Core Cases Notes Flashcards
1
Q
What is Dysarthria
A
Slurred Speech
2
Q
What is Dysphasia
A
Problem generating / comprehending speech
3
Q
What is the conus medullaris
A
End of spinal cord ~ L1-2, after which you have the cauda equina
4
Q
Describe Guillian Barre syndrome
A
AI polyneuropathy
Occurs post-infection, commonly campylobacter / cytomegalovirus
Presents with mixed proximal / distal weakness which ascends in glove-stocking
Mx: IV Ig, may spontaneously recover
5
Q
What saccadic eye movements would be typical for cerebellar disease
A
broken saccades, overshoot on lateral gaze
6
Q
What neural fibres are carried in the internal capsule?
A
Corticospinal tract fibres
7
Q
What is myeloradiculopathy?
A
Disease of spinal cord/ spinal roots
8
Q
What is syringomyelia?
A
Formation of fluid-filled cyst in spinal cord
9
Q
D
A
D
10
Q
What autoantibodies might you investigate in peripheral neuropathy
A
ANCA / ANA
11
Q
Describe trigeminal neuralgia
A
Unilateral pain,
Usually maxillary / mandibular
Precipitated by tactile stimulation e.g brushing teeth
Mx: Carbamazepine
12
Q
Differentials for weakness / wasting of hands
A
MND, cervical rib, pancoast tumour, T1 root lesion, syringomyelia
13
Q
What is cervical rib
A
Congenital abnormaility
Additional rib at C7
14
Q
What is a pancoast tumour
A
Tumour of pulmonary apex
Usually non-small cell
15
Q
Patient has peripheral motor neuropathy, gait?
A
High stepping gait due to foot drop
16
Q
Patient has peripheral sensory (proprioceptive) neuropathy, gait?
A
Ataxic / stamping gait
17
Q
Patient has a wide-based, staggering gait (ataxic), where is their likely problem?
A
cerebellum
18
Q
Describe a hemispheric gait disturbance
A
contralateral hemiplegic gait and contralteral arm flexion
circumduction
19
Q
Describe a parkinsonian gait
A
Shuffling gait, loss of arm swing, stooped posture
festinant- tendancy to hurry and turn slowly due to instability
20
Q
What is apraxia
A
Inability to carry out complex tasks e.g walking
21
Q
Causes of apraxia?
A
cortical disease, diffuse vascular disease, normal pressure hydrocephalus
22
Q
Describe anterior spinal artery thrombosis
A
Acute onset flaccid paralysis
Reduced reflexes
Normal DCML sensation (vibration, fine touch, proprioception)
23
Q
Respiratory differentials of breathlessness
A
(CC-AAA-PPP)
COPD, CA,
Asthma, ARDS, Anaphylaxis
Pulmonary Fibrosis, Pneumonia / RTIs, Pneumothorax,
24
Q
Cardiovascular differentials of breathlessness
A
Heart Failure,
Cardiac Tamponade
PE
25
What is an air bronchogram
Air filled bronchi (dark) seen on CXR caused by opacity of surrounding alveoli. This is pathognomic of consolidation - an infective process
26
CXR interpretation. What should you look out for in the apex of the lung?
Tuberculosis
| Lung CA
27
CXR interpretation. COPD patients show signs of hyperinflation, What are the features of hyperinflation?
Flattened diaphragm
| Seeing increased posterior ribs from spinal cord (8-9 normal, >/=10 abnormal)
28
What are the signs of HF on CXR?
```
ABCDE
Alveolar oedema
Kerley B lines
Cardiomegaly
Dilated upper lobe vessels
Pulmonary effusion
```
29
CXR interpretation. What is a normal cardio-thoracic ratio
Heart <50%
30
CXR interpretation. What are kerley B lines and when might you see them?
Fluid in lymphatics, short horizontal lines at lower outer lung fields
31
ABG interpretation. Low pH, low Co2. Diagnosis? Potential cause?
Metabolic acidosis.
| DKA, severe diarrhoea / dehydration, prolonged lack of O2 from shock / HF
32
ABG interpretation. Low pH. High Co2. Diagnosis? Potential cause?
Respiratory acidosis
| COPD, sedative drugs, atelectasis
33
Patient is having an asthma attack and is hyperventilating, what is likely to be seen on ABG?
Respiratory alkalosis
| Raised pH, Low Co2
34
Patient has severe vomiting, what is acid base balance diagnosis?
Metabolic alkalosis
35
ABG interpretation. High pH. High Co2. Diagnosis? Potential cause?
Metabolic alkalosis
| Vomiting
36
ABG interpretation. High pH. Low Co2. Diagnosis? Potential cause?
Respiratory alkalosis
| Hyperventilation e.g asthma / panic attack
37
Koilonychia is a sign of what biochemistry deficiency?
Fe2+
38
Clubbing nails is a sign of what GI condition?
Crohn's
39
Hydrogen breath test is used as an investigation for what?
hypolactasia
| small bowel bacterial over-growth
40
What are 2 common causes of raised Ca2+?
Primary hyperparathyroidism,
| Disseminated malignancy
41
Patient has raised Ca2+, which investigation should you do as a follow-up assists in distinguishing the differential diagnoses?
PTH
Normal/raised PTH- primary hyperparathyroidism
Low PTH- disseminated malignancy
42
Virchow's node is found where and is a sign of what?
supraclavicular lymph node
| intra-abdominal malignancy
43
```
Differential diagnoses for constipation:
Common
Metabolic
Drugs
Neoplasia
```
Common: functional (e.g IBS), depression, idiopathic, inadequate dietary fibre
Metabolic: hypothyroidism, hypercalcaemia
Drugs: opiates, antidepressants, CCBs
Neoplasia: colon/rectal CA
44
What is the management of giardia?
Tinidazole 2g
45
What is calcium resonium used in the management of?
High K+
46
What is a foecal occult blood test?
screening test for colorectal cancer
| checks for non-visible blood in stools
47
Patient has multiple myeloma, what do you see on urine sample?
Bence-Jones protein
48
What is hypochlorhydia and what might be a consequence?
low production of stomach acid
| may lead to malabsorption
49
What is chymotrypsin?
pancreatic enzyme, converted to trypsin which breaks down protein
50
Give some differential diagnoses of malabsorption
Common: coeliac, crohn's, chronic pancreatitis
Uncommon: hypolactasia, small bowel bacterial overgrowth, giardiasis, HIV
51
How can you investigate and manage a small bowel bacterial overgrowth
Ix: lactulose test
Mx: Abx (metronidazole and tertracycline)
52
Loss of lactase from small intestinal brush border is called...
hypolactasia
53
Symptoms, investigations and management of hypolactasia?
S&S: bloating, nausea, wind, dirarhoea
Ix: Lactose breath test
Mx: Low lactose diet
54
Symptoms of Vit C deficiency
Bleeding gums
Tooth loosening
Corckscrew hair,
Perifollicular haemorrhages,
55
Symptoms of Vit D deficiency
Osteomalacia- proximal myopathy, bone pain, malaise
56
Symptoms of Vit K deficiency
Easy bruising
57
What is trulove and witt's criteria for severe UC?
Bowel open >6 times /24hrs + 1 or more of:
HR> 90
Temp >37.5
ESR ? 30mm/hour
Hb<10.5
58
Pale stools are a hallmark of which overall GI pathology?
Malabsorption
59
Give 3 routine investigations for syncope?
ECG, Blood Glucose, Lying and Standing BP
60
What is syncope?
Sudden LOC
61
What is the pathophysiology of vasovagal syncope?
excessive activation of PNS in response to a specific stimuli e.g fear, stress, heat
causes vasodilation and bradycardia --> hypotension and cerebral hypoperfusion --> syncope
62
What are the ECG changes seen in wolf-parkinson-white syndrome?
Shortened PR, wide QRS, slurred upstroke of R (delta) wave
63
What is the definitive treatment of wolf-parkinson-white syndrome?
radio-ablation of accessory pathway
64
Which condition is characterised by an abnormal accessory conduction pathway between atria and ventricles?
Wolf-parkinson-white syndrome
65
First-dose hypotension is most commonly associated with which anti-hypertensive?
ACE
66
Give 2 ways in which we can minimise the risk of first-dose hypotension?
Low starting dose e.g 1.25 ramipril
| Take first few doses at night time whilst in bed
67
What are some potential symptoms of a silent MI
epigastric pain, SOB, acute pulmonary oedema, collapse, death
68
What are the different types of bronchial cancers?
Squamous cell CA (35%)
Adenocarcinoma (30%)
Small cell (20%)
Large cell (15%)
69
What are the investigations for bronchial tumours?
Bronchoscopy, washing, biopsy, CT/CXR for spread
70
Mx: small cell lung CA?
Mx: non-small cell lung CA?
Small cell mx= chemo
| Non-small cell mx= radio
71
What is mesothelioma?
Malignant tumour of pleura
72
Patient has chest pain, signs of pleural effusion and has blood-stained effusion, likely diagnosis?
Mesothelioma
73
CXR shows honeycombing and calcified pleural plaques 'holly leaves', diagnosis?
Asbestosis
74
Which type of asbestos commonly causes mesothelioma?
Blue
75
Which condition are ACEi CI for?
| As a result you should regularly monitor ptx ______?
Bilateral renal stenosis
| Regularly monitor ptx renal function
76
Give an example of a loop diuretic
Furosemide / Bumetanide
77
Mechanism of action of loop diuretic
Inhibits sodium / chloride channels in the ascending limb of the loop of henle
78
3 SEs of loop diuretics
Hyponatraemia, hypokalaemia, hypotension
79
Mechanism of action of spironalactone?
Aldosterone antagonist,
| Increased excretion sodium, reduced excretion potassium
80
3 SEs of spironolactone?
Hyperkalaemia, hyponatraemia, hypotension gynaecomastia, menstrual disturbance
81
Patient is on spironolactone, what should we monitor regularly?
Potassium levels
82
How is mesothelioma diagnosed / managed?
Pleural biopsy
| No cure, radio slows growth
83
Name and mechanism of action of thiazide diuretic
Bendroflumethiazide
| Inhibit sodium/chloride reabsorption at DCT
84
SEs of Thiazide diurteics
Hypokalaemia, hyponatraemia, hypotension
| Hyperuricaemia (can precipitate gout)
85
Which endocrine problem may cause a hoarse voice?
Thyroid CA
| laryngeal nerve palsy
86
Which is the commonest type of thyroid CA?
Papillary (80%)
Others: follicular and anaplastic
87
Name a medication that can be iaetrogenic cause of hypothyroidism
Amiodarone
88
Phaeochromocytoma is a tumour of what?
Chromaffin cells of adrenal medulla
89
Phaeochromocytoma causes secretion of what?
Catecholamines (adrenaline and noradrenaline)
90
Eye signs of graves disease
Proptosis (exophthalmous), lid lag, dipolopia
91
What is carbimazole and what is its major SE we should monitor for?
Hyperthyroidism treatment
| Agranulocytosis - monitor WBCs
92
S&S of thyroid storm
Substantial weight loss, AF, profuse sweating, previous thyroid surgery, enlarged heart, pleural effusion
93
Mx of thyroid storm
Fluids and electrolytes
Anti thyroid drugs and glucocorticoids
B Blockers
94
US thyroid reveals single hot nodule, differentials?
Thyroid adenoma /CA
95
US thyroid reveals multiple 'patchy hot' nodules, likely diagnosis?
Hashimoto's thyroiditis
96
US thyroid reveals diffuse hot gland, likely diagnosis and explanation?
Graves disease, diffuse stimulation of whole gland by thyroid antibodies
97
Give an non-infective cause of a febrile patient
Multiple pulmonary emboli
Remember that not all febrile patients have infections!
98
What is 'double pnemonia'?
Severe infections predispose patients to further infections e.,g px with flu more likely to get pneumonia
99
What defines an 'atypical' pneumonia
Prominent extra-pulmonary manifestations (in addition to main lung infection)
100
What does convalescent mean?
A person recovering from an illness
101
Give an example of a macrolide antibotic?
Erythromycin
Azithromycin
Clarithromycin
102
What is Sydenham's chorea and in which condition would you see it?
Rapid purposeless movements of face / arm jerky movements
| Rheumatic Fever
103
Describe erythema marginatum, what condition is this pathognomic?
rash starts on trunks / arms as maccules
spreads to form snake like ring with clear middle
worse with heat
rheumatic fever
104
Patient presents with suspected DVT, they have a family history of PE, give 2 tests that may be carried out as part of a thrombophilia screen
Genetic causes: factor V leiden, antibody protein C resistance
Acquired: anti-phospholipid syndrome, antibody protein C resistance
105
Give an investigation that may be carried out in a patient with suspected glomerulonephritis?
antistreptolysin O
| detects antibodies against group A strep
106
Patient has a positive direct coombs test, diagnosis?
AI haemolytic anaemia
107
What is the mechanism / indication of an indirect coombs test?
measures antibodies against foreign RBCs in serum
| prenatal testing / prior to blood transfusion
108
What is the causative organism of scarlet fever?
Strep pyogenes
109
Give a cause of haemolytic anaemia?
mycoplasma pneumoiae
110
Treatment of mycoplasma pneumoniae?
macrolides e.g erythromycin / clarithromycin
| doxycycline
111
Give an example of a cardiac, neuro and haem extra-pulmonary manifestation of mycoplasma pneumoniae
```
Cardiac= myocard/pericarditis, conduction abnormality
Neuro= GBS, peripheral neuropathy, encephalitis
Haem= haemolyitic anaemia
```
112
What is the pathophysiology of rheumatic fever
hypersentivity reaction to group A strep
113
What are the major criteria for Rheumatic Fever?
Migrating polyarthritis, carditits, syndeham's chorea, erythema marginatum, subcutaneous nodules
114
How is rheumatic fever diagnosed?
2 major / 1 maj + 2 minor criteria
Antistreptolysin O titre +
Echocardiogram
115
What is the difference between Staph Aureus bacteraemia / septicaemia
Staph aureus bacteraemia= positive blood cultures, no systemic features of sepsis
Staph aureus septicaemia= positive blood cultures with systemic features of sepsis
116
Name a group A strep
Strep pyogenes
117
Raised ALP is a reliable indicator of...
post-hepatic bile duct obstruction
118
What does indurated mean?
Increased fibrous element of tissue commonly associated with inflammation
119
What are red cell fragments on a blood film an indicator of?
haemolytic anaemia
120
Does an increase or a decrease of antithromin make you more likely to develop DVT?
Decreaseased antithrombin = more likely to develop DVT
Antithrombin is a mild blood-thinner
121
What is protein S?
a mild-blood thinner
| deficiency of protein S increases the likelihood of blood clots
122
What is the relationship between HRT and DVT?
HRT increases your risk of developing DVT 2-fold
123
What is fluconazole?
Anti-fungal medication
124
Give 3 classes and examples of drugs that warfarin typical interacts with
antibiotics - macrolides e.g erythromycin
antifungals- e.g fluconazole
anticonvulsants e.g valproate
125
Describe warfarin's therapeutic index
Low / narrow therapeutic index (small changes in metabolism of warfarin can cause bleeding / clotting)
126
Give a cause of flow murmur due to hyperdynamic circulation
severe anaemia
127
Bone marrow failure resulting in a low production of RBCs is known as...
anaplastic anaemia
128
Give a sign in the eyes which would indicate anaemia
pale conjunvtiva
129
What is fresh frozen plasma? Indications?
liquid portion of whole blood
treat conditions with low blood clotting factors (INR >1.5)
replace plasma in fluid exhange
replace low blood proteins
130
normal range for INR?
0.9-1.2
131
therapeutic range for INR?
2-3
132
high INR score indicates increased risk of...
haemorrhage
High=Haemorrhage
133
low INR score indicates an increased risk of ...
clotting
LOw=cLOt
134
What constitutes prothrombin complex concentrate, when might you give it?
Clotting factors 2, 9 and 10
Given to prevent bleeding
Specifically in haemophilia B if pure clotting factor 9 not available
Note it does NOT contain clotting factors:
7- haemophilia A
8- the other vit k clotting factor
135
Which haemophilia type can be treated with prothrombin complex concentrate?
Haemophilia B because prothrombin complex concentrate contains clotting factor 9
136
Patient has DIC, what does this stand for?
| PPh?
Disseminated Intravascular Coagulation
blood clots develop in small vessels around the body, this uses up platelets and clotting factors increasing the risk of excessive bleeding
137
Patient has DIC:
| Describe their prothrombin time, activated partial thrombin time, fibrinogen levels and d-dimer levels
Prothrombin time = prolonged
Activated partial thrombin time= prolonged
Fibrinogen levels= low
D-dimer= raised
138
What is meant by polychromasia? Give an example of when this may be seen?
High levels of immature RBCs (reticulocytes)
Bone marrow stress e.g haemolytic anaemia
139
Haemophilia A is a genetic mutation resulting in deficiency of which clotting factor?
Haemophilia A= factor VIII
140
Haemophilia B is a genetic mutation resulting in deficiency of which clotting factor?
Haemophilia B= factor IX
141
What is the mechanism of action of aspirin?
Anti-platelet
Irreversibly inhibits COX enzyme reducing the production of thromboxane and arachiodonic acid therefore reducing platelet aggregation
142
Give an indication for aspirin
ACS, acute ischaemic stroke
| 2nd prevention of cardiac, cerebrovascular or peripheral artery disease
143
What are the vitamin K dependent clotting factors?
2,7,9,10
144
What is the relationship between COCP and DVT/PE?
COCP increases risk of developing DVT/PE
145
Give 2 causes of microcytic anaemia
iron deficiency
| thalassaemia
146
Give 3 causes of normocytic anaemia
acute bleeding
mixed Fe2+ + Vit B12 / folate deficiency
aplastic
chronic disease
147
Give 3 causes of macrocytic anaemia
vit b12 / folate deficiency
haemolytic anaemia
low T4
148
Patient has an uncomplicated DVT and is treated with LMWH. They should be discharged on what medication and for what duration?
Warfarin
| 3-6months
149
Biochemistry reveals raised urea, indications?
urinary tract obstruction, congestive heart failure, dehydration, severe burns, shock, upper GI bleed
150
What is a seminoma
Germ cell tumour of testicles
151
What type of medication is demeclocycline?
Tetracycline abx, used in tx of acne
152
i
I
153
Where would you expect to find metastases in oestrogen receptor negative breast CA?
Negative= visceral mets (liver, lung, brain)
154
What is the commonest site for a malignancy causing hypercalcaemia?
Lung CA
155
In addition to an elevated PSA which feature seen on XR would be pathognmonic of prostate CA?
Elevated PSA and sclerotic bone mets
156
High levels of Ca2+ detected in blood.
| Which hormone is released to reduce Ca2+ levels and from where?
Calcitonin released from parafollicular cells in thyroid gland
(when high Ca2+ detected)
157
What is the action of calcitonin?
Reduced Ca2+ levels
Inhibits gut absorption
Inhibits reabsorption in kidneys
Stimulates bone deposition (++osteoblasts, -- osteoclasts)
158
Low levels of Ca2+ detected in blood. Which hormone is released to raise Ca2+ levels and from where?
PTH released from Paraythyroid gland
159
What is the action of parathyroid hormone?
Raises Ca2+ levels
Stimulates reabsorption at kidneys
Stimualtes conversion of Vit D to Calcitriol which increases absorption in gut
Stimulates bone resorption (--osteoblasts, ++osteoclasts)
160
Symptoms of hypercalcaemia
Bones= pain
Stones= urinary
Abdo Groans= N+V, constipation, indigestion
Psychic Moans= depression, psychosis, fatigue, memory loss
161
What is the purpose of doing a mediastinoscopy?
Assess the operability of a potentially curable lung CA
162
Male patient has high levels of B-hCG, what do you suspect?
Testicular CA (tumour marker)
163
Patient has high levels of lactate dehydrogenase, what might this indicate?
Tissue turnover, may indicate tumour burden
164
What is meant by flaccid paraplegia?
Weakness or paralysis due to decreased muscle tone
165
What is mean by spastic paraplegia?
Stiffness and increased tone
166
Give a cause of marked ptsosis?
CN3 palsy
167
Give a cause of partial ptosis
myaesthenia gravis
| partial ptosis
168
a young patient presents with bilateral facial pain similar to trigeminal neuralgia. what must you work to exclude as a cause?
MS
169
Give a neurological presentation of vitamin B12 deficiency?
Positive Babinski sign
| extensor platar reflexes
170
Balance requires 3 sensory inputs.. these are from...
vision
vestibular (head position)
proprioception (dorsal column)
171
Patient has a positive romberg's test, what happens on examination, what is the cause?
Lose balance when closing eyes
| Problem is in spinal cord (dorsal columns)- they cannot detect proprioception
172
Patient is ataxic but has a negative romberg's test, what is seen on examination and what is that cause?
Maintain balance when closing eyes
| Problem is in cerebellum
173
A lesion in the internal capsule would cause what symptoms?
Mid-moderate hemiplegia with predominant spasticity
174
What are the symptoms of CN3 palsy?
Muscles- down and out
Pupil- dilation
Lid- marked ptsosis
(CN3 does 3)
175
Why does a CN3 palsy present with down and out pupil?
Superior oblique- CN4 and lateral rectus- CN6 action are unopposed
176
Give 3 causes of anterior spinal artery thrombosis
Emboli
In-situ thrombosis
Decompression sickness
177
What sensations are spared in anterior spinal artery thrombosis?
fine touch, vibration, proprioception (dorsal column)
178
S&S of anterior spinal artery thrombosis?
```
Rapid evolution,
Back pain,
Dorsal column sensation sparing
Flaccid paralysis
Reduced reflexes
```
179
Pregnant mother 38wks goes into cardiac arrest, what changes to CPR would you suggest and why to maximise possibility of spontaneous circulation returning?
Position mother in left lateral position
This ensures the foetus is not compressing the IVC
Normal circulation doesn't return for 5 mins consider emergency C section
180
In pregnancy what normal changes might be detected in:
ECG
Murmurs
Resp/Blood gases
ECG- left axis deviation
Murmur- innocent flow murmur
Resp= higher RR--> increased minute volume ventilation--> lower PaCO2
181
Give 4 complications of MI
```
Valve disease- acute mitral valve regurg due to papillary muscle rupture
Arrythmias- ventricular arr / AF
Pulomary oedema
Pericarditis (2-10 wks post)
vsd
```
182
What is the commonest cause of pre-hospital death as a result of MI?
Ventricular arrhythmia
183
What is orthostatic oedema
Leg swelling following a prolonged time sitting / standing that goes away when recumbent
184
What is thrombophlebitis
inflammatory process causing the formation of blood clots that block 1 or more vessels
superficial clots= superficial thrombophlebitis
deep clots= DVT
185
What is an IVC filter and what are the indications for one?
a mechanical filter surgically inserted into IVC to catch blood clots and prevent PEs
Indicated if anticoagulation is CI or if recurrent PEs despite anticoagulation
186
What is the most likely causative organism for IE in IVDU patients?
Staph aureus
187
```
Third heart sound (S3)
What is it?
When does it occur?
Where is it heard best?
How to hear it?
Who has ut?
```
What- additional heart sound forming a gallop rhythm, lower pitched and fainter than normal sounds, cadence follows work KentuckY
When- mid-diastole after S2
Where- apex
How- bell of stethoscope, ptx. lateral left debicutus position
Who- heart failure
188
What are the indicators on pleural effusion biochemistry of malignancy?
Low pH <7.3
Blood
Exudate
Glucose <3.3mmol/L
189
Patient has blood in their pleural effusion, what might this indicate?
Malignancy, PE with infarction, trauma
190
What does a MET team stand for?
Medical Emergency Team
191
What is the commonest abnormal vital sign seen in critically ill patients?
Resp rate
192
What is flumezanil
Benzodiazepam antagonist, given IV
193
In what circumstances would you prescribe naloxone?
Opiate overdose
194
What type of poisoning is forced alkaline diuresis a treatment?
Salicylate poisoning
195
Give 4 examples of opiates
Heroin, morphine, plethadine, coedine (metabolised to morphone)
196
What are the scores for GCS (eyes)
```
Eyes / 4
Spontaneous (4)
To speech (3)
To pain (2)
None (1)
```
197
What are the scores for GCS (best verbal response)
```
Best verbal response / 5
Orientated (5)
Confused (4)
Inappropriate words (3)
Incomprehensible sounds (2)
None (1)
```
198
What are the scores for GCS (best motor response)
```
Best motor response / 6
Obey commands (6)
localises pain (5)
withdraws to pain (4)
Flexion to pain (3)
Extension to pain (2)
None (1)
```
199
What are the differentials for dullness on respiratory percussion?
Tumour
Collapse
Fluid, consolidation, pleural effusion
200
What is the cause of hyper-resonance on respiratory percussion?
Pneumothorax
201
What is pleurodiesis
Medical procedure that adheres 2 surfaces of pleura together
202
What may cause air under diaphragm on CXR
intestinal perforation
203
Which medication overdose causes
a) pupil consitriction
b) pupil dilation
```
constriction= opiate overdose
dilation= tricyclic overdose
```
204
What is section 2 of MHA
28 day assessment
205
What drug should be given alongside activated charcoal and why?
```
laxative,
activated charcoal (used for detoxification) causes constipation
```
206
What is the timeframe for when activated charcoal is an effective detoxification method?
If given within 2 hours of ingestion of toxin
207
What are the symptoms of a patient who has just been given IV naloxone?
sweaty, agitated, hyperventilating, pupil dilation
208
In what patients would non-invasive ventilation be indicated?
Type II respiratory failure
209
Bilateral hilar lympahdenopathy is usally a sign of...
sarcoidosis
210
Give 3 iatrogenic causes of lung collapse?
overrigorous bagging
high inspiratory pressures
inserting ET tube too far
211
What are the components of CURB 65
Confusion
Urea >7mmol/L
Resp Rate >30
BP < 90/60
Age >65
212
Pre-tibial myxoedema is a sign seen in what condition?
Graves' disease
213
What is empyema?
| When does it occur?
Pus in the pleural cavity
| Complication of pneumonia or thoracic trauma
214
Are ptx with nephrotic syndrome hyper or hypocoagulable? What is the implication of this?
Hypercoagulable
| Increased risk of DVT/PE
215
What are the risk factors and suspected trigger for SLE?
Female, child-bearing age
Afro-caribbean / asian
Trigger= EBV
216
Signs and symptoms of SLE
| DUAL RASH FACE
Discoid rash, Ulcers (oral), ANA+, Light sensitive
Renal disorder, Anti-dsDNA, Serositis, Haem disorder
Flushed (malar rash), Arthritis, CNS disorder, ESR raised (crp normal!)
217
Which autoantibodies are abnormal in SLE?
ANA (antinuclear antibody)
anti-dsDNA
anti-smooth muscle
antiphospholipid
218
Give 3 investigations for SLE
ANA, anti-dsDNA
ESR= raised, CRP=normal
Complement C3/C4 depleted
219
Ptx is having a severe flare up of their SLE?
IV cyclophosphamide
| High-dose prednisolone
220
What are the 2 rashes typically seen in SLE ptx?
```
Malar rash (butterfly)
Discoid rash
```
221
What is cystinuria
Autosomal recessive condition
Proximal tubule does not reabsorb positively charged AAs (especially cysteine). These then pass into urine.
Acidic/neural pH urine causes crystallising of AA forming stones.
222
What is the treatment of cystinuria?
penicillamine
223
Give the treatment of each of these 3 causes of renal/bladder stones:
hypercalcuria
urate calculi
cystinuria
hypercalcuria- tx thiazide diuretics
urate calculi- tx allopurinol
cystinuria- tx penicillamine
224
What is the commonest composition of a kidney stone
calcium oxalate
225
Give 3 dietary components which increase your risk of kidney stones?
sodium, protein, oxalate
226
What simple measure can patients do to reduce their risk of getting kidney stones?
increase hydration to >3L/day
227
You suspect the patient has Wilson's disease
You order a 24hr urine sample
What are the results?
Raised copper in urine
228
What acid-base balance complication can GBS cause?
Respiratory acidosis
| Decreased ventilation causes TII respiratory failure
229
How is serum osmolality calculated?
(2 x Na) + (2 x K) + glucose + urea
230
What is a U wave (ECG)?
small deflection up after T wave
| sign of hypokalaemia
231
What is a J wave / Osborne wave (ECG)?
immediate deflection up after QRS complex
| sign of hypercalcaemia
232
Describe the QRS complex in ventricular tachycardia?
Wide QRS complex
233
Describe the ECG features of wolf-parkinson-white syndrome?
Short PR
Slurred upstroke of r wave (delta wave)
Wolf= short and slurred
234
What should be involved in a annual DM check
```
Retinopathy, foot check,
ACR, U+E
Cholesterol, weight,
HbA1c, glucose
Smoking status
```
235
Postural hypotension defined as...
Drop in BP >20mmHg from sitting to standing
236
Sx of hypoglycaemia
sweating, tachycardia, palpitations, tremor
237
Tinel's sign and Phalen's sign are present in carpal tunnel syndrome. What are they?
```
Tinel's= tapping causes paraesthesia
Phalen'= flexion causes wrist symptoms
```
238
Give 4 indications for tetracyclines?
Acne vulgaris
Lyme disease
Chlamydia
Mycoplasma pneumoniae
239
Which class of antibiotics is associated with photosensitivity?
Tetracyclines
240
Patient has open-angle glaucoma. Prescribed beta blocker, how does this help?
Reduces aqueous secretion by ciliary body
241
Gliclazides are an example of which drug class?
Sulfonylurea
242
What is meant by moribound?
At the point of death (look like about to die)
243
What is the common cause of anterior shoulder dislocation?
Fall on outstretched hand (FOOSH)
244
What type of shoulder dislocation is associated with seizures/electric shock? What does it look like?
Posterior shoulder dislocation
Shoulder locked in internally rotated position
245
What is the karyotype of kleinfelter's syndrome?
47XXY
246
A partial/missing X chromosome in females causes what syndrome? How do they present?
Turners syndrome
Short stature, webbed necked, AI hypothyroid,
Primary hypogonadism, primary amenorrhoea
247
Thyrotoxicosis.. AKA...
Hyperthyroidism
248
What are the TSH and T4 levels in sick euthyroid?
TSH low, T4 low (e.g in chronic illness)
249
Give causes of secondary hypertension
Renal artery stenosis, PKD
Conn's, cushing's
Phaeochromocytoma, Acromegaly
Aortic coarctation
250
What is the pharmacological mx of HTN caused by phaeochromocytoma?
Alpha blockers followed by beta blockers
251
Give the 3 things to do in mx of hypercalcaemia 2nd to CA?
IV fluids
Oral/ IV bisphosphonates
Referal to oncology
252
Testosterone is given by what route? what frequency? what should you monitor for?
IM , every 4 weeks
| Monitor for BPH, prostate CA (PSA/DRE)
253
What cancers metastasise to bone?
BLT with kosher pickle
| Breast, Lung, Thyroid, Kidney, Prostate
254
How can cancer effect levels of calcium?
```
bone mets cause ca2+ leakage
paraneoplastic syndrome (produces protein similar to PTH)
```
255
Patients with T2DM are more likely to develop hyperosmolar hyperglycaemia state or DKA?
Hyperosmolar hyperglycaemic state
256
You are managing a patient with suspected DKA. Blood gas reveals metabolic acidosis. What pH level concerns you enough to call ICU?
pH<6.99 call ICU
257
What is the difference in onset between DKA and hyperosmolar hyperglycaemic state?
```
DKA= acute history.
HHS= insidious history
```
258
Describe "sick day rules" and an example of a condition in which this applies?
If patient gets sick the patient is under increased stress so need to double their dose of steroids
E.g if low corticosteroid levels in body e.g adrenal insufficiency
259
Give 4 causes of hypocalcaemia
AI hypoparathyroidism
Pseudohypoparathyroidism
DiGeorge syndrome
260
Dexamethasone suppression test is used for diagnosing which condition?
Cushing's
261
ACTH synacthen test is used for diagnosing which condition?
Adrenal insufficiency
"Adrenal I, ACTH"
262
What at the rotterdam criteria?
For diagnosing PCOS, 2/3 of....
Annovulation / oligomenorrhoea / amenorrhoea
Polycystic ovaries on TVUSS - 1 ovary >12 small follicles volume >10
Raised androgens
263
What is the managemnet of PCOS?
Weight loss, COCP, Metformin
Anti-androgens= cyproterone acetate
Ovulation induction= anti-oestrogen (clomifene citrate)
Gonadatrohpine (FSH, LH, GnRH analogues)
IVF
264
What is meant by virilization ?
Development of male physical characteristics (hair, deep voice, muscle bulk) due to excess androgen production
265
A female patient is diagnosed with an androgen-secreting tumour. How might a excess androgens effect them/
Virilisation- develop male physical characteristics e.g hair growth, deep voice, muscle bulk
266
A patient has dry mucous membranes, poor urine output, is thirsty. You suspect they are dehydrated. How do you calculate serum osmolality and do you expect it to be high or low in a dehydrated patient?
Serum osmolality= 2 (Na + K) + urea + glucose
Dehydration = high serum osmolality
267
What is the colour change of patients with raynauds?
White, Blue, Red
268
What is meant by obstructive sleep apnoea?
loss of airway patency despite constant breathing effort
Linked to obesity, hypothyroid, asthma
269
What is balantitis?
Inflammation of glans of penis due to infection
270
What bone condition can result in hearing loss?
Paget's disease
271
Kleinfelter's syndrome is associated with hypogonadism, what is the karyotype for this syndrome?
47XXY
272
Kleinfelter's syndrome is a condition which only effects men, true or false?
True,
| Men with an extra X chromosome (47 XXY)
273
Female patient presents with primary amenorrhoea, you notice they have a webbed neck, which syndrome could cause this?
Turners syndrome
| missing / partially missing X chromosome
274
```
What are the non-operative tx options for renal stones in the following locations:
Bladder
Lower 1/3 ureter
Middle 1/3 ureter
Upper 1/3 ureter
```
Bladder= endoscopic retrieval
Lower 1/3= uretero rhinoscopy
Middle 1/3= shock wave lithotripsy
Upper 1/3= percutaneous nephrostomy
275
```
A patient presents with haematuria, give differentials which relate to the following structures:
Renal
Ureteral
Bladder
Urethral
```
Renal- glomerulonephritis, pyelonephritis, renal cell carcionma, trauma, renal cyst
Ureteral- transitional cell carcinoma, stone, trauma
Bladder- bladder CA, trauma
Urethral- prostate CA, stone, trauma
276
Patient presents to GP embarassed. He says he's got what feels like a "bag of worms" in his scrotum. What is the diagnosis? What cause should you rule out?
Varicocele- dilated veins in scrotum, next to/above 1 or both testes
Rule out renal vein obstruction due to renal tumour
277
You've been asked to examine the next gentleman's hydrocele, what is a hydrocele? how can you examine this?
fluid collection in front of testes, usually benign
278
A male patient comes in telling you they have a scrotal swelling, what are the differentials?
Testicular cancer
Hydrocele
Varicocele
Epididymal cyst
Sebaceous cyst on scrotum
Inguinal hernia
279
Which bedside test/examination would differentiate between a hydrocele and varicocele?
Transillumination
280
A distressed young woman comes to see you saying that she has gotten pregnant unintentionally and wants you to sign off for a termination of pregnancy. What is the criteria for ToP?
<24wks pregnant
ToP reduces risk to mothers life
Top reduces risk to mother mental / physical health
Top reduces risk to mental / physical health of existing children
Substantial risk of baby being born with severe mental/physical handicap
281
Give 3 symptoms of an ectopic pregnancy?
Abdo pain, amenorrhoea, vaginal bleeding
282
Give 3 differentials of antepartum haemorrhage?
Placental abruption, placenta praevia, vasa praevia
283
Patient has painless PV bleeding whilst pregnant, what is likely diagnosis?
Placenta praevia
284
What do acromegaly, conn's syndrome, cushing's syndrome and phaeochromocytoma all have in common?
All causes of secondary hypertension
285
What are the 5 geriatric giants?
falls, incontinence, confusion, impaired homeostasis, iatrogenic disorders
286
How is postural blood pressure measured?
Measure BP when lying down, immediately on standing, after 1 minute standing, after 3 minutes standing
287
What s the definition of postural hypotension?
sustained reduction of systolic BP at least 20, diastolic of at least 10 within 3 minutes of standing
288
Give 2 examples of pharmacological tx of postural hypotension?
midodrine
| fludrocortisone
289
What is a fragility fracture?
fractures resulting from mechanical forces that would not ordinarily result in fracture equivalent to fall from standing height or less
(i.e. mechanical fracture from fall from standing height/less)
290
Primary prevention of osteoporosis?
| Secondary prevention of osteoporosis?
```
Primary= FRAX score / DEXA scan
Secondary= alendronate
```
291
What % on FRAX score warrants further assessment on DEXA scan?
>10%
292
What is the management of osteoporosis?
Lifestyle- smoking, alcohol, exercise
Vit D
Bisphosphonates
Others:
Denosumab (inhibits receptors which when activated cause osteoclast maturation)
Strontium ranelate (reduce bone turnover, stimulate bone growth)
Raloxifene (binds to oestrogen receptors, same effect
HRT
293
Elderly patient falls on their face, what is the more likely cause of fall?
Cardiac
294
Patient falls, are you looking for on urine dipstick? what do you suspect as cause?
Protein, blood, nitrites, leukocytes (UTI)
295
Patient falls, why do bladder scan?
Urinary retention
296
Which painkiller lowers the seizure threshold and therefore should be avoided in patients with a history of epilepsy?
Tramadol
297
Patient is an ex-boxer with parkinsons' and eplilepsy who has started fighting the staff. The nurses asks you to prescribe haloperiodol to calm him down, what do you do?
Don't prescribe it.
Antipsychotics lower seizure threshold
Instead try a benzodiazepine
298
What is charles bonnet syndrome?
Visual hallucinations due to visual loss e.g cataracts / age-related macular degeneration. Patients are generally aware that hallucinations are not real
299
What is the route of administration for gentamycin?
IV only!
| if question is GP scenario the answer is not going to be gentamicin
300
What is another name of augmentin?
Co-amoxiclav
301
Female patient presents with unilateral throbbing headaches, with flashing lights in vision beforehand.
Likeky diagnosis? Which medication might they be taking which is an absolute contraindication?
Diagnosis= migraine with aura
| COCP CI with migraine with aura
302
CT head shows midline shift, this might indicate...
severe swelling, haemorrhage, space occupying lesion
303
CT head shows oedema / swelling, this might indicate...?
raised ICP
304
CT head shows crescent shaped dark shadow, what is this likely to be? Pathophysiology?
Sub-dural haemorrhage
| Strethcing and breaking of bridging cortical veins
305
What colour are dense structures on CT scans?
Whiter
306
How can you tell the difference between acute and chronic brain haemorrhage?
Acute is brighter
| Chronic is darker
307
What might indicate raised ICP on CT head?
| If you see what should you do/not do?
Ventricles thin/squashed/absent
Loss of differentiation between grey and white matter due to oedema
Don't lumbar puncture!
308
Patient has a headache, visual disturbance, jaw pain, raised ESR but normal WCC. Which investigation would you follow up with?
Temporal artery biopsy- ?GCA
309
What is the consequence of doing a LP in patient with raised ICP
Brain herniation and death
310
You suspect SAH, do a LP after what time?
>12hours,
311
Raised protein on LP, indications?
Bacterial meningitis, GBS, TB
312
What are the findings on temporal artery biopsy in patient with GCA?
Vasculitis
Lymphocyte infiltration
Granulomatous inflammation
Multinucleated giant cells
313
What does papilloedema look like? What does this indicate?
Blurring optic disc margins
| Raised ICP
314
Patient presents with bilateral pressing headache, history of stressful job and poor sleep. How can you manage this patient?
Non-pharm- avoid stressors, exercise, sleep etc.
Ibruprofen 400mg / Paracetamol
Aspirin
Tricyclic antidepressants
315
Amitryiptyline SE
Drowsiness, Dry mouth, Constipation
316
What is the pharmacological prophylaxis and management of a patient with migraine?
Prophylaxis- propanolol / amitriptyline
Acute-
1) simple analgesia +/- anti-emetic. 2) sumatriptan
317
Patient has very severe headache around the eye which comes on suddenly. They have had several in the past week and had a similar series of headaches a year ago. What is the diagnosis? What is the acute and prophylactic management?
Cluster headache
Acute:
Sumatriptan 6mg SC
100% O2 for 15 mins (12-15L)
Prophylaxis- verapamil
318
Patient complains of an electric shooting pain across their face which lasts a couple of seconds, what is the likely diagnosis and management?
Trigeminal neuralgia
Carbamazepine / Gabapentin
Surgery to decompress trigeminal nerve
319
Which headache is treated acutely with paracetamol/sumatriptan 50mg and prophylactically with pronaolol/amitriptyline?
Migraine
320
Your patients medical records show they are prescribed verapamil for prophylactic treatment for headaches. What is the likely diagnosis? They are worried about having an acute attack, what will you prescribe them to take during a headache?
Cluster headache (prophylaxis verapamil)
Acute at tack:
Sumatriptan, 100% O2 for 15 mins
321
How can you assess a patient with NAFLD for fibrosis?
Fibroscan (US scan of liver)
| NAFLD Fibrosis Score calculator e.g BMI, LFTs, DM
322
Child presents with lethargy, fever, headache assoc. w/slapped cheek rash spread to proximal arms and extensor surfaces. Likely diagnosis?
Erthema infectiosum
| Parvovirus
323
CT shows petechial haemorrhages in tempral lobe
| Patient has fever, headache, confusion, aphasia. Likely diagnosis?
Herpes Simplex Encephalitis
| Mx- aciclovir
324
Why might a patient with GCA complain of generalised myalgia?
Polymyalgia Rheumatica associated with GCA
325
Young man presents with acute headache associated with unilateral periorbital oedema, on examination there is a lateral gaze palsy. Likely diagnosis?
Cavernous sinus thrombosis
326
Intense pain around one eye associated with watery eye, redness and constricted pupil. Likely diagnosis?
Management?
Cluster headache
| Mx- verapamil (proph), sumatriptan 6mg SC / 100% O2 (acute)
327
Frontal headache developed following URTI, worse on leaning forwards, likely diagnosis? usual cause?
Sinusitis - usually viral
328
Elderly man presents with severe pain around right eye, assoc. nausea, redness, misty vision, semi-dilated pupil. Likely diagnosis?
Acute narrow-angle glaucoma
329
Patient has a headache and nausea which is worse at the weekends, not bad when they are at work or on holiday, what do you need to suspect?
Carbon monoxide poisoning
330
What is the definition of domestic abuse?
Incident / pattern of incidents of controlling, coercive, threatening behaviour, violence of abuse between those aged 16 or over who are or have been, intimate partners or family members regardless of gender or sexuality.
Includes: psychosocial, physical, sexual, financial. emotional
331
What is definition paraesthesia?
abnormal sensation caused chiefly by pressure / damage to peripheral nerves
e.g tingling, burning, numbness, warmth, chills
332
What is the pmneumonic VITAMINN CDEF
```
Vascular
Infectious/inflammatory
Trauma
AI
Metabolic
Iatrogenic
Neoplasm/ Neurological
```
Congenital
Degenerative
Endocrine
Functional
333
Vascular differential of parasthesia?
Raynaud's
| Stroke/TIA
334
What is the pattern of colour change in raynaud's?
White--> Blue --> Red
335
Inflammatory/infectious cause of parasthesia?
GBS, leprosy
HIV
Lime disease
Sarcoidosis
336
What is saturday night palsy?
Prolonged pressure on medial side of upper arm (e.g arm hung over back of bench)
337
Trauma differentials parasthesia?
saturday night syndrome
fracture
carpal tunnel syndrome
338
Metabolic differentials of parasthesia?
Diabetes
Thyroid disease
Renal failure
Hypocalcaemia
Hyper/hypoglycaemia
Hyperkalamaemia
Hypermagnasaemia
339
Iatrogenic differentials of parasthesia?
Anticonvulvants e.g topiramate
| Chemo e.g cisplatin
340
Neurological differentials of parasthesia?
Spinal cord compression
Cauda equina syndrome
Aura of parasthesia e.g migraine
Epilepsy
341
Congenital / inherited differentials of parasthesia?
Hereditary neuropathy with pressure palsies
| Charcot-marie-tooth disease
342
Degenerative differentials of parasthesia?
MS
343
Environmental differentials of parasthesia?
```
Alcohol
Lead posioning
Arsenic posioning
Mercury poisoning
Deficiencies in B1, B6, B12, E, Folate
```
344
Functional differentials of parasthesia?
Carpal tunnel syndrome
345
Who is carpal tunnel syndrome more common in?
Women (smaller wrists)
346
2 common antibiotics that cause parasthesia?
nitrofurantoin
| metronidazole
347
Blood tests for parasthesia?
```
Glucose, hba1c- ?DM
U+E- ?CKD
WCC- ?infection
TFTs- ?hyper or hypothyroidism
Vit D- too much causes
Vit B1, B6, B12, E deficiency
Folate
ESR
```
348
Patient presents with tingling in fingers, you perform nerve conduction studies, which condition are you trying to rule out?
carpal tunnel syndrome
349
Non-pharmacological measures for pain management
```
Wt loss- OA
TENS machines
Distraction techniques
Acupuncture
Capsaicinn
```
350
Step 1 of pain ladder
Non-opioid analgesics
Paracetamol- avoid in chronic excess alcphol
NSAIDs
351
Step 2 of pain ladder
```
Mild opioids e.g
Co-codamol
Coedine
Dihydrocodeine
Tramadol
```
352
SEs of opioids?
Constipation
N+V
Addiction
Neuro/respiratory depression
353
Step 3 of pain ladder + examples
```
Strong opioids e.g:
Morphine, diamorphine
Oxycodone
Fentanyl
Alfentanil
Buprenorphoine
Methadone
```
354
Step 4 pain ladder
nerve blocks
Epidurals
Pumps e.g syringe driver
355
Adjuvant pain management
Antidepressants e.g amitryiptylline
Antiepileptics e.g gabapentin / pregabalin
Steroids
356
Child presents with pain, what diagnosis should we always suspect and attempt to rule out?
NAI
357
What might indicate a child in pain?
Say- they say so
Do- behaviour changes e.g holding arm
React- vital sign changes
358
Streptococcus pneumoniae is a common cause of community acquired pneumonia. Describe the microbiology of strep pneumonia?
```
Strep pneumonia:
Gram + chains
Coagulase negative
Alpha haemolytic (green)
Optichin sensitive
```
359
Staph aureus is a common cause of hospital acquired pneumoinia. Describe the microbiology of staph aureus?
Staph aureus:
Gram + clusters
Catalase + (vs strep negative)
Coagulase + (vs staph epidermidis negative)
staph are always positive
360
Give several side effects of opiate use?
```
Constipation
N+V
Droswiness
Dry mouth
Histamine release (itchy / bronchoconstriction)
Toxicity
```
361
What is a standard start dose of morphine?
20-30mg daily
| e.g 5mg 4hrly / 10mg 12hrly
362
Give several factors that increase a patients pain tolerance?
```
Relief of sx
Sleep / Rest
Physiotherapy
Empathy
Social/psychological support
```
363
Give several factors that decrease a patients pain tolerance =?
```
Discomfort
Anxiety
Fear
Poor sleep
Fatigue
```
364
How can we manage a palliative patient who is experiencing dysponoea?
Optimise asthma/COPD/HF/Infection tx
Opiates e.g morphine
Anxiolytics (mx associated anxiety)- diazepam/TCA/SSRIs
O2 therapy (only if hypoxic)
365
Palliative patient is experiencing restlessness, give 2 examples of medications which can be used for sedating?
Haloperidol (less sedating)
| Midazolam (quite sedating)
366
Palliative patient is experiencing restlessness, give 2 examples of medications which can be used for sedating?
Haloperidol (less sedating)
| Midazolam (quite sedating)
367
Anorexia associated with palliative care patient, what medication can be used?
15-30mg prednisolone
| 2-4mg dexamethasone daily
368
Hyoscine butylbromide used for...
| Hyoscine hydrobromide used for...
Hyoscine butylbromide used for respiratory secretion
| Hyoscine hydrobromide used for travel sickness
369
What is the theory behind why anorexia nervosa patients develop hirsutis?
develop languno hairs to insulate the body
