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OSCE 3 > Clinical Reasoning > Flashcards

Clinical Reasoning Flashcards

1
Q

What are the 3 components of triple assessment for a breast lump?

A

Clinical examination
Mammogram
Fine needle aspiration

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2
Q

The patient has - distended abdomen, hyper-resonance on percussion and shifting dullness. What does this indicate?

A

Ascites

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3
Q

These are the ascitic tap results - cloudy, SAAG <1.1, neutrophils >250. What is the diagnosis?

A

Infection - spontaneous bacterial peritonitis

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4
Q

What are the symptoms of myasthenia gravis?

A 
Ptosis
Fatigability 
Diplopia 
Dysphonia
Dysarthria
Dysphagia
Facial weakness
Proximal and axial muscle weakness
Breathlessness
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5
Q

What investigation could be carried out to diagnose myasthenia gravis?

A

Anti-Ach receptor antibody
Muscle-specific tyrosine kinase antibody
Electromyography
CT imagine (exclude thymoma)

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6
Q

What would suggest a myasthenic crisis?

A

Breathlessness - life-threatening weakness of respiratory muscles

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7
Q

How is a myasthenic crisis treated?

A 
Ventilatory support 
Plasmapheresis/IVIg 
Identify trigger (medication, infection)
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8
Q

What is the initial management of bacterial pneumonia?

A 
Oral antibiotics (amoxicillin/doxycycline)
Oral steroids (prednisolone)
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9
Q

How would you manage an acute deterioration in a patient with pneumonia?

A

A-E assessment
Senior help
Escalate antibiotics
Re-scan

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10
Q

What investigation would you do if you suspected critical limb ischaemia?

A

ABPI

Doppler US

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11
Q

What surgical option is available for critical limb ischaemia?

A

Bypass

Balloon angioplasty

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12
Q

What is Charcot’s triad?

A

Symptoms of ascending cholangitis

RUQ pain, jaundice and fever/rigors

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13
Q

What is Reynold’s pentad?

A

Charcot’s triad (RUQ pain, jaundice and fever/rigor)
Shock (low BP, tachycardia)
Altered mental state

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14
Q

How is an MI initially managed?

A 
Aspirin 
Morphine
GTN
Oxygen
Clopidogrel
Call PCI centre
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15
Q

How is an MI definitively managed?

A

Primary percutaneous coronary intervention

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16
Q

Who is the breast screening service for?

A

50-70 year old women every 3 years

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17
Q

What are the symptoms of breast cancer?

A 
Skin dimpling
Nipple retraction/discharge/bleeding/eczema 
Tethering of skin around areola
Mass in axilla/breast 
Peau d’orange
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18
Q

What are the treatment options for breast cancer?

A

Surgery (masectomy, lumpectomy)

Neo-adjuvant (chemotherapy, radiotherapy, endocrine therapy, HER2 therapy)

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19
Q

What are the indications for masectomy?

A

More than 1 tumour
Diffuse DCIS
Large tumour in small breast
Recurrence after lumpectomy

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20
Q

What is the pathophysiology of myasthenia gravis?

A

Antibodies created against the acetylcholine receptors at the postsynaptic neuromuscular junction

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21
Q

How is myasthenia gravis managed?

A

Pyridostigmine (anti-acetylcholine esterase)

Steroids, IVIg (immunosuppressants)

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22
Q

What conditions is myasthenia gravis associated with?

A

Thymoma/thymic hyperplasia
Pernicious anaemia
T1DM

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23
Q

What is the pathophysiology of Guillain-Barre?

A

After an infection (campylobacter, CMV, EBV), the imune system attacks the part of the myelin sheath which resembles the pathogen

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24
Q

What are the symptoms of Guillain Barre?

A

Progressive ascending weakness
Flaccid quadraparesis
Areflexia
Respiratory/bulbar/autonomic involvement

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25
Q

How is Guillain Barre treated?

A

IVIg or apheresis

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26
Q

What investigations could be used to confirm Guillain Barre?

A

Lumbar puncture - CSF has high protein

Nerve conduction studies - delayed impulse

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27
Q

What are the symptoms of multiple sclerosis?

A

Central - fatigue, cognitive impairment, depression
Visual - nystagmus, optic neuritis, diplopia
Throat - dysarthria, dysphagia
MSK - weakness, spasms, ataxia
Sensation - pain, paraesthesia
Bowel - incontinence
Urinary - incontinence, retention, frequency

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28
Q

What is optic neuritis?

A

Painful vision loss which develops over days

Blurred vision and loss of colour vision

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29
Q

What is transverse myelitis?

A

Inflammation of the spinal cord causing weakness and sensory loss

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30
Q

How is multiple sclerosis diagnosed?

A

Evidence of 2 or more episodes of demyelination disseminated in time and space

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31
Q

How do symptoms of multiple sclerosis present?

A

Focal neurological deficits which develop gradually, last more than 24 hours and may improve over days/weeks

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32
Q

What investigations could help to confirm multiple sclerosis?

A

MRI brain
Lumbar puncture (oligoclonal bands)
Visual evoked potentials

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33
Q

How is multiple sclerosis managed?

A 
Steroids 
Physiotherapy
Occupational therapy 
Disease modifying therapies 
Alemtuzumab 
Natalizumab 
Fingolimod
Dimethyl fumarate
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34
Q

What are the symptoms of a stroke?

A

Right sided weakness
Dysphagia
Visual disturbance
Light-headedness

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35
Q

How are ischaemic strokes managed?

A 
IV thrombolysis (alteplase)/thrombectomy/aspirin 
Stroke unit
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36
Q

How are haemorrhagic strokes managed?

A

Reversal of anticoagulant/BP control

Stroke unit

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37
Q

What are the cardiovascular risk factors for stroke?

A 
Hypertension 
Obesity 
Physical inactivity 
Hyperlipidaemia 
Smoking
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38
Q

How is a further stroke prevented?

A 
Smoking cessation 
Anti-platelets (aspirin, clopidogrel)
BP management (ACEi)
Statin 
Diabetic control 
Atrial fibrillation management
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39
Q

What are the symptoms of a subarachnoid haemorrhage?

A 
Sudden onset thunderclap headache 
Photophobia
Meningism 
Loss of consiousness
Seizures 
Visual/speech/limb disturbance 
Sentinel headache weeks before
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40
Q

What investigations would be used to diagnose subarachnoid haemorrhage?

A 
CT brain (and angiography)
Lumbar puncture
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41
Q

How is subarachnoid haemorrhage managed?

A

Fluids
Nimodipine (calcium channel antagonist - neuronal protection)
Analgesia
Surgical clipping/endovascular coil

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42
Q

What are the complications of subarachnoid haemorrhage?

A

Rehaemorrhage
Delayed ischaemia
Hydrocephalus
Hyponatraemia

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43
Q

What are the symptoms of meningitis?

A 
Headache
Neck stiffness
Reduced GCS
Fever
Petechial rash 
Photophobia
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44
Q

How is meningitis diagnosed?

A

PCR

Lumbar puncture - high WCC, low glucose, high protein

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45
Q

What are the 2 main bacterial caused of meningitis?

A

Pneumococcus (+ve) - streptococcus pneumoniae

Meningococcus (-ve) - neisseria meningitides

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46
Q

How is meningitis treated?

A

IV ceftriaxone
Add amoxicillin if listeria
Add dexamethasone if bacterial

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47
Q

What are the symptoms of heart failure?

A 
Breathlessness (dyspnoea, orthopnoea, PND)
Exercise intolerance 
Fluid retention 
Fatigue
Cough
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48
Q

What investigations can be used to confirm heart failure?

A

ECG
Chest x-ray
Echo
Natriuretic peptides (BNP)

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49
Q

How is heart failure managed?

A 
Beta-blocker (bisoprolol) and ACEi (enalapril)
MRA (spironolactone)
Valsartan
Ivabradine/ICD
Digoxin
LVAD/transplant
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50
Q

How is an acute deterioration of heart failure managed?

A 
A-E assessment 
Inotropes 
Ventilatory support 
Diuretics 
Investigate trigger (infection, ischaemia, PE)
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51
Q

What are the symptoms of an MI?

A 
Chest pain 
Indigestion 
Sweatiness
Shortness of breath 
None (dementia/diabetes)
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52
Q

How is an MI managed?

A 
A-E assessment
Aspirin 
Heparin 
Morphine 
Anti-emetic 
Clopidogrel/ticagrelor
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53
Q

What are the symptoms of atrial fibrillation?

A 
Asymptomatic 
Palpitations 
Breathlessness 
Chest pain 
Syncope 
Stroke
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54
Q

How is atrial fibrillation diagnosed?

A

Irregular pulse
ECG
Echo

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55
Q

What are the major risk factors for stroke in atrial fibrillation?

A

Previous stroke
TIA/embolism
Age >75

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56
Q

How is atrial fibrillation managed?

A

Anticoagulation - warfarin/dabigatran/rivaroxaban/apixaban

Rhythm control - cardioversion, antiarrythmic drugs (flecainide), catheter ablation

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57
Q

How is hypertension defined?

A

BP of >140/90 mmHg

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58
Q

What are the risk factors for hypertension?

A

Age, gender, ethnicity, genetics, diet, physical activity, obesity, alcohol, stress

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59
Q

How is hypertension managed?

A

ACEi or calcium channel blocker (>55, black)
Both together
Add thiazide diuretic
Add another diuretic or alpha/beta blocker

60
Q

What are the symptoms of endocarditis?

A

Fever
Murmur
Fatigue

61
Q

How is endocarditis investigated?

A

Blood cultures

Echo

62
Q

What is Duke’s criteria for endocarditis?

A

2 major/1 major 3 minor/5 minor criteria
Major - 2 blood cultures, echo, new valve
Minor - predisposition, fever, vascular, immunological

63
Q

How is endocarditis managed?

A

IV antibiotics for 4-6 weeks

64
Q

What are the symptoms of alcoholic liver disease?

A 
Malaise 
Nausea
Hepatomegaly 
Fever
Jaundice
Sepsis
Encephalopathy 
Ascites 
Renal failure
Death
65
Q

What are the signs of portal hypertension?

A 
Hypersplenism
Oesophageal varices
Encephalopathy
Ascites
Hepato-renal syndrome
66
Q

How is ascites managed?

A

Low salt diet

Diuretic (spironolactone, furosemide)

67
Q

How is encephalopathy managed?

A

Lactulose

68
Q

What are the symptoms of hepatitis?

A 
Malaise 
Fever
Headaches
Anorexia
Nausea 
Vomiting 
RUQ pain 
Dark urine 
Jaundice
69
Q

How is hepatitis managed?

A

Interferon

Tenofovir/entecavir

70
Q

How can hepatitis B be prevented?

A

Education
Immunisation
Mother to child

71
Q

How is hepatitis C cured?

A

Direct acting antivirals for 8-12 weeks

72
Q

How is pancreatitis diagnosed?

A

Classic pain (central to back, eases on leaning forward)
Blood amylase 3x upper limit of normal
Characteristic CT

73
Q

What are the causes of pancreatitis?

A 
Gallstones
Alcohol 
Trauma (ERCP)
Drugs 
Autoimmune 
Viral
74
Q

How is pancreatitis treated?

A 
A-E assessment 
Fluids 
Oxygen 
Allow body to recover
Treat cause 
Necrosectomy
75
Q

What are the complications of pancreatitis?

A

Pseudocyst
Fistula
Necrosis
Diabetes

76
Q

What are the symptoms of cholecystitis (gallstones)?

A

RUQ pain
Fever
Raised WCC
Normal amylase

77
Q

How is coeliac disease managed?

A

Gluten free diet

78
Q

What are the histological features of coeliac disease?

A

Atrophy of villi
Crypt hyperplasia
Intraepithelial lymphocytes

79
Q

What are the symptoms of coeliac disease?

A 
Diarrhoea/constipation
Flatulence 
Nausea and vomiting
Recurrent stomach pain
Cramping/bloating.
Tiredness
80
Q

What are the symptoms of critical limb ischaemia?

A 
Severe pain or Numbness in the legs and feet 
Decrease in the temperature 
Toe or foot sores/infections/ulcers 
Gangrene
Shiny, smooth, dry skin 
Thickening of the toenails
Absent or diminished pulse
81
Q

How is critical limb ischaemia treated?

A

Angioplasty and shunt

Bypass

82
Q

What are the symptoms of an upper GI bleed?

A

Haematemesis
Coffee-ground vomit
Melaena

83
Q

How is an upper GI bleed managed?

A 
A-E assessment 
Resuscitation - fluids, oxygen 
Endoscopy 
Blood transfusion
Antibiotics, beta-blocker and terlipressin 
TIPS/banding/balloon tamponade (varices)
84
Q

What are the symptoms of asthma?

A 
Wheeze
Cough 
Breathlessness 
Exercise intolerance 
Trigger
85
Q

How is asthma diagnosed?

A

Serial peak flow measurements

Spirometry reversibility

86
Q

How is asthma managed?

A

SABA and ICS

87
Q

How is an acute asthma attack managed?

A 
A-E assessment 
Oxygen 
Salbutamol nebuliser
Ipratropium bromide nebuliser
Prednisolone (oral/IV)
Magnesium sulphate infusion
88
Q

What are the 2 pathophysiological components of COPD?

A

Chronic bronchitis - sputum most days for 3 months in 2 years
Emphysema - permanently enlarged airspaces

89
Q

What are the symptoms of COPD?

A 
Exertional breathlessness
Chronic cough 
Regular sputum production 
Frequent winter bronchitis 
Wheeze
90
Q

How is COPD managed?

A

Bronchodilators (SABA, LABA)
Corticosteroids
Oxygen therapy
Mucolytics

91
Q

What is a blue bloater and pink puffer?

A

BB - chronic bronchitis, type 2 respiratory failure

PP - emphysema, type 1 respiratory failure

92
Q

What are the symptoms of a pneumothorax?

A 
Pleuritic chest pain 
Breathlessness
Respiratory distress
Reduced air entry 
Hyper-resonance 
Tracheal deviation
93
Q

What investigations may aid diagnosis of pneumothorax?

A

X-ray

CT

94
Q

What are the management options for a pneumothorax?

A

Observation
Aspiration
Intercostal drain

95
Q

Where would you aspirate gas from a pneumothorax?

A

2nd intercostal space mid clavicular line

96
Q

What are the symptoms of extrinsic allergic alveolitis/hypersensitivity pneumonitis?

A 
Flu-like 
Cough 
Fever
Chills
Dyspnoea
Malaise
Chest tightness
Myalgia 
Sputum production 
Weight loss
97
Q

How is extrinsic allergic alveolitis/hypersensitivity pneumonitis managed?

A

Avoid trigger
Corticosteroids
Cytotoxics
Oxygen

98
Q

What are the symptoms of pulmonary fibrosis?

A

Breathlessness
Hacking dry cough
Fatigue and weakness
Appetite and weight loss

99
Q

What are the signs of pulmonary fibrosis?

A

Finger clubbing
Bibasal crackles
Subpleural honeycombing

100
Q

How is pulmonary fibrosis investigated?

A

High resolution CT

Video assisted thoracoscopic surgery (biopsy)

101
Q

How is pulmonary fibrosis managed?

A

Symptomatic
Oxygen
Pulmonary rehabilitation
Transplant

102
Q

What are the 3 types of skin cancer?

A

Basal cell carcinoma
Squamous cell carcinoma
Malignant melanoma

103
Q

How is basal cell carcinoma managed?

A

Surgical excision with 3-4mm margin

104
Q

How is squamous cell carcinoma managed?

A

Surgical excision with 4mm margin

105
Q

What are the risk factors for melanoma?

A 
Genetics 
Family history 
UV radiation 
Sunburn
Fair skin 
History of melanoma 
High socioeconomic status 
Immunosuppression
106
Q

What classification is used to determine prognosis of melanoma?

A

Breslow depth

107
Q

How is malignant melanoma treated?

A

Surgical excision with 1-2cm margin

Immunotherapy (ipilimumab)

108
Q

What types of eczema are there?

A

Atopic
Seborrhoeic
Varicose
Contact

109
Q

How is eczema managed?

A 
Emollients 
Topical steroids 
Antihistamines 
Antibiotics/antivirals/antifungals 
Immunosuppressants 
Biologic agents 
Avoid triggers
110
Q

What is the Koebner phenomenon?

A

Psoriasis develops at site of trauma/scars

111
Q

What are the symptoms of psoriasis?

A

Salmon pink plaques on extensor surfaces
Onycholysis
Pitting/thickened/dystrophic nails
Psoriatic arthritis

112
Q

How is psoriasis managed?

A 
Topical moisturiser, steroid, vitamin D analogue, retinoids
UV phototherapy 
Oral retinoids
Methotrexate/cyclosporin 
Biologics (abalumimab)
113
Q

What are the symptoms of hyperthyroidism?

A 
Weight loss 
Irritability/restlessness
Malaise 
Itching 
Sweating 
Breathlessness
Palpitations 
Heat intolerance 
Muscle weakness 
Stiffness
Tremor
Diarrhoea 
Eye changes 
Oligomenorrhoea 
Loss of libido
114
Q

What are the symptoms of hypothyroidism?

A 
Tiredness 
Weight gain 
Cold intolerance 
Depression 
Poor memory 
Dry/brittle hair 
Dry/course skin 
Arthralgia 
Myalgia
Muscle weakness
Constipation 
Menorrhagia
115
Q

How is hypothyroidism managed?

A

Levothyroxine

116
Q

How is hyperthyroidism managed?

A

Beta-blocker
Carbimazole/propylthiouracil
Radioactive iodine

117
Q

What antibodies are involved in thyroid disease?

A

TSH receptor antibody - Grave’s

TPO antibody - Hashimoto’s

118
Q

What are the symptoms of diabetes?

A 
Excessive thirst and hunger
Frequent urination 
Weight loss 
Fatigue
Irritability
Blurred vision
Slow-healing wounds
Nausea
Skin infections
Acanthosis nigricans
Fruity/sweet/acetone breath
Tingling or numbness in the hands or feet
119
Q

What are the x-ray features of osteoarthritis?

A

Narrowed joint space
Osterophytes
Subchondral sclerosis
Subchondral cysts

120
Q

What are the joint features of rheumatoid arthritis?

A 
Boutonniere deformity 
Swan neck deformity 
Z-thumb 
Subluxation of wrist 
Ulnar deviation of digits 
Radial deviation of wrist 
Piano key ulnar head
121
Q

What investigations can be used to diagnose rheumatoid arthritis?

A

Rheumatoid factor
Anti-CCP
ANA
Imaging - x-ray

122
Q

How is rheumatoid arthritis managed?

A

Occupational/physiotherapy
NSAIDs/analgesia
DMARDs (methotrexate, sulfasalazine)
Biologics (anti-TNF infliximab, anti-CD20 rituximab, anti-IL6 tocilizumab)

123
Q

How is a hot, swollen joint investigated?

A

Synovial fluid aspirate
Gram stain and culture
Polarised microscopy
Blood culture

124
Q

What are the symptoms of reactive arthritis?

A

Non-gonococcal urethritis, post-infectious arthritis, conjunctivitis

125
Q

How are gout and pseudogout differentiated using polarised light microscopy?

A

Gout - negatively bifringent, needle shaped crystals of sodium urate
Pseudogout - weakly positive birefringent rhomboidal crystals of sodium pyrophosphate

126
Q

How is gout managed?

A

Acute - NSAIDs, colchicine

Chronic - urate lowering therapy (e.g. allopurinol, xanthine oxidase inhibitor)

127
Q

What investigations are used for diagnosing disseminated intravascular coagulation?

A

Look for underlying cause
Coagulation panel
D-dimer
FBC and blood film

128
Q

How is isseminated intravascular coagulation managed?

A

Fresh frozen plasma

Platelets

129
Q

What is the most common pathogen to cause pneumonia?

A

Streptococcus pneumoniae

130
Q

What are the symptoms of bacterial pneumonia?

A

Abrupt cough
Pleuritic chest pain
High fever

131
Q

What are the signs of bacterial pneumonia?

A

Consolidation (dull percussion)
Coarse crepitations
Increased vocal resonance

132
Q

How is bacterial pneumonia treated?

A

Penicillin

doxycycline if allergy

133
Q

What is the CURB65 score?

A 
Clinical assessment of pneumonia - >2 severe 
C - confusion 
U - urea (>7)
R - respiratory rate (>30)
B - BP <90/<60 mmHg
65 - age >65
134
Q

How can pneumonia be investigated?

A

ABG
Chest x-ray
Blood/sputum culture

135
Q

How is TB treated?

A

Rifampicin
Isoniazid (prophylactic pyridoxine)
Pyrazinamide
Ethambutol

136
Q

What is the most likely STI to cause urethral discharge?

A

Gonorrhoea (neisseria gonnorhoea)

137
Q

How is gonorrhoea treated?

A

Ceftriaxone IM and azithromycin oral

138
Q

How is chlamydia treated?

A

Doxycycline

139
Q

What are the symptoms of syphilis?

A 
Macropapular rash 
Patchy alopecia 
Lip/anal chancre 
Ophthalmic 
Aortic root dissection
140
Q

How is syphilis treated?

A

Penicillin IM

141
Q

How are genital warts treated?

A

Topical podophyllotoxin
Aldara immune modulator
Liquid nitrogen

142
Q

How is herpes treated?

A

Aciclovir

143
Q

What are the symptoms of HIV?

A 
Macropapular rash 
Glandular fever 
Weight loss
Mouth sores 
Myalgia
Fever
Nausea and vomiting 
Headache 
Diarrhoea 
Oesophageal candida
144
Q

How is HIV treated?

A

HAART - highly active antiretroviral treatment (triple therapy)

145
Q

When can a person with HIV have unprotected sex?

A

Viral load undetectable (<200) for >6 months - untransmissible

OSCE 3 (3 decks)

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