Acute Medicine

Question 1

What is acute medicine?

Answer 1

Acute medicine refers to immediate and early management of adults in hospital who require urgent or emergency care. Although it is closely linked to emergency medicine and critical care, it is firmly rooted in the principles of general internal medicine. Mostly based in AMUs etc.

Question 2

What are the key aspects of the job of acute medicine?

Answer 2

Reviewing patients admitted from A&E and GP. Including diagnosis, initial management and treatment. Need to decide who is admitted and discharged, who needs specialist review and who needs escalation to critical care/HDU
(key role of acute medicine is to convert presenting complaint into differential diagnosis)

Question 3

What are the typical presentations seen in acute medicine?

Answer 3

1. Chest pain
2. SOB
3. Abdominal pain
4. Vomiting/haematemesis
5. Sepsis
6. Confusion

Question 4

What score is used to predict the outcomes in patients with a PE?

Answer 4

PESI - pulmonary embolism severity index

Question 5

What is the treatment for someone with a CURB65 score of 0-1?

Answer 5

Consider outpatient treatment and single antibiotic

Question 6

What is the treatment for someone with a CURB65 score of 2?

Answer 6

Short in-patient treatment and dual antibiotic

Question 7

What is the treatment for someone with a CURB65 score of 3?

Answer 7

In-patient treatment and IV therapy

Question 8

What is the treatment for someone with a CURB65 score of 4-5?

Answer 8

These patients have a mortality rate of 41-57%. The treatment is in-patient therapy HDU/specialist care dual antibiotics

Question 9

What does SNOUT and SPIN refer to?

Answer 9

SNOUT means a negative test rules out and SPIN means a positive test rules in.
So the SNOUT is sensitive and the SPIN is specific

Question 10

When is a fat embolism more likely to occur?

Answer 10

With broken bones

Question 11

What are the symptoms of PE? (5)

Answer 11

1. SOB
2. Chest pain - pleuritic in nature
3. Cough
4. Associated leg swelling
5. Haemoptysis (rarely)

Question 12

What are the signs of PE? (5)

Answer 12

1. Tachycardia (most common)
2. Hypotension (only happen if massive PE)
3. Raised JVP
4. Pleural rub (rare)
5. May have no signs

Question 13

What are the risk factors for PE? (8)

Answer 13

1. Previous DVT/PE
2. Current DVT
3. Immobility
4. Major surgery
5. Long bone fracture
6. Acute malignancy
7. Oral contraceptive pill
8. Pregnancy

Question 14

What are the differential diagnoses for PE? (7)

Answer 14

1. Pneumonia
2. LRTI
3. ACS
4. Pleurisy
5. Pericarditis
6. MSK chest pain
7. Upper GI symptoms (GORD)

Question 15

What is it called when the PE is across the bifurcation in the pulmonary artery?

Answer 15

Saddle PE

Question 16

What is the initial treatment for a PE?

Answer 16

1. Low molecular weight heparin
2. Option of warfarin or DOAC or longer-term LMWH
3. Treatment options depend on whether provoked or unprovoked
   Other considerations - duration of treatment and further investigations required

Question 17

1 in how many patients on warfarin are at risk of intra-cerebral haemorrhage?

Answer 17

1 in 200

Question 18

What is a D-Dimers sensitivity and specificity in terms of %s?

Answer 18

Sensitive 95%
Specific 50%
(because can be positive due to many causes - but won’t miss PE)

Question 19

There is a WELLs score for PE and DVT. What are the elements of WELLs score for calculating PE? (7)

Answer 19

1. Clinical signs/symptoms of DVT
2. PE is first diagnosis or equally likely
3. Heart rate >100
4. Immobilisation at least 3 days or surgery in the previous 4 weeks
5. Previous, objectively diagnosed PE or DVT
6. Haemoptysis
7. Malignancy w/treatment within 6 months or palliative

Question 20

If there is a possibility of PE, what is the flow chart to decide upon performing a CTPA?

Answer 20

PE possible –> WELLS score –> if high risk 4 or more –> CTPA.
If WELLS score is low <4 –> D-Dimer –> positive then CTPA, negative PE excluded

Question 21

When would someone with a PE require admission to HDU/CCU/ARCU? (what signs/symptoms)

Answer 21

Massive
- hypotension
- cardiac arrest
- patients receive Alteplase 
Sub-massive
- hypoxia
- cardiac ECHO/ECG
- positive cardiac biomarker - troponin

Question 22

Which anti-hypertensive is most likely responsible for a patient with deranged bloods including hyperkalaemia and AKI?

Answer 22

ACE inhibitors

Question 23

Of the following drugs, which are most likely important to withhold in someone with an AKI? 
Amlodipine
Metformin
Simvastatin
Ramipril
Aspirin

Answer 23

Ramipril
Metformin
Amlodipine

Question 24

Why is VBG useful in someone with AKI?

Answer 24

Measures:
acidosis
lactate
potassium

Question 25

What is the treatment for someone with high potassium?

Answer 25

Calcium gluconate, insulin and dextrose (be careful as patients with diabetes are prone to a hypo - need careful monitoring)

Question 26

What are the ECG signs of hyperkalaemia? (6)

Answer 26

1. Flattened P waves 2. Broad bizarre QRS 3. Sloping ST 4. Tented T waves 5. Sine wave ECG 6. Any arrhythmia

Question 27

What does the calcium gluconate do in the treatment of hyperkalaemia?

Answer 27

It is cardioprotective

Question 28

What is the emergency management of hyperkalaemia?

Answer 28

1. Calcium gluconate IV (10ml 10% bolus) 2. Salbutamol 5mg NEB 3. Insulin dextrose (10 units actrapid in 50ml 50% dextrose) IV over 20 min 4. Haemofiltration/dialysis if not responding to the above (uraemic symptoms (confusion, twitchy, itchy), hyperkalaemia not responding, flash pulmonary oedema, pericardial effusion, metabolic acidosis not responding) - may need cardioversion if BP <100 systolic

Question 29

What are the indications for haemofiltration/dialysis?

Answer 29

1. Uraemic symptoms 2. Hyperkalaemic not responding with treatment 3. Flash pulmonary oedema 4. Pericardial effusion 5. Metabolic acidosis not responding with treatment

Question 30

What questions can be asked to assess the severity of COPD? (5)

Answer 30

1. Usual exercise tolerance/functional status 2. Weight loss (unexplained) 3. Use of long term oxygen therapy 4. Previous need for NIV 5. Number of admissions for COPD and number of courses of ABX/steroids for COPD in last 12 months

Question 31

What is the chronic management of COPD? (6)

Answer 31

1. Stepwise progression of inhalers; SABA, LAMA, combination of steroids and LABA 2. Carbocysteine 3. Nebulisers 4. Home oxygen 5. Pulmonary rehab 6. Vaccinations

Question 32

What is the management of acute exacerbation of COPD? (7)

Answer 32

1. Nebs 2. Steroids 3. Antibiotics (if infection) 4. Oxygen 5. Consider other causes e.g. MI 6. Assisted ventilation; NIV, mechanical ventilation 7. Consider level of care and DNACPR if appropriate

Question 33

What type of infections can produce symptoms of confusion?

Answer 33

1. Pneumonia 2. UTI 3. Cellulitis 4. Gastro 5. Neuro

Question 34

What are the commonest causes of delirium/confusion?

Answer 34

1. Infection 2. Drugs 3. Electrolyte disturbance 4. Pain

Question 35

What are the 3 indications for dialysis in someone with AKI?

Answer 35

1. Pericarditis - if someone has developed pericarditis (will present with chest pain that improves upon leaning forwards and worse on inspiration) 2. Uraemic encephalopathy - hallucinations and confusion 3. Metabolic acidosis after attempts at treating - the dialysis will remove excess acid / same with hyperkalaemia if not responding to treatment

Question 36

What needs to be assess immediately in a paediatric patient with fever?

Answer 36

1. Patent airway 2. Breathing 3. Circulation 4. Consciousness

Question 37

What signs/symptoms of a child puts them at high risk for serious illness? (9)

Answer 37

1. Pale/mottled/ashen/blue skin, lips or tongue 2. No response to social cues 3. Appearing ill to a healthcare professional 4. Does not wake or if roused does not stay awake 5. Weak, high-pitched or continuous cry grunting 6. Respiratory rate greater than 60 breaths per minute 7. Moderate or severe chest indrawing 8. Reduced skin turgor 9. Bulging fontanelle

Question 38

What needs to be measured/assessed in a routine assessment of a child with a fever? (4)

Answer 38

1. Temperature 2. Heart rate 3. Respiratory rate 4. Capillary refill

Question 39

What NEWS scores correspond to low, intermediate and high risk?

Answer 39

``` Low = 1-4 Intermediate = 5-6 (or a red score) High = 7 or more ```

Question 40

What are the 6 physiological parameters included in the NEWS score?

Answer 40

1. Respiratory rate 2. Temperature 3. Heart rate 4. Blood pressure 5. Oxygen saturations 6. Level of consciousness (AVPU/GCS)

Question 41

What clinical features increase the chances of a diagnosis of asthma? (8)

Answer 41

At least one of the following: wheeze, cough, difficulty breathing, chest tightness ...particularly if these symptoms occurs: 1. Frequently/recurrent 2. Worse at night/early in the morning 3. Triggers; exercise, animal hair, cold/damp hair, emotions 4. Occur separate to colds 5. Personal history of atopy 6. Family history of asthma/atopic disorder 7. Widespread wheeze heard on auscultation 8. History of improvement of symptoms in response to adequate treatment

Question 42

What clinical features would decrease the chances of a diagnosis of asthma? (6)

Answer 42

1. Symptoms only occurring in conjunction with colds 2. Isolated cough without wheeze or difficulty breathing 3. Prominent dizziness, light-headedness or peripheral tingling 4. Repeatedly normal physical examination of chest when symptoms present 5. Normal PEFR 6. No response to asthma treatment

Question 43

What are the various causes of shock? (6)

Answer 43

1. Cardiogenic 2. Hypovolaemic 3. Obstructive 4. Septic 5. Anaphylactic 6. Neurogenic

Question 44

What are the cardiogenic causes of shock? (6)

Answer 44

1. MI 2. Dissection of the thoracic aorta 3. Cardiac arrhythmias 4. Acute valvular failure or acute VSD 5. Drug overdose 6. Myocarditis

Question 45

What are the causes of hypovolaemic stroke? (4)

Answer 45

1. Haemorrhage (GI tract, aortic dissection, ruptured AAA, trauma) 2. Fluid losses (diarrhoea, vomiting, polyuria, burns) 3. 3rd space fluid losses (acute pancreatitis) 4. Adrenal failure

Question 46

What are the causes of obstructive shock? (3)

Answer 46

1. Cardiac tamponade 2. Pulmonary embolus 3. Tension pneumothorax

Question 47

What is the initial assessment of shock?

Answer 47

1. If BP is unrecordable, call the cardiac arrest team and begin basic life support and establish venous access 2. Check the airway is unobstructed. Give highflow O2