Phase 4 Mocks Medschool Flashcards
(189 cards)
1
Q
What are common causes of hypoglycaemia ?
A
- Insulinomas
- Self-administration of insulin/Sulphonylureas
- Liver failure
- Addison’s disease
- Alcohol
- Nesidioblastosis (beta cell hyperplasia)
- Critical illness e.g. sepsis
2
Q
Which medications can cause hypoglycaemia ?
A
- Insulin
- Sulphonylureas e.g. gliclazide
3
Q
What is the bodies physiological reaction to hypoglycaemia
A
- Hormonal response first response is decreased insulin secretion and increased glucagon secretion
- Growth hormone and cortisol are released but later there is increased catecholamine-mediated (adrenergic) and acetylcholine-mediated (cholinergic) neurotransmission in the peripheral autonomic nervous system in the central nervous system
4
Q
What are features of hypoglycemia with a blood sugar <3.3 mol ?
A
- Autonomic symptoms due to the release of glucagon and adrenaline
- Sweating, shaking, anxiety, hunger and nausea
5
Q
What are features of hypoglycemia with blood <2.8mmol
A
- Weakness
- Visual changes
- Confusion
- Dizziness
- Severe = convulsions and coma
6
Q
How could one check for possibility of deliberate excess exogenous insulin ?
A
- Test C-peptide
- Its production is absent from exogenous insulin
7
Q
What would high insulin and high C-peptide suggest ?
A
- Endogenous insulin production
- Cause likely to be insulinoma/sulfonylurea use/abuse
8
Q
What would high insulin and low C-peptide suggest ?
A
- Exogenous insulin administration
- Suggesting exogenous insulin overdose/fictitious disorder
9
Q
What would low insulin and low C-peptide level suggest ?
A
- Alcohol induced hypoglycemia
- Critical illness e.g. sepsis
- Adrenal insufficiency
- Fasting/starvation
- Growth hormone deficiency
10
Q
Management of hypoglycaemia community
A
- Oral glucose 10-20g liquid, gel or tablet
- Hypokit can be prescribed containing a syringe and vial of glucagon for IM or SC injection
11
Q
Management of hypoglycaemia
A
- If patient is alert then oral glucose 10-20g should be used in liquid, gel or tablet form
- Unable to swallow then SC or IM glucagon
- IV glucose 20% 100ml over less than 15 mins
12
Q
What condition will around 50% of patients with temporal arteritis also have ?
A
- Polymyalgia rheumatica
13
Q
Typical features of TA ?
A
- Typically > 60 YO
- Rapid onset
- Headache
- Jaw claudication
- Reduced vision
- Tender, palpable temporal artery
- Lethargy, depression, low grade fever, anorexia, night sweats
14
Q
What polymyalgia rheumatica symptoms could present in a patient with TA ?
A
- Aching
- Morning stiffness (but not weakness) in proximal limb
15
Q
What investigations should be done in TA ?
A
- Inflammatory markers i.e. CRP, ESR
- Temporal artery biopsy/ultrasound
16
Q
How is TA treated ?
A
- High dose glucocorticoids – no visual loss then pred, if visual loss than IV methylprednisolone
- Urgent ophthalmology review
- (bisphosphonates are required due to long, tapering course of steroids required)
17
Q
- How does trigeminal neuralgia present ?
A
- Unilateral brief electric shock like pains with abrupt onset and termination limited to one or more divisions of the trigeminal nerve
18
Q
- What can trigger pain in trigeminal neuralgia ?
A
- Light touch including washing, shaving, smoking, talking and brushing teeth
- Frequently occurs spontaneously
19
Q
- What would one consider red flag symptoms in a potential trigeminal neuralgia presentation ?
A
- Sensory changes
- Ear/hearing problems
- Hx of skin or oral lesions
- Pain only in the ophthalmic division of the trigeminal nerve
- Bilateral presentation
- Optic neuritis
- Fx of MS
- Age < 40
20
Q
Trigeminal neuralgia first line management
A
- Carbamazepine
- Failure to respond and/or atypical features should prompt referral to neurology
21
Q
What condition do 5-10% of pts diagnosed with HTN also have ?
A
- Primary hyperaldosteronism (including Conn’s)
- Making it the most common cause of secondary HTN
22
Q
Renal causes of secondary hypertension
A
- Glomerulonephritis
- Pyelonephritis
- Acute polycystic kidney disease
- Renal artery stenosis
23
Q
Endocrine disorders that can lead in secondary hypertension
A
- Phaeochromocytoma
- Cushing’s syndrome
- Acromegaly
- Congenital adrenal hyperplasia
24
Q
Medications that can cause secondary HTN
A
- Steroids
- MOA-I
- COCP
- NSAIDs
- Leflunomide
25
What features of a patients presentation would indicate a case more likely to be secondary hypertension ?
- HTN occurs at a younger age with significantly elevated BP which is often resistant to medication
26
1. What examination signs might suggest coarctation of the aorta ?
- Radio-femoral delay
- Left ventricular heave
- Weak peripheral pulses in the legs
- Ejection systolic murmur
27
2. How could coarctation of the aorta be diagnosed ?
- Echocardiography
- CT aorta
28
3. How would coarctation of the aorta be managed ?
- Conventional open surgery
- Ballon angioplasty and stent insertion
29
1. What is the law that governs capacity ?
- The Mental Capacity Act of 2005
- Applies to all adults over the age of 16
30
2. What are the 5 key principles of the capacity act ?
- A person must be assumed to have capacity unless it is established that they lack capacity
- A person should not be treated as unable to make a decision unless all practicable steps to help him to do so have not been taken without success
- An unwise decision does not mean a person is unable to make a decision
- An act or decision under this act for or on behalf of a person should be in their best interest
- Before the act is done or the decision made regard must be taken to make the process as least restrictive of the person’s rights and freedom of action
31
3. What must be tested for in a Capacity Assessment ?
- He or she has an impairment or disturbance in the functioning of their mind or brain whether permanent or temporary AND
- A. Can understand the information
- B. Can retain the information
- C. Can use or weight the information
- D. Communicate the decision
32
4. What must occur if a patient lacks capacity ?
- A best interest decision must be made
33
5. What must be considered when making a best interest decision ?
- Whether a person is likely to regain capacity and can the decision wait
- How to encourage and optimise the participation of the person in the decision
- The past and present wishes, feelings, beliefs, values of the person and any other relevant factors
- Views of other relevant people
34
6. What can be made by a person who could lose their capacity in the future ?
- Lasting Power of Attorney (LPAs)
- Can make health and welfare decisions and decisions about life-sustaining treatment if the LPA specifies that
35
7. What is an advance decision ?
- Can be drawn up by anybody specifying what specific treatments someone would like where they to loose capacity
- Can be verbal unless they specify refusing life-sustaining treatment
- ADs cannot demand treatment
36
8. In a medical ward what actions could be considered a deprivation of liberty
- Restraint
- Sedation
37
9. What are core requirements that need to be followed to ensure a Deprivation of Liberty Safeguard is valid
- Avoid if possible
- Act in the patients best interest
- Only for the immediate intervention required
- For as short as possible
- Alternatives need to have been considered
38
10. GMC good practice principles
- Making the care of patients the first concern
- Providing a good standard of practice and care, and working within competence
- Working in partnership with patients and supporting them to make informed decisions about their care
- Treating colleagues with respect and help to create an environment that is compassionate, supportive and fair
- Acting with honesty and integrity and being open if things go wrong
- Protecting and promoting the health of patients and the public
39
1. What laws/acts are used to treat patients in emergency scenarios ?
- Common law: used to treat patients in emergency scenarios
- Mental Capacity Act: used to treat patients for a physical disorder e.g. delirium/sepsis
- Mental Health Act: used in patients who require treatment for mental disorders (5(2), 2 or 3)
40
2. What is a Section 2 for ?
- Admission for assessment up to 28 days (cannot be removed)
- Treatment may be given against the patients wishes
41
3. Who can approve a Section 2 ?
- An Approved Mental Health Professional (AMHP) or rarely the nearest relative (NR) makes the application on the recommendation of 2 doctors
- One of the doctors should be approved under section 12(2) of the Mental Health Act (usually consultant psychiatrist)
42
4. What is a Section 3 ?
- Admission for treatment for up to 6 months that can be renewed
- AMHP along with 2 doctors both of whom which must have seen the patient within the past 24 hours
43
5. What is a Section 4 ?
- 72 hour assessment order
- Used as an emergency, when a section 2 would involve an unacceptable delay
- A GP or AMHP or nearest relative
- Often changed to Section 2 upon arrival at hospital
44
6. What is a section 5(2) ?
- A patient who is voluntary patient in hospital can be legally detained by a doctor for 72 hours
45
7. What is a section 5(4) ?
- Allows a nurse to detain a patient who is voluntarily in hospital for 6 hours
46
8. What is a Section 17a ?
- Supervised Community Treatment (Community Treatment Order)
- Can be used to recall a patient to hospital for treatment if they do not comply with conditions of the order in the community, such as complying with medication
47
9. What is a Section 135 ?
- A order to obtained to allow the police to break into a property to remove a person to a Place of Safety
48
10. What is a Section 136 ?
- Someone found in a public place who appears to have a mental disorder can be taken by the police to a Place of Safety
- Can only be used for up to 24 hours whilst a Mental Health Act assessment is arranged
49
1. What surgical options are available for patients with severe peripheral artery disease ?
- Angioplasty
- Sent
- Bypass graft surgery
50
2. What symptoms would present if a patients bypass graft had occluded ?
- Cool and pale foot
- Absent pulse in graft
51
3. How does compartment syndrome present ?
- Swollen, tense and tender calf with a pink foot
- Pain on dorsiflexion
- Presence of a pulse does not rule out
52
4. When can compartment syndrome occur ?
- Fracture
- Ischemia reperfusion injury in vascular patients
53
5. Which injuries are commonly associated with compartment syndrome ?
- Supracondylar fractures
- Tibial shaft injuries
54
6. How is compartment syndrome diagnosed ?
- Measurement of intercompartmental pressure
- Excess of 20mmHg are abnormal and >40mmHg is diagnostic
55
1. What could be discussed to support and advice a patient with a new diagnosis of metastatic cancer ?
- Sign post to spiritual care
- Alternative therapies
- Management of pain
- Mental health support
- Palliative care and end of life care
- Advance directives
56
2. What medications can be deprescribed in palliative care ?
- Long term prophylaxis medications
- Statins
- Antihypertensives
57
3. What can be prescribed in palliative care for agitation ?
- Midazolam
58
4. What can be prescribed for respiratory secretions ?
- Hyoscine butylbromide
59
5. What can be used to treat muscle spasm and spasticity in palliative care ?
- Baclofen 1st line
- Diazepam or midazolam 2nd line
60
6. What could be prescribed for bowel colic/obstruction in palliative care ?
- Hyoscine butylbromide
- Also consider laxatives
61
7. What can be used to treat constipation in palliative care ?
- Stimulant laxatives e.g. Bisacodyl or Senna 1st line
- Add osmotic laxatives e.g. macrogol 3350 or lactulose 2nd line
- Add Docusate sodium 3rd line
62
8. What can treat dysphagia in palliative care ?
- Dexamethasone
63
9. What should be prescribed for nausea and vomiting associated with gastric issues in palliative care ?
- Metoclopramide 1st
- Domperidone 2nd
64
10. What can be prescribed for nausea and vomiting with chemical causes (hypercalcemia, morphine use or renal failure) in palliative care ?
- Haloperidol
65
11. What anti-emetic can be used in palliative care associated with raised intracranial pressure ?
- Cyclizine (in conjunction with dexamethasone)
66
12. What can haloperidol be used to treat in palliative care ?
- Nausea and vomiting (associated with chemical causes)
- Agitation/delirium
67
13. What can be prescribed for patients with anxiety in palliative care ?
- Months left to live – SSRIs
- Weeks – diazepam or lorazepam
68
14. What can be used to treat seizures in palliative care ?
- Levetiracetam
- Midazolam may be preferred in last days
69
15. How can hiccups be treated in palliative care ?
- Prokinetic e.g. Metoclopramide
- Peppermint oil
- PPI e.g. Lansoprazole
70
16. What can help treat noisy respiratory secretions in a patients last days ?
- Hyoscine butylbromide
71
17. How could a malodourous fungating tumour be treated ?
- Topical metronidazole in conjunction to systemic treatment
72
18. How can pruritus be treated in palliative care ?
- Emollients
- Levomenthol if resistant
73
1. What kind of sickle cell crisis’s can there be ?
- Thrombotic ‘vaso-occlusive’ and ‘painful crises’
- Acute chest syndrome
- Anaemia (aplastic or sequestration)
- Infection
74
2. What can precede a thrombotic sickle cell crisis ?
- Infection, dehydration, deoxygenation
75
3. How is a thrombotic crisis diagnosed ?
- Clinically – no specific test
76
4. What is acute chest syndrome sickle cell crisis
- Vaso-occlusion within the pulmonary microvasculature Infarction in the lung parenchyma
- Presents with dyspnoea, chest pain, pulmonary infiltrates on chest x-ray and low pO2
77
5. How is an acute chest syndrome sickle cell crisis treated ?
- Pain relief
- Respiratory support e.g. high flow oxygen
- ABxs
- Transfusion
78
6. What is an aplastic crises in sickle cell ?
- Infection with parvovirus
- Causing a sudden fall in haemoglobin
- Bone marrow suppression causes a reduced reticulocyte count
79
7. What is a sequestration crises in sickle cell ?
- Sickling within organs such as the spleen or lungs causing pooling of blood with worsening of anaemia
- Associated with an increased reticulocyte count
80
8. General management of a sickle cell crisis
- Analgesia e.g. opiates
- Rehydrate and keep warm
- Oxygen
- Consider Abx
- Blood transfusion if severe
- Exchange transfusion if vaso-occlusive crisis (i.e. stroke, acute chest syndrome, multi-organ failure)
81
9. Long term management of sickle cell
- Hydroxyurea
- Pneumococcal polysaccharide vaccine every 5 years
82
1. What is ascites ?
- An abnormal collection of fluid in the abdomen
83
2. What can cause ascites with a SAAG > 11g/L
- Indicates portal hypertension
- Liver disorders e.g. cirrhosis/alcoholic liver disease, acute liver failure and liver metastases
- Cardiac – right heart failure or constrictive pericarditis
- Other – Budd-Chiari syndrome, portal vein thrombosis, veno-occlusive disease or myxoedema
84
3. What can cause ascites with SAAG < 11g/L
- Hypoalbuminemia e.g. nephrotic syndrome or severe malnutrition
- Malignancy – peritoneal carcinomatosis
- Infections – tuberculous peritonitis
- Other – pancreatitis, bowel obstruction, biliary ascites
85
4. How is ascites managed ?
- Reducing dietary sodium
- Fluid restriction if sodium < 125
- Aldosterone antagonist e.g. spironolactone
- Often add loop diuretics e.g. furosemide
- Drainage if tense ascites (with albumin cover)
- Prophylactic antibiotics – oral ciprofloxacin if ascitic protein 15g/l
- Transjugular intrahepatic portosystemic shunt in some patients
86
5. Which blood tests best examine synthetic liver function ?
- INR
- Albumin
87
6. Name potential causes for confusion in a patient with cirrhosis
- Hepatic encephalopathy
- Intracerebral bleed
- Electrolyte or vitamin deficiency
- Alcohol withdrawal (Wernicke’s encephalopathy)
- Sepsis
- Medication or intoxication
- Spontaneous bacterial peritonitis
- GI bleed
88
1. In audiograms what should the results be above on the x axis ?
- 20dB
89
2. In sensorineural hearing loss what type of hearing is impaired ?
- Air and bone condition
90
3. In conductive hearing loss what type of hearing is impaired ?
- Air conduction
91
4. How is Weber’s test performed ?
- Strike the tunning fork
- Place at centre of the patients forehead
- Ask the patient if they can hear the sound and in which ear is it loudest
92
5. How will Weber’s test present in sensorineural hearing loss ?
- Sound will be louder in the normal ear as it is better at sensing the sound
93
6. How will Weber’s test present in conductive hearing loss ?
- The sound will be louder in the affected ear
- When the tuning fork’s vibration is transmitted directly to the cochlea, rather than having to be conducted, the increased sensitivity makes it sound louder in the affected ear.
94
7. What does Weber’s Test test ?
- Which ear is affected
- Is it conductive hearing loss ?
95
8. How is Rinne’s Test Performed ?
- Strike a tunning fork
- Place the flat end on the mastoid process (tests boney conduction)
- Ask the patient when they can no longer hear the noise
- When yes move the tunning fork and hover 1cm from ear
- Ask patient if they can now hear (tests air conduction)
96
9. What is a normal Rinne’s test ?
- The pt can hear the sound when the fork is moved from the mastoid process to the ear
- It is normal for air conduction to be better than bone conduction
- This is Rinne’s positive
97
11. What is an abnormal Rinne’s test ?
- When bone conduction is better than air conduction
- This suggests a conductive cause for the hearing loss
- Sound can still be transmitted through the bones whoever sound is less able to travel through the air, ear canal, tympanic membrane and middle ear to the cochlea due to a conductive problem
98
12. What are causes of sensorineural hearing loss ?
- Presbycusis (age related)
- Nosie exposure
- Meniere’s disease
- Labyrinthitis
- Acoustic neuroma
- Neurological conditions e.g. stroke, MS or brain tumour
- Infections e.g. meningitis
- Medications e.g. furosemide, gentamicin or chemo medications
99
13. What are causes of conductive hearing loss ?
- Ear wax
- Infection e.g. otitis media or otitis externa
- Fluid in the middle ear
- Eustachian tube dysfunction
- Perforated tympanic membrane
- Otosclerosis
- Cholesteatoma
- Exostoses
- Tumours
100
14. How would a right sided labyrinthitis present on hearing tests ?
- Labyrinthitis is a sensorineural hearing loss
- Weber’s test = the tunning fork is heard loudest in the unaffected ear e.g. left ear
- Rinne’s test will be normal in both ears
101
15. Which parts of the ear mediate conductive hearing ?
- The outer and middle ear
102
16. Which part of the ear mediates sensorineural hearing loss ?
- The inner ear
103
1. X-ray changes associated with osteoarthritis
- LOSS
- Loss of joint space
- Osteophytes (bone spurs)
- Subarticular sclerosis (increased density of the bone along the joint line)
- Subchondral cysts (fluid-filled holes in the bone)
104
2. Hand signs of Osteoarthritis
- Heberden’s nodes (DIP joints)
- Bouchard’s nodes (PIP joints)
- Squaring at the base of the thumb (CMC joint)
- Weak grip
- Reduced range of motion
105
3. Hand signs seen in advanced RA
- Z-shaped deformity (thumb)
- Swan neck deformity (hyperextended PIP and flexed DIP)
- Boutonniere deformity (hyperextended DIP and flexed PIP)
- Ulnar deviation if the fingers at the MCP joints
106
4. X-ray Changes in RA
- Periarticular osteopenia
- Boney erosions
- Soft-tissue swelling
- Joint destruction and deformity (in more advance disease)
107
1. How is C. difficle tested for ?
- Stool sample for PCR/microscopy and culture
- Also test stool sample for C.difficle toxin
108
2. List indications for ICU admission in a deteriorating patient with pneumonia
- Respiratory or metabolic acidosis (pH < 7.26)
- Persistent hypotension
- PaO2 <8 despite inspire O2
- PaCo2 >6.5
- Serial ABGs indicating respiratory failure
- Exhaustion, drowsiness, LOC
- Evidence of septic shock
109
3. Management of low severity CAP
- Amoxicillin 500 mg TDS for 5 days
- Doxycycline or clarithromycin if pen allergy
110
4. Management of high severity CAP
- Co-Amoxiclav
111
5. Moderate CAP with suspected atypical micro cause
- Amoxicillin Plus
- Clarithromycin (erythromycin if pregnancy)
112
1. What is the most common cause of hypercalcemia in outpatients ?
- Primary hyperparathyroidism
113
2. What is the most common cause of primary hyperparathyroidism ?
- Solitary adenoma (85%)
114
3. What is a good pneumonia for hypercalcemia ?
- Bones, stones, groans and moans
115
4. How can hypercalcemia present ?
- Polydipsia and polyuria
- Depression
- Anorexia, nausea and constipation
- Peptic ulceration
- Pancreatitis
- Bone pain/fracture
- Renal stones
- Hypertension
116
5. How can primary hyperparathyroidism be investigated ?
- Bloods – raised Ca2+, low phosphate, PTH may be raised or normal (if face of high Ca2+ this is abnormal)
- Technetium-MIBI subtraction scan
- X-ray – pepperpot skull, osteopenia
117
6. How is primary hyperparathyroidism managed ?
- Definitive = total parathyroidectomy
- Cinacalcet can be used if not suitable for surgery
118
7. How does hypercalcemia present ?
- Bones, stones, groans and moans
- Corneal calcification
- Hypertension
- Shortened QT interval on ECG
119
8. How does hypercalcemia present on ECG ?
- Shortened QT interval on ECG
120
9. How is hypercalcemia managed ?
- Rehydration with NaCl 1000ml 4 hours
- Bisphosphonates can also be used after rehydration
121
10. How is hypercalcemia associated with malignancy managed ?
- Calcitonin (salmon)
122
1. What are essential questions when taking a Hx for testicular torsion ?
- Trauma
- Sexual history
- Urinary symptoms
- Previous hx
- Systemic symptoms
- Speed of onset
123
2. What would one find on examination of a testicular torsion ?
- Cord is most tender
- Testical is retracted
- Absence of cremasteric reflex
124
3. What is epididymis-orchitis ?
- Infection of the epididymis +/- the testes resulting in pain and swelling
- Most commonly caused by local spread of infections from the genital tract (Chlamydia trachomatis and Neisseria gonorrhoeae in young adults and E.coli in older adults)
125
4. What would one find on examination of epididymis-orchitis ?
- Erythema and warmth
- Involvement of the scrotal sac
- Prehn’s sign (alleviation of scrotal pain by lifting the testical)
126
5. What is testicular torsion ?
- The twisting of the spermatic cord resulting in testicular ischemia and necrosis
- Most common in males between 10 and 30 with peak incidence 13-15 years
127
6. What are the presenting features of testicular torsion ?
- Sudden onset severe pain which may referrer down to the lower abdomen
- Nausea and vomiting
- Swollen and tender testis retracted upwards
- Loss of cremasteric reflex and no Prehn’s sign
128
7. What are features of Epididymo-orchitis ?
- Unilateral testicular pain and swelling
- Urethral discharge may be present but urethritis is often asymptomatic
- Prehn’s sign
- Cremasteric reflex present (lost in TT)
129
8. How is Epididymo-orchitis investigated ?
- In younger patients assess for STI e.g. urethral swabs, NATT testing for GN
- In older adults with low-risk sexual history send a mid-stream urine sample for culture
130
9. How is Epididymo-orchitis managed ?
- Chlamydia – doxycycline 7 days course
- Gonorrhea – IM ceftriaxone once
- Enteric organism ofloxacin
131
1. What are DDs of peritonsillar abscess ?
- Tonsilitis
- Glandular fever
- Tonsillar cancer
132
2. General symptoms of tonsillitis
- Sore throat
- Painful swallowing
- Fever
- Neck pain
- Referred ear pain
- Swollen tender lymph nodes
133
3. Specific signs that suggest peritonsillar abscess
- Trismus (unable to open mouth)
- Change in voice
- Swelling and erythema in area beside tonsils
134
4. What causes trismus in peritonsillar abscess ?
- Pus causes the pterygoid muscle to go into spasm preventing the opening of the mouth
135
5. What bacteria are associated with peritonsillar abscess ?
- Streptococcus pyogenes (group A strep)
- Staphylococcus aureus
- Haemophilus infuenza
136
6. How are patients with peritonsillar abscess managed ?
- Referral to hospital under ENT for needle aspiration or surgical incision and drainage
- IV penicillin and metronidazole
- ENT surgeons can use dexamethasone to settle inflammation
137
1. What are the components of a CURB 65 score ?
- Confusion
- Urea (>7mmol/L)
- RR > 30
- Systolic BP < 90 or diastolic < 60
- Age >65
138
1. Risk factors for pyelonephritis
- Female sex
- Structural urological abnormalities
- Vesico-ureteric reflux
- DM
139
2. MCC of pyelonephritis
- E.coli
140
3. How is pyelonephritis investigated ?
- Urine dipstick
- Midstream urine for microscopy, culture and sensitivity testing is essential to establish causative organism
- Blood tests – FBC and inflammatory markers
- CT or ultrasound KUB
141
4. How is Pyelonephritis managed ?
- Referral to hospital is symptoms of sepsis
- 1st line = Abxs for 7-10 days
- Absx Cefalexin, co-amoxiclav, trimethoprim or ciprofloxacin depending on cultures
142
5. What is the sepsis 6 ?
- Out – lactate, blood cultures and urine output
- In – oxygen, abxs, IV fluids
143
6. What could be DDs of pyelonephritis if pt does not respond to treatment ?
- Renal abscess
- Kidney stones
144
1. Causes of transudate effusion (< 30g/L protein)
- HF
- Hypoalbuminemia (liver disease, nephrotic syndrome, malabsorption)
- Hypothyroidism
- Meig’s syndrome (benign ovarian tumours (+ ascites)
145
2. Causes of exudate (> 30g/L protein)
- MCC is pneumonia
- TB
- Connective tissue disease (RA, SLE)
- Neoplasia e.g. lung cancer
- Pancreatitis
- PE
146
3. What tests should be performed on a exudate effusion fluid ?
- Microscopy, culture, sensitivity and cytology
147
4. What investigations would you order for an exudate pleural effusion ?
- CT thorax
- Ultrasound guided biopsy
148
1. What question would you ask a 8 week pregnant pt with pain and bleeding ?
- Bleeding volume
- Bleeding colour e.g. fresh red or brown or dark
- Intensity of pain
- Location of pain
- Pregnancy symptoms
149
2. What is a missed miscarriage ?
- Fetus is no longer alive but no symptoms have occurred
150
3. What is a threatened miscarriage ?
- Vaginal bleeding with closed cervix and a fetus that is alive
151
4. What is an inevitable miscarriage ?
- Vaginal bleeding with an open cervix
152
5. What is an incomplete miscarriage ?
- Retained products of conception remain in the uterus after the miscarriage
153
6. What is complete miscarriage ?
- A full miscarriage has occurred and there are no products of conception left in the uterus
154
7. What is an anembryonic pregnancy ?
- A gestational sac is present but contains no embryo
155
8. What are 3 key features looked at on a transvaginal US when investigating miscarriage ?
- Mean gestational sac diameter
- Fetal pole and crown-rump length
- Fetal heartbeat
156
9. At what crown-rump length is a heartbeat expected ?
- 7mm
- If a heartbeat isn’t found in a 7mm pregnancy the scan is repeated after 1 week before confirming a non-viable pregnancy
157
10. When is a fetal pole expected ?
- Once the mean gestational sac diameter is 25 mm or more
- Once 25 mm or more without a fetal pole the scan is repeated after 1 week before confirming an anembryonic pregnancy
158
11. How is a potential miscarriage managed when less than 6 weeks ?
- Expectantly managed (providing no pain or complications e.g. previous ectopic)
- This means awaiting the miscarriage without investigation or treatment
- Repeat urine pregnancy test after 7-10 days and if negative confirm miscarriage
159
12. How is a potential miscarriage managed when more than 6 weeks ?
- Referral to an early pregnancy assessment service
- Transvaginal US to confirm location and viability of pregnancy
- 3 options expectant, medical or surgical management
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13. When should a urine pregnancy test be performed post-expectant management decision ?
- 3 weeks after bleeding and pain have settled
161
14. What does medical management of a missed miscarriage involve ?
- Oral misoprostol (prostaglandin analogue)
- 48 hours later vaginal, oral or sublingual misoprostol
162
15. How is a incomplete miscarriage medically managed ?
- A single dose of misoprostol (vaginal, oral or sublingual)
163
16. How do prostaglandins works ?
- Soften the cervix and stimulate uterine contractions
164
17. How can miscarriage be managed surgically ?
- Vacuum aspiration (local as outpatient)
- Surgical management (under GA in theatre)
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1. Why is Rhesus status checked during the booking scan in pregnancy ?
- If a Rh -ve mother delivers a Rh +ve child a leak of fetal red blood may occur
- This causes anti-D IgG antibodies to form in the mother
- In later pregnancies these can cross the placenta and cause haemolysis in fetus
- Can also occur in the 1st pregnancy due to leaks
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2. How is Rhesus negative mothers managed ?
- NICE advises anti-D to non-sensitised Rh -ve mothers at 28 and 34 weeks
167
3. What are Rhesus sensitising events ?
- Delivery of Rh +ve infant (alive or stillborn)
- Any termination of pregnancy
- Miscarriage if gestation > 12 weeks
- Ectopic if managed surgically
- External cephalic version
- Antepartum haemorrhage
- Amniocentesis, chronic villus sampling, fetal blood sampling
- Abdominal trauma
168
1. What is the pathophysiology of hyperosmolar hyperglycemic state
- ↑ serum osmolality → osmotic diuresis → severe volume depletion
169
2. What are precipitating factors for HHS ?
- Intercurrent illness
- Dementia
- Sedative drugs
170
3. What is the timescale of the development of HHS ?
- Days
- Hence the metabolic and dehydration are worse than DKA
171
4. What is typically seen that would suggest HHS ?
- Hypovolemia
- Marked hyperglycemia (>30 mmol/L)
- Significant raised serum osmolarity (> 320 mosmol/kg)
- No significant hyperketonemia (<3 mmol/L)
- No significant acidosis (bicarbonate > 15 or pH > 7.3)
172
5. How is serum osmolarity calculated ?
- 2*Na + glucose + urea
173
6. How is HHS managed ?
- NaCl 0.9% 0.5-1L/h
- Monitor potassium
- Insulin should not be given unless BM stops falling while giving IV fluids
- VTE prophylaxis
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7. How does hypokalemia present ?
- Muscle weakness and hypotonia
- On ECG – U waves, small or absent T waves, prolonged PR interval, ST depression and long GQ
175
8. What signs may present on physical examination of a patient with hypokalemia ?
- Hypotension
- Irregular pulse
- Bradycardia or tachycardia
- Hypoventilation
- Lethargy
- Muscle fasciculations, tetany, decreased muscle power, diminished tendon reflexes
- Hypoactive bowel sounds
176
1. RFs for Hodgkin’s lymphoma
- HIV
- EBV
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2. Classic features of Hodgkin’s lymphoma
- Lymphadenopathy
- B symptoms
- Mediastinal lymphadenopathy on chest x-ray
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3. How can Hodgkins lymphoma be investigated ?
- Normocytic anaemia
- Eosinophilia
- LDH raised
- Lymph node biopsy – Reed-Sternberg Cells
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4. What physical signs may be found on physical examination of a patient with Hodgkin’s lymphoma ?
- Cervical or axillary lymphadenopathy
- Hepatosplenomegaly or splenomegaly
180
1. How does one convert from codeine to morphine ?
- Divide by 10
181
2. How does one get from oral morphine to SC ?
- Divide by 2
- Then if need be calculate for 24 hours
182
3. What is the ‘double effect doctrine’
- Sometimes it is permissible to cause a harm as a side effect of brining about a good result, provided the side effect was not the intended outcome
183
4. What pharmacological options are available to a pregnant patient in pain ?
- Paracetamol
- Codeine may be useful where paracetamol is not
- Systemic NSAIDs are avoided from 20 weeks and contraindicated after 28 weeks
184
5. In the last weeks of pregnancy which drugs should be avoided and why ?
- NSAIDs – risk of oligohydramnios
- Opioids – risk of neonatal respiratory depression
185
1. What are the 4 common types of leukaemia
- Acute myeloid leukaemia
- Acute lymphoblastic leukaemia
- Chronic myeloid leukaemia
- Chronic lymphoblastic leukaemia
186
2. What is a key identifying feature of acute lymphoblastic leukaemia ?
- Most common in children and is associated with Down syndrome
187
3. What is a key identifying feature of chronic lymphoblastic leukemia ?
- Smudge cells
- CLL can transform (Richter’s transformation) into a high-grade B cell lymphoma
- Typically affects adults over 60 years
188
4. What is a key identifying feature of chronic myeloid leukemia ?
- Philadelphia chromosome
189
5. What is a key identifying feature of acute lymphoblastic leukemia ?
- Blast cells and Auer Rods
