On Examination Flashcards
To go over the things you get wrong (116 cards)
1
Q
What is the philidelphia chromosome
A
Translocation of part of chromosome 9 to chromosome 22.
This creates the gene BCR-abl on chromosome 22 and is termed the philidelphia chromosome.
Often found in chronic myelogenous leukaemia and sometimes in acute lymphocytic leukaemia.
Results in abnormal tyrosine kinase activity and so positive cancers can be treated with tyrosine kinase inhibitors
2
Q
Cutaneous anthrax is more common in which profession and what do you use to treat?
A
Any professions which work with the hides of hooved animals like sheep or goats.
Sheep herder Vetinary surgeon Farm workers Tannary workers Wool workers
Treat with:
Penicillin, ciprofloxacin or doxycycline
3
Q
What is the treatment for mastitis?
A
Oral flucloxacin
Warm compresses
Encourage continued emptying of the breast by breastfeeding or breast pumping
4
Q
What antibiotic treatment should be given for a generalised peritonitis like infection after abdominal surgery?
A
IV cefuroxime and metronidazole
Covers both aerobic and anaerobes
5
Q
Congenital adrenal hyperplasia:
- What is the most common cause of congenital adrenal hyperplasia?
- What may occur in the first few days of birth?
- How can you prevent virilisation?
- Which metabolite is found in excess?
A
- 21 hydroxylase deficiency in >90% of cases
- Salt losing adrenal crisis (from birth onwards):
- Severe hyponatraemia
- Hypotension
- Hypoglycaemia - Catch early and treat mother with IV glucocorticoids
- Blood 17-hydroxyprogesterone concentrations are greatly increased
6
Q
What is a cephalhaematona in paediatrics?
What are the complications?
A
Subperiosteal swelling resulting from forceps delivery
Complications can include anaemia or jaundice (from bleeding)
7
Q
What is the clinitest?
A
Clinitest is a reagent tablet based on the Benedict’s copper reduction reaction, combining reactive ingredients with an integral heat generating system. The test is used to determine the amount of reducing substances (generally glucose) in urine.
8
Q
An infant presents with jaundice, poor feeding and a haemaglobin of 120g/L
The liver and spleen are palpable and there is a family history of lethargy, hepatosplenomegaly and poor feeding. The raised bilirubin is initially unconjugated; in the second sample, the conjugated fraction tended to rise. Urine examination is positive for reducing substances using Clinitest.
What is the diagnosis?
Explain
A
Galactosaemia is an autosomal recessive condition due to the absence of galactose-1-phosphate uridyl transferase. This results in the intracellular accumulation of galactose-1-phosphate which is toxic. Upon commencement of milk feeds the child develops jaundice, vomiting, diarrhoea and failure to thrive.
9
Q
What are the clinical signs of congenital CMV infection?
A
Petechiae hepatosplenomegaly thrombocytopenia pertially conjugated hyperbillirubinaemia Chorioretinitis intracranial calcification on MRI
10
Q
What is the definition of breast milk jaundice?
A
Neonatal jaundice persisting for more than 28 days, with a total bilirubin level greater than 5.9 mg/dL, in an otherwise healthy, thriving, breastfed infant.
11
Q
Neonatal jaundice occurs in what percentage of newborns within the first week of life (term and preterm)?
A
60% term
80% preterm
12
Q
What factors make a baby more likely to develop significant hyperbillirubinaemia?
(4 marks)
A
- gestational age under 38 weeks
- a previous sibling with neonatal jaundice requiring phototherapy
- mother’s intention to breastfeed exclusively
- visible jaundice in the first 24 hours of life
13
Q
What are the complications of post-term delivery?
A
Hypoglycaemia (depleted glycogen stores) Birth asphyxia (meconium aspiration and traumatic delivery)
14
Q
The use of the pincer grip and meaningful words usually develops when?
A
10 months
15
Q
Atopic excema can be exacerbated by what?
3 marks
A
Infection
Stress
Environmental exposure to allergens such as the dust mite
16
Q
Atopic excema predisposes you to what?
2 marks
A
Excema herpeticum
Infection with the herpes simplex virus
17
Q
What are the features of Di George syndrome?
A
CATCH-22 (varies on which abnormalities are present)
- Cardiac Abnormalities (80%)
- –Persistant TRUNCUS arteriosus (aorta and pulmonary artery do not separate)
- –Interupted aortic arches
- –Tetrology of Fallot
- –ASD and AVD
- Abnormal Facies
- –Cleft lip can be present (nasal regurgitation of fluids)
- –High broad noses
- –Low set ears
- –Small teeth
- –Narrow eyes
- Thymic Hypoplasia
- –Lack of thymus shadow on x-ray of neonate
- –Immunodeficiency due to lack of T cell production
- Hypocalcaemia
- –Poor development of parathyroid glands
-Deletion on chromosome 22 (region 22q11.2)
18
Q
What is the name of the characteristic rash seen in secondary syphilis?
A
Keratoderma blennorrhagica
Affects the hands and soles of the feet (differentiating it from HIV seroconversion rash)
19
Q
What is the treatment of secondary syphilis?
A
long acting penicillin
20
Q
What organisms cause epididimo-orchitis in younger and older men?
A
Younger:
- Neisseria Gonorrhoea
- Chlamydia trachomatis
Older:
- E. Coli
- Klebsiella
- Proteus
21
Q
Give 2 congenitally acquired organisms which can cause jaundice, purpura and hepatosplenomegaly in the neonate
A
CMV
Toxoplasmosis
22
Q
A pregnant woman comes into contact with someone with rubella and cannot remember if they are immunised.
Explain the management of this patient
A
Serology must be taken
IgG will tell if they have immunity from vaccination or previous infection
IgM tells you if there is recent or current infection
If she is not immune but infected she needs treatment with immunoglobulins NOT vaccination
23
Q
What is the timing for the MMR vaccine?
When is the vaccine contraindicated?
A
12-15 months
History of anaphylaxis, concurrent febrile illness, neomycin or gelatin allergy
24
Q
Bacteriodes species:
Where are they commensal bacteria?
What type of bacteria are they?
What conditions can they cause?
A
Bowel
Obligate anaerobes
Nosocomial pneumonia and septicaemic shock
25
What percentage of adults who have chickenpox get varicella pneumonia 3-5 days into the illness?
20%
26
Long QT Syndrome can be phenotypically organised into 3 categories.
Give these along with their clinical features.
Romano-Ward syndrome is inherited as an autosomal dominant trait. It may result from a mutation in any one of 13 identified genes and is not associated with deafness.
Jervell and Lange-Nielsen syndrome is inherited as an autosomal recessive trait and results from a homozygous mutation in KCNQ1. It is clinically characterised by a very severe form of LQTS and sensorineural deafness, and those affected may experience their first cardiac event during infancy.
Andersen-Tawil syndrome, also known as hypokalaemic periodic paralysis or LQT7, is a rare autosomal dominant condition. These patients have periodic paralysis and ventricular tachyarrhythmias, and have a variety of dysmorphic features
27
Describe the defect in Marfan syndrome
Mutation of the FBN1 gene, which codes for the production and transport of fibrillin, a glycoprotein that contributes to microfibril formation which gives tissues elasticity.
28
Explain the criteria used in the diagnosis of marfan's syndrome
The Ghent criteria
Dilated aortic root (over an age-adjusted threshold) combined with displacement of the optic lens (ectopia lentis) OR positive FBN1 mutation = Marfan syndrome
In the absence of ectopia lentis or FBN1 mutation 7 or more systemic findings must be present
-Other syndromes like Ehlor-Danlos must be excluded too
29
Describe the management of patients with diagnosed marfan's syndrome
People with suspected Marfan syndrome require echocardiographic surveillance of their aortic root to identify dilatation or aneurism.
Prophylactic medications, such as beta blockers or ACE inhibitors are usually used to reduce the chance of aortic root dilatation and therefore aortic regurgitation developing.
In those that do develop aortic regurgitation surgery is usually indicated to replace or alter the valve and prevent the left ventricle from otherwise failing secondary to volume overload.
Patients with Marfan syndrome are advised not to undertake strenuous sport or be in high or low pressure environments (such as deep sea diving) due to the risk of sudden dissection of an undetected aortic aneurism.
30
Coxsackie A16 virus is the cause of what?
The cause of hand, foot and mouth disease characterised by fever, sore throat and ulcerating vesicles in palms, orophaynx and on soles. Incubation period is five to seven days and these heal without crusting. Treatment is symptomatic.
31
What is the luteal phase of the menstrual cycle?
Following ovulation, the mature ovarian follicle forms the corpus luteum. This marks the beginning of the luteal phase, which is characterised by the production of progesterone from the corpus luteum.
32
What are the hormone changes during the luteal phase?
Serum levels of progesterone are such that LH and FSH production is relatively suppressed. This effect is amplified by high levels of inhibin and oestradiol, also produced by the corpus luteum.
33
How long is the luteal phase?
The duration of the luteal phase is fairly constant at about 14 days in most women, correlating with the lifespan of the corpus luteum.
34
What is the luteal phase also called?
Shortly after ovulation, subnuclear intracytoplasmic granules appear in glandular cells within the endometrium. These vacuoles progress to the apex of the glandular cells releasing their contents into the endometrial cavity. This whole process is induced by progesterone, with peak secretory activity occurring at the time of implantation. Hence, the luteal phase is also known as the secretory phase.
35
How can hyperprolactinaemia cause anovulation?
Hyperprolactinaemia through negative feedback on gonadotrophs in the pituitary produces hypogonadotrophic hypogonadism and amenorrhoea.
36
Can obesity cause anovulation?
yes
37
A woman presents with continuous leaking of urine three weeks following hysterectomy, without urinary retention.
What is the diagnosis?
Vesicovaginal fistula
may occur after many abdomino-pelvic operations such as hysterectomy, caesarean section or prolapse repair.
38
The median nerve is composed of fibres from what spinal roots?
What muscles does it supply in the hand?
C5-T1
In the hand it innervates:
- Abductor pollicis brevis
- Opponens pollicis
- Flexor pollicis brevis, and
- First and second (lateral) lumbricals.
39
Which individuals with IgA deficiency may benefit from replacement immunoglobulin therapy?
Most individuals with IgA deficiency do not require treatment. Immunoglobulin preparations for replacement therapy are usually very low in IgA anyway. A proportion of individuals with IgA deficiency are also deficient in IgG2. Some of these patients may benefit from immunoglobulin replacement (to replace IgG2 antibodies) - the decision regarding whom to treat should be left to an experienced clinical immunologist.
40
Are primary or secondary immunodeficiencies more common?
Secondary
41
List the causes of hemiballismus
In addition to strokes there are a number of other causes of hemiballismus.
These include:
- traumatic brain activity
- amyotrophic lateral sclerosis
- hypergylcaemia
- malignancy
- vascular malformations
- tuberculomas, and
- demyelinating plaques.
42
What are the clinical features of hemiballismus?
Hemiballismus is usually characterised by involuntary flinging motions of the extremities, which are often violent.
It is continuous and random, and can involve proximal, distal or facial muscles.
It is always unilateral, but it is common for arms and legs to move together.
The movements worsens with activity, and decrease with relaxation.
43
Hemiballismus is due to a defect where?
It results from a decrease in activity of the subthalamic nucleus of the basal ganglia, which results in decreased suppression of involuntary movements.
44
Which virus would present with roseola infantum?
HHV-6
Responsible for roseola infantum in infants. In adults it presents with a mononucleosis type picture and is thought to increase the risk of rejection in transplant patients.
45
beta HCG:
What cells of the conceptus produce it?
How does it then trigger implantation and prevent menstruation?
Following conception, beta hCG is produced by the syncytiotrophoblast cells of the conceptus.
It stimulates receptors on the corpus luteum which prevents its degradation, maintaining production of progesterone. The progesterone in turn maintains the endometrial lining, allowing implantation to occur and preventing menstruation.
46
How accurate are pregnancy tests and when is the earliest they can be used?
Beta-HCG is first detectable in the blood as early as 7-8 days after ovulation by very sensitive HCG research assays.
In day-to-day practice, blood pregnancy tests will be positive (> 2 mIU/ml) by 10-11 days. In general, the levels will double every 2-3 days in early pregnancy.
T Beta hCG levels peak around week 10/40. At this point, the placenta is well developed and can produce adequate progesterone itself.
In non-pregnant women, beta hCG is present in very low concentrations, which are usually undetectable using standard assays.
Although precise cut-offs vary between laboratories, in general diagnosis of pregnancy requires:
- A beta hCG concentration >25 U/l, or
- A doubling of hCG levels within two days.
47
What is Vincent's angina?
Vincent's angina is due to an acute gingivitis plus pharyngeal infection and caused by Borrelia vincentii.
48
Cavitating lesion's on Chest X-ray are commonly caused by what?
```
Squamous cell carcinoma
Abscess (Staph. aureus, Klebsiella and Pseudomonas aeruginosa)
Lymphoma
Mycobacerium tuberculosis
Rheumatoid nodule
Pulmonary infarction, or
Wegener's granulomatosis.
```
49
What can be used to provide symptomatic relief in diffuse oesophageal spasm?
Nifedipine
50
What can provide symptomatic relief in GI conditions characterised by smooth muscle spasm such as IBS and diverticulitis
Hyoscine butylbromide (buscopan)
51
Advice given to women before levonorgestrel IUS (Mirena)?
It decreases the volume of bleeding by approximately 90% in women with menorrhagia.
The levonorgestrel IUS, also known as Mirena, also reduces the number of bleeding days during a menstrual cycle.
It has a failure rate of less than 1%, (around 0.2%), and is not associated with loss of bone mineral density on evidence from a 10 year follow up cohort study.
It should not be inserted straight after delivery, because of risk of uterine rupture.
Increase in weight, increased risk of vulvovaginitis and decreased libido are seen, in keeping with other progesterone only contraceptive methods.
52
How can a wrist X-ray be useful in pubertal assessment?
Wrist x ray is a useful investigation in children with short stature because it allows an assessment of bone age.
Bone age is most affected by circulating sex hormone levels that cause progressive fusion of the epiphyseal plates during puberty. This means it is possible to assess whether children are progressing through puberty. It also allows a comparison bone and chronological age, if there is a discrepancy then it is often due to delayed puberty.
In girls an ultrasound of the uterus for assessment of endometrial thickness may be used to estimate pubertal development. A thicker endometrium suggests a girl is closer to menarche.
53
Which topical treatment for psoriasis must be applied only onto the plaques, as it causes irritation and staining of skin.
Dithranol
54
Why should you not correct hypokalamia in patients who have just had dialysis?
Ninety five per cent of body potassium is in the intracellular fluid, and therefore cannot be removed by haemodialysis. Following dialysis, it is normal to have transient hypokalaemia before equilibration from intracellular fluid occurs.
If you are reviewing a patient who has just had dialysis, do not treat any hypokalaemia. A better option in most cases is to repeat the sample in one to two hours to check for adequate equilibration. Generally, hypokalaemia in these circumstances is not associated with symptoms.
In dialysis patients, potassium levels generally rise over several days until their next dialysis session. Treating post-dialysis hypokalaemia aggressively makes hyperkalaemia a greater risk several days later.
55
A transverse fracture of the medial malleolus usually occurs due to what movement?
Eversion
56
What are the differentials of an intraductal papilloma?
What are the investigations and management?
Differentials include:
- Paget's disease of the nipple
- Adenoma of the nipple
- Carcinoma
Mammography is indicated
Ductography
-injection of contrast will show the duct failing to fill
Treatment is by surgical excision of the affected segment of breast tissue - microdochectomy.
57
Which drugs may reveal coronary steal syndrome?
Dipyridamole has been shown to reduce regional myocardial blood flow and this may contribute to the coronary steal phenomenon
58
When do you do endarterectomy for stroke?
Carotid doppler shows >70% stenosis
59
How do you manage food intake post stroke?
NIL by mouth until SALT assessment
If they don't have a safe swallow:
- Patients should receive nutrition probably within a few days of being kept nil by mouth, initially by NG feeding.
- A PEG should be arranged within two to four weeks thereafter, to reduce the risk of aspiration pneumonia and for patient's comfort.
60
In viral hepatitis what is characteristically raised in Hep E infection?
Acute hepatitis E is characterised by more pronounced elevation of alkaline phosphatase.
It is diagnosed by presence of serum IgM antibody to hepatitis E virus (IgM anti-HEV).
61
Which type of testicular cancers occur in which age groups?
Teratoma is commonest in 20-30 years and seminoma in the 30- to 40-year-old range.
62
What are the tumour markers for testicular teratomas?
LDH and human chorionic gonadotrophin are useful tumour markers.
63
What is the medical term for an ingrowing toenail?
How is it treated?
Onychocryptosis (ingrowing toenail) is most common in young adults who wear poorly fitting shoes. There is pressure necrosis of the nail wall due to pressure from the nail itself, leading to inflammation and secondary infection.
Acute infections should be treated with antibiotics and the patient listed for a Zadek's procedure (avulsion of the nail and ablation of the nail bed).
64
What is onchogryphosis?
Onychogryphosis is a hypertrophy that may produce nails resembling claws or a ram's horn.
65
What is the best treatment for a frozen shoulder?
intra-articular prednisolone
66
What is the treatment for osteomalacia?
Vitamin D
| caused by a vitamin D deficiency
67
LTRAs (e.g. monteleukast) are particularly useful for what?
Exercise induced bronchospasm
68
What is the most suitable test to differentiate osteomalacia and paget's?
PTH
Raised in osteomalacia but normal in pagets
69
What endoscopy features are classic for a gastrointestinal stromal tumour?
polypoid lesion with intact mucosa in the antrum
70
What are the clinical features of toxoplasmosis?
Toxoplasmosis is caused by intracellular protozoon, Toxoplasma gondii.
It can be difficult to distinguish from infectious mononucleosis, except in toxoplasmosis; there is no pharyngitis, oral petechiae or splenomegaly.
Serological tests can be used to confirm acquired infection. Paul-Bunnell (Monospot) test is negative.
"Recent onset of painless, smooth and mobile cervical lymphadenopathy, and erythema nodosum. There is evidence of lymphocytosis, with atypical lymphocytes on the blood film."
71
What investigation findings are common in Legionella pneumonia?
Often little is found on the chest or chest x ray but a high fever is typical. There may be a hyponatraemia on biochemistry. The diagnosis can be confirmed with urinary antigens to Legionella pneumophila.
72
What is the characteristic feature of Klebsiella pneumonia?
Red-jelly sputum
73
What monoclonal antibody is associated with autoimmunity?
It is not clear why, but one of the well-known side effects of alemtuzumab is autoimmunity after treatment. Up to a third of patients develop autoimmune thyroid disease but other disorders have been described including autoimmune cytopenias and anti-GBM disease. This seems to be more frequent in patients who have prior history of autoimmune diseases.
It is important that all patients who have received alemtuzumab have regular thyroid function screening.
None of the other monoclonal antibodies are known to be associated with autoimmunity.
(Alemtuzumab, or Campath, is a monoclonal antibody used in the treatment of autoimmune diseases such as multiple sclerosis and ANCA associated vasculitis. It can also be used as an induction agent in solid organ transplantation. It acts on CD52 to cause profound lymphocyte depletion within 24-48 hours.
B cells begin to recover by three to six months
CD8 T cells by six to nine months but
CD4 T cells can remain suppressed for years.)
74
What is the side effect of the protease inhibitor atazanavir?
The protease inhibitors atazanavir and, to a lesser extent, indinavir are associated with unconjugated hyperbilirubinaemia. This patient presented with this biochemical abnormality. The renal function is normal and the liver enzymes are only mildly raised. The biochemical abnormality often reverses when the drugs are stopped. The course of this drug reaction is often benign and except for stopping the drug no other intervention is needed. The mechanism of the drug reaction is competitive inhibition of the UGT1A1 enzyme. Naturally, people with Gilbert's syndrome are more predisposed to this reaction of the drug.
75
In asymptomatic women how many urine samples need to be positive before you treat bacteruria?
2 samples
76
How do you diagnose CLL?
According to Guidelines on the diagnosis and management of chronic lymphocytic leukaemia, a definitive diagnosis of CLL is based on the combination of a lymphocytosis and characteristic lymphocyte morphology and immunophenotype.
This means you need:
- Lymphocytosis (FBC)
- Morphology (smudge cells on blood film)
- Immunophenotype
All other tests are for work up bot not necessary to reach the diagnosis
77
What are the common causative organisms in peritoneal dialysis infection?
Fifty per cent of episodes of PD peritonitis are caused by Gram positive organisms, and the most common organism is coagulase negative staph. contamination from skin flora.
Staph. aureus is increasing in frequency, but is currently still less common.
Gram negative organisms such as E. coli cause only around 15% of episodes of PD peritonitis.
Pseudomonas is rare and extremely difficult to treat.
Fungal organisms cause peritonitis in only a fraction of patients, less than 2%.
78
What are the causes of dilated and small pupils?
Causes of dilated pupils include:
Holmes-Adie (myotonic) pupil
Third nerve palsy, and
Drugs and poisons (atropine, CO, ethylene glycol).
Causes of small pupils include:
```
Horner's syndrome
Old age
Pontine haemorrhage
Argyll Robertson pupil, and
Drugs and poisons (opiates, organophosphates).
```
79
How do you distinguish between a papillary rupture and a VSD following acute MI?
Need to demonstrate a shunt in VSD through coronary catheterisation
80
What drugs need to be changed in hepatic impairment?
In hepatic impairment certain drugs may need to be stopped or prescribed at a reduced dose to prevent further hepatotoxicity or reduced drug metabolism by the liver.
Drugs that need to be avoided include:
```
Paracetamol
Carbamazepine
Oral contraceptive pill
Ergometrine, and
Anticoagulants or antiplatelets such as aspirin or warfarin (due to the risk of GI bleeding).
```
Other drugs such as opiates, methotrexate, theophylline and phenytoin need to be prescribed at reduced dose.
81
What are the causes of erythema nodosum?
The causes of erythema nodosum are:
Acute sarcoidosis
Streptococcal infection
Rheumatic fever
Primary tuberculosis
Drugs, for example, sulfonamides, penicillin, oral contraceptive pill, codeine, salicylates, barbiturates
Others - pregnancy, ulcerative colitis (UC), Crohn's disease, malignancy, Behcet's syndrome.
82
Cyclophosphamide is well known to cause which cancer?
How can the risk be reduced if you have to use it?
Bladder cancer
Prescribe Mesna
Mesna is mixed with IV cyclophosphamide to bind acrolein, a product of cyclophosphamide degradation that is toxic to the bladder epithelium and can lead to hemorrhagic cystitis and sometimes transitional cell carcinoma of the bladder.
83
What are the complications of obstetric cholestasis?
Obstetric cholestasis is associated with:
```
Perinatal mortality
An increased incidence of passage of meconium
Premature delivery
Fetal distress
Delivery by caesarean section
Postpartum haemorrhage.
```
84
What are the different types of renal stones?
Triple phosphate (staghorn calculi associated with Proteus sp)
Other types of kidney stones can be composed of:
- Calcium oxalate - The main issue here is high oxalate levels. Oxalate is a breakdown product of glyoxylate and glycine.
- Calcium phosphate - The main underlying issue here is hypercalciuria which is often aggravated by a failure to acidify the urine adequately.
- Cystine stones - These occur in patients with cystinuria, a rare autosomal recessive condition which presents in the second and third decade of life. Patients excrete excessive amounts of cystine, ornithine, arginine and lysine (COAL) due to a defect in a renal transporter in the proximal tubule.
- Urate stones - These are fairly uncommon and account for around 8% of renal stones.
85
What is the most common cause of lobar pneumonia?
Staph aureus
86
What are the clinical features of Pneumocystis jirovecci pneumonia?
What is characteristically seen on X-ray?
What is the treatment?
There is marked hypoxia (particularly on exercise) and malaise with a DRY COUGH.
X-ray changes may be much less severe than clinical features. Commonly shows "peri-hilar fine mottling"
In some cases the history may be longer and more gradual.
The treatment is with co-trimoxazole and/or dapsone with or without steroids.
87
What is McArdle's disease?
Rhabdomyolysis following exertion or minor illness should prompt investigation for possible inherited causes. Many healthy people will have mild rhabdomyolysis after running a marathon.
McArdle's disease is one of the most common inherited disorders resulting in rhabdomyolysis, typically on minor illness and/or with mild-moderate exertion. There is an inherited defect in the gene for the muscle phosphorylase enzyme which is usually inherited in an autosomal recessive manner. During exercise, normal muscle contains glycogen which is broken down by muscle phosphorylase to create more glucose to supply the ongoing energy needs of the contracting muscle. In McArdle's disease, the deficiency of this enzyme means that glucose runs out prematurely, causing a lack of ATP which makes muscle cells prone to damage during exertion.
88
Describe the use of dopamine to preserve renal function in ICU
Dopamine is a renal arterial vasodilator.
Can ensure kidneys get blood flow in AKI or acute cardiogenic shock
(this is a bit of a fringe ICU thing. Extremely low yield)
89
A patient presents to A+E with chest pain and non-specific ST-T wave changes on the ECG.
They had an MI 4 days ago
How would you diagnose a further MI?
Troponin T remains elevated for ten days following an MI so a second episode of chest pain within that time, suspicious of MI, needs to be evaluated with creatine kinase (CK)-myoglobin (MB) which rises over three days to form a diagnostic profile.
90
Photosensitivity is a side effect in which 2 common cardiac drugs?
Photosensitivity is a common adverse effect and the cardiology drugs affected include amiodarone and thiazide diuretics.
91
What is a common cause for dysphagia a week or two following stenting for oesophageal cancer?
Bolus obstruction
Despite issuing detailed instructions regarding diet following stenting, readmission with obstruction is common, due to patients 'forgetting' the rules.
92
What does pulsus alterans signify?
Pulsus alternans is a physical finding characterised by a regular alternation of the force of the arterial pulse.
It almost invariably indicates the presence of severe left ventricular systolic dysfunction.
93
What are the risks of Hep B, HIV and Hep C following transfusion?
The risks are variable depending on the source of donation and the type of testing employed but generally in the United Kingdom the risks for hepatitis B are in the order of 1 per 1.3 million donations while those for HIV and hepatitis C are 1 in 6.5 million and 1 in 28 million donations.
A broad knowledge of the risks may be required while consenting a patient for blood transfusion.
94
What are the 3 causes of lens dislocation?
In Marfan's syndrome the lens often dislocates in an upward and outward direction.
Other causes of lens dislocation include homocystinuria. and following cataract surgery.
95
What is the first line investigation in suspected Phaeochromocytoma and why?
The investigation of phaeochromocytoma can be difficult because the tumour secretes the catecholamines in an unpredictable manner which increases the risk of false negative results. This is particularly a concern for urine catecholamines which are fairly short lived and unstable in the blood so levels can be normal between episodes.
Because of this phenomenon, the first line test is a 24 hour urine collection for metanephrines. Metanephrines are metabolites of catecholamines which are more stable in the bloodstream. Their excretion rates show less day-to-day variation. Borderline results can be obtained in stressed individuals and should be repeated. Urine catecholamine levels are now seldom used in clinical practise.
96
What are the clinical features of Churg-strauss?
What is seen on X-ray?
How do you differentiate from sarcoidosis and Wegener's?
Churg-Strauss syndrome is a granulomatous vasculitis which usually occurs in males.
Classically it presents with
```
Asthma
Rhinitis
Eosinophilia
Vasculitis.
There is pulmonary eosinophilic infiltration. The lungs, peripheral veins and skin are most often involved.
```
The chest x ray shows transient patchy pneumonic shadows. Skin shows tender subcutaneous nodules and purpuric lesions. Perinuclear anti-neutrophil cytoplasmic antibody (pANCA) is usually positive.
This is unlikely to be sarcoidosis as wheeze is not typical and bilateral hilar lymphadenopathy is the typical x ray feature.
Wegener's is a possibility although ENT symptoms are expected and wheeze is not typical.
97
Palmar crease xanthoma are associated with what condition?
remnant hyperlipidaemia (type III hyperlipidaemia)
98
What risk do you have to remember when starting folic acid supplementation?
If concomitant vitamin B12 deficiency replacing folate (or giving it in pregnancy) can worsen B12 deficiency and cause subacute combined degeneration of the cord.
99
Describe the classification of supracondylar fractures
Gartland classification:
- Type 1 = Undisplaced
- Type 2 = Angulated with intact posterior cortex (posterior hinge)
- Type 3 = Completely displaced
- Type 4 = Unstable on flexion and extension (all over the shop)
Type 2 usually fixed with percutaneous pinning
100
What are the common complications of a supracondylar fracture?
Vascular (5% -> need to check brachial and distal pulses)
Nerve injury
Compartment syndrome
Malunion
(nasty fractures)
101
When does calcium homeostasis become a problem in CKD?
Multiple abnormalities in calcium homeostasis are seen in patients with kidney disease.
At CKD3, most patients have normal plasma concentrations of calcium and phosphate.
However, there may be more subtle abnormalities, particularly as CKD3 advances towards CKD4, such as a slight increase in PTH due to reduced hydroxylation of vitamin D by the kidney.
102
What is the treatment for a post-partum breast abscess?
Ultrasound guided needle aspiration followed by antibiotics
103
What percentage of those with cirrhosis from Hep C develop hepatocellular carcinoma?
2%
104
When do you stop tranexamic acid if no improvement for menorrhagia?
Stop if no improvement after 3 cycles.
105
When measuring child growth how can you differentiate from chronic disease and genetic/constitutional causes?
Weight seems to be maintained in genetic/constitutional
Both weight and height affected in chronic disease.
106
What is Weber's syndrome?
mid-brain stroke with ipsilateral third nerve palsy and contralateral hemiparesis
107
What is Osler-Weber-Rendu syndrome?
Hereditary haemorrhagic telangiectasia
108
What does Hansen's syndrome refer to?
leprosy
109
Papillary thyroid tumours are the most common thyroid malignancy. However, how can you differentiate them from follicular by the clinical picture?
Papillary commonly spreads to lymph nodes while follicular commonly spreads by haematogenous means.
110
Clawing of the toes (pes cavus) with loss of muscle bulk of the lower leg suggests what?
Charcot-Marie-Tooth disease
| loss of muscle bulk is LMN degeneration with pes cavus being one of the earliest deformities seen
111
Describe the Stamford classification for aortic dissection.
type A: A Affects Ascending Aorta and Arch (all As)
- accounts for ~60% of aortic dissections
- surgical management
- may result in:
- --coronary artery occlusion
- --aortic incompetence
- --rupture into pericardial sac with resulting cardiac tamponade
type B: B Begins Beyond Brachiocephalic vessels (all Bs)
- accounts for ~40% of aortic dissections
- dissection commences distal to the left subclavian artery
- medical management with blood pressure control
112
What's the difference between an aneurysm and a pseudoaneurysm?
Aneurysms are described as false if they involve only the outer layer and are contained by the adventitia, whereas true aneurysms involve all three layers of the aortic wall.
113
What is Apert's syndrome?
Apert's syndrome is one of the craniosynostoses (premature fusion of the cranial sutures). It is characterised by syndactyly of fingers and toes.
114
What serology is seen in primary biliary cirrhosis?
mitochondrial 83-98%
smooth muscle 50%
ANF 20%.
115
What are the features of primary biliary cirrhosis?
```
Granulomatous destruction of bile ducts
Insidious pruritus then jaundice
Sicca syndrome in 70% cases
Finger clubbing
Xanthomata + type IIa hyperlipidaemia
Neuropathy
Fleshy lymphadenopathy at porta hepatis
Widespread tissue granulomata, and
Kveim -ve impaired cell mediated immunity.
```
Other associations are:
- CREST syndrome (calcinosis, Raynaud's phenomenon, (o)esophageal dysfunction, sclerodactyly, and telangiectasis), and
- Renal tubular acidosis type 1.
116
How do you differentiate between cardiac tamponade and constrictive pericarditis?
Cardiac tamponade is characterised by Beck's triad of:
- hypotension
- raised JVP, and
- muffled heart sounds.
Constrictive pericarditis tends to present with features of right-sided cardiac failure with hypotension as a late feature.
In cardiac tamponade there is pulsus paradoxus (a greater than 10 mmHg fall in systolic BP on inspiration) but this is less commonly seen in constrictive pericarditis, though can still be present in both.
Kussmaul's sign (a rise in the JVP on inspiration) is more likely to be seen in constrictive pericarditis than cardiac tamponade.
Muffled heart sounds is neither distinctive nor helps to discriminate. It is non-specific and subjective so should not be relied upon in clinical practice.
