Acute Flashcards
1
Q
Excluding pain and pallor, give other clinical features of an acutely ischaemic limb
A
Pulseless Paralysis Paraesthesia/numbness Cold Fixed staining /mottling of skin Capillary refil time over 2 secs
2
Q
Give examination findings of a patient that may indicate embolic source of ischaemic limb
A
AF/irregularly irregular pulse AAA Popliteal artery aneurysm Mechanical heart valve New or changed murmur Femoral bruits
3
Q
Give features of an affected limb which would suggest irreversible ischaemia
A
Fixed staining /mottling of skin
Gangrene / necrosis
Profound paralysis
Severe sensory deficit
4
Q
How do you calculate an ankle brachial pressure index?
A
BP in leg / BP in arm
5
Q
What does an ABPI result of 0.4 show?
A
Severe arterial disease
6
Q
In a patient with an ABPI of 0.4 and symptoms and signs of a critically ischaemic limb, give mediation which should be immediately prescribed and route of administration
A
IV heparin or subcutaneous LMWH
7
Q
What is phlegmasia cerulea dolens?
A
Severe form of DVT which results from extensive thrombotic occlusion of major and collateral veins of an extremity
8
Q
What are characteristic features of phlegmasia cerulea dolens?
A
Sudden severe pain
Swelling
Cyanosis
Oedema of affected limb
9
Q
What is there a high risk of with phlegmasia cerulea dolens?
A
PE
Venous gangrene
Underlying malignancy
10
Q
What are signs and symptoms of TCA overdose?
A
Tachycardia/arrhythmia Tachypnoea due to metabolic acidosis Urinary retention Dilated pupils Pyrexia Hyperreflexia Hypotension
11
Q
What problems can occur if c diff goes untreated?
A
Dehydration
Perforation
Obstruction
12
Q
A 38 year old female attends ED after falling onto muddy path in park. She has grazes on both knees and a very deep wound to her left thenar eminence. An X-ray of hand confirms presence of foreign body. The patient says she is fully immunised against tetanus. According to the Department of Health guidance, what should be done?
A
Immediate dose of tetanus immunoglobulin
13
Q
A 24 year old man presents with left chest trauma. A CT thorax shows multiple fractured ribs and a lung contusion. On the second day he develops worsening dyspnoea and hypoxia. What is the likely pathology?
A
Acute respiratory distress syndrome
14
Q
What is acute respiratory distress syndrome?
A
Lungs begin to fill with fluid due to activation of the inflammatory cascade resulting in impaired gas exchange
15
Q
A 74 year old man develops oliguria following an emergency open abdominal aortic aneurysm repair. Despite aggressive fluid resuscitation, his serum creatinine rises to 600. What is going on?
A
Acute kidney injury
16
Q
A 24 year old alcoholic man with severe acute pancreatitis ha been admitted to intensive care. Despite aggressive management he has developed cardiac, respiratory and renal failure. What is going on?
A
Multi organ dysfunction syndrome
17
Q
A 19 year old lady is admitted to ITU with severe meningococcal sepsis. She is on maximal inotropic support and a CT scan of her chest and abdomen is performed. The adrenal glands show evidence of diffuse haemorrhage. What is the diagnosis?
A
Waterhouse Friderichsen syndrome
18
Q
A 38 year old man is noted to have a blood pressure or 175/110 on routine screening. On examination there are no abnormalities of note. CT scan shows a left sided adrenal mass. Plasma metanephrines are elevated. What is the diagnosis?
A
Phaeochromocytoma
19
Q
What are clinical features of a thoracic aorta rupture?
A
Mechanism of injury - RTA, fall from height
Contained haematoma - persistent hypotension
CXR changes: widened mediastinum, tracheal deviation to right, depression of left main stem bronchus, widened paratrachal stripe, space between aorta and pulmonary artery obliterated
Rib fracture/ left haemothorax
20
Q
What percentage body surface area burns should be transferred to a burns unit in children and adults?
A
Adults >20%
Children and elderly >10%
As soon as they are stabilised
21
Q
What methods can be used to get IV access in burns if percutaneous access cannot be obtained?
A
IV cutdown in cubital fossae or long saphenous vein (anterior to medial malleolus or groin)
In children less than 6, intraosseous approach in tibia
22
Q
In the absence of IV access what is the next preferred route of administration of adrenaline during cardiac arrest?
A
Intraosseous
23
Q
What is the dose of adrenaline given in a cardiac arrest?
A
1 mg of 1:10000 adrenaline IV every 3-5 mins
24
Q
What are the surviving sepsis guidlines?
A
TO BE COMPLETED WITHIN 3 HOURS OF TIME OF PRESENTATION:
1. Measure lactate level
2. Obtain blood cultures prior to administration of antibiotics
3. Administer broad spectrum antibiotics
4. Administer 30ml/kg crystalloid for hypotension or lactate 4mmol/L or more
TO BE COMPLETED WITHIN 6 HOURS OF TIME OF PRESENTATION:
5. Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to
maintain a mean arterial pressure (MAP) 65mmHg
6. In the event of persistent hypotension after initial fluid administration (MAP < 65 mm Hg) or if initial lactate was 4 mmol/L or more, re-assess volume status and tissue perfusion and document findings. Place a central line and aim for CVP greater than 8 and ScvO2 greater than 70
7. Re-measure lactate if initial lactate elevated
25
What causes Kussmaul breathing in DKA?
Ketone bodies produce acidosis which causes deep rapid breathing
26
Why do patients with DKA get dehydrated?
Ketones and glucose produce osmotic diuresis
27
A 65 year old man presents to ED with a sudden onset tender mass in the left lower quadrant. His PMH includes valve replacement for rheumatic heart disease and he takes regular warfarin. He has also recently been on a course of erythromycin for a chest infection as he has a penicillin allergy. On examination there is a tender mass to the left of the midline which appears to become more prominent on lifting the patient's head from the bed. His Hb is 89 and his INR is 7.2. What is the diagnosis?
Rectus sheath haematoma
28
If you suspect a PE in a patient, what should be done while waiting for the CTPA to be done?
```
ABG
FBC
CRP
CXR
Place patient on LMWH
```
29
What are causes of traumatic pneumomediastinum after penetrating trauma? How do you investigate?
Injury to pharynx, larynx, trachea and oesophagus
| Multislice spiral CT or contrast study endoscopy
30
What is the management for salicylate poisoning?
ABCDE
Gastric lavage
Blood levels
Encourage high fluid intake - may need resus and maintenance IVI
Monitor urine volume and pH
Forced alkaline diuresis induced with bicarbonate infusion
If coagulopathy - vitamin K administration
31
Which bug causes cat scratch disease?
Bartonella henselae
32
Which bugs are responsible for reactive arthritis?
Ureaplasma urealyticum
| Mycoplasma genitalium
33
Which bug is responsible for Lyme disease?
Borrelia burgdorferi
34
What is the typical skin lesion seen in Lyme disease?
Erythema migrans
35
Which bug causes necrotising fasciitis?
Group A streptococcus
36
Which bug typically causes cold agglutinin production and autoimmune haemolytic anaemia?
Mycoplasma pneumoniae
37
How do you treat organophosphate poisoning?
Pralidoxime
38
What are features of organophosphate poisoning?
Hypersalivation
Sweating
Bradycardia
Due to increased cholinergic activity
39
What should be given to treat methanol poisoning?
Ethanol - inhibit build up of toxic metabolite products of methanol
40
What problems can methanol consumption cause?
Blindness
Lactic acidosis
Liver failure
41
What should be done to treat a child who has taken an excessive amount of ferrous sulphate?
Desferrioxamine
42
Which organisms does the BCG vaccine protect against?
Mycobacterium tuberculosis
| Mycobacterium leprae
43
What is a Mantoux?
Tuberculin sensitivity test - screen for TB
44
What dose of adrenaline should be given for a PEA arrest?
1mg IV
| 10 ml of 1:10000
45
How often should adrenaline be given in a PEA arrest?
Immediately then after every 2 cycles (roughly once each 3-5 mins)
46
What are GI symptoms of iron overdose in a child?
Vomiting
Diarrhoea
Abdominal distension
Symptoms of intestinal haemorrhage
47
What can be a long term complication of iron overdose in a child?
Pyloric stenosis
48
What are non GI features of iron overdose in a child? Why?
Hepatic toxicity - jaundice, deranged liver function and clotting abnormalities
Metabolic acidosis
Hypoglycaemia
Iron is absorbed and accumulated into the mitochondria
49
Why is gastric lavage no longer used in iron overdose?
Iron tablets are large and sticky so it is unlikely to be of benefit
50
What are you at risk of if being bitten by an IV drug user?
Hep B, C and HIV
51
How is Lyme disease diagnosed?
Clinical picture
| ELISA
52
How is malaria diagnosed?
Clinical picture
| Blood film stained with Giemsa to identify Plasmodium infections
53
What is the treatment for someone presenting with haemoptysis who's sputum sample shows Aspergillus fumigatus?
IV amphotericin B
54
In patients with isolated nasal injuries, which are the 3 major exceptions where the patients will need admission?
Septal haematoma
Compound nasal fracture
Associated epistaxis
55
When is it best to review patients with uncomplicated isolated nasal injuries?
After 5 days in ENT clinic when swelling has subsided and it can be determine whether manipulation is appropriate
56
A 30 year old man who works in a lab which handles animal products presents to ED with a skin ulcer with a black area in the centre. The patient explains that this started with a small itchy pimple that began to ulcerate a couple of days later. What is the diagnosis?
Bacillus anthracis - anthrax
57
What are the 3 main types of anthrax?
Cutaneous: direct contact with skin or tissue of infected animals
Inhalation: spores, sore throat, cough, fever. Abrupt resp failure 2-4 days
Intestinal: swallowing spores, nausea, bloody diarrhoea, pain
58
How does aciclovir work?
Via thymidine cycle
Phosphorylated by this pathway, then further phosphorylated by cellular enzymes to triphosphate, then competes with deoxyguanosine triphosphate for a position in viral DNA
59
Which drug is effective against CMV?
Ganciclovir
60
What is the commonest adult muscular dystrophy?
Myotonic dystrophy
61
What are features of myotonic dystrophy?
Frontal baldness in men
Atrophy of temporalis, masseters and facial muscle
Cardiac abnormalities including first degree heart block and complete heart block
62
What is progressive multifocal leucoencephalopathy?
Rapidly progressing demyelinating disease related to infection of oligodendrocytes by papovirus
AIDS defining illness
63
Which enzyme is essential in duplication of the HIV genome which cleaves RNA strands during transcription?
Ribonuclease H
64
Which enzyme in HIV helps in forming the DNA strand from viral RNA?
Reverse transcriptase
65
What form of meningitis is commons in HIV infected patients?
Cryptococcal meningitis
66
What is a an important feature of cryptococcal meningitis for which the treatment is CSF drainage?
Raised intracranial tension
67
What is the treatment for cryptococcal meningitis?
Amphotericin B 0.7-1mg/kg daily IV
| 5-flucytosine 100mg/kg oral daily
68
What are different types of polycythemia?
Primary
Secondary: chronic hypoxia
Relative: reduced plasma volume, normal red cell mass
Inappropriate: excess EPO production
69
What are features of legionella?
```
Flu like symptoms
Dry cough
Bradycardia
Confusion
Lymphopenia
Hyponatraemia
Deranged LFTs
Pleural effusion
```
70
How is a diagnosis of legionella made?
Urinary antigen
71
How is legionella treated?
Erythromycin
72
What are causes of a metabolic acidosis with a raised anion gap?
Lactic acid - sepsis, ischaemia
Urate - renal failure
Ketones - DKA
Drugs/toxins - salicylates, methanol, ethylene glycol
73
What are causes of a metabolic acidosis with normal anion gap?
```
Renal tubular acidosis
Diarrhoea
Addison's disease
Diarrhoea, ureterosigmoidostomy, fistula
Acetazolamide
```
74
What is the management for starvation ketosis?
IV pabrinex if alcohol related
| IV dextrose
75
What are complications of ecstasy use?
Arrhythmia
Seizures
Water intoxication
Acute hyponatraemia
76
What are features of tricyclic antidepressant overdose?
```
Reduced conscious level
Tachycardia
Urinary retention
Dilated pupils
Seizures
Ventricular arrhythmias
```
77
What does ecstasy cause?
```
Increased alertness and self confidence
Euphoria
Extrovert behaviour
Increased talkativeness and rapid speech
Lack of desire to eat or sleep
Tremor
Dilated pupils
Tachycardia
Hypertension
```
78
What does a more severe ecstasy intoxication cause?
```
Excitability
Agitation
Paranoid delusions
Hallucinations and violent behaviour
Hypertonia
Hyperreflexia
Convulsions
Rhabdomyolysis
Hyperthermia
Cardiac arrhythmia
DIC
Renal failure
Hyponatraemia
```
79
What are causes of high anion gap metabolic acidosis?
```
CAT MUDPILES
Carbon monoxide
Aminoglycosides
Theophyline/toluene
Methanol
Uraemia
Diabetic ketoacidosis/alcoholic/starvation
Paracetamol
Iron/isoniazid
Ethanol/ethylene glycol
Salicylates
```
80
Which fluid should be given for resuscitation in the setting of acute kidney injury?
500ml 0.9% saline over 15 mins as it does not contain potassium and hyperkalaemia is a concern
81
How can streptococci be subdivided?
Alpha haemolytic: partial haemolysis. Strep pneumoniae and viridans
Beta haemolytic: complete haemolysis. Groups A, B, D. Group A strep pyogenes (impetigo, cellulitis, Nec fasc, pharyngitis, rheumatic fever, scarlet fever. Group B strep agalactiae neonatal meningitis, sepsis. Group D enterococcus
82
What are red flag signs of sepsis?
```
Systolic blood pressure <90 or >40 from baseline
Mean arterial pressure <65
Heart rate >131
Resp rate >25
AVPU: V P or U
```
83
What doses of adrenaline, hydrocortisone and chlorphenamine are required in an adult or child >12 anaphylaxis?
Adrenaline 500mcg
Hydrocortisone 200mg
Chlorphenamine 10mg
84
What doses of adrenaline, hydrocortisone and chlorphenamine are required in an child age 6-12 anaphylaxis?
Adrenaline 300mcg
Hydrocortisone 100mg
Chlorphenamine 5mg
85
What doses of adrenaline, hydrocortisone and chlorphenamine are required in an child age 6m to 6y anaphylaxis?
Adrenaline 150mcg
Hydrocortisone 50mg
Chlorphenamine 2.5mg
86
What doses of adrenaline, hydrocortisone and chlorphenamine are required in an child age less than 6 months anaphylaxis?
Adrenaline 150 mcg
Hydrocortisone 25mg
Chlorphenamine 250mcg
87
What steps do you take for acute pulmonary oedema?
```
Loop diuretic 40-80mg IV
Morphine
Nitrate 2 sublingual
Oxygen
Position upright
```
88
What are main indications for emergency dialysis?
Severe hyperkalaemia >7 resistant to medical therapy
Pulmonary oedema resistant to medical therapy
Metabolic acidosis <7.2 or BE
89
What are the causes of malignancy associated hypercalcaemia?
Lytic bony metastasis
Myeloma
Production of osteoclast activating factor or PTH-like hormone by the tumour
90
What can be presenting symptoms of hypercalcaemia?
```
Nausea
Polydipsia
Polyuria
Constipation
Confusion
Weakness
```
91
What is the important first line management of malignancy associated acute hypercalcaemia?
Rehydration with IV 0.9% saline 3-4L/day
IV pamidronate to lower serum calcium
Calcitonin if resistant to bisphosphonates
92
An underweight 21 year old female comes to ED with palpitations. Her ECG shows first degree heart block, tall P waves and flattened T waves. An ABG shows pH 7.55, HCO3 30, Cl 85. What is the underlying cause of the presentation?
Bulimia nervosa
ECG shows hypokalaemia causing palpitations
ABG shows metabolic acidosis - hypochloraemic
93
What is Gitelman syndrome?
Autosomal recessive kidney disorder characterised by hypokalaemic metabolic alkalosis with hypocalciuria and hypomagnesaemia
Loss of function mutations of thiazide sensitive sodium chloride symporter in the distal convoluted tubule
94
What is Bartter syndrome?
Inherited defect in thick ascending limb of loop of Henle characterised by low potassium, alkalosis and normal to low blood pressure
Neonatal and classic forms
95
What are features of lead poisoning?
```
Anorexia
Hyperirritability
General apathy
Vomiting
Colicky abdominal pain
```
96
What are features of superior vena cava obstruction?
```
Dyspnoea
Swelling of face, neck and arms
Headache
Visual disturbance
Pulseless jugular venous distension
```
97
What are causes of superior vena cava obstruction?
```
Small cell lung cancer
Lymphoma
Metastatic seminoma
Kaposis sarcoma
Beast cancer
Aortic aneurysm
Mediastinal fibrosis
Goitre
SVC thrombosis
```
98
What is the management of superior vena cava obstruction?
```
Dexamethasone
Balloon venoplasty
Stenting
Small cell: chemo and radio
Non small cell: radiotherapy
```
99
What is the management for acute stroke?
Blood glucose, hydration, O2 sats and temp maintained within normal limits
Blood pressure shouldn't be lowered in acute phase unless complications - hypertensive encephalopathy
Aspirin 300mg orally or rectally given asap if haemorrhagic stroke excluded
Thrombolysis: if within 4.5 hours of onset of symptoms and haemorrhage has been excluded - alteplase
100
What are absolute contraindications to thrombolysis?
```
Previous intracranial haemorrhage
Seizure at onset
Intracranial neoplasm
Suspected SAH
Stroke or traumatic brain injury in previous 3 months
Lumbar puncture in previous 7 days
GI bleeding in preceding 3 weeks
Active bleeding
Pregnancy
Oesophageal varices
Uncontrolled HTN >200/120
```
101
What are relative contraindications to thrombolysis?
Concurrent anticoagulation INR >1.7
Haemorrhagic diathesis
Active diabetic haemorrhagic retinopathy
Suspected intracardiac thrombus
Major surgery/trauma in preceding 2 weeks
102
What are criteria for liver transplantation in paracetamol overdose?
```
Arterial pH <7.3, 24 hours after ingestion
Or all of:
Prothrombin time > 100 secs
Creatinine >300
Grade III or IV encephalopathy
```
103
What is required for a diagnosis of DKA?
Glucose >11
pH <7.3
Bicarbonate <15
Ketones > 3 or urine ketones ++
104
What are features of DKA?
Abdominal pain
Polyuria, polydipsia, dehydration
Kussmaul respiration
Acetone smelling breath
105
What are the most common precipitating factors of DKA?
Infection
Missed insulin
Myocardial infarction
106
What is the management of DKA?
Fluid replacement: isotonic saline 5-8L
Insulin: IV infusion 0.1 unit/kg/hour. Once glucose <15, 5% dextrose started
Correction of hypokalaemia
107
What is a good fluid replacement regime for a patient with systolic BP of 90 and over in DKA?
0. 9% NaCl 1L over 1 hr
0. 9% NaCl 1L with KCl over 2 hr
0. 9% NaCl 1L with KCl over 2 hr
0. 9% NaCl 1L with KCl over 4 hr
0. 9% NaCl 1L with KCl over 4 hr
0. 9% NaCl 1L with KCl over 6 hr
108
What are complications of DKA and it's treatment?
Gastric stasis
Thromboembolism
Arrhythmia secondary to hyperkalaemia/hypokalaemia
Iatrogenic due to incorrect fluid therapy: cerebral oedema, hypokalaemia, hypoglycaemia
Acute respiratory distress syndrome
Acute kidney injury
109
What are guidelines on potassium correction in DKA?
Potassium over 5.5: no correction
Potassium 3.5-5.5: 40 mmol/L
Below 3.5: senior review
110
How is low molecular weight heparin activity measured?
Anti factor Xa levels
111
What is the organism that causes Lyme disease?
Borrelia burgdorferi
112
What are symptoms of Lyme disease?
```
Joint pains
Facial nerve palsy
Palpitations
Headache
Fever
```
113
What are causes of a prolonged prothrombin time?
Warfarin
Unfractionated heparin
DIC
Liver disease
114
What is the recommended antibiotic for neutropenic sepsis?
Tazocin
115
What are features of leptospirosis? (Weils disease)
```
Fever
Flu like symptoms
Renal failure
Jaundice
Subconjunctival haemorrhage
Headache
Sewage workers, farmers, vets
```
116
What is the management for leptospirosis?
High dose benzylpenicillin or doxycycline
117
What are the stages of AKI?
1: creatinine 1.5-1.9x, urine <0.5ml/kg/h for >6h
2: creatinine 2-2.9x, urine <0.5ml/kg/h for >12 h
3: creatinine 3x or >354, urine <0.3ml/kg/h for >24 h or anuric for 12h
118
What are the BNF recommendations for management of hyperkalaemia?
If K+ is >6.5 or ECG changes
Administer calcium gluconate 10% 10-20ml by slow IV injection titrated to ECG response
Give 10 units actrapid in 50ml 50% glucose over 10-15 ml IV
Consider nebulised salbutamol
Consider correcting acidosis with sodium bicarbonate
119
What is the management for acute heart failure in a patient who is haemodynamically stable?
Oxygen
Morphine 2.5-10mg IV 2-6h
Furosemide 40-160mg IV increase by 20-40 mg every 6-12 h according to response. Max 600mg
GTN 5 micro grams/min IV. Increase by 5-20 micro grams/min every 3-5 mins. Max 200 micro grams
CPAP
120
What investigations should be done for acute heart failure?
```
ECG
CXR
Hb
TFT
Troponin
BNP
Echo
```
121
What is the PEP for hep A?
Human normal immunoglobulin or hep A vaccine
122
What is the PEP for hep B?
HBsAg positive source: booster dose of vaccine, if in process of vaccination or non responder - hep B immune globulin and vaccine
Unknown source: booster dose, non responder - HBIG and vaccine, in process of vaccination - accelerated course
123
What is the PEP for hep C?
Monthly PCR
| If seroconversion then interferon and ribavirin
124
What is PEP for HIV?
Oral antiretrovirals: tenofovir, emtricitabine, lopinavir, ritonavir
Can be started up to 72h following exposure for 4 weeks
Serological testing at 12 weeks following completion of PEP
125
By how much does PEP reduce risk of transmission in HIV?
80%
126
What is PEP for varicella zoster?
VZIG for IgG negative pregnant women or immunosuppressed
127
What is the estimated risk of transmission of hep B, C and HIV from a needle stick?
Hep B: 20-30%
Hep C: 0.5-2%
HIV: 0.3%
128
What are complications of acute heart failure?
Arrhythmia
Complication of GTN: headache and hypotension
Complication of diuretics: worsening of renal function, hypotension, hypokalaemia
129
What are features of salicylate poisoning?
```
Fever
Sweating
Hyperventilation
Tachycardia
Nausea and vomiting
Dehydration
```
130
What does the treatment of amitriptyline involve?
ABC resus
Gastric lavage followed by activated charcoal in severe cases
Treatment of arrhythmias and seizures as necessary
131
What are features of stage 1 shock?
```
Volume loss <750ml
Urine output >35ml/hr
Pulse <100
Cap refil normal
Blood pressure normal
Resp 14-20
Mental state alert
```
132
What are features of stage 2 shock?
```
Volume loss 750ml to 1.5L
Urine output 20-35 ml/hr
Pulse >100
Cap refil prolonged
SBP normal
DBP raised
Resp 20-30
Mental state anxious
```
133
What are features of stage 3 shock?
```
Volume loss 1.5 to 2L
Urine output 5-15 ml/hr
Pulse >120
Cap refil prolonged
SBP reduced
DBP reduced
Resp 30-40
Mental state confused, anxious
```
134
What are features of stage 4 shock?
```
Volume loss >2L
Urine output <5ml/hr
Pulse >140
Cap refil absent
SBP severely reduced
DBP severely reduced
Resp rate >35
Mental state drowsy unresponsive
```
135
What are examination findings in aortic artery dissection?
Hypertension
Aortic regurgitation
Pleural effusion
Inferior lead ECG changes if right coronary is compromised
136
What are the 4 main derangements seen in Reye's syndrome?
Raised ICP
Hypoglycaemia
Coagulopathy
Hyperammonaemia
137
What is Reye's syndrome?
Acute non inflammatory encephalopathy and hepatotoxicity caused by ingestion of aspirin in under 12s
138
How is Reye's syndrome managed?
Give activated charcoal as soon as possible
Measure salicylate level
Treat pathological derangements
139
What are clinical features of organophosphate poisoning?
```
Miosis
Blurred vision
Hypersalivation
Expectoration of frothy secretions
Nausea
Vomiting
Abdominal cramps
Diarrhoea
Bronchospasm
```
140
What are antidotes to organophosphate poisoning?
```
Atropine
Pralidoxime (cholinesterase reactivators)
```
141
What are clinical features of mild abuse of ecstasy?
```
Agitation
Tachycardia
HTN
Widely dilated pupils
Trismus
Sweating
```
142
What are features of severe ecstasy abuse?
Hyperthermia
DIC
Rhabdomyolysis
Acute renal failure
143
In a patient who is on warfarin who is haemorrhaging and has an INR greater than 8, what is the emergency management?
```
A to E approach
Fluid resus and cross match
Prothrombin complex concentrates (FFP if not available)
Vitamin K IV 5mg
Stop warfarin
```
144
In patient on warfarin who has an INR over 8 but only minor bleeding, what is the management?
```
A to E approach
Stop warfarin
Give IV vitamin K 1-3mg
Repeat dose of Vit K if INR still too high after 24 hours
Restart warfarin when INR <5
```
145
In patient on warfarin who has an INR over 8 but NO bleeding, what is the management?
Stop warfarin
Give Vit K 1-5mg by mouth
Repeat dose of Vit K if INR still too high after 24 hours
Restart warfarin when INR <5
146
In patient on warfarin who has an INR between 5-8 but only minor bleeding, what is the management?
Stop warfarin
Give IV Vit K 1-3mg
Restart warfarin when INR <5
147
In patient on warfarin who has an INR between 5-8 but NO bleeding, what is the management?
Withhold 1-2 doses of warfarin
| Reduce subsequent maintenance dose
148
A patient with long alcohol history, presenting with palpitations has an irregular tachycardia (165 bpm) with broad QRS complex (155ms). His potassium is 2.1. There are no signs of shock, heart failure or syncope. What is the differential diagnosis and how should it be managed?
Polymorphic VT - most likely torsades due to hypokalaemia
Pre-excited AF
AF with bundle branch block
Manage: 2g magnesium
149
Which scoring system is used to determine need to anticoagulate a patient in AF?
CHA2DS2VASc
150
Which scoring system is a prognostic score used to risk stratify patients who have had a suspected TIA?
ABCD2
151
Which scale is used to determine severity of heart failure?
New York heart association
152
Which scale is used to measure disease activity in rheumatoid arthritis?
DAS28
153
Which scale is used to assess severity of liver cirrhosis?
Child Pugh classification
154
What is a wells score for?
Estimate risk of patient having a DVT
155
What is an epworth sleepiness scale?
Assessment of suspected obstructive sleep apnoea
156
What is a Gleason score?
Indicate prognosis in prostate cancer
157
What is an APGAR score?
Assess health of a newborn immediately after birth
158
What is a bishop score?
Assess whether the induction of labour will be required
159
What score is used to assess the risk of a patient developing a pressure sore?
Waterlow score
160
What is a FRAX tool?
Risk assessment tool calculates 10 year risk of developing osteoporosis related fracture
161
What is the ranson criteria used for?
Acute pancreatitis
162
What is a MUST score used for?
Malnutrition
163
What is the treatment for severe ecstasy abuse?
IV fluids
| Dantrolene 1mg/kg
164
How is severe warfarin toxicity managed?
Whole blood
Fresh frozen plasma
Clotting factor concentrates
Vitamin K
165
What are potential complications of opioid toxicity?
```
Coma
Respiratory depression
Pin point pupils
Convulsions
Hypotension
Peripheral circulatory failure
Cardiac arrhythmia
Conduction defects
Hypothermia
Pulmonary oedema
Renal failure
Rhabdomyolysis
```
166
Which electrolyte abnormalities increase the risk of digoxin toxicity?
Hypokalaemia
| Hypomagnesaemia
167
What is the management for beta blocker overdose?
0.5mg IV atropine
IV glucagon
IV isoprenaline
Transvenous temporary cardiac pacemaker
168
Which local anaesthetic is used for cleaning, exploring and suturing wounds in ED? What is the maximum dose?
1% lidocaine
| Max dose 3mg/kg or 200mg (20ml of 1%)
169
If lidocaine with adrenaline is used for wound local anaesthetic, what is the maximum dose?
7mg/kg or 500mg
170
What is the single most important factor in determining need for liver transplant according to the kings college hospital criteria in paracetamol overdose? What are the other factors?
Arterial pH <7.3, 24 h after ingestion
| All of: prothrombin time >100, creatinine >300, grade III or IV encephalopathy
171
What is the parkland formula for calculating fluid requirements in burns?
4x body weight and burn percentage
First half given in 8 h
Remaining over 16 h
172
Why does tricyclic overdose lead to metabolic acidosis?
Acidity of drug
Rhabdomyolysis
Renal failure
173
An 18 year old male with sickle cell disease presents with severe abdominal pain, his BP is 105/80 HR 110, temp 38. What is your first action?
IV normal saline
Opiate analgesia
Consider antibiotics: ceftriaxone, erythromycin and cefuroxime
174
What may be features of aspirin ingestion in a child?
```
Fever and sweating
Hyperventilation
Tachycardia
Nausea and vomiting
Dehydration
Lethargy
Seizures
```
175
Why is aspirin absolutely contraindicated in children under 12?
Side effects
| Potential risk of Reye's syndrome
176
What is Reye's syndrome? What are the main derangements?
```
Acute non inflammatory encephalopathy and hepatotoxicity
Raised ICP
Hypoglycaemia
Coagulopathy
Hyperammonaemia
```
177
What are the essentials of management in paracetamol overdose?
Check paracetamol level four hours after ingestion against Rumack Matthew nomogram
Gastric lavage if large dose ingestion (>7.5g) or presenting within 8 hours, consider oral charcoal
Give N acetylcysteine or methionine
Hourly BMs monitored
Check INR 12 hourly
178
What are signs associated with a poor prognosis and indicating transfer to liver unit in paracetamol overdose?
```
INR >2 within 48 hours
INR >3.5 within 72 hours
Creatinine >200
pH <7.3
Signs of encephalopathy
Hypotension
```
179
What type of bug causes cholera?
Vibrio cholerae
Aerobic
Comma shaped
Gram negative bacillus
180
What are features of enteric fever?
```
Chills
Diaphoresis
Cough
Headache
Myalgia
Delirium
Fever
Constipation due to swollen peyers patches
Rose spots
```
181
A man weighing 75kg requires maintenance fluids as he is not able to drink. What fluids should be prescribed and at what rate?
500ml 0.9% sodium chloride at 100ml/hr
182
In a patient presenting with typhoid type symptoms, what name is given to the erythematous rash that is irregular and discrete?
Rose spots
183
What are features of typhoid fever?
```
Systemic upset
Relative bradycardia
Abdo pain, distension
Constipation
Rose spots
```
184
What are possible complications of typhoid?
```
Osteomyelitis
GI bleed/perforation
Meningitis
Cholecystitis
Chronic carriage
```
185
Which organism is responsible for kaposis sarcoma?
Human herpes virus 8
186
What is rheumatic fever?
Immunological reaction to recent (2 to 6 weeks ago) streptococcus pyogenes infection
187
What are major diagnostic criteria for rheumatic fever?
```
Erythema marginatum
Sydenham's chorea
Polyarthritis
Carditis
Subcutaneous nodules
```
188
What evidence is required of a streptococcus pyogenes infection in order to diagnose rheumatic fever?
ASOT >200
History of scarlet fever
Positive throat swab
Increase in DNase B titre
189
What are minor criteria for diagnosis of rheumatic fever?
Raised ESR or CRP
Pyrexia
Arthralgia
Prolonged PR interval
190
What are 4 diagnostic criteria for hereditary haemorrhagic telangiectasia?
Epistaxis
Telangiectasia: lips, oral cavity, fingers, nose
Visceral lesions: GI, pulmonary AVM, hepatic AVM, cerebral AVM, spinal AVM
Family history in first degree relative
191
What are symptoms of dengue fever?
```
Fever
Headache
Retro orbital pain
Myalgia
Nausea and vomiting
Skin rash
Mild bleeding
```
192
What are complications of opioid misuse?
Viral infection: HIV, hep B and C
Bacterial infection: infective endocarditis, septic arthritis, septicaemia, necrotising fasciitis
VTE
Overdose: resp depression, death
Psychological problems
Social problems: crime, prostitution, homelessness
193
What is a curlings ulcer?
Acute peptic ulcer of duodenum as a complication of severe burns when reduced plasma volume leads to ischaemia and cell necrosis of the gastric mucosa
194
What are complications of infectious mononucleosis?
```
Splenic rupture/infarction
Upper airway obstruction
Immune mediated pneumonia
Rash with ampicillin
Viral meningitis
Guillain Barre
```
195
What psychiatric disturbances can occur with acute intermittent porphyria?
```
Delirium
Depression
Emotional lability
Schizophreniform psychoses
Hysteria
```
196
What are causes of atypical lymphocytosis?
```
EBV
Chicken pox
Cytomegalovirus
Rubella
HIV
Toxoplasmosis
```
197
Which antidote is used for arsenic poisoning?
Dimercaprol or penicillamine
198
What should be used parenterally as a chelating agent for iron overdose?
Desferrioxamine
199
What causes gas gangrene?
Clostridium perfringens
200
How does clostridium tetani cause motor symptoms?
Produces a neurotoxin called tetanospasmin which acts at synapses resulting in disinhibition
201
What are some benign causes of SVC obstruction?
```
Fibrotic disease
Infections
Thoracic aortic aneurysms
Central venous catheters
Pacemaker wires
```
202
In what time span does a GP have to have seen a patient before their death in order to issue a death certificate?
They have to have seen the deceased within 14 days of the death
203
What does a whirl pool sign on USS suggest?
Ovarian torsion
| Volvulus
204
Which organisms most commonly cause post splenectomy sepsis?
Strep pneumoniae
Haemophilus influenzae
Meningococci
205
What are features of dengue fever?
```
Headache
Fever
Myalgia
Pleuritic pain
Facial flushing
Maculopapular rash
```
206
What are features of Lyme disease?
Erythema chronicum migrans
Systemic features: fever, arthralgia
CVS: heart block, myocarditis
Neuro: cranial nerve palsies, meningitis
207
How is toxoplasmosis investigated?
Antibody test
| Sabin Feldman dye test
208
What is the treatment for severe toxoplasmosis infection in immunosuppressed patients?
Pyrimethamine plus sulphadiazine for 6 weeks
209
What physiological response accounts for the sensory symptoms experienced during a panic attack?
CO2 is blown off due to increased RR
This leads to respiratory alkalosis
This causes a decrease in plasma ionised calcium concentration which leads to sensory symptoms of tingling in fingertips and around mouth
210
Why might a patient with chronic diarrhoea present short of breath?
Loss of HCO3 and K ions from gut
Kidneys compensate by conserving K at the expense of H
This generates HCO3 ions but if it continues then a metabolic acidosis predominates
A compensatory respiratory alkalosis and kussmaul respiration ensues resulting in low PaCO2 and SOB
211
Over what time period is a patient with rubella infectious?
Eight days prior and nine days after onset of rash
212
What is the most useful test to establish whether an episode is due to anaphylaxis?
Serum tryptase
213
What is the advice to give to someone regarding playing sports after having glandular fever?
Avoid contact sports for 8 weeks
214
What is cushings triad?
Widening of pulse pressure
Respiratory changes
Bradycardia
215
Which antibiotics are best for ESBL bugs?
Carbapenems
216
What are classic differential diagnoses for rigors?
Biliary sepsis
Pyelonephritis
Visceral abscess
Malaria
217
What are clinical findings of dehydration?
```
Prolonged cap refil
Dry mucous membranes
Reduced skin turgor
Tachycardia
Tachypnoea
Reduced urine output
Sunken eyes
Low blood pressure
Thready/weak pulse
Decreased consciousness
```
218
What is required to pronounce an individual dead?
Fixed dilated pupils
No respiratory effort for 3 mins
No pulse or heart sounds for 1 min
219
What are clinical features of adult onset stills disease?
```
High spiking fever (X1/day with return to normal)
Arthralgia/arthritis
Sore throat
Transient maculopapular rash
Lymphadenopathy
Hepato splenomegaly
Pleuritis/pericarditis
```
220
What is the kings college criteria for identifying patients with poor prognosis and needing transplant after paracetamol overdose?
Arterial pH <7.3
| Or all 3 of: INR >6.5, creatinine >300, HE grade 3-4
221
What are some neurological complications of HIV?
```
Cerebral toxoplasmosis
Lymphoma
TB
Encephalitis - CMV, HIV, HSV
Cryptococcus
Progressive multi focal leukoencephalopathy
AIDS dementia complex
```
222
What is the cause of a sudden anaemia and a low reticulocyte count in a patient with sickle cell disease?
Parvovirus infection
223
What is the parkland formula for fluid resuscitation in burns?
Fluid requirement in 24 hours:
4ml x ((total burn surface area%) x body weight (kg))
50% given first 8 hours
50% given next 16 hours
224
What are duke criteria for endocarditis?
Positive blood cultures
Evidence of endocardial involvement - echo, murmur
Coxiella burnetii infection
Minor: predisposing factor or IV drug use, fever, vascular phenomena, immune (oslers nodes, Roth spots, glomerulonephritis), microbiological evidence
225
What are the kings college criteria for liver transplant after paracetamol overdose?
Arterial pH <7.3 24 hours after
| Or all of: prothrombin time >100, creatinine >300, grade III or IV encephalopathy
226
What is first line management for severe falciparum malaria?
IV artesunate
227
What is the abortive management for cluster headaches?
100% oxygen at least 12L/min via non rebreathe mask
| Subcutaneous/nasal triptan
228
What is first line management for prevention of cluster headache?
Verapamil
229
What are differentials for hyperamylasaemia?
```
Acute pancreatitis
Pancreatic pseudocyst
Mesenteric infarct
Perforated viscus
Acute cholecystitis
Diabetic ketacidosis
```
230
What is the Mackler triad for boerhaave syndrome?
Vomiting
Thoracic pain
Subcutaneous emphysema
231
What is the most common cause of diarrhoea in hiv patients?
Cryptosporidium
232
In a postmenopausal woman presenting with a fracture, what is the next management step?
Bisphosphonates and calcium supplements (no need for dexa scan)
233
What are contraindications to lumbar puncture?
Signs suggesting raised intracranial pressure: Relative bradycardia and hypertension, Focal neurological signs, Abnormal posturing, Unequal, dilated or poorly responsive pupils, Papilloedema, Abnormal 'doll's eye' movements, Reduced or fluctuating level of consciousness (Glasgow Coma score less than 9 or a drop of 3 or more)
Shock
Extensive or spreading purpura
After convulsions until stabilised
Coagulation abnormalities: Platelet count below 100, Receiving anticoagulant therapy
Local superficial infection at lumbar puncture site
Respiratory insufficiency (lumbar puncture is considered to have a high risk of precipitating respiratory failure in the presence of respiratory insufficiency)
234
How do different depths of burn present?
Superficial / 1st Degree - Erythema, pain, no blisters
Partial thickness / 2nd Degree - Mottled, Blisters, Wet and pain
Full thickness / 3rd Degree - Pale, dark, leathery, dry and no pain
235
What are the different zones of a burn?
Zone 1: zone of coagulation
Zone 2: zone of stasis
Zone 3: zone of hyperaemia
236
What counts as a major and minor burn?
Minor < 10% children or 15% adults
| Major >10% children or 15% adults
237
What are signs that a patient may have experienced an inhalational burn?
```
Fire in an enclosed/confined space
Face and neck burns
Singeing of eyebrows and nasal hair
Hoarse voice
Dyspnea
Carbonaceous sputum
Brassy cough
Carboxyhemoglobin (HbCO) >10%
```
238
Which burns victims require fluid resuscitation?
Indicated in Burns >10% in children and >15% in adults
239
How should burn wounds be dressed and managed?
Deroof blisters if possible
Adequate wound cleaning before dressing
Flamazine, Mepitel or Urgotul SSD
Face - leave exposed (Polyfax or Chloramphenicol ointment)
Hand - Flamazine hand bag or light Mepitel dressing. The fingers must move
In transfer use cling film or sterile sheet
Review all dresings within 48 hrs
240
What might be signs that a patient has suffered an electrical burn?
History of fit/thrown over
Unconsciousness or depressed GCS
Entry and Exit wounds
Changes in ECG, myoglobinuria or abnormal CK/Troponin
241
Which patients should be referred to burns services?
```
Suspected airway involvement
Any full thickness burn
Partial thickness burns greater than 10% adult and 5% in children
Burns to special areas (hands, face, neck, feet, perineum)
Electrical burns
Chemical burns
Suspected NAI
Associated major trauma
Associated co-morbidities
Circumferential burns
```
242
What CSF findings would you expect in viral meningitis?
Cells: predominantly lymphocytes
Gram stain: negative
Protein: normal or slightly raised
Glucose: usually normal
243
What CSF findings would you expect in bacterial meningitis?
```
Cells: mainly polymorphs
Gram stain: positive
Bacterial Ag detection
Protein: high
Glucose: less than 60% of serum
```
244
What CSF findings would you expect in TB meningitis?
```
Cells: mainly lymphocytes
Gram stain: positive
Protein: high/very high
Glucose: <60% serum
Lactate: raised
```
245
How do you adjust WCC in bloody CSF?
For every 500-700 RBCs deduct 1 white cell from WCC
246
Who is most at risk of meningococcal meningitis?
>1 year old
247
Who is most at risk of pneumococcal meningitis?
Children
Elderly
Immunocompromised
248
Who is most at risk of beta haemolytic streptococcus group B meningitis?
Neonates
249
Who is most at risk of listeria meningitis?
Neonates
Immunocompromised
>60 years old
Pregnant women
250
Who is most at risk of cryptococcal meningitis?
HIV
| Immunocompromised
251
Who is most at risk of TB meningitis?
HIV
Immunocompromised
Concurrent TB infection
252
Which antibiotics are appropriate to use against meningococcal meningitis/pneumococcal/haemophilus influenzae?
Ceftriaxone/cefotaxime
Meropenem
Chloramphenicol
253
Which antibiotics are appropriate to use for pneumococcal meningitis?
Ben pen
| Vancomycin
254
Which antibiotics are appropriate to use for listeria meningitis?
Amoxicillin
Ben pen
Co trimoxazole
255
Which antiviral is used to treat HSV/VZV encephalitis?
Aciclovir
256
Which drug should be used to treat cryptococcal meningitis?
Amphotericin with flucytosine then fluconazole
257
What bugs can cause septic arthritis?
Staph aureus
Beta haemolytic strep
Coagulase negative staph (prosthetic joints)
Alpha haemolytic strep (prosthetic joints)
258
What antibiotics are used to treat septic arthritis?
Flucloxacillin
Clindamycin if pen allergic
Vancomycin
Co amoxiclav
259
Which bugs can cause UTI?
Coliforms: E. coli, proteus, klebsiella
Enterococci
Staph saprophyticus
Pseudomonas aeruginosa (catheter)
260
What clinical findings are consistent with a diagnosis of necrotising fasciitis?
Septic shock
Extreme pain out of proportion to clinical findings
Lack of pain in area which previously had extreme pain
Skin infection with vesicles or bullae
Woody feel to tissues and crepitus
261
What causes necrotising fasciitis?
Type 1: immunosuppression, chronic disease, staph aureus, coliforms, anaerobes
Type 2: beta haemolytic strep group A (strep pyogenes), staph aureus
262
How is alcoholic ketoacidosis managed?
Infusion of saline and thiamine
263
What are symptoms of hypoglycaemia?
```
Autonomic: Sweating, Palpitations
Tremor
Hunger
Neuroglycopenia: confusion, clumsiness, behavioural change
Headache
Nausea
```
264
What are causes of fasting hypoglycaemia?
```
Pituitary failure
Liver disease
Addison’s
Islet cell tumours
Retroperitoneal fibrosarcoma
```
265
What is the management of a hypo in a patient who is conscious and able to swallow?
15-20g quick acting carbohydrate: glucotabs, lucozade, fruit juice
Repeat blood glucose 10-15 mins later
If less than 4, repeat carbs
If still less than 4 after 3 cycles/30 mins, consider 1mg glucagon or IV glucose
Once glucose over 4: long acting carb
266
What is the management of a hypo in a patient who is conscious but confused/unable to cooperate but able to swallow?
1.5-2 tubes glucogel/dextrogel between teeth and gums
Glucagon 1mg IM if ineffective
If glucose <4 after 10/15 mins repeat (only 1mg glucagon in total)
267
What is the management of a patient with a hypo who is unconscious/having seizures/aggressive?
```
A to E
20% glucose 75-100ml IV over 15 mins
Or 10% 150-200ml
Or glucagon 1mg IM
Repeat if needed
Once glucose over 4, long acting carb
```
268
What is the management for hypercalcaemic crisis?
IV fluids: 3-4L isotonic saline in 24 hours
Furosemide 40mg IV 6 hourly after hydration
Bisphosphonates
Calcitonin 100 units SC or IM every 6-8 hours
Steroids
Denosumab
Dialysis
269
What are common causes of hypercalcaemic crisis?
Malignancy
Granulomatous disease
Primary hyperparathyroidism
Drug induced
270
What complication can occur if sodium is corrected too quickly? What are symptoms of this?
```
Central pontine myelinosis
Quadriplegia
Pseudobulbar palsy
Aspiration
Seizures
Coma/death
```
271
Which vessels bleed in epistaxis?
Anterior (80-90%), Little’s area anterior nasal septum – Keisselbach plexus of vessels
Posterior from branches of sphenopalatine artery in posterior nasal cavity
272
What are local traumatic causes of epistaxis?
```
Nosepicking
Nasal fractures
Septal ulcers / perforation
Foreign body
Blunt trauma e.g. falls
```
273
What are local inflammatory causes of epistaxis?
Infection
Allergic rhinosinusitis
Nasal polyps
274
What are some local causes of epistaxis?
```
Trauma
Inflammation
Topical drugs: cocaine, nasal decongestants
Vascular: hereditary haemorrhagic telangiectasia, Wegeners granulomatosis
Post-operative: ENT, max fax, ophthalmic
Benign tumours: angiofibroma
Malignant tumours: squamous cell
Nasal oxygen
```
275
What are some general causes of epistaxis (not local)?
Hypertension
Atherosclerosis
Increased venous pressure from mitral stenosis
Alcohol
Environmental: temperature, humidity, altitude
Haematological: Thrombocytopaenia, Platelet dysfunction, Leukaemia, Haemophilia, Anticoagulant drugs, antiplatelet drugs e.g aspirin, clopidogrel
276
What is important in a history of a nosebleed?
```
Duration
Which nostril
Estimated blood loss
Any home management / packing
Previous epistaxis and management
PMH –likely underlying causes
Surgery
Trauma
Symptoms suggestive of tumour: Nasal obstruction, Rhinorrhoea, Facial pain, Facial numbness, double vision
Drugs
FH bleeding disorders
Environmental
```
277
What investigations might be required for epistaxis?
FBC if heavy or recurrent bleeding or clinically anaemic
Coagulation – if on warfarin or bleeding diathesis suspected
Group and save / cross match - if bleeding heavy, shock, severe anaemia
278
What are possible management options for epistaxis? Describe details of each
Naseptin (chlorhexidine and neomycin) qds for 10 days, Avoid in peanut allergy – use mupirocin instead, Reduces crusting and vestibulitis, Very useful in young children as cautery inappropriate
Nasal cautery: Use if first aid unsuccessful, not for young children, Need appropriate expertise and equipment, Blow nose, Anaesthetic spray preferably with vasoconstrictor (lignocaine and phenylephrine), Allow 3-4 mins for anaesthetic to work, Identify bleeding point, Apply silver nitrate stick to bleeding point for 3-10 seconds until grey-white colour develops, Only one side of septum to avoid septal perforation, Avoid touching area not requiring treatment
Nasal packing: If bleeding not controlled, Local anaesthetic and vasoconstrictor, Nasal tampon (merocel), Inflatable packs (rapid rhino), Impregnated ribbon gauze – needs specific expertise, Position sitting forward mouth open, Secure pack to cheek, Check no pressure on cartilage around nostril, Check oropharynx for bleeding, may need to pack both nostril, Admit ENT
279
What self care advice can be offered after epistaxis?
Avoid blowing or picking nose
Avoid heavy lifting
Avoid strenuous exercise
Avoid lying flat
Avoid alcohol and hot drinks ( cause vasodilation)
If further bleeding unresponsive to first aidmeasures, return to ED
280
What are possible complications of nasal packing?
Sinusitis
Septal haematoma /abscess (from traumatic packing)
Pressure necrosis (from excessively tight packing)
Toxic shock syndrome (prolonged packing)
Airway obstruction
281
When is an ENT referral required for epistaxis?
Uncontrolled bleeding
Posterior bleeding
Nasal pack
Significant comorbidities clotting disorder, anaemia
Recurrent with high risk of underlying cause
282
What more advanced treatment options may be offered by ENT for epistaxis?
```
Formal packing
Endoscopy and electrocautery
EUA and surgical intervention e.g. Arterial ligation
Radiological arterial embolisation
IV or oral tranexamic acid
```
283
What are examples of third space losses?
```
Pleural cavity: effusion, oedema
Pancreatitis
Burns
Major fractures
Obstruction
Peritoneal cavity: ascites
```
284
What are normal fluid requirements for a 70kg man per day?
1.5 ml/kg/h - 2.5L
285
What are normal sodium requirements for a 70kg male per day?
1-2 mmol/kg/24h - 100mmol
286
What is the daily potassium requirement for a 70kg male?
0.5 mmol/kg/24h - 50mmol
287
What should be the daily urine output for a 70kg male?
>0.5 ml/kg/h - 800ml
288
What problems may increase a person's fluid requirements?
Fever/Sweating. Increase by 100 to 150 mL/day for each C degree body temperature increase
Burns
Tachypnoea
Surgical drains
Polyuria
Gastrointestinal losses (eg vomiting or diarrhoea)
289
What are some benefits of IV fluids?
Immediate / Therapeutic effect
Control over the rate of administration
Patient cannot tolerate drugs / fluids orally
Some drugs cannot be absorbed by any other route
Pain and irritation is avoided compared to some substances when given SC/IM
290
What are some disadvantages of IV fluids?
```
Cannot recall drug/Reverse action of drug/may lead to toxicity
Phlebitis: Mechanical/chemical irritation
Microbial contamination/Infection
Extravasation
Circulatory overload / can cause shock
Anaphylaxis/Allergic reactions
Administration time
Serious Technical problems (Air in line)
```
291
What are the electrolyte components of Hartmanns solution?
Na: 131
Cl: 111
K: 5
HCO3: 29 as lactate
292
What are causes of rhabdomyolysis?
Muscle injury: Trauma, burns, electrocution, immobilisation (long lie), DKA, ischaemia, compression, vascular injury, compartment syndrome
Medications/Toxins: Alcohol, cocaine, amphetamines, statins, major tranquillizers, tetanus, venom
Increased muscular activity: Sport, seizures, status asthmaticus, inflammatory/inherited myopathies
293
What are symptoms of lithium toxicity?
CVS arrhythmias
| CNS eg, tremor, confusion, coma
294
Which drugs can cause ANCA vasculitis?
```
Hydralazine
Ciprofloxacin
Sulphonamides
Phenytoin
Allopurinol
Some PPIs
Propylthiouracil
Minocycline
Penicillamine
```
295
What is the treatment for digoxin toxicity?
Supportive: Correction of electrolyte imbalances, Atropine for bradycardia, Avoid cardio stimulants because arrythmogenic
Limitation of absorption: Charcoal effective within 8 hours (or cholestyramine)
Specific measures: DIGIBIND = Fab digoxin specific antibodies. Binds plasma digoxin and complex eliminated by kidneys (used when OD is high/near arrest)
Enhanced elimination: Dialysis is ineffective. Charcoal/cholestyramine interrupt enterohepatic cycling
296
Why does rhabdomyolysis lead to decreased phosphate and calcium?
Injury to muscles causes phosphate release which then binds to calcium
297
What are causes of neutropenia?
Drugs: Cytotoxic chemotherapy, Bone marrow transplantation
DMARDs, Antithyroid drugs (carbimazole), Antipsychotic drugs (clozapine)
Infections: HIV/ TB, Overwhelming sepsis leading to bone marrow suppression and increased destruction of neutrophils, Transient neutropenia after viral infections (measles/ EBV)
Nutritional deficiency: B12, Folate
Medical conditions: Aplastic anaemia, acute leukaemia, Hypersplenism (Felty’s syndrome)
298
What are risk factors for neutropenic sepsis?
Rate of decline of neutrophil count and duration of neutropenia
Hypophosphataemia and hypoproteinaemia
Inpatient chemotherapy regimens (especially for haematological malignancies)
Exposure to prior chemotherapy or current immunosuppression e.g.oral steroids
Pre-treatment elevations in ALP, bilirubin or AST levels
Reduced eGFR
299
What is SIRS?
Systemic inflammatory response syndrome
2 of the following in response to an insult:
T > 38 C or < 36 C
HR > 90 bpm
RR > 20 bpm or PaCO2 < 32 mmHg
WBC > 12 000 cells/mm3 , < 4 000 cells/mm3 or >10 % bands
300
What infections can group A beta haemolytic strep cause?
```
Pharyngitis
Impetigo
Cellulitis
Pneumonia
Osteomyelitis
Necrotizing fasciitis
```
301
What are complications of group A strep infection?
Scarlet fever – Erythrogenic toxin
Rheumatic fever – Molecular mimicry
Post-streptococcal glomerulonephritis –Molecular mimicry
302
What are examples of group A strep?
Streptococcus pyogenes
| Streptococcus dysgalactiae
303
Which bugs can cause meningitis in neonates?
E. coli and other Gram negative bacillus
Streptococcus agalactiae
Listeria monocytogenes
304
Which bugs can cause meningitis in infants?
Neisseria meningitidis
Haemophilus influenzae
Streptococcus pneumoniae
305
Which bugs can cause meningitis in children?
Streptococcus pneumoniae
| Neisseria meningitidis
306
What features of CSF are measured from a lumbar puncture and what are normal values?
Glucose – Along with a peripheral glucose just before LP (Normal - 2/3 of peripheral glucose)
Protein (Normal – up to 45mg/dl)
Culture
Cell count (Normal - up to 5 cells/microL)
307
What are the drugs of choice in treating meningitis?
Amoxicillin if treating Listeria meningitis
Benzyl penicillin or cefotaxime in neonates depending on causative agent
Ceftriaxone in children
308
What is the sepsis six?
```
Administer high flow oxygen
Take blood cultures
Give broad spectrum antibiotics
Give intravenous fluid challenges
Measure serum lactate and haemoglobin
Measure accurate hourly urine output
```
309
What should target sodium reduction be in hypernatraemia?
<12 mmol/day
310
Which patients are at increased risk of developing hepatotoxicity following paracetamol overdose?
Liver enzyme inducing drugs: rifampicin, phenytoin, carbamazepine, chronic alcohol excess, St. John’s wort
Malnourished patients: anorexia, CF, hep C, alcoholism, HIV
Patients who have not eaten for a few days
311
What is trousseaus sign?
Carpal spasm on inflation of BP cuff to pressure above systolic due to hypocalcaemia
312
What is chovsteks sign?
Tapping over parotid CN7 causes facial muscles to twitch due to hypocalcaemia
313
What organisms can cause UTI?
E.coli: Gram negative rod, Facultative anaerobe, Gut commensal
Klebsiella
Proteus
Enterococcus
314
What are different methods of microbiologically confirming a UTI?
Mid Stream Urine (MSU)
Clean catch specimen
Supra pubic puncture
Collection using a catheter
315
What is a Jarisch Herxheimer reaction?
Acute febrile reaction due to rapid release of treponema antigen with associated allergic reaction
Caused by anti syphilitic treatment, especially penicillin
316
Which is the antibiotic of choice in osteomyelitis?
Clindamycin
317
Which is the antibiotic of choice in bacterial endocarditis with penicillin allergy?
Vancomycin
318
Which antibiotics are used to manage bite wounds from human or animal bites?
Co amoxiclav
319
Which antibiotic is used to manage malignant otitis externa?
Ciprofloxacin
320
What are features of yellow nail syndrome?
```
Lymphatic hypoplasia
Bronchiectasis
Pleural effusions
COPD
Carcinoma
Dystrophic nails
```
321
Which bugs are post splenectomy patients susceptible to? What prophylaxis is therefore required?
Capsulated bacteria - streptococcus pneumoniae
Spleen important in sequestration and phagocytosis, and production of antibodies
Prophylaxis: pneumococcal vaccine, penicillin
322
What are features of kartageners syndrome?
```
Dextrocardia
Situs invertus
Otitis media
Sinusitis
Infertility
Bronchiectasis
Frontal sinus dysplasia
```
323
Which burns need referral to secondary care?
Deep dermal and full thickness
Superficial burns more than 3% TBSA in adults or 2% children
Superficial burns on face, hands, feet, perineum, genitals, flexures
Circumferential burns of limb, torso, neck
Inhalation injury
Electrical or chemical burn
Suspicion of NAI
324
Why is there no benefit to giving paracetamol for the hyperthermia seen in serotonergic syndrome?
Caused by sustained isotonic muscle contractions
| Not hypothalamically mediated
325
What are features of serotonin syndrome?
```
Extremes of temperature
Mental agitation and confusion
Hypertonia
Hyperreflexia
Clonus
Dilated pupils
Sweaty
Metabolic acidosis
Rhabdomyolysis
Hyperkalaemia
```
326
Which drugs could cause serotonin syndrome?
```
SSRI
MAOI
TCA
Antipsychotics
Tramadol
Pethidine
St. John's wort
Triptans
Ondansetron
Linezolid
Recreational drugs: cocaine, ecstasy, LSD, amphetamines, GHB
```
327
What are symptoms of giant cell arteritis?
```
Headaches
PMR features: shoulder/hip pain, weakness
Temporal artery tenderness
Jaw claudication
Amaurosis fugax
Blindness
```
328
What blood test abnormalities might you expect in giant cell arteritis?
Raised ESR and CRP
High alk phos
Low Hb
329
How does thiamine deficiency lead to peripheral oedema/pleural effusions (wet beriberi)?
Thiamine is essential cofactor for pyruvate dehydrogenase
Without thiamine, pyruvate formed from glycolysis cannot be converted to acetyl co A to enter Krebs cycle
This leads to impaired glucose metabolism with accumulation of lactate and pyruvate resulting in vasodilation and oedema
330
How should anti HBs levels be interpreted after a vaccine to check response?
Level >100: adequate response. No further testing required. Should still receive booster at 5 years
Level 10-100: suboptimal response, one additional vaccine dose should be given. If immunocompetent, no further testing required
Level <10: non responder. Test for current or past infection. Give further vaccine course (3 doses again) then retest. If still fails to respond then HBIG required for protection if exposed
331
What are absolute contraindications to thrombolysis?
```
Active internal bleeding
Suspected aortic dissection
Recent head trauma/intracranial neoplasm
Previous haemorrhagic stroke at any time
Previous ischaemic stroke in past year
Previous allergic reaction to fibrinolytic agent
Trauma/surgery in past 2 weeks
```
332
Which pathogen causes owls eye appearance in infected cells?
Cytomegalovirus due to intranuclear inclusion bodies
333
What are features of CMV retinitis? What is the management?
HIV: CD4 count <50
Visual impairment
Retinal haemorrhages and necrosis (pizza retina)
IV ganciclovir
334
What can cause haemolysis in G6PD?
Fava beans
Antimalarial drugs
Nitrofurantoin
335
What biochemical abnormalities are found in rhabdomyolysis?
```
Myoglobinuria
Elevated CK
Elevated K
Elevated urate
Elevated calcium intracellularly in myocytes, can be normal or low in blood but increases as disease progresses
Acidosis
```
336
What is Kala azar?
```
Visceral leishmaniasis (protozoa transmitted by sandfly)
Black fever - skin darkens
```
337
What is the wells score for a PE?
Clinical signs of DVT (leg swelling and pain on palpation) 3
Alternative diagnosis less likely 3
Heart rate >100 1.5
Immobilisation for more than 3 days or surgery in previous 4 weeks 1.5
Previous DVT/PE 1.5
Haemoptysis 1
Malignancy 1
PE likely if more than 4 points - immediate CTPA, if delay, treat with LMWH until scan
338
What are criteria for severe falciparum malaria?
```
High parasitaemia >2%
Hypoglycaemia
Severe anaemia
Renal failure
Pulmonary oedema
Metabolic acidosis
Abnormal bleeding
Multiple convulsions
Seizures
Shock
```
339
What is the management of severe falciparum malaria?
IV artesunate
340
What is the most common cause of osteomyelitis in patients with sickle cell anaemia?
Salmonella
341
Which infections are HIV patients susceptible to with a CD4 count of 200-500?
Hairy leukoplakia
Shingles
Kaposi sarcoma
Oral thrush
342
Which infections are HIV patients susceptible to with a CD4 count of 50-100?
Oesophageal candidiasis
Cryptococcal meningitis
Primary CNS lymphoma
Aspergillosis
343
What is Ludwig’s angina?
Cellulitis which occurs on floor of mouth
| Spreads in fascial spaces of head and neck
344
What drugs are sickle cell patients likely to be on?
Hydroxyurea
Folic acid
Penicillin
345
What is samters triad?
Asthma
Aspirin sensitivity
Nasal polyposis
346
What is the triad of features of haemolytic uraemic syndrome?
Haemolytic anaemia
Renal failure
Thrombocytopenia
347
Which bug is associated with haemolytic uraemic syndrome?
Ecoli 0157
