Exam course Flashcards

Question

Causes of limp in a 20 month old indigenous child?

Answer 1

NAI - metaphyseal corner fracture Septic arthritis Acute rheumatic fever Malignancy - leukaemia Juvenile rheumatoid arthritis Toddlers fracture

Answer 2

Non weight bearing Temp > 38.5 ESR > 40 WBC > 12 If 2 positive 40% likelihood If 3 93% probability If 4 99%

Answer 3

Gonococcus infection Chlamydia Streptococcus/ staph HSV Adenovirus PCR swab for gonorrhoea and chlamydia Vaginal swab or urine testing of mother Treatment -IV cefotaxime 50mg/kg -PO azithromycin 10mg/kg -Eye toilet: Normal saline or breast milk -Topical chloramphenicol ointment Treat mother and all sexual contacts for STD IM ceftriaxone 500mg and 1g azithromycin PO, metronidazole 400mg BD for 14 days

Answer 4

Risk factors -Alcohol misuse -Elderly -Coagulopathy -Brain mass Acute < 3 days, sub acute 3 days to 3 weeks -More likely to present with focal neurological signs e.g. hemiparesis Chronic > 3 weeks -More likely to present with non focal symptoms -Cognitive impairment, headache, presyncope, ataxia, seizures Treatment -HOB up 30 degrees -RSI -Urgent neurosurgical consultation -Reverse anticoagulation -Maintain SBP > 100mmHg -Maintain SBP < 220 (labetalol)

Answer 5

Acute coronary syndrome Thyrotoxicosis Electrolyte abnormalities - hypokalaemia Infection Dehydration Exacerbation of COPD, pulmonary embolism Alcohol Myocarditis

Answer 6

Exclude and manage secondary causes e.g. hypokalaemia, hyperthyroidism, PE Unstable patient -Urgent synchronised electrical cardioversion Known LV systolic dysfunction or clinical heart failure -Amiodarone No systolic dysfunction or heart failure Rate control vs rhythm control Rhythm control -Use if patient preference, highly symptomatic or physically active, difficulty achieving rate control, LV dysfunction, paroxysmal or early persistent AF, absence of severe atrial enlargement, acute AF -Electrical cardioversion acutely if low thromboembolic risk -Flecainide if structurally normal heart and low thromboembolic risk -Amiodarone can be considered in those with structural heart disease Rate control (80bpm goal but accept < 110) -Use if advanced age, longstanding AF, severe LA enlargement, minimal symptoms, multiple previous attempts to restore sinus rhythm -Beta blockers (avoid in severe COPD) e.g. 2.5-5mg IV q 10 mins, up to 3 doses, or calcium channel blocker diltiazem 0.25mg/kg IV (avoid if LVEF < 40%) -Digoxin can also be considered if above contraindicated

Answer 7

Point for each of Congestive heart failure Hypertension Age > 65 = 1 > 75 =2 Diabetes Stroke Vascular disease Female Score 1 consider anticoagulation Score > 1 require anticoagulation

Answer 8

Hypertension Abnormal renal function Abnormal hepatic function Haemorrhagic stroke History previous major bleeding Labile INR Elderly Alcohol use Score > 2 associated with increased bleeding risk

Answer 9

Atrial flutter is less serious it tends to revert back to sinus rhythm spontaneously and has less risk of embolisation

Answer 10

Risk factors -High energy transfer mechanism -Displaced midface fracture (Le Forte II or III) -Complex skull fracture/ base of skull fracture -C-spine fracture/ subluxation/ ligamentous injury -Near hanging / anoxic brain injury -Clothesline type injury -Upper rib fractures -Direct blow to neck Signs/ symptoms -Cervical bruit in patient < 50 -Headache/ facial pain -Tinnitus -Horners syndrome -Expanding cervical haematoma -Focal neurological deficit: hemiparesis, horners syndrome -Neurologic findings unexplained by intracranial findings -Stroke on CT or MRI Treatment -Surgical options such as stenting or bypass if > 70% occlusion or expending pseudoaneurysm -Aspirin for minimum of 3 months

Answer 11

Common peroneal -Tibialis anterior, foot dorsiflexion -Peroneus longus and brevis, foot eversion Tibial nerve -Gastrocnemius, soleus, foot plantarflexion Femoral nerve -Quadriceps, knee extension Sciatic nerve -Hamstrings, weakness of knee flexion -Loss of power of all muscles below the knee causing foot drop

Answer 12

L4/5 root lesion Sciatic nerve palsy Peripheral neuropathy Motor neurone disease Common peroneal nerve palsy

Answer 13

IV fluid to promote renal clearance of unwanted metabolites -5-6L/day of normal saline -May require diuretics or renal replacement therapy if UO does not improve or gets hypervolaemia Only treat hypocalcaemia if dysrhythmia/ heart block, seizure Mange hyperkalaemia the same as for any other etiology Treat hyperuricaemia with rasburicase IV and allopurinol

Answer 14

Reduce demand In community -Improved funding for complex care for GPs -Integrated and coordinated care of frequent attenders -Hospital outreach - hospital in the home In ED -Senior decision making 24/7 -Short stay units -Accelerated evidence based protocols -Access to consultations and investigations Increase capacity ED -Fast track -Short lab and radiology turn around times -Senior staffing 24/7 -Full capacity protocol (send patient to ward) ED department beds Ward processes -Bed coordinator -Daily coordination rounds -Clinical inpatient rounds at least once daily -Improved speed of investigations and consultations Ward beds -> 3 acute hospital beds per 1000 population Improving exit Ward processes -Morning discharge -Weekend discharge -Improved allied health and pharmacy access -Better use of transit lounge Community capacity -Increase residential age care beds

Answer 15

Causes -Blunt or penetrating chest trauma -Neck, thoracic or retroperitoneal surgery -Oesophageal perforation (boerhaave syndrome) -Tracheal or bronchial perforation -Laryngeal fracture -Vigorous exercise -Child birth -Asthma -Barotrauma - diving -PPV -Retropharyngeal infection XR features -Linear density parallel to heart border -Extending above aortic root -Does not change with position -Subcutaneous emphysema -Pneumopericardium -Gas around pulmonary artery -Continuous diaphragm sign Ultrasound -Cervical subcutaneous emphysema - 'dirty' posterior acoustic shadow -Loss of the parasternal and apical views on TTE, preservation of subxiphoid window -Air gap sign

Answer 16

Causes -PPV -Thoracic surgery/ pericardial fluid drainage -Penetrating trauma -Blunt trauma -Infectious pericarditis with gas producing organisms XR features -Heart partially or completely surrounded by gas -Continuous diaphragm sign -Halo sign -Limited to pericardial reflection -Changes with position US -Reverberation artefacts similar to A-lines -Heart remains obscured throughout cardiac cycle -Involves subxiphoid window

Answer 17

Perforated hollow viscous -Peptic ulcer disease -Ischaemic bowel -Bowel obstruction -Diverticulitis -Malignancy -IBD -Perforation -Peritoneal dialysis -Vaginal aspiration - water skiing -PPV AXR -Double wall sign 'Riglers sign' -Telltale triangle sign -Periportal free gas sign -Falciform lifament sign CXR -Subdiaphragmatic free gas -Continuous diaphragm sign -Cupola sign US -Enhancement of peritoneal stripe sign -Discrete hyperechoic foci representing gas bubbles

Answer 18

Brugada 89% Griffith 94% Vereckei aVR 87%

Answer 19

5mg IV, followed by 1mg/min up to 15mg

Answer 20

If stable then procainamide first line Alternative is DC cardioversion

Answer 21

In general avoided with WCT Can be used for RVOT VT Probably safe in antidromic WPW but need to beware of adenosine induced AF Cannot treat WPW with antidromal conduction with atrial fibrillation with AV nodal blockers -Avoid adenosine, amiodarone, beta blockers, CaCh blockers -Options are cardioversion or procainamide

Answer 22

Excellent success rates for all types of WCT More effective than amiodarone for monomorphic VT VT SVT or AF with BBB SVT or AF with WPW Side effects -Hypotension -Prolong QRS/ QT interval

Answer 23

Pregnancy Prolonged QT Rapid AF + WPW Accelerated idioventricular rhythm Other slow VT conditions

Answer 24

Normal anion gap 4-12 Depends on normal serum albumin and phosphate Reduced concentration of unmeasured anions such as albumin Increased concentration of unmeasured cations -Magnesium -Calcium -Lithium Certain populations -Myeloma -Hypertriglyceridaemia -Bromide OD NAGMA causes Chlorine (chloride excess) Acetazolamide/ Addisons Gastrointestinal (diarrhoea, fistulae, ileostomy) Extras (RTA) Calculate urinary anion gap to differentiate between GI and renal cause of NAGMA AG > 30 HAGMA, 20-29 (1/3 not have acidosis)

Answer 25

Phantom - reassurance Inappropriate -Magnet -AF or SVT - B blockers, CaCh blockers, activate SVT discriminators, ablation Lead oversensing -Magnet -ICD reprogramming Appropriate -Evaluate and treat reversible causes (electrolytes, ischaemia) -Antiarrhythmic agents -Sedation -IABP and ablation for refractory VT

Answer 26

Risk factors -Age > 55 -Uncontrolled pain -Lung disease: smoker, COPD, asthma -Obesity -Respiratory compromise: increased WOB, RR, reduced saturations -3 or more rib fractures -Inability to cough -Associated pneumothorax or haemothorax, pulmonary contusion, flail chest Management -Incentive spirometry -Analgesia: paracetamol/ NSAID/ opioids/ PCA/ epidural -Prevent complications: mobilise, chest physiotherapy, VTE prophylaxis

Answer 27

If haemodynamically unstable and concern for tension --> immediate needle decompression, intercostal catheter Primary survery -eFAST -If lung sliding absent then CT or erect CXR If CXR/ CT show large pneumothorax then small tube thoracostomy or pigtail. If small can observe.

Answer 28

Tenecteplase up to 50mg IV (weight adjusted dose) or alteplase 100mg over 2 hours 1L 0.9% saline bolus Enoxaparin 1mg/kg subcutaneous Analgesia - fentanyl 1mcg/kg Adrenaline or noradrenaline infusion Liaise with respiratory/ ICU/ cardiothoracics re ECMO, open thrombectomy

Answer 29

Use wither wells or geneva rules to assess pretest probability If low risk (wells score < 2) -Apply PERC rule and if all 8 criteria -ve then no further testing required -Risk of testing greater If intermediate risk (wells score 2-6) or PERC +ve --> D-dimer -Age adjusted for patients over 50 -D-dimer x 10 -If normal then PE excluded -If positive --> CTPA If wells score > 6 --> CTPA If contraindication to CTPA (contrast allergy, thyroid disease, renal failure) then V/Q scan

Answer 30

Validated in pregnant and non pregnant If no clinical DVT and no hemoptysis then proceed to D-dimer testing If PE unlikely and D-dimer < 1000ng/ml then PE excluded If PE likely and D-dimer < 500ng/ml then PE excluded

Answer 31

CXR to assess for alternate diagnosis such as pneumonia If clinical DVT then can order an DVT duplex US and if DVT present treat with enoxaparin and assume PE If no DVT then can use YEARS criteria (no DVT, no haemoptysis) -If felt to be likely and< 500ng/ml excludes diagnosis, or < 1000ng/ml if PE felt to be unlikely Alternative -Request bilateral DVT duplex US - if DVT then treat and assume PE -If no DVT but PERC negative can with shared decision making order a D-dimer and interpret as per trimester -1st < 750ng/ml -2nd < 1000ng/ml -3rd < 1250ng/ml ---> PE excluded Investigations -If imaging required then options are V/Q scan or CTPA -Shared decision making with patient -Need normal CXR to have accurate V/Q scan -CTPA is lower risk of radiation to fetus but higher to breast tissue of mother than V/Q scan -Both are low risk overall to fetus -If undergo CTPA shield abdomen, if undergo V/Q scan then IDUC and fluids to clear isotope