patients usually respond to atropine
- Permanent pacing is rarely required
32
On an ECG strip
- What is this rhythm?
- Salient features?
- Causes?
- Clinical significance?
AV Block: 2nd degree, Mobitz II (Hay block)
**Features**
- The PR interval in the conducted beats remains constant
- The P waves ‘march through’ at a constant rate
- The RR interval surrounding the dropped beat(s) is an exact multiple of the preceding RR interval (e.g. double the preceding RR interval for a single dropped beat, triple for two dropped beats, etc)
**Mechanism**
- Mobitz II is usually due to failure of conduction at the level of the His-Purkinje system (i.e. below the AV node)
- While Mobitz I is usually due to a functional suppression of AV conduction (e.g. due to drugs, reversible ischaemia), Mobitz II is more likely to be due to structural damage to the conducting system (e.g. infarction, fibrosis, necrosis)
- Patients typically have a pre-existing LBBB or bifascicular block, and the 2nd degree AV block is produced by intermittent failure of the remaining fascicle (“bilateral bundle-branch block”)
- In around 75% of cases, the conduction block is located distal to the Bundle of His, producing broad QRS complexes.
- In the remaining 25% of cases, the conduction block is located within the His Bundle itself, producing narrow QRS complexes.
- Unlike Mobitz I, which is produced by progressive fatigue of the AV nodal cells, Mobitz II is an “all or nothing” phenomenon whereby the His-Purkinje cells suddenly and unexpectedly fail to conduct a supraventricular impulse.
- There may be no pattern to the conduction blockade, or alternatively there may be a fixed relationship between the P waves and QRS complexes, e.g. 2:1 block, 3:1 block.
**Causes**
- Anterior MI (due to septal infarction with necrosis of the bundle branches)
- Idiopathic fibrosis of the conducting system (Lenègre-Lev disease)
- Cardiac surgery, especially surgery occurring close to the septum e.g. mitral valve repair
- Inflammatory conditions (rheumatic fever, myocarditis, Lyme disease)
- Autoimmune (SLE, systemic sclerosis)
- Infiltrative myocardial disease (amyloidosis, haemochromatosis, sarcoidosis)
- Hyperkalaemia
- Drugs: beta-blockers, calcium channel blockers, digoxin, amiodarone
**Clinical Significance**
- Mobitz II is much more likely than Mobitz I to be associated with haemodynamic compromise, severe bradycardia and progression to 3rd degree heart block
- Onset of haemodynamic instability may be sudden and unexpected, causing syncope (Stokes-Adams attacks) or sudden cardiac death
- The risk of asystole is around 35% per year
- Mobitz II mandates immediate admission for cardiac monitoring, backup temporary pacing and ultimately insertion of a permanent pacemaker
33
Red flags Hospital Admission in Community Acquired Pneumonia
- Tachypnoea (respiratory rate 22 breaths/minute or more)
- Heart rate higher than 100 beats/minute
- Hypotension (systolic blood pressure lower than 90 mmHg)
- Acute-onset confusion
- Oxygen saturation lower than 92% on room air (or lower than baseline in patients with comorbid lung disease)
- Multilobar involvement on chest X-ray
- Blood lactate concentration more than 2 mmol/L
34
Checklist of (Almost All) Abdo Pain causes
- Infected?
- Inflamed?
- Bleeding?
- Ischaemic?
- Twisted?
- Blocked?
- Ruptured
- Growing? - as in should be growing, or shouldn't be.
35
In ED
What is a framework for ordering investigations?
**Bedside**
- Urinalysis
- BGL
- Ketones
- ECG
- Point of care US
**Imaging**
- XRay - chest, abdo
- CT
- U/S
**Bloods**
-
Caveats that you must know:
- What will I do with positive/negative findings?
- Will this change what I do?
- Do I need to know what this is today?
36
ABCDEFG Rule for melanoma diagnosis
37
SOCRATES for Presenting History
Site
Onset
Character
Radiation
Associated symptoms
Timing
Exacerbating and relieving factors
Severity
38
DDXs for Haematuria
Think:
- Aetiology
- Cause
- Origin/Location
39
Risk factors for urinary tract malignancy in patients with haematuria
* Age > 60 (90% cases in Aus)
* Male - 3:1 ratio
* Family Hx
* History of gross haematuria
* Irritative lower urinary tract symptoms
* Smoking (current or past history) - 3x increase
* Occupational exposure (dyes, benzenes, aromatic amines) - machinists, hairdressers, firefighters, printers, truck drivers, rubber/plastics manufacturing industries
* Cyclophosphamide exposure
* History of chronic/frequent urinary tract infection
* History of extensive urinary catheter use
* History of pelvic irradiation
* Bladder infection by **Schistosoma haematobium**, which is common in Africa and the Middle East
40
DDx - Causes and mimicers of **Renal Tract Pain**
(answer is table)
41
GOLD criteria for categorising COPD
- **Postbronchodilator FEV₁ / FVC ratio of < 0.7** is commonly considered diagnostic for COPD
- The Global Initiative for Chronic Obstructive Lung Disease (GOLD) system categorizes airflow limitation into stages.
- GOLD 1 - mild: FEV₁ ≥ 80% predicted
- GOLD 2 - moderate: 50% ≤ FEV₁ < 80% predicted
- GOLD 3 - severe: 30% ≤ FEV₁ < 50% predicted
- GOLD 4 - very severe: FEV₁ < 30% predicted.
42
Review appropriate diagnostic imaging pathway for **renal tract pain**
43
What are the 3 main types of bladder cancer?
44
What is the main type of kidney cancer?
Subtypes
**Renal Cell Carcinoma - 90% cases of kidney cancer**
- Subtypes in picture
Other rarer cancers include:
**Urothelial carcinoma** - or transitional cell carcinoma
- begins in upper urinary tract where kidney and ureter meet
**Wilms tumour** - or nephroblastoma
- rare but more common in younger children
**Secondary cancer**
- very rare
45
Standard lab workup for suspected osteoporosis includes:
- Calcium
- Phosphorus
- Albumin
- Liver function tests - Alkaline phosphatase
- Creatinine (serum and urine)
- 25 hydroxyvitamin D,
- TSH and free T4
- Intact PTH levels
- Males should have a free testosterone level checked to rule out hypogonadism.
46
Interpretation of BMD scans
The scan also reports a T-score and a Z-score.
The T-score is measured in standard deviations and reflects the difference between the patient's measured BMD and the mean value of BMD in healthy, young, matched controls (30-year-old women).
*By definition, a normal BMD measurement is within one standard deviation of the young adult mean*
**The WHO defines T-scores:**
- Between -1 and -2.5 as osteopenic
- Below -2.5 as osteoporotic
**Z-score**
- Measured in standard deviations
- Compared to a healthy, age-matched control group.
- Most clinically relevant when obtaining a DXA scan in younger patients when secondary osteoporosis is being considered.
- Z-score less than -1.5 warrants a comprehensive secondary osteoporosis workup.
47
Initial opioid doses for acute pain management in ED
48
Flowchart stopchecks to see if another dose of opioids in ED for acute nociceptive pain is appropriate
**Sedation score must not be 2 or more**
0 = awake, alert
1 = easy to rouse, remains awake
2 = easy to touse, unable to remain awake
3 = difficult to rouse
**Is respiratory rate low?**
- Child 1-12 - < 20 Breaths/min
- Child 12-17 - < 15 Breaths/min
- Adult > 17 - < 8 Breaths/min
49
Assessment steps for Urinary Incontinence:
- Hx
- Exam
- Initial tests
- Follow up tests
50
Treatment options for urinary incontinence
51
Indications for specialist referral in patients with urinary incontinence
- Haematuria
- Suspected pelvic mass or urogenital fistulae
- Symptomatic prolapse
- Palpable bladder post voiding
- Persistent pelvic pain
- Suspected neurological disease
- Voiding difficiiulty
- Previous continence surgery or pelvic cancer surgery
- Poor respose to conservative management
- Unclear type/diagnosis oof continence
**Patient factors to consider**
- Severity of symptoms
- Psychosocial impact of symptoms
- Likelihood of future improvement with therapy
- Goals and treatment preferences
- General fitness for invasive procedures
52
Types of urinary incontinence
Include relevant:
- Symptoms
- Pathophysiology
- Common Aetiologies
53
Diagnostic criteria for PolyCystic Ovary Syndrome
54
Pharmacological management for symptoms of PCOS
55
Causes of urinary retention
Neurological
- MS
- GBS
- Stroke
- Cord/Cauda equina
- Diabetes
- Parkinsons - detrusor muscle not talking to sphincter
Prostatic
- BPH
- Cancer
Drugs -
- Anticholinergics
- Nexium
- Antidepressants
- Opiates
Mechanical
- Calculi
- Stricture formation
Haematuria
- Bladder cancer
- Radiation
- Instrumentation
56
Typical size of urinary catheter
Male - 16/18 fr
Female 12/14 fr
57
Meds for prostatic hypertrophy and associated flow reduction/urinary retention
**a blockers**
- Can cause hypotension
- prazosin
- tamsulosin (flomaxtra)
**5a reductase inhibitors**
- stops prostatic hypertrophy
- can cause oestrogen related side effects - ie gynaecomastia
- dutasteride (avodart)
Can get a combination of the dutasteride with tamsulosin!
-
58
Causes of autonomic dysreflexia in spinal cord injury patients
- Bladder
- Bowel
- Boils - painful skin thingies
- Bones - #s or dislocations
- Babies
- Back passage
Causes are below level of injury
59
Risk factors for head and neck cancer:
* smoking tobacco (including cigarettes, cigars and pipes)
* drinking alcohol
* having had human papillomavirus (HPV)
* having persistent sores or red or white patches in the mouth
* chewing tobacco, snuff, betel nut, areca nut, paan or gutka
* breathing in asbestos fibres, wood dust or certain chemicals
* poor dental health
* having a weakened immune system
* having had radiation therapy to the head or neck area in the past
* having too much sun exposure (for lip cancer and skin cancer)
* having a parent, child or sibling with head and neck cancer
(possibly because you have similar lifestyle factors)
* inheriting a condition linked to head and neck cancer
(e.g. Fanconi anaemia, Li-Fraumeni syndrome)
* having had Epstein-Barr Virus (also called glandular fever).
60
System for tooth numbering in Australia/rest of world that isn't the USA
Note - the way you say it is 1-2, not "12"
ie one, two, not twelve
First quadrant is upper right - then rolls clockwise as in looking at the person
61
What is Peridontitis vs Pulpitis
**Peridontitis**
- Disease of the bone under the gum, as in breakdown of bone around tooth
- More slow
- Tooth may wiggle when palpated directly
**Pulpitis**
- Acute pain - likely from snapped tooth
- Simple analgesia - nsaids, paracetamol - and if required small short doses of opioids
- Dentist will fix this, thats where the patient needs to go, not keep bouncing back to ED
62
Maxoficial red flags
- Unable to fully open mouth
- If able to open mouth fully, reassuring as its likely parotid or other infection
- Ludwigs angina - like actual ludwigs angina which is very uncommon
- Describe what you see, don't red flag it as this is "seen" more common than it occurs
- Critical airway occlusion - very swollen throat, tripod breathing, won't want to lay flat due to fear of airway obstruction
- Tenderness under the jaw -
- Never let the sun go down on pus
63
Trauma Layers - superficial to deep
Also applies to cancer
- Skin
- Subcut fat
- Sensory nerves
- Musculature
- Motor Nerves
- Vessels
64
Red flags for eye trauma
What may these mean
Management
**Retrobulbar haematoma**
- Bulging firm eye
- Retropulsion test, compare L and R
- Pupil size and reactivity
- Opthalmoplegia
- Kids unable to look up with one side after eye/face injury - "Trapdoor fracture"
- Visual acuity - lose red colour early
- Pain
- Autonomic symptoms: Bradycardia - induced by Trigeminal V2 nerve injury - causing vagal nerve stimulation
- Nausea + vomiting
**Medical management**
- Carbonic anhydrase inhibitors
- Corticosteroids
- Hyperosmotics
- Topical - ie Timolol
**Surgical management**
- Lateral canthotomy and cantholysis - ED and ACCRM procedure
- Orbital decompression
64
Resp symptom exam in GP
Note - get them on the bed so you enter "exam mode"
* Observation
* Vitals
* Glands
* Ears
* Throat
* Sinuses
* Percuss
* Resonance
* Chest auscultate
65
When to start a T2DM patient on insulin?
- Treatment resistant - ie maxed out on orals, couldnt tolerate ozempic
- ~8-9% HBA1C
- Start with Basal insulin
- 0.2 Units/kg (up to 30 units) - ie 150kg once daily at same time each day
- Give them a glucose sensor
66
Key parts of physical exam for VERTIGO
67
DDXs for non syncopal vertigo and their presentations
68
Describe Epley Maneuvre for treatment of BPPV (Benign Paroxysmal Positional Vertigo)
69
Summary table of Webber and Rinne's test
70
Considerations for DDxs in GP or undiagnosed patients
**1. Probability Dx**
- What's the most likely
**2. Important thing not to miss**
- DDx List
- Phase 3 OSCE - good to rattle some off
**3. Pitfalls**
**4. Masquerades**
- Anaemia
- Depression
- Thyroid
- UTI
- Diabetes
- LBP
**5. Is the patient trying to tell me somthing?**
- ie - yellow flags!
71
Orbital # summary
- Most commonly inferior
- Can trap /damage inferior rectus
- Pain on up gaze
- Diplopia on up gaze
- Paeds can cause syncope/bradycardia due to reflex - much less common inadults
- Maxilliary nerve damage - V2 - lose sensationin cheek and upper teeth
72
Retrobulbar haemorrhage
- Black eye
- Eye proctosed - popped out
- Eye rock hard
- Must get CT scan
- Worse if there is no # to release pressure
- Complication is infarction of occular nerve within hours
- Lateral Canthotomy as temporary measure- give local anaesthetic cut lateral eyelid - ED specialist should be able to do this
73
Most common cause CNIII palsy
Microvascular complication
- Communicating berry aneurysm
- Best way to image is a CT angiogram
73
What is blepheritis?
Oil production problem in the edge of the eyelid
74
What is glaucoma?
- Optic nerve neuropathy
- Typically caused by higher pressures
- 2 subtypes
- Open angle - Resistance to aqueous humour flowing out through trabecular meshwork
- Closed Angle - Occlusion of trabecular meshwork
75
What is uveitis
- Inflammation of the middle (of 3 ) layers of the eye
- Uvea
- Purple grape like layer - due to vessels
- Iris front, ciliary body, Choroid
76
Hx Vision loss quesions to ask
- total/partial
- Sudden/gradual
- One eye/both
- Painful or not
- Flashers or floaters? - vitreous or retinal tear/detachment
- "Curtain" raising or falling - retinal detachment
-
77
What is 6/36 vision
- This punter can see at 6m what the average punter can see at 36m
- It's a ratio!!
78
How to assess vision
1. Snellen chart
2. Move closer to snellen chart
3. Count fingers
4. Movement - "tell me when my fingers are moving" - MP - movement perception
5. Light - "Tell me when im shining a light in your eye" - LP - Light perception
6. NLP - no light perception
79
Commonest cause of visionloss australia
1. Macular degeneration
2. Diabetes
3. Glaucoma
80
Steps of macular degeneration
- Breakdoen bruchs membrane
- Dry macular degeneration - drusen
- Wet macular degeneration - neovascularisation in there, bleeding
- Anti-VEGF intravitreal injections, avastin, lucentis, eylea
- Photodynamic therapy
-
81
Proliferative vs Non-proliferative diabetic retinopathy
Proliferative looks whispy - plenty of new crappy vessels that bleed and scar
82
Causes of secondary hypertension and investigations for them
83
Breakdown of some clinical associations of ACROMEGALY
- There is an increased risk of colonic polyps which may be malignant.
- Patients with acromegaly have hypercalciuria and renal stones (direct action of GH on renal tubules) but rarely have hypercalcaemia (only where acromegaly forms part of multiple endocrine neoplasia type I: parathyroid hyperplasia, pituitary and pancreatic tumours).
- Excessive daytime drowsiness is seen as an enlargement of the tongue produces obstructive sleep apnoea. Other features include DM, osteoarthritis, carpal tunnel syndrome, hypertension, cardiomyopathy and skin tags.
- Biochemical abnormalities include raised serum phosphate, hyperglycaemia, raised triglycerides and prolactin.
- Growth hormone secretion is stimulated by high protein meals and suppressed by glucose in normal individuals. In acromegaly, basal growth hormone levels are raised and these fail to suppress after a glucose load; other conditions where GH fails to suppress include poorly controlled diabetes mellitus, myxoedema, Cushing's syndrome and anorexia nervosa.
- The major cause of morbidity and mortality in patients with acromegaly is cardiovascular (myocardial infarction).
84
Breakdown of some clinical associations of BELLS PALSY
- Paralysis of the 7th cranial nerve is often idiopathic but there may be a viral aetiology with demyelination. Cranial nerves 5, 9 and 10 as well as C2 may also be involved but are not strictly part of Bell's palsy.
- Bilateral palsy suggests other diagnoses e.g. carcinomatous meningitis, Lyme disease, HIV, sarcoid, etc. Facial myokymia (flickering of facial muscles) is a feature of multiple sclerosis, not Bell’s palsy.
- Associations include diabetes mellitus, severe hypertension, 3rd trimester of pregnancy, dental anaesthesia and cold exposure. Hyperacusis is common and is due to involvement of the branch of C7 that supplies the stapedius.
- Loss of taste and numbness of the tongue may also occur. (Facial numbness suggests 5th nerve involvement; scalp tingling – C2 nerve; loss of gag reflex – 9th nerve; palatal weakness – 10th nerve.) Crocodile tears are due to reinnervation by the tympanic branch of the glossopharyngeal nerve which also supplies the parotid nerve via the lesser superficial petrosal nerve. Treatment: early treatment with prednisolone 80 mg/day tapering over 10 days may improve recovery.
85
Breakdown of some clinical associations of PRIMARY POLYDIPSIA
- Urine output is diminished by water deprivation
- Patients with primary polydipsia most commonly present with fitting due to severe
hyponatraemia.
- Up to 80% have underlying schizophrenia.
- It is generally associated with a low plasma osmolality (~275 mOsm/kg cf. nephrogenic diabetes insipidus where the plasma osmolality rarely falls below 295 mOsm/kg).
- Diagnosis is by a water deprivation test: the normal response is to concentrate the urine (urine osmolalty > 800 mOsm/kg); in patients with psychogenic polydipsia the urine osmolality may rise slightly but unless they are contained and prevented access to water scrupulously, the rise is less than normal.
- In diabetes insipidus the urine remains abnormally dilute (urine osmolality < 400 mOsm/kg).
86
Barriers for Adolescents accesing Healthcare
5C & D
The 5 Cs:
* **Cost of care**
* **Confidentiality** – fear of a lack thereof
* **Compassion** – lack of non-judgemental clinicians with sensitivity to developmental stage
* **Clinical skill** – poor communication by clinician (eg use of jargon) and low evidence-based management of common problems such as depression and anxiety or requests for effective contraception
* **Convenience** – difficulty getting a timely appointment, inflexible appointment systems, waiting times, inadequate transport options, restrictions on when can make time to attend care independently
And D
* **Developmental issues** – embarrassment, poor self-identified needs, low knowledge of services, little experience with healthcare systems and expressing needs, low health literacy
87
HEADSS Assessment things
* Home environment
* Education and employment
* Eating and exercise
* Peer-related Activities
* Drugs, tobacco and alcohol
* Sex and sexuality
* Suicide, depression and other mental health issues
* Safety from injury, violence, abuse, and safety precautions to reduce sun damage and vaccine preventable infections
88
Definition of a hernia
Defect - Sac - Contents
Abnormal exit of abdominal contents and surrounding sac through the wall of a cavity in which it normally resides.
89
Definition of fistula
Abnormal connection between two epithelial lined surfaces
90
Find a varicocoele - which are you more concerned about L or R and why?
R - short vein - direct into IVC
L - longer, into L renal vein, can get occluded
91
Single lymph node in the groin - no other lymph nodes - what next?
DRE - common drainage of anal canal to groin
Must check - high possibility malignancy
92
When should you reduce a hernia?
Only on the way to theatre!!
Risk of strangulation etc
Also, if it reduces and is strangulated, then issues of finding the necrosed bowel!
That being said - if a hernia is reducible, if they are able to comfortably lay in crook lying position, relax, with pillows under knees, softly resting their own hand just by its weight on tummy then they can do it
Don't try this on an angry or strangulated hernia
93
Consent factors for a procedure
(7 P's)
- Consent
- Equipment
- Drugs
- Position
- Procedure
- Post Procedure
- Complication
Or;
- Paperwork
- Props
- Pharmaceuticals
- Position
- Procedure
- Post Procedure
- Problems
94
Patient with newly diagnosed HTN - say > 140/90 consistent in GP
Have tried lifestyle modifications.
What drug can we start?
What dose?
- Perindopril arginine
- 5mg oral Daily - Max 10mg Daily
95
Patient with newly diagnosed HTN - say > 140/90 consistent in GP
Have trialled Perindopril - had an annoying cough/ developed angioedema
What drug can we start?
What dose?
- Valsartan
- 80mg oral Daily
- Increase to 160mg Daily if needed - MAX 320mg Daily
95
3nd Line Rx Hypertension medication
Dose
- Metoprolol
- 50 mg oral Daily
- Increase to 50mg oral BD
96
When to consider causes for 2ndary hypertension
- Clinical suspicion - always investigate before initiating antihypertensives
- Consider when BP is not responsive to BP lowering therapy
Should be suspected in patients with:
- signs/symptoms of secondary aetiology:
- Palpitations
- Haematuria
- Delayed femoral pulse
- Epigastric bruit
- Abnormal biochemistry findings:
- Hypokalaemia
- Elevated creatinine plasma concentration
- Proteinuria
- Haematuria
- Abnormal diagnostic imaging:
- CT angio showing renal artery stenosis
- CT showing adrenal mass
Note - most common curable cause of secondary HTN in adults is primary aldosteronism
97
2nd line anti HTN medication
Dose
- Hydrochlorothiazide (Thiazide diuretic)
- 12.5-50mg Daily
- Usually taken in the morning
- Available as a combination with valsartan
98
3rd/4th line anti-HTN medication
Dose
Amlodipine
5-10mg oral, daily
99
Costa's C's of renewing prescriptions
**Compliance**
- Is patient taking meds, are they taking them properly, right time of day etc
**Control**
- How well is the disease being controlled
**Complications of disease process**
- Is the disease progressing - eg retinopathy, neuropathy, renal complications in diabetes
**Complications of medications**
- Side effects - pedal swelling, posturalhypotension
**Complexity**
- Is there a combo med available, one that you dont have to take as many times a day, etc
100
Maximum dosage Lidocaine - local anaesthetic
(give numbers for with/without adrenaline)
Max solo Lidocaine:
- 3mg/kg (up to 200 mg) single dose
Lidocaine With adrenaline 5 micrograms/mL (1:200 000)
- 7mg/kg
101
Anaesthetic Assessment
What to include on exam
LEMON
- Look externally
- Evaluate 3-3-2 - mouth opening, mentum to hyoid, thyro-mental distance -and mandibular protrusion
- Mallampatti score - how much of uvula can you see- 1 - all to 4 none
- Obstruction - tongue, Teeth, airway oedema etc, Obesity,
- Neck ROM
Note - these are indicators of difficult airway
- Add resp and cardiac exam if needed
102
DDX checklist
103
Calculations for primary metab acidosis or metab alkalosis compensations
Primary metab acidosis
- Expected CO2 in mmHg = 8 + 1.5 x HCO3
Primary metab alkalosis
- Expected CO2 in mmHg = 21 + 0.7 x HCO3
104
DDX Headachesaches
- Thunderclap
- Rash/fever
- Stiff neck
- Reduced GCS
- Carbon monoxide poisoning
- Hx/Aneurysm
- Pregnancy
- Refractory to simple analgesia
- Tinnitus
- Psychosis
- IV drug use
- Stimulant use
105
Key 4 questions to remember to ask people during pregnancy at EVERY STAGE/APPOINTMENT
- Are you having any contractions or cramping?
- Have you had any bleeding?
- Do you feel baby moving? - after 20 weeks or so, can't really tell before
- Have you had any gushes of fluid or any changes to discharge?
106
Key things back half of pregnancy
- 24-28 w - OGTT
- 28w - Anti D dose if Rh -ve
- 28-32w - Pertussis vaccine
- 34w - Anti D 2nd dose if Rh -ve
- 36w - Close to Labour - Group B strep swab - will give intrapartum Abx - penicillin, recheck iron and Hb if needed - probably do this in most cases
106
Things to check on first antenatal checkup!
History
- Previous pregnancies
- How many
- Miscarriages or terminations
- Births? Complications?
- Gestational diabetes
- PMHx
- Pre - eclampsia
- HTN
- Diabetes
- Autoimmune disease
- Antiphospholipid syndrome
- Nulliparity
- BMI > 30
- pre-existing kidney disease
- Risk nutritional deficiencies - vegan, lactose intolerance, etc
- FHx
-
- Screen
- Smoking/2nd hand smoking status
- Etoh/drugs/pharmaceuticals
- Depression - Edinburgh postnatal depression scale
- Intimate partner violence - only when alone with patient, explain screening for all
Exam
- Weight and height
- HR, RR, SPO2, BP - KEY!!!!! screening for pre-eclampsia
Urine
- Confirm pregnancy - bHCG urine
- Asymptomatic bacteriuria or proteinuria
- Chlamydia in women < 30y
Bloods
- Blood group and antibodies - KEY!! for Rh-ve
- FBC - anaemia, Hb Disorders
- Rubella immunity
- Hep B, Hep C, HIV, Syphillis
- Iron, EUC, LFT, TFT
Recommendations!
- Folic acid supps - 0.5mg -- from -1 month to +3 months pregnancy ideally - dose is 5mg if on antiepileptics such as valproate or carbamazepine
- High risk pre-ecclampsia or HTN, 1000mg Ca2+ supp if dietary intake low, 100mg aspirin may recommend for pre-eclampsia
- Iodine supp 0.15mg throughout
- Exercise - aerobic, strength, pelvic floor
107
Complications of rituximab
Need to revaccinate people after treatment as they lose memory B cells
108
Complications of men of child bearing age post chemotherapy
Advise don't fall pregnant for 1+ year post chemotherapy
Use barrier contraception - likely to have DNA issues with sperm for prolonged period
If they really want to, then freeze sperm before commencing chemo
109
Hep B serology table summary
110
Things you see in OT anaphylaxis
- Change in arterial O2
- Change in End Tidal CO2
- Patient moves
110
Common causes of anaphylaxis in an operating theatre
- Rocuronium
- Cephazolins
- Latex
111
How to answer viva questions about eg - what could go wrong?
Think
- Immediately
- Little later
- Further down the track
112
Key things to consider for preop complications
Severity
- EG COPD, not lots of steroids, not going downhill
- End organ function - micro/macrovascular functions
- Think head to toe
Stability
- Lots of hospitalisations lately, volatile - unstable.
- HbA1C < 8.5% - stable!
Generally speaking, might be happier to operate on severe and stable patient vs the opposite
113
Components of procedural sedation
Anxiolysis
Analgesia
Sedation
Amnesia
114
Ketamine doses
IMI - 4-6mg-kg
IVI - 1-1.5mg/kg
INI - watch this space, not really used in Australia yet
0.1-0.3mg/kg - Analgesia
0.2-0.5mg/kg - Recreations
0.4-0.8mg/kg Partially dissociated
>0.8mg/kg - Fully Dissociated
Remember emergence phenomena as they wake back up -
Child sedation - sutures, lumbar punctures,
Generally not used in adults for managing emergence phenomenon
115
Propofol pros/cons
Pros
Rapid onset
Short reco time
Easily titratable
Potentially deeper sedation
Cons
No analgesia
Can only be given IV
Resp depression, apnoea
Hypotension - can give small ~500mL bolus pre
Good for quick painful procedures - joint/# reductions
Good for cardioversion w fentanyl
Not good for longer things like chest drains or lumbar punctures - especially when say in LP they are side lying and need to manage airway
116
Propofol dosage for procedures
IVI - 0.5-1mg/kg for adults
IVI 1.5-2mg/kg for children - metabolise quicker
Note - crew who drink lots may metabolise quicker too
For general anaesthesia, dose is maybe double this
116
Midazolam for procedures
Good for chest drain - 5-8 mins onset even with IV access
Longer lasting vs propofol
Anxiolysis, Sedation, Analgesia, Amnesia
IVI 0.05-0.2mg/kg
Adults - 5-10mg titrated
Give the dose, give it time to sink in
Not commonly used
117
Fentanyl
Pros, Cons, dosage range
Pros
Aniolytic
Rapid onset of analgesia
Easily titratable
LEss allergenic and more cardiostable than morphine
Can be given IN or IV
Cons
Very mildly sedative
Respiratory depression,, no amnesia
IVI 1-2mcg/kg
IN 1.5mcg/kg - can be limited by volume
118
Morphine
Pros
Anxiolytic
Longer duration action
Easily titrable
Can be given IM/IV
Cons
Very mildly sedative
Resp depression, apnea
Vomiting - often need ondansetron too
Utricaria
Hypotension
IVI - 0.1mg/kg is the dose!!!
ie 80kg, 8mg
119
LEMON for anaesthetics and airway consideration
120
Monitoring requirements for procedural sedation
ET CO2 nasal prongs
SPO2
Constant ECG
Regular BP
121
Red flag/heavy caution for ED sedation
People on GLP1 agonists!
Ozempic, Wegovy etc
Seriously delayed gastric emptying
ANZCA recommendations are stay off this for 4 weeks prior to surgery
122
3 x c's of DSM 5 criteria of substance use disorder
Control
Consequences
Craving
123
Types/locations and names of eye inflammation
Keratitis - inflammation of cornea
Blepharitis - inflammation of eyelid
Iritis - inflammation of iris
Uveitis - inflam of uvea
- anterior most common
124
How to score snellen chart
x/y
X = distance from chart
y = font able to read
ie - normal is 6/6 - 6m, size 6 font
then 6/9 - 6m, size 9 font
125
Acute angle glaucoma presentation
Unilateral eye pain
Visual acuity reduced
Hazy cornea
Hard eyeball - can palpate as quick and dirty, but be careful as can cause reflex bradycardia
Non reactive pupil
Nausea/vomiting
Commonly females 60-70s, more likely asian/inuit population
Defined as Intra occular pressure > 21mmHg, can be high as >60mmHg (normal is 10-20mmHg)
RX -
Urgent opthamology referral
Acetazolamide 500mg IV - carbonic anhydrase
Topical beta blocker
Topical steroid
Analgesics/antiemetics/supine
126
Presentation acute anterior uveitis (iritis)
- Acute unilateral painful red eye, blurred vision, photophobia and tearing
- May have decreased visual acuity
50% idiopathic
Assoc with
- ank spond, sarcoidosis, crohn's, trauma
- Herpes, syphillis, TB, toxoplasmosis
127
When to do a sexual health history
Symptoms:
Vaginal discharge, abnormal vaginal bleeding
Dysuria
Testicular pain
Anogenital lumps, ulcers, sores
Or opportunistic when:
Cervical screening
Travel vaccines, returned travellers
Pre pregnancy counselling, antenatal care
Contraception
HEADSS assessment
128
5 Ps for sexual health Hx
Partners
- gender, number current/past - maybe check the last 3 months at first, risk factors of partners, overseas,
Practices
- last unprotected, types - where to test, in exchange for needs eg cash/drugs
Protection from STIs
- Condom use, vaccination, meds - HIV PrEP
Previous Rx for STIs and PID
- last test, past/current, contact
Pregnancy planning
- Plans - would you like to become pregnant in the next year especially, past and current contraception, previous pregnancies, menstrual Hx, current pregnancy status
129
STI and BBV testing
SWABS
bacterial or viral
- Chlamydia, gonnorhoea, mycoplasma genitallium, HSV, syphillis, Mpox
Site - throat, vaginal, endocervix, urethram ulcers
Urine - pcr
Chlamydia, gonorrhoeam mycoplasma genitalium, HSV
Swabs MCS -microscopy, culture, sensitivities
Gonorrhoea, general bacteria/yeast
Site - throat, vagina, endovervix, urethra
SEROLOGY
HIV, syphillis, hep a/b/c
130
Pelvic Inflammatory Disease treatment
- Ceftriaxone 500mg IM stat
- Doxycycline 100mg bd PO - 14 days
- Metronidazole 400mg bd PO - 14 days
Then :
+ pain management
+ abstinence for 7 days after treatment or until symptomatically better
+ contact tracing, patient or clinician assisted
131
5 key things to consider with all new ED patients!!
- Resuscitation required?
- What is their disposition - eg admit, d/c, or observe
- What do we need to give them? meds, fluid
- What do we need to withhold from them - food, fluid, nephrotoxic drugs, etc
- Notify if.... - tell supervising nurse to let you know if they - deteriorate, become confused, bowel opened etc
132
ECG in 20 seconds - great to think of for OSCES!!!!!!!
Hx
- Ishaemia - ST-T segments become important
- Arrythmia - P waves, QRS, QT interval
Rate
- Slow - blocks
- Fast - SVT, VT
Is it sinus? - (P wave behavoir)
- Normal P wave axis: upright in II, inverted in aVR
- Correct number of P waves to QRS complexes
QRS
- Tall vs Small - hypertrophy, pericardial effusion
- Wide vs narrow
- Clumped - Mobitz
ST - T segment
- ST elevation/depression
- T waves: peaked, inverted
Intervals: PR, QT
Pacing spikes
133
Hyperkalaemia treatment
- Initially Calcium Gluconate - helps stabilise cardiac membrane, but has very short halflife - buys you time
- Insulin/dextrose infusion
- Salbutamol
- Resonium after longer term - in eg renal or inpatient management
134
What is Felty's Syndrome?
Felty’s syndrome is a condition characterized by splenomegaly and neutropenia in a patient with rheumatoid arthritis (RA). It is strongly associated with HLA-DR4 genotype and patients are usually very strongly rheumatoid factor positive.
Management involves treating the underlying RA. If patients are not improving with medical therapy and are suffering from recurrent infections, splenectomy may be indicated.
135
Summarise presentation of Malaria, and compare with other common travel illnesses that may present with fever in a patient returning from India
The fever of malaria is classically periodic (e.g. peaking every third day).
This is caused by rupture of infected erythrocytes releasing matured merozoites and pyrogens.
This classical paroxysm may not necessarily be present in early infection.
Thick and thin blood smears are required for diagnosis.
Resistance to the traditional quinine-based drugs is now widespread and newer drugs are in development.
Dengue fever can have an initial clinical presentation similar to malaria, and periodic fever can occur (the so-called biphasic or ‘saddleback’ fever). However, jaundice and splenomegaly are uncommon.
Uncomplicated influenza does not usually cause periodic fever, jaundice or splenomegaly.
Japanese encephalitits commonly has signs of meningism (neck stiffness) and altered consciousness. It does not usually cause jaundice or splenomegaly.
India is not a yellow fever endemic region.
136
A 22-year-old G2P1 presents to the delivery suite at 32 weeks’ gestation with abdominal pain and dysuria. Her urine dipstick shows white blood cells and nitrites. Urine culture is pending. On speculum examination, the cervix is found to be 3 cm dilated with intact membranes.
What is the most appropriate next step in her management?
Urgent administration of steroids improves perinatal outcome and is indicated up to 36 weeks’ gestation.
Betamethasone (IM) is the steroid of choice, and there is no evidence to support the use of Dexamethsone.
137
A 55-year-old obese man complains of weakness, sweating, tachycardia, confusion, and headache whenever he does not eat for more than a few hours. He has prompt relief of these symptoms when he eats.
What is the most likely underlying disorder?
The correct answer is: c) Insulinoma
Tumours arising from the pancreatic β cells give rise to hyperinsulinism. Seventy-five percent of these tumours are benign adenomas and in 15% of affected patients the adenomas are multiple. Symptoms relate to a rapidly falling blood glucose level and are due to epinephrine release triggered by hypoglycaemia (sweating, weakness, tachycardia). Cerebral symptoms of headache, confusion, visual disturbances, convulsions, and coma are due to glucose deprivation of the brain. Whipple’s triad summarizes the clinical findings in patients with insulinomas: (1) attacks precipitated by fasting or exertion; (2) fasting blood glucose concentrations below 50 mg/dL; (3) symptoms relieved by oral or intravenous glucose administration. These tumours are usually treated surgically and simple excision of an adenoma is curative in the majority of cases.
138
A 32-year-old woman loses the ability to walk following a sudden and unexpected separation from her husband. She now is able to walk, but only with assistance and requires the use of a wheelchair. Her husband agrees to visit her once a week to help her out. Neurological examination is inconsistent with her symptoms and investigations are all normal.
The correct answer is: d) Conversion disorder
Conversion or dissociative disorders are associated with a loss or disturbance of normal functioning. The symptoms develop in close relationship to a psychological stressor. Symptoms include paralysis, sensory loss, seizures, amnesia, and loss of speech. The disturbance conforms to the patient’s understanding of the disorder and physical examination is often inconsistent with the patient’s symptoms. Investigations are normal. Most symptoms resolve after a few weeks or months, but some disorders may become chronic if associated with insoluble or unbearable personal problems. In this case, the patient displays a dissociative motor disorder.
139
What is pityriasis rosea?
Pityriasis rosea is a self-limiting rash, which resolves in about 6–10 weeks. It is characterised by a large circular or oval **"herald patch",** usually found on the chest, abdomen, or back.
The herald patch is followed some time later, typically two weeks or so, by the development of smaller scaly
oval red patches, resembling a Christmas tree, distributed mainly on the chest and back.
Who gets pityriasis rosea?
Pityriasis rosea is most common in teenagers and young adults (10–35 year-olds), however it can affect people of any age
Occurs very slightly more often in women
Approximate incidence of 0.5% to 2%
Most cases occur in winter
140
When to give K+ in treating a patient with DKA
Other things to monitor and how often to monitor
When K+ is <= 5.5 mmol/L
Also - constant cardiac monitoring and checking K+ every 1-2 hours
147
Flowchart for insulin dosing in DKA or HHS
(hyperglycaemic hyperosmolar state)
148
How to rate severity of DKA or HHS
(answer is a table, what are the variables)
- pH
- Ketones mmol/L
- HCO3 mmol/L
Note, notice BGL and osmolality are not key for DKA
149
Rate at which to restore fluid in DKA/HHS
What kind of fluid depletion can be expected??
Note - giving normal saline (0.9% NaCl)
1L/Hour for first 2 hours
Then 500mL/Hr for hours 3-4
Then 250mL/Hr for hours 5-6
Target urine outpur 0.5mL/kg/hr
149
What is the Modified Parkland Formula for giving fluid post burns?
What fluid do you give?
**4mL fluid x kg of bodyweight x % TBSA** - given in first 24 hours
- 1/2 given in first 8 hours
- 1/2 given in next 16 hours
**Give Hartmann's Solution!!**
151
1) Describe what you see; are these papules, pustules or vesicles?
Also, describe the distribution – is it symmetrical, and does it spare any areas?
2) Name and cause of condition
3) How is it managed?
1) There are symmetrical papules up to 3 mm in diameter distributed around the mouth or muzzle area, extending up to the nasolabial folds.
The immediate area around the vermillion of the lips is spared.
There are neither pustules or vesicles.
**A papule is a small, solid, raised bump on the skin that is less than 1 centimeter in diameter. Papules can be red, purple, brown, or pink. They can be felt or palpated.**
2) Perioral dermatitis, commonly associated with the use of potent topical corticosteroids on the face.
3) It is managed by weaning off topical steroids, and using an oral tetracycline antibiotic.
152
Table for recognising burn depth
153
Rule of 9s for burns
(Adults)
Note - do not count epidermal/superficial burns in this for resuscitation and fluid purposes
154
Paeds body surface area for burns calculation
remember - kids have big heads and relatively small legs
155
Paed fluid resusc amount
10-20mL/kg fluid
156
Severe asthma/COPD management
(answer is paeds table, but adult dosages are appropriate for >6y)
157
Antibodies to test for in Hypo/Hyperthyroidism, and what they can indicate
**Hypothyroidism** - Both of the below are often elevated in Hashimoto's
- Thyroglobulin antibody
- Thyroid Peroxidase (TPO) antibody
**Hyperthyroidism** - Elevated in graves in most cases
- TSH Receptor antibodies
158
General Toxicology Approach
***Resuscitate**
A-E
***Risk Ax**
Accurate history
***Supportive Care**
Fluid, etc
***Investigations**
FBC, Paracetamol levels,
***Decontamination**
Wash, Deactivated charcoal
***Elimination**
Multiple dose activated charcoal, urinary alkalinisation via sodium bicarb
***Antidote**
Not common, but maybe ETOH in ethylene glycol. or methanol, naloxone,
***Disposition**
Getting better, DC, or watch like a hawk
159
Imaging and follow up for thyroid nodules
- Ultrasound initially
- Then if nodule there - thyroid uptake scan to check for nodular activity
- Then, if it is "cold" - ie its not taking up technetium or iodine - then fine needle biopsy is appropriate!
More likely to be malignant as it has dysmorphed so much from original thyroid cells - ie a "hot" nodule on Tc scan is uptaking iodine
160
Key aspects of the exam in verifying death
- Details and Identification of the deceased
Clinical assessment, involving:
5 minutes of continued cessation of:
- Absence pupiliary responses to light
- Absence of response to central painful stimulus
- Absence of central pulse on palpation
- Absence heart sounds on auscultation
- Absence respiratory effort
OR
- Obvious death - eg dead for some time or injuries incompatible with lift
AND
- "I declare that the person is deceased"
- Then details of myself (or person verifying death)
161
Red Flags for Headache
162
DDx VITAMIN CDE
Can also use a top to toe systems review
163
PROMPT Murtaugh model DDX
P – Probability, i.e. What are the most likely and common diagnoses?
R – Red flag conditions, i.e. What serious disorders are not to be missed?
O – Often missed (pitfalls), i.e. pregnancy, drugs, allergies, constipation, menopause
M – Masquerades, i.e. depression, drugs, diabetes, anaemia, thyroid, UTI, spinal
PT – Is this Patient trying to Tell me something else?
164
Meds for quitting alcohol
Whilst quitting
**Benzodiazepines** - tapered dosage to prevent seizures with withdrawal
**High dose thiamine** - help with DT
Once quit:
**Acamprosate**
- mild anxietolytic, helps with cravings
- renally cleared, need tds dosage
**Disulfaram**
- Behavioural deterrent
- Inhbits aldehyde dehydrogenase - makes you feel crook
**Naltrexone**
- opioid antagonist
- thought to reduce reward stimulus
165
What to know for neonatal murmurs
Dw about location as a junior if can't work it out
When HR is 160 (which is normal in neonate) - need to hear silence between 1st and 2nd heart sound
Presence of red flags - cyanosis, FTT, etc
Innocent - thriving baby, strong pulses, not hypoxic,
166
Investigations in Failure to Thrive
- Tier 1 - fbc, euc, lft, tft, urinalysis, CXR
- Tier 2 - Coeliac screen, sweat test, UMS- undiagnosed metabolic syndromes, genetics
- Individualised approach
167
How old should bub be before they have re-gained birth weight
2 weeks
168
Precocious puberty
When to refer - and what initial investigations to order!
**When to refer**
- Girls: evidence of breast development at age < 8y
- Boys: evidence of testicular enlargement ≥ 4ml, or virilisation /development of phallus at age <9yrs
- Rapidly progressive early puberty
**Investigations**
- TFTs
- FSH, LH and testosterone/oestradiol
- Bone age X-ray
**Referral information needed**
- age of onset, rate and degree of progression
- Height and weight (include date of assessment), and previous measurements with if available
- Parental heights and history on timing of parental puberty if possible
- Relevant previous medical history (eg any known structural brain lesion)
169
Burn transfer criteria
- dermal thickness > 10%
- full thickness > 5%
- dermal > 5% Paeds
- burns w assoc inhalation injury
- priority areas involvement - hand, face, neck, feet, major joint, perineum
- circumferential
- electrical including lightning
- NAI suspected
- pregnancy
- concomitant trauma or medical condition
170
Criteria for pre-ecclampsia
Hypertension and proteinuria:
- Blood pressure >= of 140 mmHg systolic or 90 mmHg diastolic
- Occurs after 20 weeks of gestation in a woman with previously normal blood pressure,
- Or a rise in SBP >25 mmHg or DBP >15 mmHg
- Proteinuria is defined as urinary excretion of 300 mg or higher on a 24-hour urine specimen.
171
Risk factors for pre-ecclampsia
- Preeclampsia in previous pregnancy
- Chronic hypertension
- Pre-gestational diabetes
- 1st degree relative with pre-ecclampsia
- Multifoetal gestations
- Vascular and connective tissue disease
- Nephropathy
- Antiphospholipid syndrome
- Obesity
- Older age
- African race.
172
Abx for sepsis of suspected GI or Billiary source
- Ampicillin 1 g IV, 6-hourly
PLUS
- Gentamicin 4 to 7 mg/kg IV, for 1 dose
PLUS
- Metronidazole 500 mg IV, 12-hourly
173
Abx for severe sepsis of apparent Urinary tract source
- Gentamicin 4-7 mg/kg IV, for 1 dose
PLUS
- Ampicillin 2 g IV, 6-hourly
174
Meds to start after a TIA
- Aspirin
- Clopidogrel
(dapt)
175
Ages for screening common cancers in Acustralia
- 25-74 for Cervical
- 50-74 for Bowel
- 50-74 for Breast
- individuals aged 45-49 can also request a free bowel screening kit.
Phase 3
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