All things med mx

Remipril is for what?

Remipril is an angiotensin-converting enzyme (ACE) inhibitor used to treat hypertension and heart failure by relaxing blood vessels, thereby reducing blood pressure.

Atovastatin is for what?

Atovastatin is a statin medication used to lower cholesterol levels and reduce the risk of cardiovascular disease by inhibiting the enzyme HMG-CoA reductase.

Pantoprazole or Omepraole is for what?

Pantoprazole is a proton pump inhibitor (PPI) used to treat gastroesophageal reflux disease (GERD) and other conditions involving excessive stomach acid production.

A/E: Renal impact!

Dutasteride & tamsulosin is for what?

Dutasteride and tamsulosin are medications used to treat benign prostatic hyperplasia (BPH) by reducing prostate size and improving urine flow.

Hydrocholorothiazide is for what?

Hydrochlorothiazide is a thiazide diuretic used to treat hypertension and edema by promoting fluid excretion through the kidneys. Excretes potassium → ↓ K⁺ good for if you have too much (in hyperkalaemia)

Hyperkalemia mx

Insulin + glucose , Salbutamol, Diuretics that remove potassium= thiazide, Calcium gluconate,

also Sodium Bicarbonate (makes blood more basic w/ high Ph, H+ comes out by trading K+ into cells),

± exchange resins eg: Resonium

Hypocalcaemia vs Hypercalcaemia

Causes?

What Ix to do?

Complications/ symptoms?

mx ?

Ca+ levels = PTH levels

but are opposite of Phosphate levels (found on UEC)

Ix: Request for UEC, CMP, PTH, Vit D, Mg levels

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Causes of hypoCa+: low vit D, hypoPTH, CKD, Pancreatitis, loop diuretics

Causes of HyperCa+: high vit D, 1* hyperPTH,Cancer or thiazide Diuretics (dont lose Ca)

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Syx of HypoCa: “low calcium means our nervous system is not opposed, so↑muscle/ nerve excitation” = syx of muscle cramping/ tremors/ spasms, numb/ tingling fingers, seizure. Prolonged QTc / arrythmia

Syx of HyperCa: “too much Ca shuts body down” pain in abdo/bone, confusion/fatigue, polyurea, dehydration, and kidney stones. —> cuz breaks bone & too much Ca around

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Mx: HyperCa: IV fluids (sodium chloride) in all cases of hyperCa —> to fix dehydration & confusion

use w/ IV bisphosphonate aka zoledronic acid (but takes 2d at least to work) moa: stops osetoclasts from breaking bone

Denosumab (is monoclonal Ab, stops RANK → stops bone turn over —> less Ca made) eg) Prolia for osteoperosis

In severe inc Ca+ —> Calcitonin but has short half life

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Mx of hypoCa: replace lost Calcium w/ IV or oral calcium gluconate & Active vitamin D: Calcitriol

Mx for easy bruising

avoidance of medications that impair platelet function:

NO aspirin, clopidogrel, NSAIDs, anticoagulants (warfarin, DOACs), corticosteroids.

Mx for easy bruising/ bleeding in ITP

in Thrombocytopenia treat the underlying cause.

if severe: corticosteroids ± IVIG.

if severe blood loss: plt transfusion

Coagulation factor deficiency in Vit K low? or if low cogulation factors in haemophilia?

1. Replace vit K

2. replace coag factors (VIII or IX)

von Willebrand disease mx?

desmopressin or vWF-containing factor replacement.

STEMI mx

O2

Aspirin

GTN

Morphine

reduce mortality with: BBlockers, Statins, Reperfusion <90min or thrombolysis PCTA angioplasty

Alcohol withdrawl mx?

Initial assessment: ABCD

IV access

monitor vitals,GCS

withdraw score

Give Thiamine + Benzodiazepine eg) Diazepam (according to scale)

correct electrolytes (K+/Mg)

± treat hypoglycaemia

± IV fluids (if dehydrated)

± Metoclopramine (antiemetics for N / V)

Mx for school sores (impetigo) in children?

Clean the lesions gently w/ soap/ water

keep it covered

good hygiene

dont share anything! no towels/ bed/ cloths

treat all affected household contacts

Wash existing cloths/ bed

if Group A strep infection in Impetigo —> IM benzathine benzylpenicillin

If Scabies: Permethrin cream 5% w/ repeat in 7 days or Ivermectin if> 15kg child

Febrile convulsions/ seizure in a child Ix & Mx? typically a child from age 6month to 5yo.

Demonstrate how to use it buccally? allow it to absorb in cheek dont swallow

Demonstatre it intranasally? lay them down safely, follow adminitration tool steps, put in each nostril

Ix: do all for source of infection: FBC (infection) Urinalysis ±MCS, UEC (electrolytes), CRP, BSL (cause), ECG (cardiac complications), +?- CXRAY +? Stool MCS +? LP (for causes of seizure if meniningitis)

Serizure specific: MRI (causes), EEG if this is 2nd infection

• if simple febrile cause: reassurance & find cause. vs complex seizure (focal >generalized, >15min, >1h & reoccurs within itself)

• If seizure >5min : benzodiazepine ASAP to stop the seizure quickly eg) midazolam

• safety net: to call an ambulance if:

  • seizure lasts >5 minutes

  • it is their first seizure

  • they do not wake/recover afterwards

  • they have difficulty breathing or become blue/pale

  • the seizure is prolonged or they remain significantly drowsy.

In OSCE:

1. Stay calm and keep them safe

2. Time the seizure

3. Protect airways

4. Call help if >5min, if 1st seizure, if suddenly re-seizes, difficulty breathing, ongoing drowsy/confusion, meningitic signs, unilateral signs.

5. D/c once return to baseline, causes are investigated, safety net.

6. Mx at home symptomatic mx: rest and monitor for 24h + regular fluid, treat infection, urine output monitoring, follow up 1-2 days. keep emergency plan w/ benzo if complex seizure.

OSCE councilling: seizure doenst inc risk of epilepsy unless has high risk features: FHx of it, prolonged >15min, focal >generalised type, hx of neurodevelopmental problems. febrile seizures only occur with fever —> once treated usually doesnt happen & no brain damage caused but can look very scary. Watch for future febrile seizures as 1/3 likely to happen again w/ fever usuually stopped by age 6yo. So be prepared for future ones. Cannot be prevented or cured.

initial Ix/mx + actual mx: of heavy menstrual bleeding?

• Assess haemodynamic stability and severity of bleeding.

• Pregnancy test.

• FBC ± ferritin → assess iron-deficiency anaemia.

• Determine likely cause using PALM-COEIN.

• Consider pelvic examination and pelvic US depending on history/examination.

• Treat iron deficiency if present.

Mx:

• IUD (Mirena) → generally most effective medical option.

• Tranexamic acid → reduces menstrual blood loss; taken during menstruation.

• NSAIDs (e.g. mefenamic acid) → reduce bleeding + dysmenorrhoea.

• Combined oral contraceptive pill → regulates/reduces bleeding.

• Progestogen → alternative when oestrogen contraindicated.

• ± hysterectomy or endometrial ablation

Surgical emergency trauma eg: gun shot wound

• A – Airway + C-spine

• B – Breathing: RR, SpO₂, chest examination, oxygen if required.

• C – Circulation: control catastrophic haemorrhage immediately, assess pulse/BP, IV access, bloods, fluids/blood products as appropriate.

• D – Disability: GCS, pupils, BGL.

• E – Exposure: look for other injuries

Mx:

• Apply direct pressure/haemostatic dressing; use a tourniquet

• IV access

• analgesia

• Prevention of infection: tetanus shot prophylaxis + Abs

• urgent surgical assessment and imaging when stable.

How do you manage delirium?

• Identify and treat the underlying cause.

• ABCDE + observations + BGL.

• Correct dehydration/electrolyte abnormalities/hypoxia —> if those are cause

• Review medications.

• Treat any: pain, constipation and urinary retention

• Ensure glasses/hearing aids are available.

• Avoid unnecessary restraints/catheters.

• Maintain sleep–wake cycle, Provide orientation: clock, calendar, familiar people/environment.

manage mild CAP community-acquired pneumonia in a child?

mild:

• Oral antibiotics if bacterial pneumonia suspected.

• Fluids and regular feeding as tolerated.

• Paracetamol/ibuprofen for comfort/fever.

• Safety-netting and review.

manage severe CAP community-acquired pneumonia in a child?

• Admit.

• Oxygen if hypoxaemic.

• IV antibiotics if unable to tolerate oral therapy or significantly unwell.

• IV/NG fluids if required.

• Monitor respiratory status closely.

What important interaction should you remember with digoxin?

Digoxin has a narrow therapeutic index. Check renal function, electrolytes and interacting medications. Toxicity can cause GI symptoms, confusion, visual disturbance and arrhythmias.

How do you manage an uncomplicated, reducible inguinal hernia?

• may not need surgery if no symptoms (aka uncomplicated)

• if symptoms = refer for surgery esp if risk of strangulation

• observe for syx

How do you manage an incarcerated/strangulated hernia?

• Emergency surgical assessment.

• NBM.

• IV access + fluids.

• Analgesia/antiemetics.

• Bloods ± crossmatch.

(strangulation is present if severe pain + irreducable tender lump + red + N/V + ischemic / BO signs)

How do you manage major depression during pregnancy?

• Assess suicide/self-harm risk and symptoms for severity

• Discuss psychological therapy

• For mild depression → psychological interventions may be appropriate initially.

• Moderate–severe depression → psychological therapy + consider antidepressant medication: SSRIs

• Severe depression w/ inability to care for self → urgent psychiatric assessment/admission may be required.

What is the management of faltering growth/ failure to thrive in baby?

• Confirm accurate weight/length/height measurements and plot serially.

• Assess dietary intake and feeding and waste (wet nappies- if malabsorption vs inadequate intake eg) feeding issue)

• Detailed developmental and psychosocial history (inc requirements or different behaviours)

• Examine for systemic disease (IBD/ coeliac / diabetes/ infection)

• Assess parental heights/genetic potential.

• Dietitian/paediatric referral if significant or persistent.

Antiplt drugs vs Anticoagulation drugs & what their main use is?

Antiplt: arterial prevention

Anticoag: venus prevention

Returned traveller with fever + rash + diarrhoea/vomiting = Malaria vs Dengue vs typhoid treatment?

if Malaria:

• P. falciparum; severe malaria requires urgent IV artesunate

if Dengue:

• supportive care and careful fluid management. Use paracetamol for fever/pain and avoid aspirin/NSAIDs because of bleeding risk.

if typhoid:

• Antibiotics + fluids + electrolytes

Pre-Operative Mx?

-Patient education & consent

-Lifestyle modification (alcohol and smoking cessation, exercise and weight loss)

-Pre-operative fasting guidelines:

-Altered diet prior to surgery to enhance bowel recovery and avoid bowel prep if appropriate

-Solids allowed until 6 hours pre-operatively (unless contraindicated)

-Intake of clear fluids until 2 hours prior to surgery, with some centers moving towards being able to drink clear fluids up to the time of leaving the ward

-Loading with 12.5% carbohydrate beverage within 2 hours of surgery

Intra-Operative Mx?

-Use of multimodal and opioid sparing analgesia, including regional anaesthesia (e.g. spinal and epidural anaesthesia)

-Use of multimodal postoperative nausea and vomiting prophylaxis

-Use of minimally invasive surgery

-Targeting a goal-directed fluid therapy regime, including goal-directed haemostasis management

Post-Operative Mx?

-Ensure adequate pain control is achieved to allow for early mobilisation

-Early oral intake and optimising nutrition

-Multi-disciplinary post-operative patient follow-up, including in the post-acute care phase

Post op pain mx + A/E?

START: Non-opioid analgesia consists of paracetamol and/ or NSAIDs

Watch for—> NSAIDS contraindicated with Warfarin, A/E: Gastric uclers so give PPI

A/E: Renal failure (avoid)

A/E: Bleeding risk (plt dysfunction)

NEXT: -Weak opiates: codeine

-Strong opiates: morphine

If renal impairment —> use oxycodone (e.g. Endone) or fentanyl

A/E: Constipation + Nausea = need laxitives/ bowel chart w/ Anti-emetics.

A/E: sedation & confusion & resp depression

Neuropathic pain mx 2 main groups?

Non-pharmacological: CBT, transcutaneous electric nerve stimulation (TENS) or capsaicin cream (typically for localised pain)

vs

-Pharmacological therapies: gabapentin, amitriptyline or pregabalin; if these are not successful or not tolerated, specialist referral should be considered

N/V prevention & management in 2 ways?

Prophylactic measures:

-Anaesthetic measures (reduce opiates, reduce volatile gases)

-Prophylactic antiemetic therapy throughout surgery

-Dexamethasone when u start anaestasia

Conservative:

Fluids + Analgesia must be adequate

± Nasogastruc tube to aid gastric decompression

Drugs: try to tailor to cause of N/V:

If already given N meds, try a different one.

-if impaired gastric emptying —> need to start bowels use Metoclopramide (is prokinetic) “M for Move it”

or domperidone (motillium- dopamine antag) inhbits gut motility so u feel less sick

DO NOT use in bowel obstruction cuz it will not move the obstruction

if BO: use Hyscine (anti-muscarinic will dec GI secretion &N/V)

Usually start w/ Ondansetron —> then metoclopramide —> then Cyclizine

Mx for Mild COPD which is FEV1 60-80%?

Management aims to optimise function, prevent deterioration and manage exacerbations. Start:

1. smoking cessation

2. vaccinations (flu + pneumoccocal)

3. pulmonary rehabilitation (to clear symptoms of ongoing cough/sputum)

4. SNAP exercise, nutrition

5. avoidance of irritants (smoke/ pollutants/

6. Pharmacological treatment is stepwise: start with a short-acting bronchodilator (SABA/SAMA) for symptom relief

7. manage co-mobidities CVD + anxiety/ depression (COPD attacks can cause anxiety and is a chronic burden), Lung cancer (COPD is a RF for it) & osteoporosis (Repeated courses of corticosteroids for COPD exacerbations can accelerate bone loss)

Mx for Moderate COPD which is FEV1 :40-59% vs severe COPD with <40%?

moderate COPD is usually managed mainly with inhaled therapy + lifestyle measures, whereas severe COPD requires escalation of inhaled therapy and more intensive supportive management w/ inhaled steroids:

We already start with a short-acting bronchodilator (SABA/SAMA) for symptom relief → step up to a LAMA or LABA if symptoms persist → LAMA + LABA if still symptomatic → consider triple therapy (ICS + LAMA + LABA) for patients with persistent symptoms/frequent exacerbations.

For severe also manage: advanced lung disease w/ at home O2 therapies & long term non-invase ventilation ± surgery ± bronchoscopic interventions (requiring specialists).

Mx of acute COPD exacerbation?

For an acute exacerbation, treat promptly with bronchodilators ± corticosteroids and antibiotics when indicated, and provide controlled oxygen (88–92% if CO2 retention) with hospitalisation if severe.

What medications do you give for VTE prophylaxis?

vs if you actually have VTE whats used for treatment?

& who do you be cautious with?

Prophylaxis:

Hospitalised surgical patient
→ LMWHeparin (Clexane) is commonly the default

Post-operative orthopaedic patient
→ options can include LMWH or certain DOACs eg) Dabigatran, Apixiban

Patient with established DVT/PE
→ therapeutic anticoagulation such as apixaban is appropriate in many patients

For treatment/ cure of existing VTE:

Use Warfarin, Apririn

NOTES:

• Used until INR becomes therapeutic.

• LMWH dont use in renal failure or in Heparin induced thrombotic thrombocytopeoenia

• Aspirin - for thromboprophylaxis , A/E: inc risk of GI bleed & brain bleed

risk based on: hypercoagulable state:

• Surgery or trauma

• Immobility/hospitalisation

• Pregnancy and postpartum period

• Oestrogen-containing contraception or HRT

• Obesity

• Increasing age

• Previous VTE

• Long-distance travel

• Acute infection/inflammation

Monitor VTE prophylaxis in bleeding pts & those with haemorrhage, GI bleeds, severe thrombocytopenia, liver disease.

Mx of anastomotic leaks post surgery?

Ab IV

Fluids IV

Monitor urinary catheter for sepsis by seeing urine outflow volume

NBM if planing surgery —>

If really severe:

-explore site of infection w/ explorative laparotomy

-Washout

-insert/ clean drain or stoma

IX: CT for contents leak

*syx of Fever, tachycardia or hypotension, Increasing abdominal pain/peritonism

Mx of post-op Ileus ?

Is when abdo surgery dec the fx of abdo to do peristalsis, = is functional. causes constipation + obstruction (no gas) + bloating & distention w/ N/V.

Conservative function returns in 2-5d unless becomes BO or anastomotic leak

-NBM cuz bowel isnt gonna push any meds even laxitievs wont go through

-correct fluids w/ IV & electrolytes

-decompression via NG tube

-monitor, dont give opioids (constipation A/E)

IX: CT contrast for contents

Mx of post-op Atelectasis (small airways lung collapse) ?

*is very common to some degree

*can become: hypoxaemia, reduced lung compliance, pulmonary infections, and acute respiratory failure

*on Ex: crackles on affected side and low O2 sat (others will be fine)

MX: conservative w/ supplemental O2 & pain relief

Incentive spirometry (reps phsycian) + Chest physio to open chest

Anticoagulation peri op mx depends on what 2 key concepts/ risks? and the 3 key medications & investigation

compare risk in thromboemolic vs bleeding to decide if patient needs to stop their anticoagulation:

Thomboembolic risk (clot/stroke): “CHADsVASc” for ppl w/ Afib

• C — Congestive heart failure (1 point)

• H — Hypertension / high blood pressure (1 point)

• A₂ — Age 75 or older (2 points)

• D — Diabetes mellitus (1 point)

• S₂ — Stroke, TIA (transient ischemic attack), or blood clot history (2 points)

• V — Vascular disease, such as a prior heart attack (MI/ PAD/ atherosclerosis/ plaques) or peripheral artery disease (1 point)

• A — Age 65 to 74 (1 point)

• Sc — sex category, being female (1 point)

• 0 (men) or 1 (women): Low risk; blood thinners (anticoagulants) are generally not needed.

• 1 (men): Intermediate risk; oral anticoagulation may be considered.

• 2 or higher (men) / 2 or higher (women): Higher risk; oral anticoagulant medication is typically

vs bleeding risk: “HAS BLED” for candidates for or currently taking anticoagulant therapy.

• H— Hypertension (uncontrolled systolic blood pressure over 160 mmHg)

• A — “AKI vs ALP rise” Abnormal renal (kidney) and/or liver function (1 point for each)

• S — Stroke history

• B — Bleeding history or predisposition (major bleed in the past)

• L — Labile INR (unstable or high international normalized ratio readings if on warfarin)

• E — Elderly (age greater than 65)

• D — Drugs (using antiplatelet drugs like aspirin or NSAIDs) and/or Alcohol (8 or more drinks per week) (1 point for each)

• 0 to 2: Low to moderate risk for major bleeding. Anticoagulation can usually be considered safely.

• 3 or higher: High risk for bleeding. This does not mean you cannot take blood thinners, but it signals the doctor to use caution, correct reversible risk factors (like high blood pressure or alcohol use), and schedule more regular follow-ups

Warfarin has a longer half life ∴ earlier discontinuation at least 5 days pre-surgery. —> can do bridging anticoag w/ LMWH on day 4 (dec risk of embolism & dec bleeding risk ) must check INR —> must be b/w 1.5-2 before surgery

then stop LMWH 24h before surgery & restart warfarin as nomral 24h after

DOACS eg) apixiban pre surgery: can be discontinued 1-2 days prior to surgery. cuz they rapidly get used up and stop working fast once stopped.

LMWH pre surgery only used in bridging

Pre surgery mx of diabetes if insulin dependant vs oral hypoglycemic meds?

• Book for morning list

• Night before surgery —> reduce basal insulin to 2/3rds

• Omit morning insulin → start on sliding scale (Variable rate IV insulin infusion) + 5% IV dextrose (sugar)

• Monitor BSL every 2 hrs

• Continue till pateint is able to eat and drink → overlap with normal insulin regimen

vs if on oral diabeteic medications:

* Caese medication periop

• Metformin → morning of surgery (lactic acidosis)

• SGLT2 inhibitors → 3 days prior to surgery (euglycemic ketoacidosis)

• THEN CONTINUE AS ABOVE!!

• "supplemental insulin protocol" where they have a basal insulin dose + supplemental insulin based on BGL that is checked q6h

How to identify and manage: Abscess vs Cellulitis vs Nec fasciitis?

Types of clean/dirty wounds and mx & dressing to use?

Clean wound (is any wound with very low bacteria, no break in aseptic technique, no cuts into organs which have bacteria) —> no Mx prophylactic Abs needed UNLESS prosthetic/ foreign body was inserted OR pt is immunosuppressed —> Non adherent dressings (do not adhere to epithelialising tissue) Requires secondary dressing (holds the primary in place)

Clean but Contaminated wound (has some bacteria from purposely done elective entry to GI / lungs/ genitourinary area (exposing to organ bacteria) OR from breach in aseptic techniqie (introducing outside bacteria) —> Mx needs prophylactic Abs + clean the wound Lavage/ wash + can close the wound. eg) cutting finger, cholecystectomy,

Contaminated wound (unsterile entry of bacteria /infection from organs (done without electing to) eg) trauma)) or is a wound thats chronically open. —> Mx: same ^

→

Dirty wound: actually infected, foreign matter(animal/farming/bullet), pus, contaminated wounds left for 24h. —> Also needs AP prophylaxis + Lavage wash BUT KEEP OPEN TO CLEAR —> can still put dressing: antimibcrobial dressings (e.g. iodine gauze, silver containing dressings)

if deep cavity wound eg) abscess use packed dressing ti fill negative space —> Betadine-soaked ribbon gauze

The medicines that require withholding, cessation or dose reduction in acute kidney injury (AKI) or if they are sick?

“SADMAN”

S	Sulfonylureas – increased risk of hypoglycaemia
A	ACE inhibitors – risk of worsening AKI
D	Diuretics – risk of worsening AKI
M	Metformin – increased risk of lactic acidosis
A	Angiotensin receptor blockers (ARBs) - risk of worsening AKI
N	NSAIDs – risk of worsening AKI
S	Sodium-glucose co-transporter 2 (SGLT2) inhibitors – increased risk of ketoacidosis

What are some high risk medications?

“APINCHS for a pinch in time”

A	Antimicrobials	Aminoglycosides: gentamicin, tobramycin and amikacin vancomycin IV amphotericin (liposomal formulation)
P	Potassium and other electrolytes	Injections of concentrated electrolytes: potassium, magnesium, calcium, hypertonic sodium chloride
I	Insulin	All insulins
N	Narcotics (opioids) and other sedatives	Opioids e.g. hydromorphone, oxycodone, morphine, fentanyl, alfentanil, remifentanil and analgesic patches Benzodiazepines: e.g. diazepam, midazolam thiopentone, propofol and other short-acting anaesthetics
C	Chemotherapeutic agents	vincristine, methotrexate, etoposide, azathioprine Oral chemotherapy
H	Heparin and other anticoagulants	heparin and low molecular weight heparins (LMWH): dalteparin, enoxaparin warfarin Direct oral anticoagulants (DOACs): dabigatran, rivaroxaban, apixaban
S	Systems	Medication safety systems, such as independent double checks, safe administration of liquid medications, standardised order sets and medication charts etc.

Temazepam is what kind of drug ? and what are its A/E?

• Benzodiazepines carry significant risks, including excessive sedation, falls and other accidents, respiratory depression, confusion and cognitive impairment. Older patients are at particularly high risk of these harms.

• When benzodiazepines are taken regularly, for more than two to four weeks, tolerance and dependence are likely to occur.

• only for shortterm

Metoclopramide is what kind of drug / its A/E?

Antiemetic,

A/E: Elderly people and those of low body weight may be more sensitive to the adverse effects (e.g. extra-pyramidal).

What kind of drug is Citalopram? and consideration for it or A/E?

selective serotonin reuptake inhibitor (SSRI)

guidelines recommend psychological therapies for mild depression, and 6 to 12 months of antidepressant therapy for a single episode of moderate-to-severe depression

A/E: Whilst SSRIs have a generally good safety profile, they can cause hyponatraemia and increase the risk of falls.

What kind of drug is Amitriptyline? and consideration for it or A/E? Key uses?

tricyclic antidepressant (TCA). These medicines act as serotonin and noradrenaline reuptake inhibitors, but also block cholinergic, histaminergic and alpha₁-adrenergic receptors. TCAs were originally used in major depression but are now more commonly used for other indications, particularly for neuropathic pain and prophylaxis of migraine; and less rationally, to assist with sleep.

• TCAs may cause sedation and orthostatic hypotension, which may present with dizziness; both these increasing the risk of falls. TCAs also have a potent anticholinergic effect, which may result in cognitive impairment, dry mouth, dry eyes, constipation and urinary retention. As the elderly are already at an increased risk of many of these symptoms, TCAs have been described as 'Potentially Inappropriate Medicines' for older patients.

Uses: Migrane prophylaxis and major depression/ sleep

What kind of drug is Apixaban? and consideration for it or A/E?

• factor Xa inhibitor anticoagulant. It is used in non-valvular AF to reduce the risk of thromboembolism, particularly stroke.

• Elderly should continue this medicine but at a lower dose (2.5 mg twice a day) due to her renal impairment, age and low body weight

• If poor creatine clearance once/ not recovering/ allergy —> move to rivaroxiban instead

Prescribing cascade examples

• prescribing an additional medicine to alleviate the adverse effects of another medicine"—>

• prescribing a proton pump inhibitor to relieve dyspepsia caused by a NSAID

• prescribing a topical corticosteroid to treat a rash caused by an anti-seizure medicine

• prescribing a cough suppressant to relieve a cough caused by an ACE inhibitor.

Mx for shock? 

1. Simultaneously assess and resuscitate

2. ABCDE's

3. Lie down, keep warm, O2 therapy, monitor vitals, ECG, IDC

4. 2x large bore IV canulas

   • Urgent bloods – FBC, coags, LFTs, UECs, VBGs

   • IV fluids 

     • Initially crystalloid boluses

     • Followed by whole blood products

5. If bleeding → TXA; If IV fluids fail → vasopressors (e.g norepinephrine, inotropic agents)

notes: shock is when Inadequate perfusion of vital organs OR Hypotension (Systolic Blood Pressure < 90) + organ dysfunction

types: “SHOCK”

1. Septic and Distributive shock

   • Vasodilation → Inability to distribute blood to organs

   • Includes: septic, anaphylactic and neurogenic shock

2. Hypovolemic shock

   • Decreased blood volume

   • Includes: Haemorrhage, fluid loss (burn, diarrhoea, DKA/HUS)

3. Obstructive shock

   • Obstruction of heart / blood vessel → preventing adequate perfusion

   • Includes: tamponade, pneuothorax, thromboempolism

4. Cardiogenic shock

   • Issue with the heart pumping → inadequate perfusion

   • Includes: rhythm, ventricles, valves

5. Kemicals

   • Chemicals responsible for oxygen dissociating from Hb

   • Includes: CO, cyanide, methemglobinemia

Mx of post op N/V? 

Non pharm: 

• Adequate fluid hydration

• Adequate analgesia 

• Consider nasogastric tube - to aid gastric decompression

+ pharm (prophylactic during surgery and alternate drug when used post op) 

• IV Ondansetron IV (5HT3 antagonist)

• IV Dexamethasone at start of anaesthesia (corticosteroid)

  • long acting anti-emetic

• IV Droperidol at end of anaesthesia (D2 antagonist)}}

A/E (same as contraindications) NSAIDS?

• Liver : bleeding risk plt impact 

• lungs: asthma trigger 

• Gut: PUD bleed/ ulcer bleed 

• Renal: Failure esp from triple whammy & drug interaction eg) Warfarin 

Types of opioids and order of use?

Start: Codeine / tramadol - {{c1::weak opioid, AE = constipation hence often undesirable for treatment

—> Next: Morphine {{c2::strong opioid, longer lasting, better IV) —> Same as Hydromorhone

Or: 

• Oxycodone - also strong better oral than morphine 

• Tapentadol - {{c5::chronic pain (slow release)}}

• Mathadone - {{c6::patients with renal failure}}

• Tramedol / tapentadol - {{c7::both act on additional receptors (not just opioid receptors) → ∴ can be added on}}

• Fentanyl - {{c8:: strong opioid but short acting → ∴ preferred for ACS}}

Neuropathic pain responds better to alternate analgesics (amitriptyline or gabapentin

Refeeding syndrome mx and whos at risk?

if a patient hasn't eaten for > 5 days, aim to re-feed at no more than 50% of requirements for the first 2 days.

Two risk categories > 10 d vs >5 d

Fluid maintenance vs Replacemnt fluid calculation? & Ix how do we monitor the fluids?

For:

Child 16kg ?maintenance fluid

 Adult 96 kg ?maintenance fluid

Adult 40kg ?maintenance fluid + replacemnt fluid calculation if mild vs mod vs severely dehdyrated/ hypovolemic state?

Ix: check pt fluid levels:

• fluid input-output chart 

• daily weight chart

• UECs - low eGFR, high UCR, electrolyte abnormalities

Calculations:

Fluid maintencen calculation (is what they need baseline) : 4:2:1 (is mainly for paeds) 

Child 16kg ?maintenance fluid --> 

-10 —> x4 = 40 

-6 —> x2 = 12 = total 52ml/hr 

Adult 96 kg ?maintenance fluid, if using 4:2:1 vs using 25-30ml/kg/day ratio

First 10kg —> x4—> 40 

Second 10kg —> x2 —> 20  

remainder is x1 (aka kg remaining is same # as ml left to add)

 Minus from 96kg = 76kg left = 76 ml = 76+40+20= 136 ml/hr 

BUT using the 25-30ml/kg/DAY then this is= 2400 per DAY / 24hr for per hour= 100ml/hr

Adult 40kg ?maintenance fluid + rehydration of losses 

80ml/hr if using 4:2:1 or if using 25ml/kg/day —> 40×25 = / 24h per day = 42ml/hr

If dehydrated: Fluid deficit (mL) = weight (kg) × % dehydration × 10

if mild estimate based on their symptoms is 5% or 5-9% or 10%, then use it^

eg) for 40kg ^ Moderate, 9%: 40 × 9% × 10 = 3,600 mL bolus/deficit + the 42ml/hr

*ALSO replace elcteolytes if vomiting, diarrhoea

eg) 16 kg child, sunken eyes, dry mucous membranes, prolonged CRT

I'd think:

1. Assess ABCDE + severity
2. Determine % dehydration
3. Calculate deficit = kg × % × 10 mL
4. Add maintenance
5. Replace ongoing losses
6. If shock → IV isotonic boluses + reassess

7.if renal/ cardiac failure monitor for fluid overload

Which fluid choice to use for the following replacemnts of losses:

1. V/N / NGTube (loss of H,Na, CL, K)

2. Pure water loss ( (fever, dehydration, hyperventilation) = hypernatraemia!!

3. Biliary drainage (loss of Na/ CL./ bicarb/ K)

4. Diarrhoea / colostomy (Na, bicarb, K)

5. Jejunal / ileal stoma or fistula (loss of Na/ CL./ bicarb/ K)

6. Pancreatic drain/fistula (loss of Na/ CL./ bicarb/ K)

7. Inappropriate urinary loss / polyuria (Na/ K)

8. Ongoing blood loss eg) Malaena

1. 0.9% Saline ± KCL (replace Na & CL)

2. 5% dextrose (provided water via met of glucose)

3. lots of Na/ Cl so need to balance w/ crystaloid fluid Hartmann's

4. Hartmann's (bicarb replacemnt)

5. Hartmann's (Na/Cl but crystaoid )

6. Hartmann's (bicarb replacemnt)

7. depends on whats low measure urine outoput

8. blood product fluids!

🟦 Stomach → 0.9% saline (for resuscitation and maintenance fluids watch for over met acidosis.)
Because vomiting = HCl loss → Cl⁻ depletion + alkalosis

🟩 Bowel → Hartmann's (contains lactate to balance Ph otherwise same as saline)
Because diarrhoea/stomas = lots of Na⁺, Cl⁻ and/or HCO₃⁻ loss

💧 Water only → 5% dextrose (not for resus, pro:maintains hydration w/out excess electrolytes)
Because you're replacing free water

🩸 Blood → plasma/blood products

One important point: Hartmann's is not ideal for major vomiting/NG losses because the major problem there is chloride depletion, so 0.9% saline is preferred. Also, if the patient is losing potassium, you would usually need to add K⁺ separately after checking serum K⁺ and renal function.

What are things to consider in pre operative care?

• Analgesia

• Anti-emetics

• IV access

• Maintainence fluids

• Nil by mouth

• Nutrition state

• Medication cesation

• VTE assess + prophylaxis

• Abx prophylaxis

• Book / Consen

What medications may need to be ceased pre operatively? vs modified?

• Diabetic drugs 

  • Metformin - risk of lactic acidosis

  • SGLT2 inhibitors (gliflozins) - euglycemic keotacidosis

    • stop at least 3 days before 

  • → insulin therapy given if needed

• Antiplatelets / coagulants – stop / bridge / continue

  • Clopidogrel – stopped 7 days prior to surgery

  • Aspirin and other antiplatelets – can often be continued

  • Warfarin – caese 5 days prior → commenced on therapeutic dose of LMWH

  • Heparin – caese day of surgery

  • Enoxaparin – caese day before surgery

  • DOACs – caese 1-2 days before surgery

• OCP or HRT

  • Risk of DVT

  • stopped 4 wks prior to surgery’

Modify: insulin into IV & steroids must continue but switch b/w oral/ IV depending on surgery (to avoid addisonian crisis)

Aortic dissection Mx?

• ABCDEs

• Resuscitation

  • High flow O2 therapy

  • IV access (2x large bore canulas) urgent bloods 

  • Urinary catheter

• Analgesia (IV opiates)

Definitive mx is type A (surg) or B dissection (pharm) —>

• 1. MUST dec BP (approach for type B stanford) → 'anti-impulse therapy'

  • Target HR = 60-80; Target systolic BP = 100-120

  • 1st line – β blocker

  • 2nd line – CCB (non-dihydropyradines) “Aim = reduce velocity of LV contraction → decrease shear stress and minimize lesion progression”

• Refer to vascular / cardiothoracic team

  • urgent transfer to appropriate facility

  • ICU

• 2. surgery mx usually for stanford type A (at aorta)

AAA Mx?

• ABCDEs

• 2x large bore IV access, lie down, keep warm, high flow O2

• Urgent bloods – FBC, UEC, LFT, coagulation screen, G+H, crossmatch

• IV fluids resuscitation (0.9% NaCl or Hartmann's)
  
  

  • Permissive hypotension (sytolic BP ≤ 100) 

• Transfer to local vascular unit for immediate review and prep for surgery

• if stable (do CT) if collapsed to surgery for endovascular repair (EVAR)

Chronic limb Ischaemia mx before it becomes critical limb?

Manage CVD risk factors (cardiac (do ECG), DM, (BSL), cholesterol (lipids))

—> Antiplatelet (clopidogrel)

→ DM medications

—> statins

Surgical:

—> angioplasty ± stents

—> Bypass grafts

—> amputation when critical limb

General mx for arterial ulcers/ PAD?

aims to improve blood supply to the affected area, promote ulcer healing, and prevent recurrence.

1. Control: SNAP mx for RF, statins, HTN mx, DM Mx, CVD mx

2. Optimisation of blood flow: Revasculaise/ restrore blood flow since the blood has stopped supplying it, angioplasty, stenting, or bypass to open artery. 

3. Antiplatelet agents (e.g., aspirin, clopidogrel) and statins  

4. Wound care: debrivemnet/ levage to remove dead tissue and promote healing. Need approproate dressing maintain a moist wound environment and protect against infection. 

+/- Abs if infection 

monitor for osteomyelitis 

features of venous ulcer / vericose veins + mx?

• Lifestyle

  • Leg elevation (to bring blood back up) ensure doenst have PAD w/ doppler USS and check pedal pulses

  • Increased exercise

  • Weight reduction

• If visible wound → clean wound and add Dressings to avoid infex

• Dressings and emolients for surrounding skin – maintain surrounding skin health

• Compression bandage (gold standard) only one that works → decrease oedem 

• Safety net! → infection

• +/- vasodilator med

• Mx comobidities eg) DM, HTN, smoking

CP: looks like deep cellulitis on medial bone of foot but due to venous insufficiency.

• Wet, shallow with irregular borders w/ more pain in night

• Most commonly located on medial malleolus region

• Associated ft. of venous insufficiency

  • Surrounding edema / inflammation

  • Varicose veins —> Mx: conservative, elevate, avoid standing for long, weight loss, inc exercise. compression socks, eczema mx) ± laser ablasion/ foaming inflammatory,
    Haemosiderin deposition (brownish deposition)

  • Varicose eczema

  • Atrophe blanche

  • Lipodermatosclerosis

• +/- signs of infection (red, hot, swollen, tender, pus)

• +/- concommitant signs of PAD (if mixed ulcers)

Ix: venous duplex USS, dopler + pic, ABPI.

Meliodosis:

syx? Ix? Mx?

syx: Abscess everywhere (lung/ liver/ spleen)

Pneumonia w/ skin infections w/ Jt pains (osteomylitis) ± watch for : encephalitis/meningitis, and bacteremia.

Ix: Cultures - blood, urine, sputum (must use Ashdowns medium for B. pseudomallei.

• CT CAP → deep seated infections / Abscess

Mx: Erradicate w/ Meropenum OR use Ceftazamine —> then maintain and avoid 2nd infection w/ combo: TMP-SMX for 3months Trimetjprim + sulfamethoxazole + give folic acid (cuz these will dec it)

What condition is this:

Child with ≥5 days fever + conjunctivitis (red eye) + strawberry tongue/cracked lips (swollen) + rash spots and patches all oevr body + swollen hands/feet + cervical node → think coronary artery aneurysm

Dx: Kawasaki disease

Ix: FBC-anemia, thrombocytosis , inc CRP, UEC/ LFT (failures), urinalysis w/ culture can show sterile pyuria, Blood cultures and resp swabs (rule out GAS infection), ECG/Echo to chec coronary artery lesions.

Mx: Immediatly give IV immunoglobulins + Aspirin and review arteries

Mx for staphylococcus aureus causing bacteraemia?

Source control - remove/ find any devices impacting heart/lungs/ abdo. eg) remove infected IVs, PICC lines, CVC lines.

Then give:IV flucloxicillin & vencomyocin (MRSA cover) and adjust when blood cultures show senistivity.

Take ongoing blood cultures to check impact until they come back negative.

A/E for common Abs?

-in general?

-amoxicillin?

-tetracyclines?

-Metronidazole?

-Vancomyociin

-flucloxacillin?

trimethoprim?

• GI side effects – N/V, diarrhoea, abdo pain, bloating  +/- Clostridium difficile infection (in Associated with cephalosporins, clindamycin, ciprofloxacin )

• Thrush (oral or vaginal)

• Allergic reaction

• Rash with glandular fever EBV infex (amoxicillin)--> common, so if this happens switch 

• Light sensitivity (tetracyclines) --> just wear sunscreen 

• Alcohol intolerance (metronidazole) --> unpleasent, causes alcohol flush, H/N/V, abdo cramp (must avoid Etoh for first 72h post IV metro)

• 'Red man/ red neck syndrome' (vancomycin) --> is an infusio rxn : red/ itchy neck/face/ chest so give slowly 

• LFT derangement (flucoxacillin) --> avoid using long term : Important adverse effect = cholestatic hepatitis/jaundice

• Creatinine rise (trimethoprim)- just stops Cr excretion in tubules not true AKI 

Asthma Mx for:

-children <6,

-children >6yo

- adults?

(image)

AF mx?

ECG: given shows Rate: 108

Rhythm: irregular —> irregulalry irregular = AF

axis: normal no deviation

P- hard to find = no p waves —> atrial cause

QRS: not coordinated w/ P

no elevations or depressions

Ix: Anticoagulation (CHA₂DS₂-VA).

• ECG, FBC, UEC, TFTs.

• Echocardiogram.

• Treat underlying causes (e.g. infection, thyrotoxicosis, electrolyte abnormalities)

options: Rate and rhythm control

NOTE: if in shock/MI/confused —> ASAP: cardioversion

rate: BBlockers “olols” metopralol —> controls speed by slowing heart down low HR at the ventricles by slowing AV node conduction

—> if really unwell/ HFrEF = Digoxin

—> 2nd line is CaChannel blockers (also if HFrEF)

Rhythm: Restores sinus rhythm & reduce atrial remodelling (medical or shock)

—> via electrical vs medical Cardioversion (needs anticogas first)

—> or: antiarrythmic drugs: Flecainide, amiodarone (canbe used acutely and long term)

—> if not in control of chronic AF can do Catheter ablasian (of AF re-entry loop)

• prevent clots : anticoagulants (“bans” rivaroxiban, apixiban, dibigatran )

Tension headache mx vs migraine?

tension headache:

• Manage triggers/ causes

• Ibuprofen simple analgesia

migraine:

• Manage triggers + simple analgesia

• Fluid

• Triptans “tripping for migrane”

• ± Anti-emetics (ondansetron)

• ± prevention w/ amitriptyline “any tripping”

A 34-year-old woman develops generalised urticaria, wheeze, hoarse voice and dizziness five minutes after receiving intravenous cefazolin. She is pale and distressed. What is the immediate priority? (haemodynamically unstable high RR, low O2) anaphylaxis/ allergy Mx?

Lay the patient flat ABCDE unless breathing is impaired, call for help, remove the trigger and give IM adrenaline 1:1000 (1 mg/mL) 0.5 mL into the anterolateral thigh.

Repeat every 5 minutes if needed, give high-flow oxygen, secure IV access, rapidly infuse isotonic crystalloid for hypotension and prepare for a difficult airway. Observe according to reaction severity and risk factors because biphasic reactions can occur.

A 70-year-old man presents with an acute right middle cerebral artery ischaemic stroke. Routine admission telemetry in the stroke unit reveals newly diagnosed Paroxysmal Atrial Fibrillation. Past medical history includes hypertension and type 2 diabetes mellitus. Blood pressure is 134/78 mmHg, and eGFR is 72 mL/min/1.73m2. Echocardiography shows moderate left atrial dilatation and normal left ventricular systolic function with no intracardiac thrombus. Repeat CT brain at 48 hours confirms a small cortical infarct without haemorrhagic transformation. According to Australian Heart Foundation / CSANZ guidelines and the Stroke Foundation, what is the most appropriate long-term stroke prevention strategy?

CADVAS score for AF mx: This patient has non-valvular atrial fibrillation with an established ischemic stroke, which automatically gives him a high-risk CHA2DS2-VA score (Stroke/TIA = 2 points, Age >= 65 = 1, HTN = 1, Diabetes = 1; total score 5). Under CSANZ, Heart Foundation, and Stroke Foundation of Australia guidelines, Direct Oral Anticoagulants (DOACs: apixaban, rivaroxaban, dabigatran) are strongly preferred over warfarin due to superior efficacy in secondary stroke prevention and a 50% lower rate of fatal intracranial haemorrhage. Antiplatelet agents (aspirin, clopidogrel) are ineffective and inappropriate for stroke prevention in AF.

Gout Hx? Ix (what youd see on imagining?) & Mx osce style?

in Hx ask: SOCRATES esp: bilateral knees? septic jt ? ROM and weight bearing? Screen for DDx:

Gout specific: alcohol, sugar, purine rich diet, dehydrated, obesity, FHx, Renal disease/ kindey stones, DM, CVD, HTN. ANY Gouti tophi (firm nodules around ears, fingers, elbows or knees).

• Septic arthritis: hot, swollen knee with fever, rapidly progressive pain, recent infection, skin wounds, hx of joint injection or surgery, immunosuppression.

• Pseudogout: acute knee or wrist arthritis, particularly in older adults. Ix: calcium pyrophosphate dihydrate crystals

• Osteoarthritis: chronic mechanical pain, worse with activity, with brief morning stiffness.

Inflammatory arthritis: prolonged morning stiffness, multiple joints, systemic symptoms Eg:

• Rheumatoid arthritis (RA): symmetrical small-joint pain/swelling, prolonged morning stiffness (often >30–60 minutes), fatigue.

• SLE: arthritis plus photosensitive rash, oral ulcers, Raynaud's or other organ involvement.

• Psoriatic arthritis: psoriasis, nail pitting or onycholysis, dactylitis (“sausage digits”).

• Spondyloarthritis: inflammatory back pain, enthesitis, uveitis, psoriasis or inflammatory bowel disease.

Ix: XRAY (only 30% sensitive, more in chronic) may show soft tissue density (tophi), erosions or urate deposits.

Jt aspiration w/ analysis M/C/S: for Needle-shaped, negatively birefringent monosodium urate crystals support gout. Culture to look for septic jt

Serum urate levels (gives baseline)

Also check FBC (infection) UEC/ LFT (renal fx,med use)

Mx: crystals build up in jt causing inflammation/ pain. 1st we settle the inflammation/pain: NSAID 2nd stop flare with Colchicine (renal/liver fx impact)- only dec inflammation by crystals ,3rd prevention if high risk w/ Alloprurinol (actually prevents uric acid production so not helpful for acute flare only for preventio) (worst case start corticosteroids)

Concervative mx: RICE (rest/ice/elevate/ hydrate) Lifestyle: diet (low sugar/ meats) limit alcohol, weight loss. optimise co-mobidities. Safety net: if it becomes septic jt.

ADHD conservative and pharama Mx?

School strategies: eg) regular breaks, more 1-on-1 teaching, small groups. Alternate acedemic tasks with brief physical exercise & coordinate with home for clear/ concise instructions.

Personal stratehies: preventitive: eg) work on self esteem, reward positive behavior, have clear home rules, avoid engaging in small attention seeking behavior (only focus on major)

Meds:

• Stimulants eg) methylphenidate (Ritalin) and dexamphetamine

• Monitor for A/E symptoms and long term issues (increase sympathetic nervous sys activity): insomnia, tachycardia, long term: appetite suppression.

• Monitor: HR, BP, growth (weight/ height) —> in every visit, + yearly ECG (must check all these before any dose change)

What is Cerebral palsy? areas of impact? Mx?

CP: non-progressive injury to developemntal brain. Early intervention aims to maximise neuroplasticity (brain development), improve functionpersistent asymmetry, abnormal tone, delayed motor milestones or early hand preference before 12 months.

1. At risk: if M, LBW, premature, antenatal complications

2. .Delayed gross motor milestones eg) cant sit/stand/ walk = ataxic, and Dyskinetic (abnormal movements)

3. Asymmetric movement patterns (preferring functional side)

4. Poor tone & spasticity & poor power

Mx: physio —> support motor development

OT —> improve independence w/ feeding etc & avoid F# / hip displacemnt

NDIS support for ongoing referrals

Symptomatic Mx:

-visual/ hearing issues —> optometrist

-Intelecual disability —> assess w/ paediatriction

-Epilepsy: anticonvulsants

-Drooling: speech therapist / resp physio to avoid aspiration pneumonia ! biggest risk

Case: 4-year-old boy is brought to the ED by his mother because of RAPID ONSET illness: fever, vomiting, leg pain/myalgia and increasing drowsiness on exam: a rapidly spreading rash, non-blanching petechial or purpuric rash over whole body.

Red flags: Hypotension, tachycardia, prolonged capillary refill, cold mottled peripheries, altered consciousness and a non-blanching purpuric rash.

Dx? and initial Mx? Ix?

what else does he have if he also developed severe headache, photophobia, vomiting and neck stiffness?

Dx: Acute INVASIVE Meningococcal disease (becoming invasive into blood= septicaemia= high mortality) (by Neisseria meningitidis) ± meningitis (since LOC) or Septic shock/ DIC

Initial Mx: Call for senior paediatric, emergency and intensive care support= for septicaemia/ drowsy baby

• Perform ABCDE +DEFG (dextrose) + O2

• Obtain IV/IO access, blood cultures and administer immediate IV Ab ceftriaxone (third-generation cephalosporin) or ampicillin (covers GBS/listeria).

• Give isotonic IV fluid boluses for shock

Ix: to do once stable: Blood culture (since it seems its spread), meningococcal PCR *most accurate, FBC (anemia causing bruising?), UEC/ BSL (electrolytes/ renal fx/ sodium loss), blood gas VBG +lactate, and LFT+ coagulation (petechiae?).

Counselling point: A large proportion of the population are healthy, asymptomatic carriers of meningococcal bacteria in their nasopharynx and oropharynx.

Contact prophylaxis involves the treatment of at-risk contacts to prevent further disease and should be given as soon as possible + Three meningococcal vaccines are available MenACWY (at 1y odl and 14yo, menB & pneumoccocal for aboriginal kids)

If Meningitis/Encephalitis (infection in meninges eg) more LOC/ GCS issues) AND septiceaemia (infection in Bloodstream) w/ systemic illness present caused by the meningococcocal disease —>

Also cover for meningitis/ encephalitis Ix/ Mx,

Ix: add once stable: LP + CSF interpritation, MRI (if nay neuro syx of LOC/ inc ICP)

Mx: now include IV dexamethasone (coticosteroid) w/ Abs to reduce risk for hearing loss by dec inflammation.

for meningitis —> do emperical Ab (cover pneumococcal + meningococcal)

for encephalisti —> IV aciclovir (for HSV cover)

signs of inc ICP in general early/late ? vs in paeds? and main Mx?

early: N/V/ papillooedema/ H/ LOC/dec GCS/ change in vision/ drowsy / neurological deficits/ seizures/ abnormal posture.

Late deadly: Cushing's triad : 1. hyperTension 2. Bradycardia(in rsp to inc ICP) 3. Irregular respiration (Abnormal breathing patterns due to brainstem compression).

in paeds red flag:

• Bulging or tense anterior fontanelle when calm and upright.

• Rapidly increasing head circumference crossing centiles. (more than last time checked)

• Widely separated cranial sutures.

• Persistent irritability, high-pitched cry or lethargy.

• Poor feeding and recurrent vomiting.

• Sunsetting eyes / fixed— downward deviation of the eyes, with the sclera visible above the iris.

Mx: recognise raised ICP early, stabilise ABCDE + DEFG = dont ever forget glucose, Abs + if altered LOC give dextrose (dont deprive brian of sugar!!) , fluid saline & monitor Na/fluid status/ renal fx, prevent secondary brain injury (prevent hypoxia and hypotension, as both worsen secondary brain injury.), and urgently involve senior paediatric/PICU and neurosurgical teams (for possibel surgery to reduce lesion/ haemorrhage) .

What is one managemnt to not forget for brain impacts? eg) in DKA, brain injury (trauma/ mass), brain tumor, hydrocephalis, meningitis/encephalitis?

DKA Mx 4 key?

and Ix to do? if someone comes in w/ polyuria/polydipsia/lethargy/ N/V/ weight loss/ mild abnromal vitals

dont forget sugar!! do BSL + give dextrose

In a child being treated for DKA w/ cerbral oedema , suspect cerebral injury if they develop worsening headache, recurrent vomiting, irritability, reduced consciousness, slowing heart rate or rising blood pressure. in DKA mx:

1. start with IV fluids to restroe circulation

only then do you add → 2. IV insulin supresses ketogeneiss and clears acidosis

—> 3. when giving insulin also give supplemental potassium K+ into fluid

—> 4. Give dextrose if BGL< 15mmol. *remmeber in DKA main issue is insulin resistance, body thinks we dont have it, and inc ketogensis from fat = met acidosis, giving dextrose acts as a supplemnt for the body while insulin stops additional ketone enegry sources.

Also for sick children treat hypoglycaemia and provide glucose when a child cannot maintain an adequate blood glucose level. —> prevent seizure & brain injury by giving sugar + fluid.

Ix? VBG (DKA is an acidosis!!!) FBC (infection- septic), Urin dip/ urinalysis + ketones (UTI→ sepsic), ECG (potassium loss cardiac changes), Blood culture (septic source search), HbA1c + BSL (chronic and acute), Petide C (ddx b/w T1MD & T2DM) or other antibodies for DM: GAD antibodies, IA-2 antibodies (DM vs DI)

Parts of ABCD? and whats AVPU scale?

Airway

• Assess airway protection and LOC.

• Call anaesthetics/PICU early; intubation may be needed for a deteriorating child, coma or loss of airway protection.

• Maintain cervical spine precautions if trauma is possible.

Breathing

• Correct hypoxia and avoid hypercapnia.

• If ventilated, generally target normocapnia: PaCO₂ around 35–40 mmHg.

Circulation

• Obtain IV/IO access, monitor BP (for hypotension) and perfusion, and treat shock promptly.

• Use isotonic IV fluids when needed to maintain circulating Blood volume and cerebral perfusion.

Disability

• Assess AVPU (rapid assessment of a child's level of consciousness) —> Alert? (15-GCS) Voice illicits response?( Variable GCS) Pain stimulus response? (GCS 8) Unresponsive to either? (very poor GCS) if only responds to pain→ corresponds of GCS of 8 → indication for intubation to prevent aspiration

• GCS: pupils, limb movements and seizures.

• Check BSL + correct hypoglycaemia.

• Treat seizures promptly; prevent fever and excessive agitation.

Exposure and positioning

• Elevate the head of the bed by 20–30° if haemodynamically stable.

• Keep the head and neck midline to support cerebral venous drainage.

• Avoid tight neck ties, excessive hip flexion and anything obstructing venous return.

• Maintain normothermia— >esp in paeds.

Full assessment and Mx of Non-accidental injury in child?

1. Treat any injury as normal (could be accidental/ bleeding issue) Ddx: accidnetal/accidental injury, Trauma from birth, coagulopathy disorder,infection, blood disorder (leukaemia/ anemia).

2. Confirm suspicious injury w/ senior paeds clinitian + opthal review for most specific signs!

3. Get full hx: early signs Poor feeding, vomiting, apnea, irritability, seizures, decreased tone, and decreased consciousness

4. Perform full examination + get Hx from other people as well, on hx get: BINDS (birth/immunization/ nutrition/ development/ social hx) + how/ when and who saw the injury and who was at home + how long it took to come get it checked out?

5. Document + Report to police & child protection services

Ex: ABCD and observe bruising/injury+ GCS check resposne to voice/pain/stimulus?, Cranial nerves (look into eyes for haemorrhage/macular folds—>both a sensitive and specific finding. & visual acuity) Neuro: focus on tone/LOC/ movemnt: seizure movements? MSK: full tone/ROM/ power check, Skin exam: swelling/ bruising

Red flags mortality rate of approximately 30%: Unwitnesessed injury (not giving hx) —> Mechanism incompatible with the child’s age or developmental capabilities eg) child <6m cant roll in any direction only rolls back. —>any injury on an infant that cant even move —> inconsistant hx —> delayed in seeking help —> injuries in uncommon areas: neck, ear, torso, post rib f#, symetrical burns over hands, f# at different stages of healing, haemorrhage , any age w/ injury to Frenulum, Angle of jaw, Cheek, Eyelid, Sclera “FACES”, multiple/ clusters/ large bruising.

Complications: blindness, cerebral palsy, mental retardation, and seizure disorder.

Ix: hair sample obtain for illicit drug testing (poisoning) + bloods:

• FBC/ iron studies/ LFT/ coag studies/ INR/PT time/ vWB panel, = (causes of bleeding/bruising)

• for bone weakness/ disorders = check: CMP, PTH, Vit D

• ± CK (rhabdo in muscle trauma) ± UEC (uraemia = bruising)

• Xray full skeletal survey: (which shows f# of different healing stages and worse than reported on hx)

F# to look for: metaphseal f# of elbow/ knee + post rib f# + skull f#

DDx: is shaken baby syndrome:

• Retinal haemorrhage

• Rib f#

• LOC in and out

• seizures

• tense fontanelles

• Often asymptomatic! but will show brain bleed.

Mx of constipation? and types?

1. Disimpaction dose until stools are runny w/ Macrogol

2. Then mainenance dose for months

3. Slowly wean to avoid reocurrance (dont abruptly stop it)

4. ± electrolytes / lactulose or lubricants like vaselene for anal fissures.

Types:

• for creating bulk: meta mucil

• for stimulating bowels: senna

• osmotic: lactulose

• stoften stools with movicol

Coeliac disease mx?

Gluten free diet life long

Replace micronutrient dificiencies : replace iron, folate, calcium and vitamin A,D,E,K supplements

monitor for complications like: B12/ folate def anemia and osteoperosis, malnutrition and enzyme impact on liver/ pancrease (check Hba1c and LFT, TFT)

Intussusception syx and mx?

syx: sudden onset of episodes of abdo pain, baby cries a lot w/ curled legs up during these episodes. lasting upto 5min then resolves. baby gets very lethargic and then passess "current jelly stool" if you palpate abdo will find "sausage shaped abdo mass" 

Ix use abdo USS (gold standard) w/ donut or target sign. 

Mx: non-surgical reduction using contrast enema (same as in BO), can also reduce w/ air. perfirm under USS guidence bringing air or contrast into colonoscopy and the pressure pushes the bowel that has shortened into distal bowel to stretch back into its normal position.

Mx for an acutely psychotic pt or manic pt?

1. take a non-threatening stance when approaching

2. ensure exit plan is in place of how to leave if needed ± extra security staff

3. ensure is done w/ safety to self , others, and pt

4. De-stimulate the pt w/ rassurance

5. De-stimulate with meds :benzos eg: Droperadol or Lorazepam + antipsychotics eg: Olanzepine IM injection to calm pt down (works right away)

6. Bridge psychotics w/ Ariprazo (2nd gen) —> then longterm maintence antipsychotic: Depo injection (lasting 1m)

• do not use any stimulants / antidepressnets

Mx for acute cardiogenic pulmonary oedema (APO) secondary to likely heart failure

1. cannula for bloods

2. strict fluid mx (dont just give fludi cuz has fluid oevrload / oedema) so restrict oral intact + monitor urine output

3. Give a diuretic eg: Frusomide IV

4. Consider GTN if pain and no improvemnt

5. Start 4 Drug Pillers of HF: ACE “pril”/ ARBs “sartan” , BBlockers “olol”, Mineralcorticoid recpetor antagonists: spironolactone, SGLT2 inhibitors “flozin” to remove fluid.

6. Mx causes of decompensation: med adherance, infection, new arrythmia, Hx of ACS/ PE dx , acute valcular dysfunction , hyper Thyroid, dietary relapse, IDA

7. Refer to cardiologist for mx of these causes & med review

8. Regulalry monitor vitals and O2 —> cosider high flow O2 if sats <94%.

Mx for hyperThyroidism (eg: Graves) vs hypoT (eg: Hashimodo’s) ?

HyperT: Anti-thyroid medications: Methimazole (stops thyroid gland from producing excess hormones) & BBlockers (block adrenaline effects to control syx of rapid heart rate, tremors, and anxiety.)

HypoT: trial levothryoxine plus iron supplements, calcium supplements, antacids, or multivitamins. if -ve TPO Abs then just monitor TSH levels

Mx for bronchiolitis qand key syx of it?

syx: coryzal syz w/ sick contacts, high risk age group, iWOB, difficulty feeding & irritable, ± exposure to smoke, lack of RSV vaccination, potential for dehydration.

Mx:

1. admit under paeds if clinically dehydrated eg) has lethargy/ inc RR / dehydration

2. NG feeding 2/3 maintenance rate

3. replace fluid deficit and any ongoing losses

4. daily weights and monitor vitals & imporvemnt to iWOB

5. mointor for fluid output — # of wet nappies

6. Supportive care —> O2 if <90%

Give 3 different features for DDx: Delirium vs Dementia vs Depression & durations ?

5 strategies to minimise distress to a cognitively impaired pt in distress?

●Regular reorientation to person/place/time (E.g. via calendar and clock)

●Minimising hospital length of stay

●Continuing engagement with family and friends within hospital

●Keeping familiar items from home with the patient

●Reducing excess noise and and other stimuli

H.pylori suspected in: epigastric pain/ GORD like, N, bloating, early satiety, postprandial fullness, peptic ulcer syx.

Ix: + any cautions for ix?

Mx:

Ix: Urea breath test (preferred)

Stool Ag test (detects active infection + if its actually cleared from gut)

If red flags: gastroscopy w/ biopsy

caution: Before testing: Stop PPIs for 2 weeks and antibiotics/bismuth for 4 weeks, if clinically safe, to reduce false-negative results.

MX: erradicate w/ combo of acid suppression (PPI) + Abs —> then repeat IX at least 4 w post mx, (at least 2w since last PPI)

Paeds: Croup Ix & Mx?

Ix: NONE minimal handling, distress leads to apnoea so any interventions will cause the clam child to quickly struggle to breath

Mx: start w/ dexamethasone/ or pred (oral steorids) => if Mild

If worsening: add Nebulized adrenaline and Dex ± high flow O2 ± intubation if ongoing stridor.

young pt comes in with pain in fingers+ rash postules, and fever/ malaise, is sexually active. what Ix to do and what key dx in thsi age group ?

DDx: tenosinovitis from gonorrhoea inf which has become systemic w/ rash + F/Malaise & jt pain. —> “Bacteriemia” (60% of gN.Gonnorrhoea presnets as this)

Need to do Cervical + racatl + throat swabs + Blood cultures.

Mx: Ceftriaxone (skin) + Azithro (systemic) IV or IM

Can also present as septic arthritis (more localized to 1 jt rather than multiple tiny ones on hands)

that can be gonoccocal or non-gonoccocal

if older M consider GOUT + STDs

Middle age M or F comes in with severe sharp flank pain radiating down legs sudden onset + micro RBC in urine + HTN history Ix? Dx?

They later develop severe headache Dx?

Autosomal

Ix: renal USS (grape sign)—> also later screen for berri anneurisms if neuro syx

Mx: prevent complications and delay progression cuz its chronic. Mx BP (ACE-I) , UTIs

main complication: severe headache= ruptured SAH (ruptured berry aneurysm)

Cognitive decline: DDx:

a) choria (dancing UL “dangling” purposeless movements)

b) 30yo F, rigidety & slowing of movemnts (bradykanesia) + behavioral changes(mild irritability to stronger progressing to dementia) + young age in each generation & Hx of dementia/ alzhimers

c) tardive dyskinesia

a)

b) Huntingtons- adult w/ autosomal dominent FHx, + atrophy of caudate nucleus and basal ganglia. syx: chorea, behvioral change, eventually dementia. prognosis only 20y. Mx syx: resperidone/ tetrabenzine for movemnts and Antipsychotics and SSRI for depression.

c) long term anti-psychotic EPS A/E

Mx for anemias:

Microcytic —> IDA or Thalassemia

Normocytic —> chonic anemia

Macrocytic —> B12/ folate , cancer

Mx for each

microcytic :

Normocytic: anemia of chornic disease —> Erythropoiesis-stimulating agents (ESAs) + replace iron w/ supplements

Macrocytic: