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Flashcards in Kings 2018 (Jan) Deck (24)
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1

1)78 year old man presents to ED. Collapsed at home is confused and drowsy. Before collapsing had headache and nausea. Has copd, still smoked 20 a day. Temperature is 35.2, heart rate is high, blood pressure is low. Oxygen is 98% and carboxy is  35% (<1.5) what is the most appropriate form of oxygen therapy


A. 2L/min nasal canala
B. 15L/min non- rebreathable mask
C. 28% venturi mask
D. 35% venturi mask
E. 60% Venturi mask

15L/min non- rebreathable mask

2

18 month old boy drinks paracetamol suspension 100ml at 120mg/5L. Mum beings him to A&E. 7 hours after his paracetamol plasma levels were 42mg.
On graph the treatment line showed around 57mg.
What's the most appropriate management?

A discharge to community
B IV acetylcysteine
C admit for observation
D activated charcoal
E gastric lavage

admit for observation

 

100/5*120=2400mg ...anything over 150mg/kg is probably toxic so should be treated

Single acute overdose is defined as an ingestion of >4 g (or >75 mg/kg) in a period of <1 hour.

->acetylcystein

Management of paracetamol overdoes

activated charcoal if ingested < 1 hour ago

N-acetylcysteine (NAC)

liver transplantation

Acetylcysteine should be given if:

there is a staggered overdose* or there is doubt over the time of paracetamol ingestion, regardless of the plasma paracetamol concentration; or

the plasma paracetamol concentration is on or above a single treatment line joining points of 100 mg/L at 4 hours and 15 mg/L at 15 hours, regardless of risk factors of hepatotoxicity


Acetylcysteine is now infused over 1 hour (rather than the previous 15 minutes) to reduce the number of adverse effects.

King's College Hospital criteria for liver transplantation (paracetamol liver failure)

Arterial pH < 7.3, 24 hours after ingestion

or all of the following:

prothrombin time > 100 seconds

creatinine > 300 µmol/l

grade III or IV encephalopathy

3

3)50 year old female 6 months Hx of malaise and pruritis. Also jaundiced. No recent travel, use of injections, alcohol use or blood transfusion.
Albumin is low
Alanine aminotransferase high
Bilirubin high
Alkaline phosphatase high

PBC

 

Primary biliary cholangitis (previously referred to as primary biliary cirrhosis) is a chronic liver disorder typically seen in middle-aged females (female:male ratio of 9:1). The aetiology is not fully understood although it is thought to be an autoimmune condition. Interlobular bile ducts become damaged by a chronic inflammatory process causing progressive cholestasis which may eventually progress to cirrhosis. The classic presentation is itching in a middle-aged woman

Associations

  • Sjogren's syndrome (seen in up to 80% of patients)
  • rheumatoid arthritis
  • systemic sclerosis
  • thyroid disease


Diagnosis

anti-mitochondrial antibodies (AMA) M2 subtype are present in 98% of patients and are highly specific

smooth muscle antibodies in 30% of patients

raised serum IgM


Management

  • pruritus: cholestyramine
  • fat-soluble vitamin supplementation
  • ursodeoxycholic acid
  • liver transplantation e.g. if bilirubin > 100 (PBC is a major indication) - recurrence in graft can occur but is not usually a proble

4

20 year old female with severe acne has tried retinoids to no effect. She would like to try hormonal treatment but has previous history of DVT from a long haul flight. What can you prescribe her?

  1. Desogestrel
  2. Co-cyprindiol
  3. Flucoxacillin
  4. Lymecycline

Lymecycline

 

Antibiotic options: tetracycline, minocycline, doxycycline

  • Mild acne: no inflammation: 
    • topical retinoid or salicyclic acid
  • Mild acne: with inflammationtopical retinoid + topical antibiotic
    • +topical benzoyld peroxide
    • +topical azelaic acid
  • Moderate acne: No inflammation
    • topical retinoid
  • Moderate acne with inflammation: topical retinoid + Oral antibiotic
    • +topical benzoul peroxide
    • +topical azaleic acid
  • Severe/resistant acne: 
    • Oral retinoid
    • Oral corticosteroid

5

week old baby with vomiting after feeding for past few weeks getting worse in last 5 days. Vomits a large amount after breastfeeds. Has lost weight and remains hungry after feeds. What is the diagnosis?

  1. Pyloric stenosis
  2. Gastroenteritis
  3. Overfeeding
  4. Intussusception

Pyloric stenosis

Features

  • 'projectile' vomiting, typically 30 minutes after a feed
  • constipation and dehydration may also be present
  • a palpable mass may be present in the upper abdomen
  • hypochloraemic, hypokalaemic alkalosis due to persistent vomiting

6

30 year old woman with 3 months of diarrhoea which is sometimes bloody. She has pain in the right iliac fossa. Temperature is 37. What is the diagnosis?

  1. Appendix abscess
  2. Diverticulitis
  3. Ileo-caecal intussusception
  4. Crohn’s disease

Crohn’s disease

  • Diarrhoea usually non-bloody 
  • Weight loss more prominent 
  • Upper gastrointestinal symptoms, mouth ulcers, perianal disease
  • Abdominal mass palpable in the right iliac fossa

7

Man had STEMI 2 days ago. Presents with central chest pain worse on inspiration and moving forward. He has a normal HR and BP. ECG shows widespread ST Elevation and T inversion. Diagnosis?

  1. Pericarditis
  2. Aortic dissection
  3. Myocardial infarction

Pericarditis

8

Women presents with lump on neck. Moves with swallowing and lifting the tongue. Diagnosis?

 

  1. Thyroglossal cyst
  2. Branchial cleft cyst
  3. Multi modular goitres
  4. Leiomya

Thyroglossal cyst

9

Man had 100m claudication with ABPI 0.84. Treatment?

 

  1. Above knee bypass graft
  2. Below knee bypass graft
  3. Exercise therapy
  4. Long saphenous something

Exercise therapy

10

A 69 y/o man has a four-day history of breathlessness, fever and rigors. He has a previous 40-pack year history. Temp 37.7, BP normal, RR 30 breaths per minute.
Blood culture taken, IV fluids and antibiotics have been given. CXR shows left sided opacity in the lower left sternal edge.

Blood results show slightly raised urea, normal levels of sodium and potassium.

What’s the next most appropriate investigation?
A. CT pulmonary angiogram
B. Echocardiography
D. Spirometry
E. Urinary legionella and pneumococcal antigen

Urinary legionella and pneumococcal antigen

11

A 36 y/o woman has a four-day history of weakness from her wrist to the index and middle finger. She is 35 weeks pregnant. She recently developed numbness and tingling. Tinel’s test is negative.

What is the most possible diagnosis?
A. Carpal tunnel syndrome
B. Multiple sclerosis
C. Lateral epicondylitis
D. Ulnar nerve entrapment
E. Thoracic outlet syndrome

Carpal tunnel syndrome

Sensitivity and specificity of Phalen’s test was found to be respectively 67.2% and 92.9%, and for the percussion test (Hoffmann-Tinel), 53.4 and 95.6%.

98 of 436 patients with carpal tunnel syndrome showed negative results for both tests.

The false positive and negative rates of Phalen’s test were 7% and 32.7 respectively.

On the other hand the false positive and negative rates of Tinel’s sign were 4.3% and 46.5% respectively.

 

History

  • pain/pins and needles in thumb, index, middle finger
  • unusually the symptoms may 'ascend' proximally
  • patient shakes his hand to obtain relief, classically at night

Examination

  • weakness of thumb abduction (abductor pollicis brevis)
  • wasting of thenar eminence (NOT hypothenar)
  • Tinel's sign: tapping causes paraesthesia
  • Phalen's sign: flexion of wrist causes symptoms

Causes

  • idiopathic
  • pregnancy
  • oedema e.g. heart failure
  • lunate fracture
  • rheumatoid arthritis


Electrophysiology: motor + sensory: prolongation of the action potential


Treatment

  • corticosteroid injection
  • wrist splints at night
  • surgical decompression (flexor retinaculum division)

12

A baby boy has been crying at night, and tugging at his ear. This is followed by yellow discharge.

Which organism causes this?

  1. Staph aureus
  2. Strep pneumoniae
  3. E.coli
  4. Pseudomonas aureginosa

Strep pneumoniae 

 

Organisms

  • Viral
  • Pneumococcus
  • Haemophilus
  • Moraxella

13

A woman who is 11 weeks pregnant presents with a macular erythematous rash on her trunk. Her nephew has a similar rash 2 weeks ago and he has had no vaccinations.

Which infection has caused this?

  1. Chicken pox
  2. Measles
  3. Mumps
  4. Rubella

 

Chickenpox

 

...is caused by primary infection with varicella zoster virus. Shingles is reactivation of dormant virus in dorsal root ganglion

  • Chickenpox is highly infectious
  • spread via the respiratory route
  • can be caught from someone with shingles
  • infectivity = 4 days before rash, until 5 days after the rash first appeared*
  • incubation period = 10-21 days

Clinical features (tend to be more severe in older children/adults)

  • fever initially
  • itchy, rash starting on head/trunk before spreading. Initially macular then papular then vesicular
  • systemic upset is usually mild


A common complication is secondary bacterial infection of the lesions. Rare complications include

  • pneumonia
  • encephalitis (cerebellar involvement may be seen)
  • disseminated haemorrhagic chickenpox
  • arthritis, nephritis and pancreatitis may very rarely be seen

14

A lady in her 60s presents to her GP after experiencing episodes of visible haematuria. Urine dip shows blood 3+. What should the GP do?

  1. Repeat urine dip after 2 weeks
  2. Give antibiotics
  3. Request CT of kidneys, ureters and bladder
  4. Ultrasound of kidneys
  5. Urgent referral to urology

Urgent Referal to urology

 

refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for bladder cancer if they are:

  • aged 45 and over and have:
    • unexplained visible haematuria without urinary tract infection or
    • visible haematuria that persists or recurs after successful treatment of urinary tract infection, or
  • aged 60 and over and have unexplained non-visible haematuria and either dysuria or a raised white cell count on a blood test
  • consider non-urgent referral for bladder cancer in people aged 60 and over with recurrent or persistent unexplained urinary tract infection

 

15

A 24 year old man presents to A+E after coughing up green sputum and experiencing some breathlessness. Sputum microscopy shows gram positive cocci in pairs. What antibiotics should be given to him?

  1. Amoxicillin
  2. Metronidazole
  3. Gentamicin
  4. Trimethoprim
  5. Vancomycin

Amoxicillin

16

50 yr old man who had a laparoscopy for intestinal obstruction. His bp was 80/67 and pulse 115. He was on epidural for pain relief. A 500ml bolus was given and the bp remained the same.What;s the initial management

  1. Stop epidural
  2. Give 500ml saline
  3. Ionotropic
  4. Do nothing

Give 500ml saline

17

Patient with chronic Hepc. Back pain and sob. Iv drug user. Tender on l3 to l5 on palpation of the spine. New onset murmur on lower left sternal border. The  patient had fever proteinuria and haematuria

ALP raised and ALT

Urea raised

What explains this patients presentation?

  1. Inf endocarditis
  2. Pyelonephritis
  3. Hiv
  4. Exacerbation of Hep C

?Pyelonephritis/ IE

18

A 67 year old man has recently increased his dose of artorvostatin, and is now experiencing sob etc. He has a hx of hypercholesterolaemia and hypertension.

He has high ALP and very high creatine kinase.

 

What should he do?

 

          A) Stop artorvostatin
          B) Stop artorvostatin and start NSAIDs
          C) Half dose of artorvostatin
          D) Stop and switch to rosuvastatin
          E) Stop and switch to simvastatin

 

Stop artorvostatin

19

A man has anuria. He had a left nephrectomy a few years ago.

His scans show that he has ureteric dilatation.

What treatment should he have?

          A) Percutaneous nephrolithotomy

          B) Lithotripsy
          C) Ureteroscopy

Percutaneous nephrolithotomy

20

. 81y lady with 30y history of RA. Cannot have a bath for herself and finding increasing difficulty eating with knife and fork. What is the next line of management?

- refer to rheum OP

- Care package three times per day

- Physio and OT Home visit assessment

- Admit to hospital for a comprehensive geriatric assessment

Physio and OT Home visit assessment

21

75y lady having a second blood transfusion. Hb of 58. History of IHD. Developed tachycardia and bilateral crepitations on lung bases. Nurses have stopped the transfusion. What drug do you administer next?

 

- IV furosemide

- IV hydrocortisone

- IV chlorphenamine

- IV broad spectrum antibiotics

- Nebulised salbutamol

IV furosemide

22

28 year old girl with cyclical lower abdominal pain for the last 7 months whos been having difficulties trying to conceive. She has associated deep dyspareunia. All her observations were normal and she was otherwise well. No PMH, no DH, no SH.

 

What is the most diagnostic test available to identify her condition?

 

TVUS

Hysteroscopy

MRI Pelvis

Abdominal X-ray

Abdo Ct

 

Laparoscopy=Diagnostic

TVUS: Sensitivity 71%, and specificity 96% for detecting uterosacral ligament disease.Sensitivity 29%, and specificity 99% for detecting rectovaginal septal disease Ultrasound exam is limited by retroverted uterus. May detect infiltrating bladder endometriosis

MRI Pelvis: Sensitivity and specificity for deep pelvic disease is approximately 90%, but is consistently lower for uterosacral ligament and higher for gastrointestinal disease

23

9 Month old baby presenting to A&E, with a temperature of 38.9 degrees, bulging anterior fontanelle, Cap refill of 4 seconds, baby is very faint, and has severe difficulties feeding/SOB.

 

What is the most likely cause of the babies presentation?

 

Meningococcal disease

Group B Streptococcus

Viral Meningitis

Staph Aureus

Meningococcal disease

 

Neonatal to 3 months

  • Group B Streptococcus: usually acquired from the mother at birth. More common in low birth weight babies and following prolonged rupture of the membranes
  • E. coli and other Gram -ve organisms
  • Listeria monocytogenes

1 month to 6 years

  • Neisseria meningitidis (meningococcus)
  • Streptococcus pneumoniae (pneumococcus)
  • Haemophilus influenzae

Greater than 6 years

  • Neisseria meningitidis (meningococcus)
  • Streptococcus pneumoniae (pneumococcus)

24

2

6 years old lady presents with worsening headaches over the past 4 weeks. They are worse when straining on defecation. She smokes 20 cigarettes a day, drinks 10-12 cups of coffee a day, drinks 40 units of alcohol a week and has a BMI of 33.

 

CT Head; normal,

LP pressure; 40

Acuity; 6/12
 

What is the best intervention to help with the headaches?


A) Reduce caffeine intake
B) Smoking cessation
C) Reduce alcohol consumption
D) Weight loss

E)?

Weight loss