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14.03.26 Placement notes

ARDS
  • Definition
    • Type 1 respiratory failure
    • Non-cardiogenic (i.e. PAWP <16 mm Hg)
  • Diagnosis: Berlin criteria
    • Lung injury of acute onset, within 1 week of an apparent clinical insult and with progression of respiratory symptoms
    • Bilateral opacities on chest imaging not explained by other pulmonary pathology
    • Respiratory failure not explained by heart failure or volume overload
    • Decreased arterial PaO2/FiO2 ratio:
      • Mild ≤ 39.9 kPa
      • Moderate < 26.6. kPa
      • Severe < 13.3 kPa
  • Causes
    • Primary pulmonary (SARS, barotrauma)
    • SIRS (e.g. Pancreatitis)

PCA prescription
  • Morphine PCA, IV
  • 50 mg in 50 ml 0.9 % NaCl
  • 1 mg bolus; 5 minute lockout
  • No background

Notes
  • Marjolin's ulcer 
    • Aggressive ulcerating SCC presenting in an area of previously traumatized, chronically inflamed, or scarred skin
    • e.g. At a long-standing venous ulcer
  • Gallbladder polyps
    • > 1 cm with / co-occurring gallstones in people over 50 => Risk of development to adenocarcinoma
  • CXR in pancreatitis
    • ARDS
    • Alelectasis (due to pain; risk of pneumonias)
    • Perforation (alternative cause of raised amylase / late complication)
  • Antibiotics (meropenem, imipenem) are sometimes used in pancreatitis for prophylaxis, but not much evidence base
  • Evidence of end-organ dysfunction in SIRS
    • Poor or altered cerebral function
    • Hypoxemia (PaO2 less than 10 kPa)
    • Elevated plasma lactate
    • Oliguria (< 0.5 ml/kg body weight.h)
    • Hypotension
    • Raised bilirubin
    • DIC
  • Infection + 2 criteria + organ dysfunction = Severe sepsis
  • Infection + 2 criteria + lactate >4 or SBP <90 or MAP <70 after 30 ml/kg fluid bolus = Septic shock
  • Conditions associated with berry aneurysms (cf 85% of SAHs):
    • Adult polycystic kidney disease, Ehlers-Danlos syndrome coarctation of the aorta
  • Acute anterior uveitis occurs in as many as 30% of patients at some time during the course of ankylosing spondylitis (esp. with HLA-B27 allele)
  • HBeAg: Secreted version of HBcAg; Marker of active replication and infectivity
  • Hyperactivity and short stature are associated with Perthes disease
  • Low platelet count and raised transaminase level is typical of dengue fever
  • Hypercalcaemia, renal failure, high total protein = myeloma
  • Conn's syndrome is the likely diagnosis - a renin:aldosterone ratio would be an appropriate first-line investigation
  • Bilateral INO
  • Young: MS
  • Old: Stroke
  • Cluster headache prophylaxis: Verapamil
  • Osteochondritis dissecans: Pain after exercise, Intermittent swelling and locking
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