Key Learning Points (2 OF 2) Flashcards
(92 cards)
1
Q
Outline the single most severe complication that can be associated with pericarditis?
A
Cardiac tamponade secondary to pericardial effusion from the inflamed pericardium
2
Q
What is the most effective way of removing potassium from the body in patients with hyperkalaemia?
A
Calcium resonium enema; this acts as an ion exchange resin that binds to potassium that is normally secreted in the rectum, preventing its reabsorption and allowing it to be excreted
3
Q
Outline the features associated with Korsakoff’s syndrome? (5)
A
CAN-CAn
- Confusion
- Ataxia
- Nystagmus
- Confabulation
- Amnesia
4
Q
Which ECG abnormality has the highest specificity for its association with acute pericarditis?
A
PR depression; meaning that the presence of PR depression effectively rules in the diagnosis of acute pericarditis
5
Q
Outline the management of hyperthyroidism? (3)
A
- Induce remission; antithyroid drugs (ATDs) such as carbimazole upto 18 months - Maintanence; either with titration block regime or block-replace regime - Definitive treatment; radioactive iodine or surgery
6
Q
Outline the fluid replacement regimen used in patients with burns?
A
- 4 mL kg-1 %-1 burn over a 24 hour period
- Half of this volume should be given in the first 8 hours.
7
Q
Which antibody tests are most sensitive and most specific for systemic lupus erythematosus (SLE)? (2)
A
- Anti-nuclear antibodies (ANA) are the most sensitive diagnostic indicator; hence a negative test effectively rules out the diagnosis of systemic lupus erythematosus (SLE)
- Anti-double-stranded DNA (anti-dsDNA) antibodies are the most specific diagnostic indicator; hence a positive test effectively rules in the diagnosis of systemic lupus erythematosus (SLE)
8
Q
Which heart valves are most commonly affected by infective endocarditis? (2)
A
- Most patients; mitral valve
- IVDUs; tricuspid valve
9
Q
What fraction/percentage of the total maintenance opioid medication should be given PRN to manage breakthrough pain in palliative care?
A
PRN opioid medication should be 1/6th (16.67%) of the total dose of maintenance opioid dose given in a 24 hour period
10
Q
What is the threshold value of the QRISK3 score sufficient to indicate a lipid-lowering therapy (statin) in patients with hypertension?
A
QRISK3 > 10%: offer a statin
11
Q
Outline the first-line medications used in the management of chronic plaque psoriasis? (2)
A
- Topical potent corticosteroid (betamethasone)
- Topical vitamin D analogue (calcipotriol)
12
Q
Outline the causes of a raised anion gap metabolic acidosis? (8)
A
MUD PILES:
- Methanol
- Uremia
- Diabetic or alcoholic ketoacidosis
- Paraldehyde
- Iron or isoniazid
- Lactic acidosis
- Ethylene glycol
- Salicylates
13
Q
Outline the Weber classification of ankle fractures? (3)
A
- Type A; stable fracture below the level of the tibiofibular syndesmosis
- Type B; potentially usable fracture starting at the level of the tibiofibular syndesmosis that extends proximally in an oblique fashion
- Type C; unstable fracture above the syndesmosis generally associated with syndesmotic injury
14
Q
In which age group does NICE recommend the use of the Fracture Risk Assessment (FRAX) Tool to assess risk of a fragility fracture?
A
Between the ages of 40 - 90 years old, with or without a bone mineral density (BMD) value.
15
Q
Outline the components of the CRB-65 Score?
A
- Confusion; new disorientation in person, place or time = 1 - Respiratory rate > 30 = 1 - Blood pressure < 90 systolic and/or < 60 diastolic = 1 - 65; age ‚â• 65 = 1
16
Q
Outline the types of tumours associated with the multiple endocrine neoplasm (MEN) syndromes? (3)
A
MEN1; - Pituitary - Parathyroid - Pancreatic (insulinoma) MEN2A; - Parathyroid - Phaeochromocytoma - Medullary thyroid MEN2B; - Phaeochromocytoma - Medullary thyroid
17
Q
Seeing Q-waves in which ECG leads is always considered pathological?
A
All ECG leads except from aVR
18
Q
What are hyaline casts that can sometimes be seen on urinalysis in patients taking loop diuretics?
A
Casts consisting of the Tamm-Horsfall protein which is secreted by the distal convoluted tubule (DCT)
19
Q
Outline the first-line imaging modality used to investiage a suspected Achilles tendon rupture?
A
Ultrasound
20
Q
What additional electrolyte imbalance is seen in patients with a normal anion gap metabolic acidosis?
A
Hyperchloraemia
21
Q
Outline the normal range for the ankle-brachial pressure index (ABPI)?
A
Normal ABPI; 0.9 - 1.2
22
Q
Outline the indications for the use of antibiotics in the management of acute otitis media? (5)
A
- Symptoms lasting > 4 days
- Systemically unwell
- Immunocompromised
- < 2 years with bilateral involvement
- Perforation/discharge
23
Q
Outline the first abnormality seen on an ECG in a patient suffering from an ST-elevation myocardial infarction (STEMI) and why this occurs? (2)
A
- Hyperacute (tall-tented) T waves limited to the vascular territory supplied by the affected coronary artery
- Caused by localised hyperkalaemia secondary to myocardial ischaemia and release of potassium from the infarcted tissue
24
Q
Outline the causes of a normal anion gap metabolic acidosis? (4)
A
ABCD:
- Addison’s disease
- Bicarbonate loss; diarrhoea, stoma output
- Chloride; ammonium chloride injections, aggressive normal saline administration
- Drugs; acetazolomide
25
Which blood tests can be used to distinguish impaired renal function due to chronic kidney disease (CKD) from that caused by an acute kidney injury (AKI)? (2)
- **Serum phosphate**; hyperphosphataemia indicates a more chronic kidney disease picture
- **Serum calcium**; hypocalcaemia indicates a more chronic kidney disease picture
26
Outline the main ANCA-associated small vessel vasculitides? (3)
- Microscopic polyangiitis (MPA)
- Granulomatosis with polyangiitis (GPA): previously known as Wegener's granulomatosis
- Eosinophilic granulomatosis with polyangitis (EGPA): previously known as Churg-Strauss syndrome
27
Which parameter is considered the most useful prognostic marker in paracetamol overdose?
Prothombin time
28
Which parameter can be used to differentiate iron deficiency anaemia (IDA) from anaemia of chronic disease (ACD)?
**Total iron binding capacity (TIBC)**; this will be high in iron deficiency anaemia (IDA) but normal/low in anaemia of chronic disease (ACD)
29
Outline the options for secondary prevention of cerebrovascular accidents (CVA)? (2)
- **Most patients**; lifelong **antiplatelet** (clopidogrel) plus lipid modification (**statin**)
- **Atrial fibrillation**; lifelong **anticoagulation** (warfarin or DOAC) plus lipid modification (**statin**)
30
Outline the components of the CURB-65 Score?
- Confusion; new disorientation in person, place or time = 1 - Urea; > 7 mmol L-1 = 1 - Respiratory rate > 30 = 1 - Blood pressure < 90 systolic and/or < 60 diastolic = 1 - 65; age ‚â• 65 = 1
31
Outline the threshold urine output value needed for diagnosis of acute kidney injury (AKI)
Urine output of **< 0.5 mL kg-1 hr -1** for > 6 consecutive hours
32
Outline how the Wells score for PE can be used to guide investigation? (2)
- **Score > 4**; PE is likely, proceed to CT pulmonary angiography (**CTPA**)
- **Score ≤ 4**; PE is possible but arrange **D-Dimer** within 4 hours, if positive arange CTPA, if negative exclude PE
33
Outline the threshold criteria that indicate liver transplantation in paracetamol overdose? (4)
- Arterial pH < 7.3 after 24 hours following ingestion
OR all of the following:
- Prothrombin time > 100 seconds
- Creatinine > 300 µmol/L
- Grade III or IV encephalopathy
34
Outline the components of the Glasgow-Imrie Score for pancreatitis?
**PANCREAS**;
- **P**aO2 > 8kPa
- **A**ge > 55
- **N**eutrophilia/WBC > 15 x 109 L-1
- **C**alcium > 2 mmol L-1
- **R**enal; Urea < 16 mmol L-1
- **E**nzymes; LDH > 600 IU L-1 or AST > 200 IU L-1
- **A**lbumin < 32 g L-1
- **S**ugar; Glucose > 10 mmol L-1
35
Outline the screening test that can be used to identify a childhood squint?
**Corneal light reflection test (CLRT)**; hold a light source 30 cm from the child's face to see if the light reflects symmetrically on the pupils
36
Which drug can be used instead of adenosine in patients presenting with a superventricular tachycardia (SVT) who have a history of asthma?
Verapamil
37
Outline the components of the HAS-BLED Score for risk of bleeding in patients anticoagulated for AF?
- Hypertension; +1 - Abnormal liver or renal function; +1 (for each abnormality) - Stroke; +1 - Bleeding prior and/or predisposition to bleeding; +1 - Labile INR; +1 - Elderly (> 65); +1 - Drugs or alcohol; +1 (for each)
38
Which type of pupillary light defect is commonly associated with optic neuritis?
**Relative afferent pupillary defect (RAPD)**; swinging light test will cause pupillary constriction in both eyes when light is shone into the unaffected eye, but swinging to the affected eye will result in pupillary dilatation in both eyes (due to the absence of light in the unaffected eye acting as the predominant stimulus), this indicates an defect in the afferent pathway originating from the affected eye
39
Outline how the Alvarado score is used to estimate of the likelihood of appendicitis? (3)
- Score 1-4; appendicitis unlikely
- Score 5-6; appendicitis possible
- Score ≥ 7; appendicitis very likely
40
Outline the choice of P2Y12 receptor antagonist used alongside aspirin as dual antiplatelet therapy (DAPT) in patients with an acute coronary syndrome (ACS)? (2)
- **On anticoagulation**; give clopidogrel
- **Not on anticoagulation**; give prasugrel/ticagrelor
41
Outline the mechanism by which continuous positive airway pressure (CPAP) is useful in patients with heart failure that is not responding to IV diuretics? (2)
- CPAP **increases intrathoracic pressure** which **reduces venous return** to the heart and ultimately **reduces** preload and **pulmonary venous pressure**
- This **reduction in hydrostatic pressure** promotes the movement of **fluid** from the interstitium back **into** the **vascular compartment**, reducing oedema.
42
Which tests can be used to differentiate acute epididymitis from testicular torsion? (2)
- **Prehn's sign**; negative (where elevation of the testicle results in an exacerbation of pain) in cases of testicular torsion
- **Cremasteric reflex**; classically absent in cases of testicular torsion
43
Outline how the HAS-BLED score can be used to assess bleeding risk in patients on anticoagulation in the management of AF?
- Score < 3; low risk of bleeding - Score 3 - 6; high risk of bleeding - Score > 6; very high risk of bleeding
44
Why is it important to consider the administration of K+ supplementation in patients in diabetic ketoacidosis (DKA) who are due to be commenced on a fixed rate intravenous insulin infusion?
Because the administration of insulin will drive K+ into cells via the stimulation of the
Na+/K+ATPase which can cause extracellular K+ concentrations to fall resulting in hypokalaemia
45
Over what duration should non-urgent blood transfusions be adminstered?
90 - 120 minutes
46
Outline the drugs used in the management of a symptomatic bradycardia? (2)
- **Atropine** 500 μg (IV); titrated upto 3 mg
- **Isoprenaline/adrenaline** infusion
47
Outline the components of the Wells Score for deep vein thrombosis (DVT)? (10)
**APPLE IPOD A**;
- **A**ctive cancer = +1
- **P**itting oedema confined to symptomatic leg = +1
- **P**aralysis or recent plaster immobilisation of lower limb = +1
- **L**ocalised tenderness along deep venous system = +1
- **E**ntire leg swollen = +1
- **I**mmobilised > 3 days and/or recent surgery within 12 weeks = +1
- **P**revious VTE (DVT or PE) = +1
- **O**ne-sided/unilateral calf swelling > 3 cm compared to other leg = +1
- **D**ilated collateral (non-varicose) superficial veins = +1
- **A**lternative diagnosis as/more likely = -2
48
Outline what should be done regarding the administration of a patient's long and short-acting insulin where they have been admitted in diabetic ketoacidosis (DKA)? (2)
- Stop any short-acting injectable insulin
- Continue the long-acting injectable insulin
49
Outline the triad of features associated with trifascicular block? (3)
- Right bundle branch block (RBBB) - Left axis deviation (LAD) - 1st degree heart block (PR prolongation)
50
What is the equation that can be used to calculate how much fluid to give a patient with burns?
Parkland Formula
51
Which small vessel vasculitis is associated with positive p-ANCA serology?
Eosinophilic Granulomatosis with Polyangiitis (EGPA) also known as Churg-Strauss Syndrome; eosinophils are pretty in pink (p-ANCA)
52
Which investigation and specific parameter can be used to rule-out pre-renal and post-renal causes of acute kidney injury (AKI)?
**Urine dip**; if **protein is present** in the urine then it is highly likely that the cause of AKI is likely to be **intrinsically renal** in nature
53
Outline the main indications for intravenous bicarbonate therapy in the management of tricyclic antidepressant (TCA) overdoses? (3)
- Widening of the QRS interval > 100 ms
- Ventricular arrhythmia
- Hypotension
54
What is the most appropriate interval to leave before increasing a dose of metformin?
1 week
55
Why should metformin be temporarily stoppped in patients admitted with a myocardial infarction?
Due to the increased risk of lactic acidosis
56
What is the difference between a standard pacemaker, a cardiac resynchronisation therapy (CRT) pacemaker and an implantable cardioverter defibrillator (ICD)? (3)
- Standard pacemakers can be single chamber (normal AVN function) or dual chamber (impaired AVN function) and are used to prevent bradycardia - Cardiac resynchronisation therapy (CRT) pacemakers are biventricular (triple chamber) pacemakers used to coordinate the contraction of the heart chambers in patients with heart failure - Implantable cardioverter defibrillators (ICDs) can function as pacemakers to prevent bradycardia, pacemakers that terminate tachycardias and defibrillators that restore sinus rhythm by delivering A defibrillation shock if A patient goes into Refractory ventricular Tachycardia or ventricular fibrillation
57
Outline the target fluid balance for patients recovering from an acute kidney injury (AKI)?
It is usually preferred that fluid intake in patients recovering from AKI be equal to fluid output plus 500 mL to account for insensible losses
58
Which medication is specifically associated with pellegra (vitamin B3 deficiency)?
**Isoniazid**; inhibits the conversion of tryptophan to niacin (vitamin B3)
59
Outline how the Glasgow-Imrie Score can be used to asses pancreatitis severity?
Score ‚â• 3 indicates severe disease
60
Which sign can be used to confirm the correct siting of a chest drain?
**Chest drain swinging**; the **water seal level** in the drain should **rise during in inspiration** and then **fall during expiration**
61
Outline the NICE Guidelines on when to treat subclinical hypothyroidsim?
If the TSH level is > 10 mU/L on 2 separate occasions 3 months apart
62
How long are antithyroid drugs (ATDs) continued for in patients with Graves' disease?
Maximum of 12-18 months; the aim is to induce remission of the disease rendering the patient euthymic again, this typically occurs within 4-8 weeks of treatment with carbimazole
63
Which enzyme is decreased in patients with chronic myeloid leukaemia (CML)?
Leucocyte alkaline phosphatase
64
What is the main concern regarding a patient with a prolonged QTc interval?
A prolonged QT interval increases the risk of subsequent ectopics triggering an arrhythmia, particularly torsades de pointes via what is refferred to as the 'R-on-T' phenomenon
65
Outline how the CRB-65 score is used to guide referral to hospital in patients with suspected pneumonia?
CRB-65 Score >1; requires hospital referral/admission
66
Outline the components of the Wells Score for pulmonary embolism (PE)? (7)
**EAT CHIP**
- **E**dema and other signs and symptoms of DVT = **+3**
- **A**lternative diagnoses less likely; PE is #1 diagnosis or equally likely = **+3**
- **T**achycardia; heart rate > 100 bpm = **+1.5**
- **C**ancer +/- treatment < 6 months or palliative = +1
- **H**aemoptysis = +1
- **I**mmobilised for > 3 days and/or sugery within 4 weeks = **+1.5**
- **P**revious VTE = **+1.5**
67
Outline the pathophysiological mechanism associated with acalculous cholecystitis?
Acalculous cholecystitis occurs where patients undergo long periods where the gallbladder is not being stimulated to regularly empty by ingestion of food
68
Outline the histopathological findings seen in punch biopsies of Kaposi's sarcomas? (3)
- Dermal spindle cells
- Slit-like vascular spaces
- Red blood cell extravasation
69
Which medications are used first-line to maintain remission in patients with Crohn's disease and ulcerative colitis? (2)
- Crohn's disease; azathioprine or mercaptopurine
- Ulcerative colitis; mesalazine
70
Outline the three main types of ventricular tachycardia? (3)
- **Monomorphic ventricular tachycardia** (MVT); widened QRS complex but consistent in magnitude and morpholgy
- **Polymorphic ventricular tachycardia** (PVT); ventricular tachycardia with a QRS complex varying in amplitude, axis, and duration
- **Torsades des Pointes** (TdP); polymorphic ventricular tachycardia with QT prolongation and oscillatory changes in the amplitude of the QRS complexes
71
Which test can be used to differentiate primary and secondary causes of hyperaldosteronism?
**Serum renin levels**; renin levels will be elevated in secondary hyperaldosteronism but normal in primary hyperaldosteronism
72
Outline how the CHA2DS2VASc score can be used to inform whether to commence anticoagulant therapy in atrial fibrillation?
- Score = 0; no anticoagulation - Score = 1; consider anticoagulation - Score = >1; offer anticoagulation
73
How may you differentiate acute interstitial nephritis (AIN) from acute tubular necrosis (ATN) as the cause of an acute kidney injury (AKI)?
**Urine dip**; acute interstitial nephritis (AIN) will have a high urine white cell content as it is an inflammatory process, meanwhile while acute tubular necrosis (ATN) is not inflammatory in nature so it is unlikely that the urine will have any white cell component
74
Outline the threshold T scores calculated on a DEXA can that warrant bisphosphonate treatment/prophylaxis? (2)
- **Prophylaxis** in patients with concomitant/planned **steroid** therapy; T score **≤ -1.5**
- **Treatment** in women **≥ 65** years and men **≥ 75** years; T score **≤ - 2.5**
75
What is the threshold GRACE score needed to indicate coronary angiography within 72 hours of admission in stable patients presenting with a non-ST-elevation myocardial infarction (NSTEMI)
**GRACE score >3%**; coronary angiography within 72 hours of admission
76
Outline the mechanism by which renal artery stenosis (RAS) causes secondary hyperaldosteronism? (4)
- As a result of the stenosed renal artery, renal afferent arteriole hydrostatic pressure drops subsequently causing GFR to decrease
- Via the autoregulation mechanism, the kidneys respond to this drop in GFR by stimulating renin release from the juxtaglomerular apparatus (JGA)
- Renin release results in increased levels of angiotensin-II which preferentially vasoconstricts efferent arteriole restoring GFR
- However angiotensin-II also triggers aldosterone release via acting on the AT1 receptors expresed by cells in the zona glomerulosa of the adrenal cortex
77
Outline the threshold CHA2DS2-VASc scores required for anticoagulation to be offered in men and women with atrial fibrillation? (2)
- Men; CHA2DS2-VASc ≥ 1
- Women; CHA2DS2-VASc ≥ 2
78
Outline the indications for chest drain insertion in patients with a pleural effusion? (3)
- Frankly purulent or turbid/cloudy pleural fluid
- Presence of organisms identified by Gram stain and/or culture of pleural fluid
- Pleural fluid pH < 7.2
79
Outline the components of the Alvarado Score for appendicitis? (8)
**MANTRELS**;
- **M**igratory pain = +1
- **A**norexia = +1
- **N**ausea/vomiting = +1
- **T**enderness in RIF = +2
- **R**ebound tenderness = +1
- **F**ever > 37.3°C = +1
- **L**eukocytosis = +2
- **S**hifted left neutrophilia = +1
80
Outline how to differentiate the causes of a pleural effusion? (3)
- Pleural fluid protein **< 25 g L-1; transudative**
- Pleural fluid protein **25 - 35 g L-1;** apply **Light's criteria**
- Pleural fluid protein **> 35 g L-1; exudative**
81
Outline how the Wells score for DVT can be used to guide investigation?
- Score ≥ 2; DVT likely, proceed to lower limb US (< 4hrs) - Score ≤ 1; DVT unlikely but proceed to D-Dimer (< 4hrs)
82
Outline how the CURB-65 score is used to guide admission in patients with suspected pneumonia?
- Score 0 - 1; consider home treatment (no admission) - Score 2 - 3; consider hospital admission - Score > 3; consider intensive care assessment
83
Outline the clinical definition of orthostatic (postural) hypotension?
A **drop** in systolic blood pressure (**SBP**) **≥ 20 mmHg** and/or a **drop** in diastolic blood pressure (**DBP**) **≥ 10 mmHg** after **3 minutes of standing**
84
Outline the components of the CHA2DS2VASc score used in the risk stratification of stroke in patients with AF?
- Congestive heart failure = +1 - Hypertension = +1 - Age ‚â• 75 = +2 - Diabetes = +1 - Stroke/TIA/VTE = +2 - Vascular Disease = +1 - Age 65-74 = +1 - Sex Category Female = +1
85
Outline the classical triad of features associated with pellegra (vitamin B3 deficiency)? (3)
- Diarrhoea
- Dermatitis
- Dementia
86
Which medication can be used to correct vitamin-D deficiency that occurs in patients with chronic kidney disease (CKD)?
**Alfacalcidol**; this is an analogue of calcitriol that does not require activation in the kidney
87
Which condition is most commonly associated with a vertical axis where the magnitude of the deflection in lead I on an ECG is essentially zero?
Chronic obstructive pulmonary disease (COPD); hyperinflation of the chest causes a predominantly vertical vector of depolarisation
88
Outline the components of Light's criteria for the differentiation of the causes of pleural effusion? (3)
≥ 1 of the following suggest an **exudative** pleural effusion
- Pleural fluid **protein : serum protein ratio > 0.5**
- Pleural fluid **LDH : serum LDH ratio > 0.6**
- Pleural fluid **LDH > 2/3rds upper limit of the serum** LDH
89
Which antibiotic can be used in patients with a Clostridium difficile infection that is not responding to vancomycin?
Oral fidaxomicin
90
Outline the mainstay of treatment used in sickle cell crisis? (3)
- IV analgesia
- Oxygen
- IV fluids
91
Outline the indication fro the use of calcium gluconate in hypocalcaemia?
Prolonged QT interval is an indication for urgent IV calcium gluconate
92
Outline the target saturations for a patient with chronic obstructive pulmonary disease (COPD) who has a normal pCO2 on an aterial blood gas (ABG)?
Target saturations in patients with COPD who aren't CO2 retainers should be 94-98%
