Mocks Flashcards
1
Q
How to differentiate between cholecystitis and cholangitis in the stem of the question?
A
Cholangitis - bilirubin has to be raised. Triad is jaundice, fever and RUQ pain. The RUQ pain is diffuse unlike cholecystitis where the pain is Murphy positive.
Cholecystiits - Patients typically present with pain and localised tenderness, with or without guarding, in the upper right quadrant. Doesn’t have to be fever + systemic upset.
2
Q
Types of lung cancer and their features
A
Small Cell and Non-Small Cell
Small Cell - aka oat cell - is though to have derived from neuroendocrine cells in the bronchus (fetyrer cells) and so produce ectopic hormones e.g. ADH (causing SIADH and hyponatraemia), ACTH (causing Cushing’s). It rapidly divides and produces mets earlier so even though it is chemosensitive it carries a poor prognosis.
NSCC - SCC, adenoc, Large C,
SCC- smokers, male, radon gas associations, centrally located, keratinisation on histo, produces PTH which causes hypercalcaemia of malignancy
Adeno - associated with non smokers, female, far east, peripherally located, mucin production and glandular cells on histo, extra thoracic mets present early (80%)
Large Cell - Poorly differentiated large cells and poor diagnosis
3
Q
PTHrp
A
Parathyroid hormone-related protein (or PTHrP) is a protein member of the parathyroid hormone family secreted by mesenchymal stem cells. It is occasionally secreted by cancer cells (breast cancer, certain types of lung cancer including squamous-cell lung carcinoma).
4
Q
How to prescribe morphine SC
A
Dose of morphine sulfate SC in 24 hours = 0.5 x
Total Morphine sulfate oral dose in 24 hours
5
Q
Red flags of back pain
A
If red flags present get XR spine, then if negative get MRI
Cancer, Cauda Equina, Fracture & Infection
Ca - >50, PMHx ca (breast, lung, gastrointestinal, prostate, renal, and thyroid cancers), pain that remains when the person is supine, aching night pain that prevents or disturbs sleep, pain aggravated by straining, Localised tenderness, refractory to back pain therapy, wt loss.
Infection - fever, recent TB/UTI, IVDU, HIV
# - Sudden onset of severe central spinal pain which is relieved by lying down, trauma hx
Cauda - bilateral neurological deficit of the legs,
Recent urinary retention (caused by bladder distension because the sensation of fullness is lost) and/or urinary incontinence (caused by loss of sensation when passing urine); faecal incontinence (due to loss of sensation of rectal fullness); Perianal or perineal sensory loss (saddle anaesthesia or paraesthesia); Unexpected laxity of the anal sphincter.
6
Q
How do you manage neutropenic sepsis?
A
SUSPECTED:
Treat suspected neutropenic sepsis as an acute medical emergency and offer empiric antibiotic therapy immediately usually PIP-TAZ
Order FBC, kidney and LFT (including albumin), CRP, lactate and blood culture
To diagnose: pts having anticancer treatment whose neutrophil count is 0.5×109 per litre or lower and who have: > 38oC or other signs or symptoms consistent with clinically significant sepsis.
CONFIRMED:
Do a risk assessment, if low -> outpt IV if high -> admit for obs
Switch from IV to oral after 48 hours if risk is low when re-assessed
7
Q
Mesenteric Ischaemia presentation
A
Has a widely ranging, vague presentation, and different types i.e. acute, chronic and colonic
75% have a leukocytosis and ~ 50% have metabolic acidaemia
PMHx of vascular pathology would make you suspicious
Elderly
8
Q
PE different types of mx
A
UNSTABLE:
Thrombolysis IV alteplase < 4.5 hours + IV UFH
If CI use IV hep (need weight and gfr)
If IV hep and thrombolysis CI, use NA
STABLE:
1st line Apixaban /riva
2nd line LMWH for 5d then dabig OR LMWH + Warfarin for 5d
IVC filter – to prevent DVT becoming PE when you can’t anticoagulate the pt
9
Q
Pericarditis investigation findings
A
Pleuritic pain
ECG: Saddle ST elevation, T wave inversion, J wave
Troponin mildly elevated
10
Q
CHADVASc scoring and meaning
A
NB, >75 -> anticoag, >65F -> anticoag, ONLY 2 points needed
CHF history HTN Age >65 if >75 thats 2 points DM Vascular disease
2 = moderate-high and should consider anticoagulation
Also gives annual stroke risk as a percentage. Multiply this by estimate of years left to work out life time risk of stroke
Anticoagulate with DOAC (Xa e.g. apix) or Warfarin (new nice guidelines)
11
Q
ACE inhibitors monitoring and how to deal with abnormal results
A
Side effects / interactions are often due to excessive hypotension: antihypretensives, diuretics, tetracyclines, alcohol etc
Anti-diabetics- be careful of increased blood glucose lowering
Don’t use concurrently with NSAIDs
If the serum creatinine level increases by more than 20% or the eGFR falls more than 15%, re-measure renal function within 2 weeks.
An increase of the serum creatinine level of less than 30% does not require further action.
An increase of the serum creatinine level of 30–50% (or to over 200micromol/L) or eGFR less than 30 mL/min/1.73 m2 should prompt clinical review of volume status and temporary dose reduction, or withdrawal of the diuretic or ACE-inhibitor.
12
Q
Gout management
A
Acute Gout
1st line NSAIDs,
2nd line Colchicine (causes diarrhoea, can be very toxic OD), or Oral pred
± IA steroids
± Paracetamol (not first line)
Choice of first-line agent depends on patient preference, renal function and co-morbidities.
Ongoing (2-3 weeks post acute episode)
1st line Allopurinol
Febuxostat
13
Q
Hypoglycaemia mx inside hospital
A
INSIDE:
If safe swallow: Give oral glucose and re-assess in 15min, repeat this 3x if necessary, if still <4 give either IM glucagon
If non safe swallow: A-E; IV access available, give 75-100ml of 20% glucose over 15 minutes, (e.g. 300-400ml/hr)
14
Q
Diabetic medications MoA
A
Sulphonylureas - Stimulate pancreas to make more insulin
DPP4 inhibitors - Potentiate endogenous GLP-1 and GIP which stimulate insulin sec.
SGT-2 inhibitors- Sodium glucose cotransporter inhibitors
GLP-1 agonists - Lowers blood glucose post meal by increasing insulin secretion, suppress glucagon and slow gastric emptying
Thiazolidinediones - Alter transcription of genes in carb/lipid metabolism
15
Q
Diabetic Medications cautions/ci
A
Sulphonylureas - Can cause hypoglycaemia
Modest wt gain
DPP4 inhibitors - Don’t cause hypos or weight gain
CI Pancreatitis; Can cause HF, Pancreatitis
SGT-2 inhibitors- Associated with risk of DKA, UTI,
Can’t use if impaired renal function
GLP-1 agonists - N&V, diarrhoea; Acute pancrea; Hypos
Thiazolidinediones - Several long term risks (Bone #, wt gain, visual impairment) CI HF, bladder ca
16
Q
How do we manage diabetes
A
C: DIABETES PREVENTION PROGRAMME REFERRAL Weight loss, increase exs, reduce alcohol and smoking, refer to structured education programme
M: If HbA1c >53 commence treatment but should be an individualised goal (~48)
1) Metformin 500mg OD (can increase to 1000mg twice daily)
2) If above goal, add sulphonylurea, pioglitazone, SGLT-2 inhibitor or DPP4 inhibitor
3) Basal insulin added or triple therapy
17
Q
What do you need for a diagnosis of diabetes?
A
Symptomatic + 1 value or A/S + 2 values on different occaisions
Fasting ≥ = 7.0 diabetes, 6.1-6.9 IFG
Random plasma glucose ≥ 11.1
75mg OGTT ≥ 11.1 Diabetes, 7.8-11 IGTT
HbA1c of ≥ 48 met, 39 to 46 HbA1c is prediabetic
18
Q
Different in presentation of Ischaemic Colitis vs Sigmoid diverticulitis vs Meckel’s diverticulitis
A
Ischaemic - evidence of generalised atherosclerosis, and presents with abdominal pain and rectal bleeding
Acute diverticulitis - tenderness, rebound, and guarding may be present in the LLQ of abdomen, pelvic tenderness on DRE
MD - most are asymptomatic, periumbilical pain that radiates to the right lower quadrant, can present with bleeding or obstruction, clinically indistinguishable from appendicitis
Bleeding occurs in 30% to 40% of symptomatic patients in both paediatric and adult patient groups
19
Q
Ischaemic Colitis Pathophysiology
A
Ischaemia occurs secondary to hypoperfusion of an intestinal segment. When hypoperfusion is acute, collateral blood flow may develop, precluding or minimising ischaemia; however, the regions of the intestine with a solitary arterial supply, and the watershed areas, are both at increased risk of developing ischaemia. (Watershed areas - splenic and duodenal flexure)
The degree of intestinal injury is dependent on the duration and severity of ischaemia. Acute or subacute mucosal sloughing and ulcerations occur as a result of ischaemia. The loss of the mucosal barrier allows for bacterial translocation and toxin or cytokine absorption. Re-perfusion injury can also occur if blood supply is re-established after a prolonged interruption. Segments of ischaemic bowel that do not suffer acute necrosis or perforation can heal with stenosis or stricture as the long-term sequelae of bowel ischaemia.
20
Q
Types of hearing loss
A
Conductive hearing loss occurs usually in the external and middle ear by interfering with the ability of sound to be transmitted to the inner ear. Many causes can be treated successfully with surgery.
Sensorineural hearing losses occur in the inner ear (sensory) or auditory nerve/auditory pathway (neural). Many sensorineural hearing losses are permanent because the human inner ear and hair cells have only limited ability to repair themselves, unlike avian hair cells, which can re-generate after trauma or injury
Webers = If the sound is louder in one hear it either means conductive loss on same side or sensorineural on the opposite side (SOCS)
Rinnes = If Bone is louder than air its a conductors affair (Air should be louder than bone)
NB - rinne positive is normal, rinne negative is conductive loss
21
Q
Sensorineural hearing loss managment
A
Lesions of the vestibularcochlear nerve (CNVIII), such as vestibular schwannoma (acoustic neuroma), usually present with unilateral hearing loss.
Can also have tinnitus, and imbalance.
It is recommended that all patients with unilateral aural symptoms, such as unilateral tinnitus and/or unilateral sudden sensorineural hearing loss, undergo magnetic resonance imaging to assess for retrocochlear pathology.
“If on one side they need the volume high, don’t forget to do an MRI” - to rule out a vestibula schwannoma
Mx Watch and wait, gamma radiation, ENT/neurosurgery:
22
Q
Optic chiasm tumour will cause which visual defect
A
If no visual symptoms and normal visual acuity, the earliest visual field deficit will be red desaturation in the bitemporal lower visual fields and subsequent bitemporal hemianopia. The blind spots are normal in chiasmal
compression unless there is associated papilloedema from raised intracranial pressure (Foster Kennedy syndrome).
23
Q
Lesion on the optic nerve will give rise to which visual defect
A
Monocular vision loss
if the lesion is in the retina of the eye -> Central scotoma
24
Q
Lesion on the optic tract will give rise to which visual defect
A
Homonymous hemianopia (Right) = the brackets is the side you CAN see
25
Lesion on the optic radiations will give rise to which visual defect
Quadrantopia
26
A 33 year old man has recurrent episodes of collapse over 7 months. When angry, his muscles feel limp and he falls to the floor, but he remains conscious.
Cataplexy is loss of skeletal muscle tone with strong emotions
27
macula sparing lesions occur with what pathology
occipital lobe defect due to stroke because the area of the occipital lobe that corresponds to the macula has dual supply so even if you get a stroke that knocks the blood supply you will not have vision loss in retina
28
Causes of hypoalbuminaemia
Low - Negative acute phase reactant, Liver failure, 3rd space losses, increased GI losses, Nephrotic proteinuria
29
De Quervain's tendinopathy
A stenosing tenosynovial inflammation of the 1st dorsal compartment which includes abductor pollicis longus (APL) & extensor pollicis brevis (EPB)
O/E: Special test: pain at the radial styloid with
active or passive stretch the thumb tendons over the radial styloid in thumb flexion (Finkelstein test)
PC: radial sided wrist pain, pain exacerbated by gripping and raising objects with wrist in neutral
Ix: Radiographs not needed for diagnosis
C: thumb splint
M: NSAIDs, steroid injections
S: Surgical release of 1st dorsal compartment
Rf: can be traumatic, but overuse GOLFERS SQUASHERS (Racquet balls)
30
Intersection syndrome
Due to inflammation at crossing point of 1st dorsal compartment (APL and EPB ) and 2nd dorsal compartment (ECRL, ECRB)
PC: Pain over dorsal forearm and wrist; tenderness on dorsoradial forearm ~ 5cm proximal to the wrist joint
Rf: ROWERS and weights LIFTERS
31
Scaphoid fracture
Scaphoid is most frequently fractured carpal bone, often occurring after FOOSH (high/low energy) (waist 65%; proximal 1/3 25%; distal 1/3 10%)
O/E:
anatomic snuffbox tenderness dorsally
scaphoid tubercle tenderness volarly
scaphoid compression test
positive test when pain reproduced with axial load applied through thumb metacarpal
Mx:
Proximal pole or displacement >1mm = unstable = surgical management
32
Adhesive capsulitis
| Associations + management
Association: diabetes t1 + t2, thyroid disease
```
CMS
Surgery: MUA or arthroscopic release
controversial if done during freezing/inflammatory phase
diabetics- 50% failure rate
following rotator cuff or labral repair
```
33
Osteoporosis Mx
1st line - Bisphosphonate e.g. Alendronic acid
+ Calcium Vit D Supplements
2nd line- Denosumab (can be 1st line in severe osteoporosis at risk of # in post menopausal F)
3rd line - PTH receptor agonist e.g. teriparitide
If none of those are tolerated can use Raloxifene (SERM)
34
A 56 year old woman presents to the GP with 7 weeks of intermittent dizziness that she describes as 'the room tilting'. The episodes start suddenly, are usually triggered by turning her head quickly, and last less than a minute before resolving completely. She reports nausea during these episodes. She is otherwise well. Otoscopic and neurological examinations are normal.
BPPV
35
Meniere disease vs BPPV vs Acoustic neuroma vs Vestibular neuritis vs Cerbellar pathology vs Viral labrynthitis vs Vetebrobasillar ischaemi
Meniere disease - low frequency,
sensorineuronal hearing loss, tinnitus, and aural fullness that is often exacerbated during an episode of vertigo, Recurrent episodes of vertigo last for mins- hrs + NOT provoked by positional changes
BPPV - sudden, short-lived episodes of vertigo elicited by specific head movements. Dix Hallpike maneouvre for diagnosis. Epley for treatment.
Acoustic neuroma/Vestibular Schwannoma- A benign slow-growing tumour, which, following detection, usually remains stable. Unilateral sensorineural hearing loss is the most common symptom, followed by intermittent dizziness and facial numbness
Vestibular neuritis
Often a single episode of persistent vertigo lasting for days. The vertigo can be exacerbated by any positional change, unlike the specific head movements that induce BPPV attacks. Hallpike manoeuvre doesn't cause nystagmus/vertigo. May be preceded by a non-specific viral infection. NO HEARING LOSS. 'Neuronitis No hearing loss"
Cerbellar pathology - nystagmus, ocular dysmetria, abnormalities of pursuit, saccadic oscillations, and an ataxic gait. If stroke, triad of NV, headache and ataxia.
Labrynthitis - short onset again (hours) of sudden vertigo and hearing loss, HPC of viral infection, vomiting, nystagmus
Vetebrobasillar ischaemia - Elderly patient
Dizziness on extension of neck
```
Other causes of vertigo include
posterior circulation stroke
trauma
multiple sclerosis
ototoxicity e.g. gentamicin
```
36
A 73 year old woman has abdominal pain 4 days after a laparoscopic bowel
resection with primary anastomosis for bowel cancer. Her temperature is 36.9°C,
pulse rate 105 bpm, BP 120/72 mmHg and oxygen saturation 96% breathing oxygen
6 L/min via face mask. She has reduced breath sounds in both bases. She has
abdominal tenderness with guarding and reduced bowel sounds
What is the most apporpirate investigation?
a CT with contrast (not an AXR) as this is hinting at an anastomotic leak which usually presents ~4/5days post op. CT would be required after AXR anyway in this case.
37
When do you activate a major haemorrhage call?
A pragmatic clinically based definition is bleeding which leads to a systolic blood pressure of less than 90 mm Hg or a heart rate of more than 110 beats per minute
Major haemorrhage is variously defined as:
- Loss of more than one blood volume within 24 hours (around 70 mL/kg, >5 litres in a 70 kg adult)
- 50% of total blood volume lost in less than 3 hours
- Bleeding in excess of 150 mL/minute.
38
What is the single most appropriate therapeutic change to the meds?
A 59 year old man is reviewed in clinic. He has type 1 diabetes mellitus, hypertension, ischaemic heart disease and CKD stage 4 [recent eGFR 25 mL(> 60). He is taking insulin, lisinopril, metoprolol tartrate and aspirin.
His BP is 156/96 mmHg. He has pitting oedema to the knee.
Ix:
Na 136 mmol/L (135–146)
K 5.6 mmol/L (3.5–5.3)
Urea 17.4 mmol/L (2.5–7.8)
Creatinine 237 μmol/L (60–120)
eGFR 26 mL/min/1.73 m2 (>60)
Urinalysis: protein 2+
ADD IN FUROSEMIDE
| don't get distracted by potassium, offloading fluid is priority here
39
When do you oxygenate in A-E of a STEMI?
Oxygen will increase mortality for STEMI with sats of >94%. (BMJ Nov 2018).
40
Adrenal crisis presentation + mx
Adrenal crisis is acute presentation of addison's
Nearly all patients have a history of lethargy and weight loss
Bloods: Hyponatraemia + hyperkalaemia
1. Hydrocortisone should be given to patients with a suspected but unconfirmed diagnosis of adrenal insufficiency
2. Saline should be administered to correct hypotension and dehydration. It is usually necessary to administer 1 L rapidly and a further 2 to 4 L over the first 24 hours,
3. Glucose should be administered when necessary to correct hypoglycaemia
The underlying cause that precipitated the crisis should be sought and treated, and once the patient is stable
41
Cord compression imaging and management
Imaging of choice: MRI of spine
Management depends on whether its acute, traumatic infective, chronic, malignant.
ACUTE (traumatic) - Immobilise with cervical collar and then surgery (decompression/stabilisation surgery)
ACUTE (atraumatic, cauda equina) - decompressive laminectomy within 48hrs (medical intervention has shown no benefit). LMWH within 72 hrs. PPI for 4 weeks after SCC.
Infective - Abx (vanc and metro and cef) (staph)
MALIGNANT - Treatment of spinal mets is largely palliative. Historically, treatment has consisted of corticosteroids (dexamethasone) to reduce oedema and help with pain. Consider surgery (decompressive laminectomy/vertebrectomy) and radiation.
42
A 62 year old woman attends her GP surgery with shortness of breath on exertion and a cough productive of white sputum on most mornings. She has never had haemoptysis and has maintained a steady weight. She describes four chest infections in the past year treated with a short course of steroids and antibiotics. She has a 10 pack-year smoking history.
Her BP is 132/85 mmHg. Chest X-ray is normal.
What is the diagnosis and test needed to confirm?
COPD over HF
- BP/Smoking history doesn't point either way
- Symptoms (breathless on exertion) could be present in either
- PMHx of repeat chest infections and chronic cough is more COPD than HF
- Spirometry
43
Post op oliguria differentials
Pre-renal:
- Pre-renal Hypovolaemia
- Intra-abdominal HTN
- Renal artery occlusion (rare, cause loin pain, systemically unwell)
Renal:
- ATN (nephrotoxic substances used? abx/dye?)
- embolic events (esp are releasing an aortic clamp)
- Ureteric injury (to cause AKI would need to be bilateral injury)
Post-renal:
- Catheter obstruction - anuria
- Ureteric obstruction - anuria
44
A 20 year old man is brought to the Emergency Department having been struck on the side of the head with a cricket ball.
He has a minor scalp abrasion. His GCS is 15/15 and there are no focal neurological signs.
Four hours later he collapses, at which point his GCS is 6/15. A CT scan of brain reveals a biconvex haemorrhage in the right parietal region.
Hit side of the head with a ball -> likely to be pterion and underneath the pterion is the MMA
A bleed in the MMA leads to an EDH
This is supported by the 'biconvex' which basically means LENS shaped i.e. EDH
This matches the history: clear trauma + lucid interval
45
What does lung malignancy look like on CXR?
Depends on type of malignancy:
Mesthelioma - 90% of these arise from the pleura and so pleural opacity which may extend around and encase the lung is common. You can get ispilateral mediastinal shift
Mets - peripheral, rounded nodules of variable size, scattered throughout both lungs
Lung cancers - often difficult to visualise as they are small (needs to be ~1cm to be seen). Its more obvious if it occurs in the bronchus and causes a lobe collapse (Golden S sign in RUL collapse due to SCC) or if it causes cavitation (SCC most common). Adenocarcinoma and large cell are most commonly peripheral lesions. Small Cell is central and often presents with hilar/perihilar mass and LN involvement (widened mediastinum) on CXR.
46
Plaque psoriasis vs eczema
Eczema makes your skin red and inflamed. It may be scaly, oozing, or crusty. You may see rough, leathery patches that are sometimes dark. It can also cause swelling.
Psoriasis can also cause red patches. They may be silvery and scaly -- and raised. But if you look closely, the skin is thicker and more inflamed than with eczema.
47
Migraine prophylaxis and acute termination
Migraine prophylaxis: Topiromate, valproate, amitryptilline, propranolol, candesartan, amitryptlline
Migraine rescue therapy: 1st line ED IV antiemetic (e.g., metoclopramide or prochlorperazine) combined with diphenhydramine (or sc sumatriptan)
48
Myasthenia Gravis
```
Myasthenia gravis (MG) is a chronic autoimmune disorder of the post-synaptic membrane at the neuromuscular junction (NMJ) in skeletal muscle. Circulating antibodies against the nicotinic acetylcholine receptor (AChR) and associated proteins impair neuromuscular transmission. Patients present with muscle weakness, which typically worsens with continued activity (fatigue) and improves on rest. Severity varies from isolated eye muscle weakness to generalised muscle weakness and respiratory failure requiring mechanical ventilation
Double vision, ptosis, difficulty chewing and swallowing, and slurring of speech that worsen throughout the day are characteristic symptoms
```
49
Stages of diabetic retinopathy
Diabetic - D+M CIA
Background - dot and blot haemorrhages + microaneurysms
Pre-proliferative - cotton wool spots, IRMA (intra retinal microvascular anomallies)
Proliferative - Angiogenesis e.g. neovascularisation due to insufficient retinal perfusion
50
Stages of hypertensive retinopathy
SAFE
Grade I - Silver wiring and generalised arterial narrowing
Grade II - AV nipping
Grade III - flame haemorrhages, frank AV crossing (bonnet and marcus gunn signs) hard exudates + cotton wool exudates
Grade IV - Edema (Grade 3 + papilloedema)
51
Tumours in the spine
The most common tumours primarily involving the spine include central nervous system tumours such as ependymoma, glioma and meningioma, multiple myeloma, and osteosarcoma. The most common tumours metastasising to the spine include small cell lung cancer, non-small cell lung cancer, breast cancer, prostate cancer, and renal cancer.
52
Disc prolapse vs Cord Compression
In this q, the patient only had bilateral weakness and radicular pain but this was enough to consider SCC over the prolapse. The clue was that the patient had a PMHx of malignancy 20 years ago.
Disc herniation:
• axial back pain (low back pain)
• radicular pain (buttock and leg pain)
o often worse with sitting, improves with standing
o symptoms worsened by coughing, valsalva
```
Spinal cord compression:
• cauda equina syndrome (present in 1-10%)
o bilateral leg pain
o LE weakness
o saddle anesthesia
o bowel/bladder symptoms
```
53
Polyuria Investigations
Confirm Polyuria with a 24 hour collection then
1st line tests:
- Serum electrolytes (including calcium- hypercal due to hyper parathyroidism),
- Glucose (to exclude diabetes mellitus as a cause of polyuria),
- Urine and serum osmolality
2nd line:
- Water deprivation test to confirm DI (and not psychogenic) (urine osmolality <300 will confirm)
3rd line:
- Desmopressin test to differentiate between nephrogenic (no affect) or cranial DI (helps)
54
CKD and Contrast
eGFR < 30 before intravenous contrast medium is a risk factor for AKI.
If you are at increased risk of AKI, have 0.9% saline infusion to expand volume
if egfr <40 consider stopping ACE/ARBs pre contrast
Blood tests 48hrs after needed
If eGFR < 30 a radiologist and a renal specialist would be involved in the decision on whether
to continue with the scan.
55
Elderly patient had a fall overnight and was found in the morning with deranged renal function.
How to differentiate between differentials
Rhabdomyolysis would give a CK of >10,000 (blood on dipstick but you need to get urine microscopy which will show there are no RBC present)
Raised CK <10,000 consider hypovolaemia (due to long lie and lack of hydration)
56
Thiazide diuretics Side effects
Hyponatraemia
| increase this slide
57
C spine #
Commonly traumatic but can be contributed to by degenerative disease
Neck pain
Paraesthesia in the limbs
Over simplification: patient has neck pain when looking 45 degrees L and R, keep collar on and send for CT neck
58
Polymyalgia Rheumatica vs rheum arthritis presentation
PMR:
- Shoulder, hips, thighs (as opposed to hands/feet)
- 60-80yo (RA 30-50yo)
- onset is days - weeks (weeks - months)
- Associated with giant cell arteritis (Ra associated with subcut nodules)
- both have elevated CRP/ESR
- CCP /RF not elevated in PMR
- PMR responds quicker to steroids but poorly to anaglesia (prednisolone is first line)
59
Mallory weis tear vs Boerhaaves Syndrome vs Diaphragmatic rupture vs Oesophageal Varices
Both are oesophageal tears due to vomiting
MW
- partial thickness tear
- lots of haematemesis
- most heal spotaneously, if not need endoscopic repair
BS (oesophageal rupture)
- full thickness tear (transmural)
- chest pain and shock
- subcut emphysema
Diaphragmatic rupture:
- due to physical trauma
- frequently goes undiagnosed
Oesophageal Varices:
- Can be asymptomatic (without bleeding)
- If symptomatic they present with haematemesis and/or meleana
- looking for signs of liver failure (ascites, jaundice, splneomegaly, encephalopathy) (Child Pugh class)
60
Prolactinoma ix and mx
Presents: Hyperprolactinaemia in premenopausal women results in galactorrhoea, menstrual irregularity, and infertility. In men -> secondary hypogonadism e.g. decreased libido etc.
Ix: Prolactin is in 2000+ if >5,000 (macro), MRI to confirm
1st line is Dopamine agonist no matter size/symptoms e.g. cabergoline
2nd line is COCP or if you want to become pregnant/ are a man -> transphenoidal surgery
61
Raised prolactin differential
1,000 - non functioning adenoma
Mild prolactin level elevations, <2000 mIU/L (<100 micrograms/L), can occur with certain drugs, including typical and atypical antipsychotics (e.g., phenothiazines, risperidone, clozapine), opiates, anti-emetics (e.g., metoclopramide, domperidone), oestrogens, H2 blockers, and verapamil. Therefore it is important to take a full drug history.
Prolactin levels can be elevated in renal failure and in primary hypothyroidism, so renal and thyroid function should be checked prior to further investigating a raised prolactin level.
62
HF maintenance fluids
Maintenance fluid requirements for someone with underlying cardiac disease is
recommended as 20-25 mL/kg.
63
Most common cause of cellulitis
Strep pyogenes - streptococcus is most common cause incl in pts with diabetes
Staph aures
64
superficial thrombophlebitis
SUPERFICIAL Vein has a small thrombus
It isn't going to embolise so you don't anticaogulate
Treat with NSAIDs
65
Delirious parkinson's patient, what do you give them?
Lorazepam
66
Hypercalcaemia features
bone pain, osteoporosis, fatigue, confusion, memory problems, depression, nausea, vomiting, abdominal pain, weight loss, thirst, polyuria, constipation, abdominal pain, renal colic, or renal impairment.
67
Ectopic beats
Premature atrial contractions (PAC), which originate in the upper chambers, or atria e.g. paroxysmal AF (older pop), supraventricular ectopics (younger population)
Premature ventricular contractions (PVC), which originate in the lower chambers, or ventricles
68
PSC presentation
PSC often has limited symptoms at presentation ranging from lack of symptoms to complications of end-stage liver disease bilirubin and albumin are often normal.
PC: asymptomatic (50%), fatigue, pruritus
Ix: LFTs show cholestatic picture initially, bilirubin is raised towards end of disease. USS - bile duct wall thickening and dilatation. MRCP - beaded appearance of bile duct
Mx: pruritus relief + transplant
69
Indications for BiPap
Bipap has two different pressure setttings during inspiration and exspiration (Unlike CPAP)
- T2RF
- COPD exacerbation with acidosis
- Failure of cpap
- pneumonia with resp acidosis
70
CT head injury indications
```
Basal skull fracture signs (panda eyes, haemotympanum, battles csf nose ) open skull fracture or depressed #
Amnesia >30min retrograde
Neuro deficit (focal) or seizure
GCS: <13 @ any time or <15 2h after injury
Sickness: vomited > once
LOC or any amnesia and any of:
• Dangerous mechanism: RTA, great height
• Age ≥ 65
• Coagulopathy (inc. warfarin)
BANGS LOC
```
71
Urge vs stress incontinence PC and Mx
Urge or OAB:
Defined as urgency ± urge incontinence, in the absence of proven infection. It is associated with frequency and nocturia. It can be due to detrusor overactivity or other forms of urinary tract dysfunction.
Mx: Bladder retraining,
1st anticholinergics e.g. tolterodine, oxybutynin,
2nd line antimuscarinics e.g. solifenacin, trospium, festerodine
or mirabegron - might be better in older frail pts, dementia pts
botulinum,
S: Clam augmentation ileocystoplasty, tibial nerve stimulation
Stress
Involuntary leakage of urine on effort
Reduce weight, remove cough cause, PEMPT, Duloxetine, Tension free vagina tape or transobtruator tape
72
What does the H and the Vasc in Chadvasc score mean
H = Htn history >140/90 on 2 different occasions or on antihypertensive meds
VA = vascular history = TIA Thromboembolism or stroke
SC- sex category = female
73
A 65 year old man has abdominal distension and vomiting 48 hours after a
sigmoid colectomy with primary anastomosis for bowel cancer. He has not
passed any flatus for 24 hours. He is taking regular paracetamol and as
required intravenous morphine.
His abdomen is distended with tenderness over the wound but no rebound or
guarding. There are no bowel sounds.
His temperature is 37.6°C, pulse rate 96 bpm and BP 122/85 mmHg.
Diagosis and management
The patient has evidence of a paralytic ileus. The initial treatment would involve making
patient nil by mouth and inserting a nasogastric tube
74
Lymphogranuloma venereum
Proctitis and lymphadenopathy make LGV the most likely - and is endemic in MSM population in UK
Due to Chlamydia Serovars
Primary Stage: painless genital ulcer, heals fast, proctitis
Inguinal Syndrome: - Painful inguinal buboes, Fever
Anogenitorectal syndrome - Proctocolitis
Complicatons:
→ genital elephantiasis
→ Rectal strictures
→ Abscesses and fistulae
75
gastroduodenal artery (GDA)
The gastroduodenal artery (GDA) is a terminal branch of the common hepatic artery (coeliac trunk branch) which mainly supplies the pylorus of the stomach, proximal duodenum, and the head of the pancreas. Due to its proximity to the posterior wall of the first part of the duodenum, the gastroduodenal artery is one of the most important sources of upper gastrointestinal bleeding - mostly secondary to peptic ulcer disease or erosive malignant ulcers
76
Types of ulcers, ix and mx
Arterial ulcer
- Deep, painful and sharply defined, shins/foot
- O/E Reduced peripheral pulses
- Intermittent Claudication Symptoms (Cold feet, hair loss, toe nail dystrophy, cyanosis)
- Ix: Contrast angiography
- Mx: Angioplasty or vascular reconstruction
Venous Ulcer
- Painless, sloping, shallow ulcers
- Medial Malleolus is usual site
- Rf: Venous insufficiency, varicosities, DVT, obesity
- Associated with hemosiderin deposition (opaque brown large patches) and lipodermatosclerosis (waxy thickened, hypodermis layer)
- Mx: Ulcer community clinic, focus on prevention (compression stockings, venous surgery), optmise risk factors (nutrition, smoking)
Neuropathic Ulcer
- Painless, insensate surrounding skin (‘glove and stocking distribution’. Can’t feel so cause severe damage to feet without realising)
- WARM foot, GOOD pulses
- Occur on pressure points i.e. heal, tips and between toes, metartarsal heads
- Mx: Regular check ups assessing sensation, keep toe nails short and avoid walking barefoot
77
Next step?
A 68 year old man has eight weeks of back pain. It sometimes wakes him at
night, and he is feeling increasingly tired. He has no history of back problems
and has no history of recent trauma.
He has tenderness over L3 and L4 vertebrae.
Investigations
Haemoglobin 137 g/L (130–175)
Erythrocyte sedimentation rate 55 mm/hr (< 20)
Creatinine 72 µmol/L (60–120)
Calcium 2.5 mmol/L (2.2–2.6)
Serum protein electrophoresis: no paraprotein
XR spine
| then MRI
78
A 65 year old man reports sudden onset of visual disturbance with flashing
lights, floaters and loss of vision in the upper outer quadrant of his right eye.
He has a history of hypertension.
Patients with retinal detachment typically complain of an increasing number of
floaters in one eye. As detachment progresses the separating vitreous will tug on the
surface of the retina and create a mechanical depolarization of the axons running
through the nerve fibre layer of the retina. This leads to flashing lights.
79
Types of malignant melanoma
```
Superficial Spreading: 80%
§ Irregular boarders, colour variation
§ Commonest in Caucasians
§ Grow slowly, metastasise late = better
prognosis
```
Lentigo Maligna Melanoma § Often elderly pts.
§ Face or scalp
Acral Lentiginous
§ Asians/blacks
§ Palms, soles, subungual ( ̄c Hutchinson’s sign
Nodular Melanoma
§ All sites
§ Younger age, new lesion
§ Invade deeply, metastasis early = poor prog
Amelanotic
Atypical appearance -> late diagnosis
80
Prognostic factors in malignant melanomas
Tumour thickness is the single most important prognostic factor for patients with
localised melanoma. This is measured as the Breslow depth or thickness. >4mm = 50% 5ys
Other prognostic factors:
• Male sex
• ↑ mitoses
• Satellite lesions (lymphatic spread)
81
Melanoma Management
Excision + 2O margin excision depending on Bres depth
• ± lymphadenectomy
• ± adjuvant chemo (may use isolated limb perfusion)
82
Melanoma Mets
Liver and Eye
83
Causes of cellulitis
The most common bacteria causing cellulitis are Streptococcus pyogenes (two-thirds of cases) and Staphylococcus aureus (one third). Rare causes of cellulitis include: Pseudomonas aeruginosa, usually in a puncture wound of foot or han
84
Superficial thrombophlebitis
Most often a complication of varicose veins
Diagnosis: hard palpable cord in superifical vein, need Doppler to rule out any concomitant DVT
Management: Concomitant DVT/PE treat those first.
If ≥5cm or within 3-5cm of saphenofemroal junction -> you anticaoguate (if CI ligate the vein)
If <5cm and not within 3-5 of the saphenofemoral junction -> NSAIDs
85
Partial seizure vs functional episode vis TIA
Partial or focal = means you can localise it to one hemisphere i.e. RHS or LHS. Seizures last usually up to about 5 min. Seizures and Migraines usually start with positive symptoms. Post ictal weakness.
TIA - lasts < 1 hour. Symptoms mimic stroke and usually start with negative symptoms.
86
To what regional LNs are ovarian cancer likely to spread to?
Para-aortic
87
A 79-year-old woman was admitted for elective hip-replacement surgery.
On examination, she was pale. There was 2-cm splenomegaly and there were small discrete axillary lymph nodes.
Hb 107
WCC 34
Plt 183
AML ALL CML CLL MDS or Myelofibrosis
CLL
The presence of splenomegaly, anaemia and lymph nodes would make chronic lymphocytic leukaemia the most likely possibility. Acute myeloid leukaemia is unlikely to be diagnosed as an incidental finding and would more likely be associated with thrombocytopenia. Chronic myeloid leukaemia is a possibility, although this is a less common diagnosis and an elevated platelet count would be expected. Myelodysplasia would not usually be associated with a high white count. Myelofibrosis is a possible diagnosis, although the high white count with normal platelet count makes this less likely. It would be expected to request a white cell differential in the clinical setting.
88
What is the pathology of all the nephrotic/nephritic syndromes
- Good pastures - Linear deposition of IgG on the basement membrane (Anti GBM positive)
- HSP/IgA - IgA deposition in the mesangium (nephritic)
- Rapidly progressive GN - Cresenteric deposition (fibrinogen leaks into bowman's space)
- Post Strep - Hypercellular glomerulus (ASOT, anti-DNase B test and anti-hyalauronidase)
- SLE - wire loop appearance on histology
- MCD - normal light microscopy, podocyte effacement on electron
- FSGS - Collagenous sclerosis of an isolated part of only some glomeruli. Unliked MCD, Pt with FSGS are more likely to have non-selective proteinuria, hematuria, progression to chronic renal failure, and poor response to corticosteroid therapy.
89
Hepatitis B antibody /antigen interpretation
acute hepatitis B would be indicated by positive anti-hepatitis B core IgM antibody
chronic hepatitis B would be indicated by positive hepatitis B surface antigen
false-positive hepatitis B serology would be indicated by positive anti-hepatitis B core IgG antibody alone
previous infection with hepatitis B is correct as indicated by positive anti-hepatitis B surface antibody and anti-hepatitis B core IgG antibody with negative hepatitis B surface antigen
previous vaccination for hepatitis B would be indicated by positive anti-hepatitis B surface antibody but negative anti-hepatitis B core IgG antibody
90
Lupus crtieria
SOAP BRAIN MD - 4 or more of this criteria
- Serositis - pleuritis or pericarditis
- Oral ulcers
- Arthritis - 2 or more peripheral joints,
- Photosensitivity - skin rash
- Malar Rash -
- Discoid Rash - red, raised rash that has scaling and follicular plugging
- Blood disorders - HA, leukopenia, lymphopenia, thrombocytopenia
- Renal - proteinuria or casts
- ANA positive
- Immunological disorder Anti Smith, Anti-DNA or one of the APS Ab (cardiolipin, lupus anticoagulant)
- Neurological - seizure or psychosis
91
A 28-year-old man presented with a 1-month history of weight loss, abdominal distension, flatulence and foul-smelling diarrhoea following a visit to India.
Investigations:
anti-tissue transglutaminase antibodies negative
stool cultures and microscopy negative
What is the most likely diagnosis?
```
Answers
A: acute HIV seroconversion illness
B: coeliac disease
C: giardiasis
D: hookworm infection (ancylostomiasis)
E: viral gastroenteritis
```
C
The timing of the diarrhoeal symptoms and the travel history to an endemic area makes giardiasis the most likely diagnosis. Stool cultures are often falsely negative in giardiasis. Coeliac disease is much less likely as anti-tissue transglutaminase antibodies are negative. Viral gastroenteritis is unlikely to be so chronic. Acute HIV and hookworm rarely present in such a fashion and are less plausible than giardiasis.
92
Recurrent calcium renal stone management
Potassium citrate
Urinary citrate reduces urinary supersaturation of calcium salts by forming soluble complexes with calcium ions, and by inhibiting crystal growth and aggregation, hence the use of potassium citrate in recurrent stone formation.
(dietary restriction of calcium can cause increased oxalate absorption and be counter productive)
93
A 77-year-old man presented with increasing pains around his lower back and lower limb girdle. He had recently presented with symptoms of hesitancy and post-micturition dribbling.
Investigations:
ESR 28 mm/1st h (<20)
serum corrected calcium 2.34 mmol/L (2.20–2.60)
serum phosphate 0.80 mmol/L (0.80–1.45)
serum alkaline phosphatase 2985 U/L (45–105)
serum prostate-specific antigen 6 μg/L (<4)
What is the most likely cause of this man’s pain?
```
Answers
A: insufficiency fracture of the pelvis
B: osteomalacia
C: Paget’s disease of bone
D: polymyalgia rheumatica
E: prostatic carcinoma with metastases
```
C
The history of localised bony pain with significantly elevated serum alkaline phosphatase and normal serum corrected calcium and serum phosphate in an elderly man is entirely consistent with a diagnosis of Paget's disease.
Pagets - Chronic localised bone remodelling disorder characterised by increased bone resorption, bone formation, and remodelling, which may lead to major long-bone and skull deformities.
FBC - Normal Ca/P but raised ALP
XR - characteristic, bone boipsy can be done but rarely needed
If treatment is indicated, bisphosphonates are the first-line therapy to retard excessive osteoclastic activity. Adjunctive therapy includes physiotherapy, orthoses, and walking and hearing aids. Analgesics are indicated for pain and inflammatory symptoms.
94
A 32-year-old woman returned from a holiday in the Mediterranean with a suntan and numerous hypopigmented, slightly scaly lesions on the neck and upper trunk. She mentioned that the same areas had been fawn-coloured in the months before her holiday and that these areas of skin had failed to tan during her time in the Mediterranean.
What is the most likely diagnosis?
The correct answer is pityriasis versicolor, which typically affects the neck and upper trunk, causing beige- or fawn-coloured areas on untanned skin but these areas become hypopigmented while the rest of the patient’s skin becomes tanned following repeated sun exposure. Sun exposure can improve some other skin diseases such as psoriasis and eczema, and this may result in hypopigmented areas at the site of the previous lesions in some cases, but one would expect a history of lesions at other sites, for example on the upper and lower limbs, as well as on the trunk.
95
A 65-year-old woman developed bilateral lower limb swelling. She had been taking regular ibuprofen for joint pain for the previous 2 weeks. She had a past medical history of urinary tract infections.
On examination, her BP was 139/98 mmHg and she had pitting oedema below the knees. Urinalysis showed protein 2+, red blood cells 1+, leukocytes 3+ and no nitrite
Ix: Raised serum creatinine and protein to creatinine ratio 130 (<30)
Tubulointerstitial nephritis.
She has acute kidney injury with modest proteinuria and leukocyturia which is in keeping with interstitial nephritis. NSAIDs are associated with interstitial nephritis.
Renal biopsy would be needed to differentiate between the different causes of AKI.
NB - if the PCR >300 you would consider nephrotic syndrome causes such as membranous glomerulnephropathy
NBB if there were +++ haematuria you would consider nephritic causes e.g. Papillary necrosis can be associated with NSAID use but also with flank pain and higher levels of haematuria.
96
A 43-year-old woman presented with a 1-week history of polyuria and nocturia without weight loss.
Na, K, Ca within range
Serum osmol 310 mosmol/kg (278–300)
200 mosmol/kg (100–1000)
Raised serum osmolality with urine osmolality on the lower side in the setting of this patient’s symptoms indicates diabetes insipidus. There is not enough in the question to suggest compulsive polydipsia; the random plasma glucose level is not consistent with diabetes mellitus; calcium is not elevated which rules out hyperparathyroidism; and syndrome of inappropriate antidiuretic hormone (SIADH) results in a low serum osmolality.
97
A 55-year-old woman presented with a 2-day history of diplopia and progressive gait unsteadiness.
On examination, she had limited eye movements in all directions and her pupils were poorly reacting. Muscle power in the limbs was normal but tendon reflexes were absent. There was prominent bilateral finger–nose ataxia. Plantar responses were flexor. Sensation was normal.
What is the most likely diagnosis?
Miller Fisher syndrome is the triad of
ataxia,
internal and external ophthalmoplegia and
areflexia.
It is often associated with antibodies to GQ1b and is probably a variant of Guillain– Barré syndrome. The other answer options do not have the same combination of signs.
W/E: ataxia, opthalmoplegia and confusion
98
Which condition is most likely to be precipitated by the use of ciprofloxacin?
Tendinopathy
Tendon damage including rupture can occur rarely after use of quinolones. Quinolones are contraindicated in patients with a history of tendon disorders related to quinolone use.
99
Travellers Diarrhoea
Overall, the most common pathogen is enterotoxigenic Escherichia coli, followed by Campylobacter jejuni, Shigella spp., and Salmonella spp.
100
A 52-year-old woman presented with an episode of weakness of the left side of her face and left arm that resolved after 3 hours. She was otherwise well and had no significant past medical history.
On examination, her BP was 110/75 mmHg.
Treatment was started with atenolol and warfarin.
She underwent a successful DC cardioversion 4 weeks later.
How long should she continue with warfarin therapy?
Lifelong
| You still do chadvasc score after successful DC cardioversion.
101
What is the most useful investigation to determine future cardiovascular risk in pts with dm/htn?
Proteinuria is an independent predictor of cardiovascular risk in patients with diabetes mellitus and/or hypertension.
Screening for proteinuria by performing a spot urine albumin:creatinine ratio is the most commonly performed investigation to assess this risk
102
An 83-year-old man presented with a 6-month history of pain in both legs on walking, which was relieved by a short period of rest, particularly sitting down. He had a past history of myocardial infarction.
On examination, his foot pulses were present. There was crepitus in both knees and both ankle tendon reflexes were absent.
What is the most likely cause of his symptoms?
Claudication can be vascular or neurological
Normal pulses rule out vascular
Must be neurological e.g. spinal stenosis
Two differentiators are pulse absence/presence and pain on postural changes (only present in neuro- but not given in this question)
Both are relieved by rest and both are relieved by sitting
103
A 24-year-old man presented with a 2-week history of leg swelling. He had experienced an upper respiratory tract infection 1 month previously, but had not required antibiotic therapy. He had no significant medical history. A maternal uncle had undergone a successful kidney transplant.
On examination, there was peripheral oedema to the thighs bilaterally. Urinalysis showed blood 1+, protein 4+.
ix: Normal urea, creatinine and egfr, low albumin
Diagnosis?
A: Alport syndrome
B: autosomal dominant polycystic kidney disease
C: IgA nephropathy
D: membranoproliferative glomerulonephritis
E: minimal change nephropathy
This patient has nephrotic syndrome (characterised by the triad of oedema, proteinuria (>3g/24h) and hypoalbuminaemia). Of the options listed minimal change disease is the most likely cause of nephrotic syndrome in this patient. A trigger, such as a viral respiratory tract infection, can occur before the acute presentation.
IgA nephropathy and membranoproliferative glomerulonephritis can present with nephrotic syndrome, although these diseases much more commonly present with progressive renal impairment and haematuria with non-nephrotic proteinuria. Minimal change disease is a much more common cause of nephrotic syndrome than these disorders.
104
What do you need to make a diagnosis of SIADH?
Low serum osmolality
Higher urine osmolality
Normal Renal, thyroid and adrenal tests (TFTs, creatinine, morning cortisol)
105
What medication do you give after cardioversion is successful?
Antiarrhythmics to maintain rhythm- 1st Amiodarone 2nd Propafenon
Class IA (disopyramide phosphate, quinidine sulfate), Class IC (flecainide acetate, propafenone hydrochloride) and Class III (amiodarone, dofetilide, dronedarone, sotalol hydrochloride) drugs reduce recurrence of atrial fibrillation. Amiodarone and propafenone are superior to sotalol in maintaining long-term normal sinus rhythm in patients with atrial fibrillation. Amiodarone is superior to propafenone
CHADVASc for anticoagulation
106
A 43-year-old woman presented with a 2-month history of progressive muscle weakness and shortness of breath.
On examination, there was proximal limb weakness, and crackles at both lung bases.
Investigations:
ESR 55 mm/1st h (<20)
serum creatine kinase 3500 U/L (24–170)
What is the most likely diagnosis?
```
Answers
A: chronic inflammatory demyelinating polyneuropathy
B: inclusion body myositis
C: myasthenia gravis
D: polymyalgia rheumatica
E: polymyositis
```
E
107
Diabetic ulcer vs charcot arthropathy vs osteomyelitis
Neuropathic ulcer - Painless, insensate surrounding skin (‘glove and stocking distribution’. Can’t feel so cause severe damage to feet without realising)
WARM foot, GOOD pulses. Occur on pressure points i.e. heal, tips and between toes, metartarsal heads.
Charcot foot - complex, deformitive condition due to repeat # causing repeat deformity*, classically rockerbottom feet o/e. First sign is swelling/redness but no breaks in skin
Osteomyelitis - a complication of neuropathic ulcer - red, swollen, any signs of infection e.g. discharge
108
A 32-year-old man presented with increasing headache and facial weakness. Two weeks previously, he had developed a right-sided facial palsy with pain behind the right ear. The previous summer, he had camped with his family in southern Germany.
Examination revealed mild photophobia, neck stiffness, and a right lower motor neurone facial weakness, but no other neurological signs.
Which organism is the most likely cause?
Lyme - Borrelia, Travel in US or europe
presentation is as follows:
Erythema migrans develops at the site of tick bite usually within 1 to 2 weeks and is a pathognomic feature of Lyme disease.
Constitutional symptoms such as fever, headache, myalgias, fatigue, and arthralgias may occur.
Complications of Lyme disease may be neurological, cardiac, or musculoskeletal - might present with this
Neuro - classically facial (cranial nerve VII) and other cranial nerve palsies, aseptic meningitis, and radiculoneuropathy.
MSK - arthralgia and arthritis, esp knees, >1 joints
Cardio - carditis with atrioventricular block (second- or third-degree) that resolves in days to weeks
109
Mechanical valve long term treatment
Aspirin and warfarin
| LMWH used to bridge not long term
110
how do jaundice pts undergoing surgery differ in their physiology
- Generous perioperative rehydration to prevent the risk of dehydration and hepatorenal syndrome
- Pt are at increased risk of infection -> proph abx
- Effect of opiate analgesics may be prolonged
- Pt is at increased risk of bleeding to do reduced absorption of factors 2 7 9 10
111
How long after an MI should surgery be postponed for?
6 months
| risk of another MI if surgery is done between 0-3 months is 35% vs post 6 months is 4%
112
CVP and fluid bolus interpretation
CVP values on their own are not useful as there is no normal range but before and after vales of a fluid challenge can help
CVP depends on venous return to the great veins and the efficiency of the cardiac pump
Increased CVP = expanding circulating volume (rise of 2-4cm which reverses after 30min) or cardiac failure (sustained rise >5cm) (overload/HF)
113
Consequences of large blood transfusions
Massive transfusion >10 units in 24hrs
- Stored blood is deficient in platelets, clotting factors (5 + 8) -> pts should receive plt + cryo to avoid DIC
- Hypothermia (stored at lower temp)
- Hyperkalaemia (stored blood has higher K+ content
- Hypocalcaemia (anticoagulant citrate sequesters calcium) (not an issue in small units as it has time to reverse)
114
Pt post Hartmann's has high nasogastric aspirates despite slow enteral feeding. Abdomen is mildly distended and no bs but not peritonic. What is the best way to manage this?
This patient as post op ileus (paralytic ileus). They are an ideal candidate for TPN as this is a short term requirement
PEG is useful it pt has functioning GI tract.
115
How should pts on TPN be managed?
- Daily monitoring of blood glucose, electrolytes and daily FBC (sepsis is v high risk)
(anyone who gets sepsis with central line, the line should be considers as the source until proven otherwise)
- Daily weights and meticulous fluid balance
- LFTs twice weekly to monitor for cholestatic jaundice or fatty infiltration
- Give phophate supplement as hypophosh can be an issue
116
Describe TPN
- Normal a standard set regimen (not tailored to pt)
- Hyperosmolar and therefore dedicated large central line is required
- High lipid content (and lower glucose content as this causes more respiratory work for an already ill pt)
117
Confirmed IDA, what follow up ix are required?
- Coeliac serology
- Urinalysis
- H Pylori testing
- If the patient has any upper or lower GI symptoms, such as nausea, dyspepsia, or change in bowel habits, an OGD or colonoscopy is indicated as an initial evaluation depending on the symptoms. If the patient is asymptomatic, both upper and lower GI endoscopy are indicated.
(Exceptions: if pre menopausal, wouldn't routinely do OGD unless family hx)
118
A 51-year-old man presented with a 2-month history of intermittent breathlessness, and a 1-year history of a blocked nose. He had been found to have angina 2 years previously and was taking aspirin, ramipril, simvastatin, atenolol and omeprazole.
Investigations:
FEV1 2.5 L (75% predicted)
FVC 4.0 L (88% predicted)
Which drug is most likely to be causing his symptoms?
```
Answers
A: aspirin
B: atenolol
C: omeprazole
D: ramipril
E: simvastatin
```
Aspirin can worsen asthma and cause nasal symptoms in a sub-group of patients with asthma. Aspirin is associated with nasal polyps, hence the description of a blocked nose.
Ramipril and other ACE inhibitors can cause a cough and atenolol can cause breathlessness but neither of these is associated with nasal polyps. Omeprazole can be used to treat reflux-related cough.
119
Pt has a anaphylactic reaction to pencillin, which abx should be avoided?
```
Betalactams should be avoided
This includes penicillin derivatives (penams), cephalosporins (cephems), monobactams, carbapenems and carbacephems.
Pencilillins:
phenoxymethylpenicillin
benzylpenicillin
flucloxacillin
amoxicillin
ampicillin
co-amoxiclav (Augmentin)
co-fluampicil (Magnapen)
piperacillin with tazobactam (Tazocin)
ticarcillin with clavulanic acid (Timentin)
```
120
A 72-year-old man presented with loss of the lower half of the visual field of his right eye, with no associated pain. He had type 2 diabetes mellitus and was being treated for hypertension.
Examination showed normal visual acuity in both eyes, with an inferior altitudinal field defect in the right eye. Fundoscopy of the left eye was normal, and the upper part of the right optic disc showed mild disc swelling. No fundal haemorrhages were seen. His BP was 160/90 mmHg.
What is the most likely diagnosis?
```
Answers
A: optic neuritis
B: panuveitis
C: posterior communicating artery aneurysm
D: retinal artery occlusion
E: retinal vein thrombosis
```
D
The visual field defect indicates a likely vascular cause. Branch retinal vein thrombosis is typically associated with fundal haemorrhages, not seen in this case, making an arterial explanation more likely. Optic neuritis and panuveitis would usually lead to impairment of visual acuity, often with pain. A posterior communicating artery aneurysm more typically presents with a pupillary involving III nerve palsy.
121
An 85-year-old woman presented with breathlessness that had developed over the previous 2 years. She complained of a cough that frequently woke her from sleep. She had been treated with radiotherapy for a cervical lymphoma 20 years previously.
On examination, she was thin, but had no abnormal physical signs. Her oxygen saturation was 95% (94–98) breathing air.
Investigations:
high-resolution CT scan of chest basal fibrosis associated with dilated bronchi, but no honeycombing or ground-glass change
What is the most likely diagnosis?
```
Answers
A: bronchiectasis
B: chronic aspiration
C: radiation fibrosis
D: sarcoidosis
E: usual interstitial pneumonia-type pulmonary fibrosis
```
The symptoms described are consistent with chronic aspiration occurring in the elderly. The CT findings are radiological bronchiectasis, a sequela of recurrent episodes of aspiration pneumonia. This does not, however, equate to a clinical diagnosis of bronchiectasis.
The absence of honeycombing and ground-glass opacities counts against the diagnosis of radiation fibrosis and usual interstitial pneumonia-type pulmonary fibrosis.
The right middle and lower lung lobes are the most common sites affected, due to the larger calibre and more vertical orientation of the right main bronchus.
122
Still's disease
Still’s disease is a rare disease and more often seen in children than adults. It is a systemic inflammatory illness. Clinical features include fever, joint pain/inflammation and evanescent macular rash. A characteristic lab feature is very high levels of ferritin; additional lab features include anaemia, leukocytosis and high acute-phase reactants.
