ICA Flashcards
(230 cards)
1
Q
A patient with the following rash presents with bloating and abdominal pain. What is the most likely diagnosis?
A
Dermatitis hypertiformis - coeliacs rash.
2
Q
What is dermatitis hypertiformis?
A
A rash associated with elbows, knees and buttocks, seen in Coeliac’s disease.
3
Q
What is the blood test associated with Coeliac’s disease?
A
IgA TTG.
4
Q
What may be seen on a skin biopsy for a patient with dermatitis hypertiformis?
A
IgA deposits in a granular pattern.
5
Q
What is the most likely diagnosis for the following rash?
A
Erythema nodosum.
6
Q
What is the most likely diagnosis, based on the following image?
A
Erythema multiforme.
7
Q
What is the most likely diagnosis for the following condition?
A
Pyoderma gangrenosum.
8
Q
How does inflammation appear in black skin?
A
It may appear slightly red, darker brown, grey, purple or even black.
9
Q
In dark skin, what should be looked at in central cyanosis?
A
Mucous membranes, as it is harder for darker skin tones’ tongue to appear blue.
10
Q
Why may the capillary refill time of a black person not be useful?
A
A large proportion of black people do not blanch.
11
Q
What is traction alopecia?
A
Certain hairstyles such as weaves, braids or even tight ponytails can result in the hairline being pulled back significantly.
12
Q
Where does basal cell carcinoma usually present in black people?
A
On the soles of the feet.
13
Q
What is dermatitis papulosa nigra?
A
Multiple small, dark bumps on the skin that only affects people of colour. It is harmless.
14
Q
How does smoking affect the skin?
A
It causes poor wound healing.
Predisposes to skin cancer.
Nicotine staining on the fingers.
15
Q
What should be done in a dermatology examination?
A
SCAM:
- Site and distribution for a rash/ size and shape of a lesion.
- Colour and configuration.
- Associated changes.
- Morphology.
16
Q
What should be done for pigmented lesions examinations?
A
ABCDE:
- Asymmetry.
- Border (regular or irregular).
- Colour.
- Diameter.
- Evolution.
17
Q
What are different sites and distributions that skin conditions can affect?
A
Flexor surfaces.
Extensor surfaces.
Generalised.
Follicular - affected individual hair follicles.
Dermatomal distributions.
Seborrhoeic - around oily areas.
Photo-sensitive - areas exposed to the sun.
18
Q
What is this distribution?
A
Follicular.
19
Q
What are the following two distributions?
A
Left is seborrhoeic.
Right is photo-sensitive.
20
Q
What is a hive?
A
An area of raised skin due to dermal oedema.
21
Q
What is leichenification?
A
Thickening of the epidermis with exaggerated skin lines, often seen in chronic itching or rubbing.
22
Q
What is hypertrichosis?
A
Increased hair growth in non-androgenic areas.
23
Q
What do the following terms mean:
- Intertriginous
- Discoid/ nummular
- Annular
- Abscess
- Comedone
A
- Affecting the skin folds.
- Round lesion.
- A circle or ring with a different morphology in the middle to the edges.
- Localised accumulation of pus on the dermis or subcutaneous tissue.
- Pores or hair follicles that have gotten blocked with bacteria, oil and dead cells forming a bump.
24
Q
What is the difference between an erosion and ulcer?
A
Erosion - loss of epidermis.
Ulcer - loss of epidermis and dermis.
25
What is oncholysis? State some causes.
Separation of the distal end of the nail plate from the nail bed.
Trauma, psoriasis, fungal nail infection, hyperthyroidism.
26
How is atopic eczema/ dermatitis diagnosed and what is the history of it?
Based on a clinical diagnosis (history and examination).
Begins in childhood, but can occur later.
Atopy.
Family history/ genetic predisposition.
27
What are the clinical features of atopic eczema/ dermatitis?
Pruritis.
Typically in the flexural surfaces.
Can occur in response to a trigger - occupation/ changes to soaps/ fragrances/ pollution, etc.
Often in flares and remissions.
28
What is the treatment for atopic eczema/ dermatitis?
Education and support.
Avoidance of triggers.
Topical:
- Emollients.
- Soap substitutes.
- Steroids.
- Calcineurin inhibitors (immunosuppressants).
- Phototherapy (UV).
Systemic therapy.
29
What is the history of a patient with acne vulagris?
Adolescents and young adults, usually 7-12 and resolves by the 3rd decade of life.
Chronic skin disease due to blockage of hair follicles.
30
What are the multifactorial causes of acne vulgaris?
Increased sebum production due to androgen influences.
Excessive deposition of keratin in the pores.
Overgrowth of cutibacterium acnes, a skin commensal that proliferates in oily skin.
Pro-inflammatory chemicals released in the skin.
Can be triggered by drugs.
31
What are the treatments of acne vulgaris?
Topical:
- Retinoids.
- Antibiotics, such as erythromycin.
Systemic:
- Antibiotics.
- Oral contraceptive pill and hormone blockers.
- Isotretinoin.
Psychological impact.
32
Why should isotretinoin not be given to pregnant mothers?
It is teratogenic.
33
What is the history of a patient with psoriasis?
Chronic skin condition.
Usually between 20-30 and 50-60 years old.
Has a strong genetic predisposition.
Is remitting and relapsing.
Triggers/ iatrogenic causes - medications.
34
What is the cause of psoriasis?
T-cell cytokines production is stimulated, causing keratinocyte proliferation.
35
What is the treatment of psoriasis?
Topical, such as vitamin D analogues.
Phototherapy.
Oral or injectable systemic treatments.
36
How can urticaria be classified?
Acute if less than 6 weeks.
Chronic is longer than 6 weeks.
37
What are some triggers and the pathophysiology of urticaria?
Triggers - foods, inhaled allergens, medications, etc.
Mast cell degranulation and histamine release leads to increased capillary permeability and leakage of fluid into surrounding tissue.
38
What are the treatments for urticaria?
39
What is molluscum contagiosum, and how does it present?
A pox virus that is common in children.
They acquire it from direct contact with a skin lesion or object with the virus.
Small, firm spots that are umbilicated (dimple in the middle) that can appear anywhere.
It can be itchy, but is self-limiting.
40
What is shingles, the presentation and treatment?
41
What bacterial infection commonly affects the skin of children?
State the cause, presentation and treatment.
Impetigo - highly contagious.
It is caused by staphylococcus or streptococcus infections, seen in areas of broken skin - more common in eczema and psoriasis.
Red sores with blisters that burst, forming a gold/ brown crust.
It is treated with topical antibiotics and hydrogen peroxide, where patients resolve within 7-10 days.
42
What is dermatophytosis?
Superficial fungal infection of the skin.
43
What are dermatophytes?
Fungal organisms that need kertain to grow.
44
How is dermatophytosis spread and diagnosed?
Spread via direct contact from other people, animals, soil and fomites.
It is diagnosed clinically, where patients are seen to have superficial lesions of erythema and alopecia, depending on where it impacts.
45
What is the common causes of dermatophytosis and how it treated?
Excessive sweating, contact sports and use of public showers.
Treated with topical antifungals.
46
What is malignant melanoma, what are the causes and risk factors?
Cancer from melanocytes.
It is caused by UV light exposure which can come from the sun and sunbeds.
Risk factors are:
- Pale skin.
- Red/ blonde hair.
- Family history.
47
What is the appearance of malignant melanoma and how is it treated?
A new mole or change in appearance of an existing mole.
It is treated with surgery and/ or radio- or chemotherapy.
48
What is squamous cell carcinoma characterised by, and where do they usually develop?
Abnormal and accelerated growth of squamous cells, found in the epidermis.
It is a crusted lesion with a central ulcer.
They develop in area of skin exposed to the sun:
- Nose.
- Forehead.
- Cheeks.
- Back.
- Lower legs.
49
Who does squamous cell carcinoma usually present in and how is it treated?
Middle aged and older patients.
Treated with surgery.
50
What is basal cell carcinoma, who does it occur in and how is it treated?
The most common type of skin cancer that is slow growing and rarely spreads. They are often dark in colour and spontaneously bleed.
It occurs usually in older adults when one of the skin’s basal cells develops a mutation in its DNA, usually from UV light.
It is treated with surgery.
51
What is a collateral history?
Information gathered from someone other than the patient.
52
What are non-syncopal falls?
Falls not due to cerebral blood flow issues, that can occur with or without a loss of consciousness.
53
What are some causes of non-syncopal falls with and without a loss of consciousness?
With (can be partial or full):
- Epilepsy.
- Metabolic; hypoglycaemia, hypoxia or hypocapnia.
- Intoxication.
Without:
- Psychogenic.
- TIA/ stroke.
54
What is postural hypotension?
A drop in blood pressure greater or equal to 20mmHg in systolic and/or greater or equal to 10mmHg in diastolic blood pressure, that occurs within 3 minutes of standing.
55
Why write a problem list?
Helps to contextualise an acute problem within the patient as a whole, ensuring that other, potential problems or indications are not forgotten or abandoned.
56
What is the physiological definition of frailty?
Clinically recognisable state of increased vulnerability resulting from aging-associated decline in reserve and function across multiple physiologic systems. The ability to cope with everyday or acute stressors is compromised.
57
What is the phenotypic definition of frailty?
Low grip strength.
Low energy.
Slowed walking speed.
Low physical activity.
Unintentional weight loss.
58
What are the geriatric giants?
Immobility.
Instability - falls.
Incontinence.
Impaired memory - dementia, delirium.
Iatrogenesis.
59
What is delirium?
An acute, fluctuating syndrome of encephalopathy causing disturbed consciousness, attention, cognition and perception.
60
What does a ‘non-specific’ presentation in frailty mean?
Frail, older people often present without the ‘classic’ symptoms of a common illness.
61
What is the comprehensive geriatric assessment?
A multidimensional interdisciplinary diagnostic process to determine the medical, psychological and functional capabilities of a frail older person, in order to develop a coordinated and integrated treatment plan.
62
What are some intrinsic and extrinsic causes of aging?
Intrinsic:
- Chronological ageing.
- Biochemical degenerative process.
- Cortisol and hormone levels.
- DNA damage.
- Telomere shortening.
- Oxidative stress.
Extrinsic:
- Biochemical process.
- Environmental; radiation and chemical exposure.
- Mechanical.
- Lifestyle; sleep and diet.
- Behaviour.
63
What are some age related changes for the skin?
Progressive structural and functional generation:
- Atrophy of the dermis, making it more friable.
- Destruction of the dermal-epidermal junction, decreasing nutrient and waste exchange.
- Thinning of the dermis due to collagen fragmentation and elastin degradation.
64
What is this condition seen in the elderly?
Senile purpura - fragility of the skin leads to extensive bleeding under the skin.
65
What are some age related changes for the respiratory system?
Change in the structure of the chest wall, decreasing compliance - increased residual volume and functional residual capacity and decreased vital capacity.
Destruction of the ECM within the lung, leading to senile hyperinflation, air trapping and decreased gas exchange.
Increased infection susceptibility.
66
What are some age related changes for the myocardial structure?
Left ventricular hypertrophy.
Interventricular septal hypertrophy.
Decreased sympathetic innervation.
Aortic sclerosis and aortic valve calcification.
67
What are some age related changes for the myocardial function?
Decreased diastole as less compliance.
Decreased cardiac output.
Decreased maximal heart rate as decreased beta-1 adrenoceptor responsiveness.
Increased cardiac workload.
Decreased baroreceptor response.
68
What are some age related changes for the myocardial electrophysiology?
SA node atrophy.
Prolongation of action potentials.
69
What are some age related changes for the vascular structure and function?
Structure:
- Large arteries dilate.
- All arterial walls thicken.
Function:
- Decreased arterial compliance.
- Endothelial vasodilation is impaired.
70
What are some age related changes for the GI system?
Oesophagus, stomach, liver and colon.
Oesophagus:
- Decreased peristalsis.
- Delayed transit time, which can cause dysphagia and anorexia.
- Decreased relaxation of the lower oesophageal sphincter; achalasia.
Stomach - atrophic gastritis, which is pre-malignant.
Decreased size of the liver.
Colon:
- Decreased intestinal motility and increased water absorption (constipation).
- Diverticulosis.
71
What are some age related changes for the brain?
Ventricular enlargement.
Cortical thinning.
Volume loss.
Sulcal widening.
72
What is malnutrition?
A state of nutrition in a deficiency or excess of energy, protein, and other nutrients, leading to adverse effects on tissue form and function.
73
What are the consequences of malnutrition?
Impaired immune response.
Reduced muscle strength - increasing the risk of falls.
Inactivity - pressure sores and ulcers.
Loss of temperature regulation.
Impaired wound healing.
Impaired psycho-social function.
74
State the class, uses and method of action of diazepam.
State how it contributes to falls.
Class - benzodiazepine.
Uses - mild sedation, muscle spasms, anxiety, status epileptica (seizures don’t stop) and acute alcohol withdrawals.
Method of action - activates to GABA receptors, causing hyperpolarisation.
Contributes to falls by increasing drowsiness, syncope, hypotension and muscle weakness.
75
State the class, uses and method of action of amlodipine.
State how it contributes to falls.
Class - calcium channel blocker.
Uses - hypertension and heart failure.
Method of action - blocks L-type calcium channels.
Contributes to falls by causing hypotension, syncope, dizziness, drowsiness and headaches.
76
State the class, uses and method of action of olanzapine.
State how it contributes to falls.
Class - anti-psychotic.
Uses - schizophrenia, mania and disturbed sleep.
Method of action - binds to dopamine D2 receptors.
Contributes to falls by causing confusion, postural hypotension, dizziness and gait dysfunction.
77
State the class, uses and method of action of codeine.
State how it contributes to falls.
Class - opiate.
Use - pain relief, and treat diarrhoea.
Method of action - binds to mu-opioid receptors.
Contributes to falls by causing confusion, dizziness, drowsiness and sedation.
78
State the class, uses and method of action of oxybutynin.
State how it contributes to falls.
Class - muscarinic anti-cholinergic.
Uses - overactive bladder syndrome and urgency incontinence.
Method of action - inhibits mAChRs.
Contributes to falls by causing dizziness, drowsiness and visual disorders.
79
State the class, uses and method of action of tamsulosin.
State how it contributes to falls.
Class - alpha-1 blocker.
Uses - benign prostatic hyperplasia.
Method of action - blocks alpha-1 adrenoceptors.
Contributes to falls by causing dizziness, hypotension and visual disorders.
80
What is primary palliative care?
Dying, death and bereavement in the community.
81
Who might a good death be considered for?
People with life-threatening progressive incurable disease which is far advanced with a limited prognosis, who’s focus of care is quality of life.
People who are likely to die within a short period of time.
82
What is holistic care?
The physical, psychological, emotional, social and spiritual - total - care of a person.
83
What proportion of deaths occur in medicalised UK institutes?
State the impact of this.
Greater than 70%.
This means that dying is not longer a regular, natural part of the life cycle seen by people.
84
What are the aspects of achieving a good death, as a doctor?
Truthfulness with patients.
Enabling informed consent.
Allowing time for the patient to prepare for their death.
Avoiding isolation of the patient.
Overcoming the wall of silence - talking to the patient.
Maintaining hope by accompanying them on their journey.
85
What it futility?
Where curative treatment is continued where the is no prospect of success - prolonging life unnecessarily.
86
What are the aspects required for a good transition to palliative care?
Informed consent.
Caring when cure is no longer possible.
Enabling acceptance as part of the healing process.
87
What are the 5 stages of anticipatory grief?
Anger.
Denial.
Bargaining.
Depression.
Acceptance.
88
How can spiritual pain be resolved?
Being informed about the event of death and their condition.
Resolving conflicts.
Letting go.
Saying goodbye.
89
What is good dying?
Avoiding medicalisation that prolongs the dying process.
Agreements for care plans - ReSPECT and DNACPR forms.
Ability to die their own death.
Adequate symptom control.
Avoiding medical captivity.
90
What should be done for the informal carer after the death of their loved one?
Support them and give them opportunities for respite care.
Allow/ facilitate grief before and after the death.
Ensure they do not feel guilty for the death of their loved one.
91
What is euthanasia?
The act of deliberately ending a person’s life to relieve suffering.
92
What are the 4 aspects of euthanasia?
The agent.
Intention.
Subject.
Outcome.
93
What is active euthanasia?
The deliberate act of ending a person’s life to relieve suffering.
94
What is passive euthanasia?
Withholding or withdrawing treatment necessary for maintaining life, to end the life of a person to relieve suffering.
95
What is voluntary euthanasia?
The deliberate ending of a person’s life to relieve suffering, at the patients request.
96
What is non-voluntary euthanasia?
The deliberate ending of a person’s life to relieve suffering, without (or unable to) consent of the patient.
97
What is assisted suicide?
The act of deliberately assisting another person to kill themselves.
98
What is physician assisted dying?
Prescribing life-ending drugs for terminally ill, mentally competent adults to administer themselves, after meeting strict legal safeguarding.
99
What does the BMA suggest not to do for patients that request assisted dying?
100
What are the two aspects of palliative care?
Science of symptom control.
Communication with the patient.
101
How should doctors respond to a patient request for assisted dying?
Listening and acknowledgement.
Exploration of their feelings.
Anything that can be done to prevent their feelings.
Involving a colleague.
102
What is the assisted dying bill of 2021?
Enabling adults who are terminally ill to be provided at their request with specified assistance to end their own life.
103
What are the 3 aspects of the assisted dying bill of 2021?
Eligibility criteria - greater than 18 years old, have a terminal illness and are likely to die within the next 6 months, have mental capacity, voluntarily request to end their own life.
High court application.
Provision for self-administration.
104
What are the 4 ethical principles of euthanasia?
Autonomy - patients can choose when they end their own life.
Non-maleficence - doing no harm; not prolonging the suffering but ending their life.
Beneficence - actions to end the pain of a person, but not preserving life.
Justice - unjust to deny the chance of a comfortable death, providing care fairly to all patients.
105
What is the doctrine of double effect?
Permits healthcare professionals to administer potentially fatal medication, provided that their intentions are purely to control symptoms.
106
What is hospice care?
State some aspects of it.
Treatment from the initial diagnosis to end of life care, that is aimed at improving the lives of patients living with an incurable illness.
Can take place anywhere.
It is a style of care.
Holistic care - dignity, respect, medical care, emotional and spiritual care.
Hospice teams.
Services, such as bereavement.
107
What is DNACPR?
Do not attempt cardiopulmonary resuscitation.
108
Who’s decision is it for a DNACPR?
Patients with capacity.
Doctors can, without the consent of a patient, but must inform them.
109
Why may a doctor choose to give DNACPR?
The success rate is only around 15%.
It is a physical, brutal treatment.
Patients overestimate the success of CPR, and do not anticipate the side effects that come with it.
110
What are ReSPECT forms?
Process to create personalised recommendations about their care.
To ensure that they understand what should be done in future emergencies.
Patient preferences and clinical judgement incorporated.
111
For a patient whose height cannot be measured through them standing up straight, how else could their height be established?
Ulnar length - measuring from the olecranon to the styloid process, and comparing against a table of information.
112
What features on the following MRI could be indicative of dementia?
113
What is SIRS?
State the criteria.
Systemic inflammatory response syndrome:
- Temperature greater than 38 degrees or less than 36 degrees.
- Hear rate of more than 90 BPM.
- Respiratory rate of greater than 20 or PaCO2 of less than 4.3 kPa.
- White cell count greater than 12,000/mm3 or less than 4,000/mm3.
114
What is severe adult sepsis?
Systemic inflammatory response syndrome and organ dysfunction.
115
What is the issue with SIRS as a definition of sepsis?
Other signs of organ dysfunction could be excluded.
It is very explicit.
Some of the parameters have a significant delay to their identification.
They are non-specific.
116
What is the sepsis 3 definition of sepsis?
Life-threatening organ dysfunction caused by a dysregulated host response to infection.
117
What is organ dysfunction quantified as?
An acute change in total SOFA score of 2 or more, due to infection.
This is shown to have an increased mortality risk of around 10%.
118
What is a SOFA score?
An ICU specific measurement that attempts to assess how 6 organ systems are functioning to help predict mortality for those patients.
119
What is septic shock?
Persistent hypotension, due to sepsis, that requires vasopressors to maintain a mean arterial pressure of 65mmHg or more, with a serum lactate level of greater than 3mmol/l, despite adequate volume resuscitation.
120
How do vasopressors work?
Give an example of one.
They are drugs almost always given in intensive care units to cause vasoconstriction, increasing blood pressure.
Adrenaline.
121
What is the treatment of sepsis determined by?
The NEWS2 score and the clinical judgement.
122
What is red flag sepsis?
A NEWS2 of 7 or above.
A NEWS2 of 5/6 and one of:
- Lactate >2mmol/l.
- Chemotherapy in the last 6 weeks.
- Patient looking extremely unwell.
- Patient actively deteriorating.
123
What is amber flag sepsis?
A NEWS2 of 5 or 6 or above.
A NEWS2 of 1-4 and one of:
- Lactate >2mmol/l.
- Chemotherapy in the last 6 weeks.
- Patient looking extremely unwell.
- Patient actively deteriorating.
124
What is the A-E approach when assessing adult sepsis?
Airway.
Breathing.
Cardiovascular.
Disability - GCS.
Everything else.
125
What does BUFALO sepsis treatment stand for?
Blood cultures.
Urine catheter/ output.
Fluids (IV).
Lactate levels.
Oxygen.
126
If a patient remains in hypotensive shock after fluid resuscitation, what should be done?
Vasopressors should be given.
127
What does the prognosis of child sepsis depend on?
The speed of recognition and antibiotic administration.
128
What are some significant complications of paediatric sepsis associated with bacterial meningitis and meningococcal disease, respectively?
Bacterial meningitis - developmental delay and hearing loss.
Meningococcal disease - limb ischaemia, which may lead to amputation.
129
What aspects are involved in the abnormal response to infection seen in sepsis?
Exaggerated pro-inflammatory response - infection distant to the initial site.
Endothelium dysfunction.
Cell death.
Mitochondrial dysfunction.
Immunoparalysis.
130
What type of bacteria cause sepsis?
Gram-negative bacteria as it is the lipopolysaccharide that enters the blood stream to cause sepsis.
131
What TLR recognises the lipopolysaccharide?
TLR-4.
132
What factors are required to confirm sepsis?
Infection - bacterial, viral or fungal (usually immunosuppressed).
Systemic inflammatory response.
133
What are some common sources for infection?
Urine.
Chest.
Ear, nose and throat.
Skin.
Abdomen.
Indwelling lines.
134
What is the criteria for a systemic inflammatory response?
At least two of:
- Temperature greater than 38 degrees, or less than 36.
- Tachycardia, greater than 90.
- Tachypnoea, greater than 20.
- A high or low white cell count.
135
What is severe sepsis?
Sepsis with organ dysfunction.
136
What are some things seen in organ dysfunction?
Cardiac, respiratory, renal, hepatic, neurological and haematological.
Cardiac - hypotension, acidosis and poor urine output.
Respiratory - hypoxia, hypercapnia, respiratory support.
Renal - high creatinine.
Hepatic - jaundice and coagulopathy.
Neurological - GCS < 11.
Haematological - thrombocytopenia.
137
Why can paediatric sepsis be difficult to diagnose?
They often present with non-specific symptoms - lethargy, nausea, vomiting and headache.
There are lots of other illnesses that mimic sepsis.
Identifying an unwell child is difficult - some look unwell, but others look fine and only have tachycardia.
There is a constantly evolving picture.
138
What can be looked at in the history of a paediatric septic patient?
Age - under the age of 3 months are more immunocompromised.
Variable duration of illness.
Temperature can be high or low - parental report is accepted.
Determine the source of infection - cough, rash, abdominal pain, etc.
Behaviour - can be playful or lethargic; eating, drinking, vomiting, headache.
Possibly have unwell contacts.
Vaccinations history.
139
On examination, what can be some signs of the source of infection, and of shock?
Infection - lung crackles, cellulitis, non-blanching rash in meningococcal disease.
Shock - hypotension, tachycardia, cool peripheries and confusion.
140
What is the paediatric sepsis 6?
These should be given within the hour.
1) Supplementary oxygen.
2) Obtain IV/ IO access and take bloods - culture, glucose and lactate, FBC, CRP.
3) Give IV/ IO broad spectrum antibiotics.
4) Consider fluid resuscitation.
5) Escalation.
6) Inotropic support if needed.
141
What is IO access?
Intraosseous - a line into 2cm below the tibial tuberosity, going into the bone marrow.
142
At less than 1 month, what antimicrobials may be given for what organisms?
Cefotaxime - group B strep, strep pneumoniae, staph A.
Amoxicillin - listeria.
Gentamicin - E. coli.
Aciclovir - herpes simplex virus.
143
At 1-3 months, what antimicrobials may be given for what organisms?
Ceftriaxone - group B strep, strep pneumoniae and staph A.
Amoxicillin - listeria.
144
At over 3 months, what antimicrobials may be given for what organisms?
Ceftriaxone - strep pneumoniae, neisseria meningitidis, staph A.
145
What IV fluids should be given and at what rate?
A bolus of crystalloids (saline) - 0.9% NaCl, at 10-20ml/kg over 5-10 minutes, especially if lactate >2.
Maintenance fluids and monitoring fluid balance.
146
What should be given if 40ml/kg is given and the patient is still hypotensive?
Inotropes - increase heart rate and force of contraction. They can also have vasoconstrictor effects, such as in adrenaline.
147
When should a consultant be informed?
Lactate > 4mmol/ L.
No response to fluid bolus.
148
What is early onset and late onset neonatal sepsis?
Early onset - < 72 hours old.
Late onset - > 72 hours old.
149
Which antibiotic class does Ceftriaxone belong to, and what is the mechanism of action?
Cephalosporins - inhibits cell wall synthesis.
150
What is torsion of hydatid of morgagni?
Twisting of the top of the testicle, that is usually seen in the very young.
151
What is the treatment of testicular torsion?
Emergency scrotal exploration.
152
What is the most common cause for epididymo-orchitis in 20-40 year olds, and those older than 40?
20-40 year olds - STI, often chlamydia trachomatis.
>40 years old - UTI, often E.coli.
153
What is the treatment for epididymo-orchitis, epididymal abscess’ or fournier’s gangrene?
Epididymo-orchitis - antibiotics.
Abscess - surgical drainage and antibiotics.
Fournier’s gangrene - emergency debridement and antibiotics.
154
What lymph nodes do the testes drain into?
Para-aortic.
155
Why can venous stasis and sleep apnoea cause LUTS?
Venous stasis - peripheral oedema can form, and then at night the fluid can shift to the kidneys when laying down.
Sleep apnoea - increased ANP production increases urine output.
156
What drug is given to males with hesitancy symptoms, and what is the mechanism of action?
Tamsulosin - alpha blockers.
Relaxing the smooth muscle of the prostate and bladder neck so allow for easier voiding.
157
What drug is given to BPH patients, and what is the mechanism of action?
Finasteride - 5alpha-reductase inhibitor.
Preventing the conversion of testosterone to dihydrotestosterone slows the progression of prostatic enlargement, reducing the risk of enlargement.
158
Where within the testicle do cancers usually arise from?
The body.
159
What percentage of men die before the age of 65?
19%.
160
What is the leading cause of death across all ages?
Ischaemic heart disease.
161
At what age range is suicide the leading cause of death in males, and females?
10-49 in males.
10-34 in females.
162
What are some health-seeking trends of males?
Less likely to attend cancer screening.
Less likely to visit GP, exception of very late years of life.
More likely to present to GP at a later stage of illness.
Less likely to present with concerns regarding mental health.
163
Why do men often not present with mental health concerns?
Embarrassment or ashamed.
Concerns about their employer would think worse of them.
Negative stigma around mental health.
Learning to deal with it.
Not wanting to burden anyone.
Not wanting to appear weak.
164
What are some risk factors for poor male mental health?
Relationship breakdown.
Mid-life.
Lack of social support - fewer social connections.
Socio-economic factors - unemployment.
Substance abuse.
Stress - work, financial, relationship.
Societal expectations of masculinity.
Trauma.
165
What are some symptoms of male depression?
Anger and agitation.
Recklessness.
Substance abuse.
Working obsessively.
Physical symptoms such as headaches.
Core symptoms of depression.
166
What are some causes of male depression?
Difficult life events.
Family or personal history.
Abuse.
Personality traits.
Physical health issues.
167
What are some symptoms of male anxiety?
Alcohol abuse.
Drug abuse.
Difficulty sleeping.
Self-medication.
Core anxiety symptoms.
168
What are some causes of male anxiety?
Genetic.
Traumatic experience.
High stress.
Health problems.
Lifestyle factors.
169
How can men’s mental health be improved?
Raising awareness to reduce stigma.
Addressing societal expectations of masculinity.
Improving access to mental health services.
Promoting healthy coping mechanisms - exercise, meditation, hobbies, etc.
Developing targeted interventions.
Understanding of male presentations.
170
What are some modifiable and non-modifiable risk factors of CVD in men?
171
How do you approach a patient who’s lifestyle needs changing?
Establish a rapport.
Ensure accurate information is obtained from the patient - taking a full history.
Shared understanding with the patient.
Calculate BMI and talk about what it means.
Be direct but non-judgemental.
Motivational interviewing.
172
What is motivational interviewing?
A technique that engages patients, eliciting their desires and goals, to help facilitate behavioural changes.
173
What are some physical causes of erectile dysfunction?
Atherosclerosis.
Smoking cigarettes.
Diabetes.
Medication.
Spinal cord injuries.
Alcohol - damage the nerves to the penis, reduces testosterone and increases oestrogen.
Prostate gland surgery.
174
What is nervous supply for erections?
Parasympathetic pelvic nerves.
175
What are some psychological causes of erectile dysfunction?
Stress and anxiety.
Depression.
Relationship conflicts.
Sexual boredom.
Unresolved sexual orientation.
176
What is the non-medical treatment for erectile dysfunction?
CVS risk screening (QRISK) and lifestyle changes.
Therapy.
177
What is the medical treatment for erectile dysfunction - 1st, second and 3rd line?
First line:
- PDE5 inhibitors (sildenafil, etc).
- Vacuum erection devices.
Second line:
- Intracavernous alprostadil.
- Intraurethral alprostadil.
3rd line:
- Penile prosthesis.
178
When should PDE5 inhibitors not be used, and what are the adverse effects of vacuum erection devices?
Should not be used with nitrates as it can cause headaches and flushing.
Brushing.
Local pain.
Failure to ejaculate.
179
What is the normal histology of breast tissue?
Each acinus contains a basement membrane, with myoepithelial cells attached, which surround cuboidal-columnar epithelial cells.
Multiple acini with intralobular stroma form a lobule.
180
What is the pathway of milk production to release?
Synthesised by the cuboidal/ columnar epithelial cells, and is pushed out into the terminal duct lobular unit by myoepithelial cells.
It then travels through the major duct, into the lactiferous duct, to be excreted out via the nipple.
181
What is the terminal duct lobular unit?
State the significance of this.
Terminal duct and multiple acini.
All epithelial cancers arise from here.
182
What is the stroma of breast tissue?
Intralobular - connective tissue, which is dense and collagenous.
Interlobular - adipose tissue.
183
What is the triple approach to breast assessments?
History and examination.
USS vs mammograms .
Biopsy or FNA.
184
What is duct ectasia?
Benign disorder of extralobular ducts - dilation of the ducts, associated with inflammation and stasis of secretions.
185
Who is duct ectasia seen in and what is a risk factor for this?
State the treatment options.
Peri-menopausal women.
Smoking.
Observation - antibiotics - excision.
186
What is a fibroadenoma and who are they seen more commonly in?
A benign (most commonly), biphasic intralobular mass - contains glandular and stromal elements.
More commonly seen in younger patients.
187
What are some lesions of the intralobular stroma?
Fat necrosis.
Lipoma.
Fibrous tumour.
Fibromatosis.
Sarcoma.
188
What is seen microscopically and macroscopically in fat necrosis?
Micro - disrupted fat with foamy macrophages.
Macro - ill-defined, spiculated mass with calcifications.
189
What is seen histologically in gynaecomastia?
Proliferation of ducts and stroma.
190
What are some physiological and pathological causes of gynaecomastia?
191
What is seen on a mammogram and histologically with ductal carcinoma in situ?
Mammogram - new, coarse calcifications.
Histologically - ducts filled with atypical cells and focal necrosis.
192
What is ductal carcinoma in situ confined to and how can it be graded?
Ductolobular system.
Low - intermediate - high.
193
What are the physical examination of a breast cancer?
A firm, irregular, fixed lump.
Associated skin changes - pau d’orange/ bruised skin.
194
What are the mammographical changes seen in breast cancer?
Irregular, dense mass with spiculated margin.
195
What are the histological changes seen in ductal breast cancer?
Infiltration cells with gland formation.
Atypical cells with nuclear pleomorphism.
Extension into fat.
196
What is the most common subtype of breast adenocarcinoma, and what are some other subtypes?
Invasive ductal adenocarcinoma, no special type.
Lobular.
Tubular.
Mucinous.
Micropapillary.
197
What is seen histologically for:
- Lobular.
- Tubular.
- Mucinous.
- Micropapillary.
Lobular - chins of single cells
Mucinous - pools of extracellular mucin.
Tubular - well-formed tubular spaces.
Micropapillary - tufts of cells.
198
What does mammary duct ectasia result from?
The shortening and dilation of subareaolar ducts.
199
What are the risk factors for breast cancer?
Age - increasing age, most over 50.
Previous breast cancer.
Family history - BRCA1/2.
Benign breast disease - lobular carcinoma in situ/ atypical ductal hyperplasia.
Hormonal factors - HRT, COCP, early menarche/ late menopause, nulliparity.
Lifestyle - obesity, alcohol, smoking.
200
Who is invited for breast cancer screening, and how often are they screened?
50-70 year olds, every 3 years.
Those that have a strong family history can have earlier screening or genetic screening.
201
What are the differences between the malignant and benign breast metastases on examination?
202
What are the two types of in-situ breast adenocarcinoma?
Ductal.
Lobular.
203
What is the definition of DCIS?
Aggregations of neoplastic cells confined to the ductotubular system, that does not invade through the basement membrane.
204
What non-hormonal drug can be given for treatment of DCIS?
Bisphosphonates.
205
What is child abuse?
Maltreatment of a child, a person less than 18 years old, that is an infliction of harm, or a failing of actions to prevent harm.
206
What is significant harm?
Ill-treatment or impairment of health of development, allowing for legal justification for intervention in family life.
207
What are the categories of abuse?
State any subcategories.
Neglect.
Physical:
- Factitious, induced illness.
- FGM.
Sexual.
Emotional.
208
What things can a parent or carer fail to do for it to be classed as neglect?
Provide adequate food, clothing or shelter.
Protect the child from physical and emotional harm or danger.
Ensure adequate supervision.
Ensure access to appropriate medical care or treatment.
Unresponsiveness to, or neglect of a child’s basic emotional needs.
209
What may a history of neglect look like?
Non-attendance to multiple appointments or non-adherence to medication.
Missed routine screening/ immunisation.
Faltering growth.
Delayed development.
Recurrent infestations/ infections/ injuries.
Poor school attendance.
History of injury, possibly due to inadequate supervision.
210
What may a examination of neglect look like?
Poor nutritional status/ poor growth.
Dental decay.
Signs of recurrent/ chronic infection or infestation.
Dirty/ unkempt/ smelly.
211
What may a history of physical abuse look like?
Lack of adequate explanation for an injury.
Delays in seeking medical attention/ inappropriate response.
Inconsistent accounts.
Presence of multiple risk factors.
Child or family known to social care.
Direct disclosure.
212
What may a examination of physical abuse look like?
Unexplained bruising in a vulnerable child, usually less than 2 years old.
Unexplained fractures/ burns/ scalds/ head injuries.
Patterns - implements, sparing, bites.
Injury not consistent with history/ developmental age - falling out of a cot if cannot even crawl yet.
213
What are the different types of sexual abuse?
Contact - penetrative or non-penetrative.
Non-contact - children looking at or producing sexual images, watching sexual activities or encouraging children to behave sexually inappropriately.
Online.
214
What are the two forms of child sexual exploitation?
The exchange of sexual activity for something that the victim wants.
Coercing or manipulating a child into sexual activity for financial advantage or increased status of the perpetrator.
215
What may a history of sexual abuse look like?
Disclosure.
Pregnancy/ signs of sexual activity in children under the age of 13.
STIs.
Anogenital injury/ unexplained injury.
Recurrent vaginal discharge.
Soiling/ wetting.
Behavioural change.
216
What needs to be completed to ensure that a child is placed into social care?
A forensic assessment.
217
What is emotional abuse and what are some examples?
The persistent maltreatment of a child, causing severe and persistent adverse effects on the child’s emotional development.
Rejection.
Isolation.
Terrorising.
Ignoring.
Corrupting.
Cyberbullying.
218
What may emotional abuse involve?
Conveying worthlessness/ unloved/ inadequacy.
Deliberately silencing or making fun of the child, impairing development.
Imposing age/ developmentally inappropriate expectations on the child:
- Overprotection and limitations on their learning and exploration.
- Inhibiting the participation in normal social interactions.
Bullying.
219
How may the history of an emotionally abused child change between the following age groups:
- Infants.
- Toddler.
- School-aged.
- Adolescents.
Infants - feeding difficulties, crying, poor sleep patterns, developmental delay.
Toddler - overactive or apathetic, noisy or quiet, developmental delay.
School-aged - wetting or soiling, relationship difficulties, poor school performance, non-attendance, antisocial behaviour.
Adolescents - depression, self-harm, substance misuse, eating disorders, aggression.
220
What may be seen on examination of an emotionally abused child?
Underweight.
Emotional signs.
Developmental delays.
Academic failure.
221
What are some risk factors for child abuse?
Triad of vulnerability - domestic abuse, mental illness of parent, parental drug/ alcohol misuse.
Under 2 years old.
Pre-verbal children.
Additional needs/ disabled children.
Vulnerable/ marginalised young people.
222
What are some interventions and support for children who may be abused?
Universal services - primary care, social services, etc.
Early help - additional needs/ mental health help, which is voluntary.
Child in need - requires consent.
Child protection - state interventions, not requiring family consent.
223
What should be done if a child discloses abuse?
Don’t ask leading questions.
Document what was said.
Don’t promise confidentiality.
Involve other professionals and escalate appropriately.
224
How can vaccines effectiveness be measured?
Measuring antibodies.
Epidemiological assessments - population trends.
225
How many diseases are there vaccines against?
26.
226
What are the benefits of vaccines?
Herd immunity - protect infants and the elderly, and those on medications/ with co-morbidities that cannot have the vaccine.
Limit antibiotic resistance.
Healthcare cost savings.
Prevent illness.
Improvement of children’s cognitive skill and physical strength - improved school performance.
227
How can vaccines help households, collectively?
One of the parents, a wage earner, does not have to stay off work.
Long-term, not having to cope with caring for disabled children, due to infections.
228
What are some vaccines recommended for all children?
BCG.
Hepatitis B.
Polio.
Diphtheria (DPT) vaccine.
Haemophilus influenza B.
Pneumococcal.
Rotavirus.
Measles.
Rubella.
HPV.
229
What factors does vaccine hesitancy include?
Complacency.
Convenience.
Confidence.
230
What are the 5 things doctors need to do to help boost uptake of vaccines?
Understand the specific vaccine concerns of the patient.
Use clear language to present evidence of vaccine benefits and risks fairly and accurately.
Inform parents about the rigour of vaccine safety.
Address issues of pain with immunisation.
Address issues of thoughts that natural disease is better than vaccinations.
