QM/BM Flashcards
(321 cards)
1
Q
Give the triad in multiple endocrine neoplasia.
A
Phaeochromocytoma is a rare cause of secondary hypertension in young patients, which causes a classic “triad” of symptoms - headache, sweating and tachycardia.
2
Q
How do we treat bradycardia with adverse effects?
A
First line atropine up to 3mg, then temporary pacing
3
Q
What are the two types of aortic dissection?
A
Stanford type A and type B.
4
Q
How do we manage aortic dissection?
A
If B: intravenous beta blockers (to prevent propagation of the dissection) and opioid analgesia.
If A: ^ + open surgery
5
Q
IE: how do perivavlular or aortic root abscesses present on ECG?
A
They manifest through prolongation of the PR interval on the ECG, which can be followed by higher degrees of heart block. Patients with infective endocarditis are monitored for this complication through daily ECGs.
6
Q
What is the GRACE score?
A
GRACE risk score to estimate in-hospital mortality and another score to estimate mortality up to 6 months post-discharge in STEMI.
7
Q
What is the pathophysiology of NSTEMI?
A
The underlying pathology of an NSTEMI is caused by an incomplete blockade of the coronary arteries.
8
Q
Where do you see the pacing spikes in a) atrial and b) ventricular pacing?
A
a) preceding p waves
b) preceding QRS complex
9
Q
How do we treat atrial flutter?
A
Beta-blockers are usually 1st line in management of atrial flutter
10
Q
Give a common observation which can be serious in Brugada pts
A
Fever - can be life-threatening, treat with paracetamol
11
Q
Define PR interval
A
The start of the P wave to the start of the QRS complex
12
Q
How do we treat Brugada?
A
Implantable cardiac defibrillator
13
Q
How do we treat stable ventricular tachycardia?
A
Amiodarone (anti-dysrhytmic), initially with a loading dose of 300mg IV over 20-60 minutes, followed by 900mg of amiodarone over 24hrs.
14
Q
How do we treat beta blocker overdose?
A
Resus council guidelines state in such cases where beta-blocker (or calcium channel blocker) overdose is suspected, glucagon should be trialled before opting for transcutaneous pacing.
15
Q
How do we treat AF within 48h of presentation?
A
With either pharmacological or electrical cardioversion along with low molecular weight heparin.
16
Q
What is Behçet’s syndrome?
A
A systemic inflammatory disorder associated with oral and genital ulceration, anterior uveitis, arthritis, vasculitis, skin lesions (such as erythema nodosum) and is a known cause of acute pericarditis
17
Q
What is Kussmaul’s sign?
A
Physiologically, the jugular venous pulsation should reduce and not rise when the intrapulmonary pressure reduces in inspiration. This is due to an inability of the right ventricle to fill with blood and instead the blood backs up into the venous system and causes a raised jugular venous pulsation.
18
Q
What is the dose of atorvastatin post MI?
A
80mg
19
Q
ST elevation in V1-3 and I, aVL and V5/6 shows occlusion of which artery?
A
This ECG shows ST-segment elevation in the anterior chest leads (V1-V3) and the lateral chest leads I, aVL, and V5/V6. This is, therefore, an anterolateral STEMI. In this infarction, it is usually the left anterior descending artery (or the left circumflex artery) that is involved.
20
Q
When is PPCI indicated?
A
PPCI is indicated as first-line in patients with acute ST-segment elevation myocardial infarct if: a) presentation is within 12 hours of onset of symptoms, and b) PPCI can be delivered within 120 minutes of the time when fibrinolysis could have been given.
21
Q
When do we commence rate control in AF?
A
If resting HR is >80
22
Q
What is the murmur heard in aortic regurgitation?
A
Early diastolic murmur, exacerbated by leaning forward
23
Q
What is the maximum dose of bisoprolol?
A
10mg
24
Q
How does AF present on ECG?
A
The ECG showed no discernible p waves and irregularly irregular rhythm.
25
How does acute decompensated HF present?
His impaired left ventricle secondary to ischaemic heart disease is unable to meet the demands of his body, this has resulted in lack of forward flow to the kidneys causing an AKI and back pressure through the pulmonary veins into the lung parenchyma which is causing the alveolar oedema on his chest and driving the tachypnoea.
26
How do we treat AF in pts with HF?
Electrical cardioversion, and if the patient has permanent atrial fibrillation (rhythm control has failed to restore sinus rhythm). Patients with heart failure benefit from the combination of carvedilol (for rate control) with digoxin (which may improve ejection fraction). A warfarin is important for stroke prophylaxis in those with valvular AF and is required in this patient as the CHA2DS2-VASc score is 2.
27
What heart condition can cocaine use predispose you to?
Coronary artery vasospasm
28
How does mitral stenosis present on examination?
Rumbling mid-diastolic murmur best heard at the apex
29
How do we medically manage angina?
Immediate symptomatic relief: GTN spray
Long term symptomatic relief: beta blocker or calcium channel blocker
Secondary prevention: aspirin, atorvastatin, ACEi
30
How do we treat htn in pts with T2DM?
in patients with a new diagnosis of hypertension who also have type 2 diabetes, first line management for controlling blood pressure is an angiotensin converting enzyme inhibitor.
31
What ECG changes can digoxin cause?
The patient's ECG findings are consistent with digoxin toxicity of which frequent premature ventricular complexes are the most common.
32
How do NSAIDs increase BP?
NSAID use can increase blood pressure by inhibiting COX-2 in the kidneys and reducing sodium excretion. Through this mechanism it can inhibit the effectiveness of the diuretic based antihypertensive therapies – notably it has less effect on calcium channel blockers which act via a vasodilatory action.
33
What is apixaban an example of?
A NOAC (novel oral anticoagulant)
34
In which pts do we offer transcatheter aortic valve implantation (TAVI)?
Over 75's who are haemodynamically stable. If younger, surgical aortic valve replacement
35
Will troponin be elevated in NSTEMI?
Yes, but not in unstable angina
36
What is Wellen's syndrome?
Wellens syndrome describes an abnormal electrocardiographic (ECG) pattern, deeply inverted T waves in leads V2 and V3, that are secondary to proximal LAD stenosis. Treated like secondary angina.
37
How would RCA infarct present on ECG?
The RCA is the artery that supplies the inferior and posterior aspects of the left ventricle which corresponds to the leads II, III and aVF on the ECG.
38
Weber's vs Rinne's
Weber's = middle of forehead: with unilateral conductive loss, sound lateralizes toward affected ear. With unilateral sensorineural loss, sound lateralizes to the normal or better-hearing side.
Rinne's = mastoid bone: air conduction is better than bone conduction. The patient should be able to hear the sound of the tuning fork adjacent to their ear, persist for approximately twice as long as the sound they heard over their mastoid process. This is considered a "positive test."
39
Key differential to Bell's Palsy?
Ramsay-Hunt syndrome - presents with lesions in ear and vestibulocochlear nerve symptoms (tinnitus, unilateral hearing impairment) compared with Bell's Palsy
40
How does empty nose syndrome present?
Rare, late complication of turbinate surgery
The most common clinical symptoms are paradoxical nasal obstruction, nasal dryness and crusting, and a persistent feeling of dyspnea.
41
What is presbycusis?
Presbycusis is one of the commonest causes of symmetrical bilateral hearing loss. It occurs gradually and most noticeable at higher frequencies. It is due to natural ageing of the auditory system: cochlear hair cells and auditory nerve fibres damaged symmetrically over time.
42
How does acute mastoiditis present?
Typical presentation of acute mastoiditis is severe otalgia, classically centred behind the ear and with a history of acute otitis media and fever. The patient is very unwell with swelling, erythema and tenderness over the mastoid process. The external ear may protrude forwards.
43
What is the most common source of epistaxis?
Blood vessels in Little's area, hence why pinching the soft part of the nostrils is usually successful
44
How do we treat ongoing posterior epistaxis?
Nasal tampon
45
How does vitamin C deficiency present?
Loose teeth and poor gingival health
46
What is the most common type of mouth cancer, and how does it present?
Squamous cell carcinoma
| A non-healing mouth ulcer, that is both painful and bleeding
47
What is an acoustic neuroma?
To do
48
How does Meniere's disease present?
The three cardinal features of Meniere's disease are tinnitus, deafness and vertigo. The majority of people with Meniere's also experience aural fullness, which is frequently described as a feeling of fullness or pressure within the ear.
49
What causes Meniere's disease?
Meniere's disease is thought to be due to a build-up of lymphatic fluid in the inner ear, although the mechanism is incompletely understood.
50
What is the most common cause of progressive deafness in young adults?
Otosclerosis, an autosomal dominant condition. Ear examination is normal.
51
How does vestibular neuronitis present?
This is otherwise known as acute vestibular failure or labyrinthitis. This most frequently follows a recent upper respiratory tract infection
52
Notitis media vs otitis externa
to do
53
Hodkin's vs non=hidkins
To do
54
Which manoeuvre is used to diagnose benign paroxysmal positional vertigo?
Dix-Hallpike
55
Which manoeuvre is a treatment option for BPPV?
Epley manoeuvre
56
How do we treat severe hayfever short term?
Short course oral prednisolone - not to be prescribed long term
Useful when improvement is needed for a short time
57
When do we use rigid bronchoscopy vs Magill forceps?
A circular radio-opaque foreign body with a halo seen on the chest radiograph is very suggestive of a button battery. This must be removed immediately. Since the patient is wheezy, this suggests a lower airway obstruction. Therefore, rigid bronchoscopy is the most appropriate intervention. Magill forceps is only used if the foreign body is located in the oropharynx and laryngeal inlet.
58
How does peritonsillar abscess present?
Similar to tonsillitis, on examination, the patient is having some difficulty fully opening her mouth, but you can see an erythematous swollen soft palate on the right side, and the uvula is deviated towards the left.
59
What is a Stokes-Adams attack?
Cardiogenic syncope due to bradycardia. Treated with IV atropine initially, and then transcutaneous pacing.
60
When would we treat with apixaban instead of thrombolysis in massive PE?
If there is a high risk of haemorrhage, such as due to recent stroke
61
How does ascending cholangitis present?
Charcot's triad: RUQ pain, fever/raised WCC, jaundice
Acute cholecystitis presents with both but w/o jaundice
Biliary colic is just pain
62
In which patients can we not use 6mg IV adenosine to treat narrow complex tachycardia?
Those with asthma, so verapamil is used instead
63
What would you do with a COPD patient who has become drowsy after being started on 60% oxygen?
This patient has started to become drowsier, confused and developed a headache about half an hour after being started on 60% oxygen. In the context of a COPD patient, this must be treated as hypercapnia, and thus reduce oxygen to 20%
64
When do we investigate leads V7-9?
The ECG changes are typical of those which appear in a posterior myocardial infarction. If a STEMI occurs then in the posterior area of the heart then reciprocal changes are seen in the anterior and septal leads of V1-3. In order to investigate the posterior aspect of the heart directly leads must be placed on the back - these are leads V7-9.
65
How do we treat pneumothorax?
Chest drain insertion
66
How do we treat tension pneumothorax?
Immediate needle decompression with a large-bore needle in the 2nd intercostal space mid-clavicular line
67
What is IV phenytoin given for?
To do
68
A pt with anorexia nervosa presents with paracetamol overdose. How does this affect management?
There is increased risk of paracetamol toxicity in patients that are in glutathione deplete states. This includes eating disorders, HIV and malnutrition. A history of anorexia nervosa would warrant immediate administration of NAC.
69
How much glucose do we give to patients with severe hypoglycaemia?
15-20g of rapid-acting carbohydrate
70
Which antibiotics can cause torsades de pointes?
Macrolide antibiotics can cause QT prolongation, which increases the risk of developing torsades de pointes. She has likely been started on this for the treatment of pneumonia.
71
How does Budd-Chiari syndrome present?
Budd-Chiari syndrome describes a syndrome where there is hepatic vein obstruction. It is considered primary if there is hepatic vein thrombosis, often seen in patients with underlying haematological conditions or in pro-coagulable state
In this case, the patient has polycythaemia rubra vera. It is considered secondary if it there is external compression of the hepatic vein, secondary to a liver, renal or adrenal tumour. Budd-Chiari presents with the classic triad of severe abdominal pain, ascites and tender hepatomegaly.
72
How do we diagnose Budd-Chiari syndrome?
Gold standard for diagnosis is an abdominal ultrasound with Doppler studies.
73
How do we treat MALT lymphoma?
MALT lymphoma is a low-grade form of non Hodgkin's lymphoma. The initial treatment for a patient with H. Pylori-positive gastric MALT lymphoma is H. Pylori eradication therapy. Most patients can be fully treated using these antibiotics.
74
What is Barrett's oesophagus, and what can it lead to?
Barrett's oesophagus refers to metaplasia of the lower oesophageal mucosa, whereby the usual squamous epithelium is replaced by gastric columnar epithelium. The strongest risk factor is gastro-oesophageal reflux disease (GORD). Other risk factors include obesity, male gender and smoking. There is an increased risk oesophageal adenocarcinoma (almost 50 fold). This is now the most common type of oesophageal cancer.
75
Define excoriations
Skin-picking
76
How does Coeliac disease present dermatologically?
Dermatitis herpetiformis is a dermatological manifestation of coeliac disease, characterised by pruritic papulovesicular lesions over the extensor surfaces of the arms, legs, buttocks, and trunk.
77
What is the Rockall risk score used for?
The Rockall risk score can be used to assess patients who are at high risk of further upper GI bleeds and deterioration.
78
How do we treat sudden onset hepatic encephalopathy?
This patient's confusion is likely secondary to hepatic encephalopathy and first line treatment for this is lactulose. Lactulose is a laxative which also helps by eliminating ammonia. Patients with hepatic encephalopathy should be prescribed regular lactulose and aim for 2-3 loose stools per day.
79
How does pharyngeal pouch present, and how is it diagnosed?
To do, but barium swallow
80
What do we advise to pts using symptomatic relief of angina?
Take GTN, then repeat after 5 minutes. If there is still pain 5 minutes after the repeat dose – call an ambulance.
81
How does Munchausen's syndrome present?
The patient in this question is intentionally faking signs and symptoms (i.e. adding blood to urine and complaining of pain) in order to gain attention and play “the patient role”. This is consistent with Munchausen's syndrome.
82
How does Normal Pressure Hydrocephalus present on CT brain scan?
This man is is presenting with the triad of "Wet, Wobbly & Weird". This is typical of Normal Pressure Hydrocephalus, which is caused by an abnormal increase in cerebrospinal fluid (CSF) in the ventricles. The sulci are absent because they are compressed by the ventricles which allows for the pressure to be normal despite the CSF increase. The fact that he has not had headaches, nausea nor vomiting helps to point away from any causes of raised intracranial pressure.
83
What is the most common cause of haemolytic uraemic syndrome?
E Coli 0157
84
How does haemolytic uraemic syndrome present?
Bloody diarrhoea, fever and abdominal pain
| Low platelets, an AKI and a haemolytic anaemia
85
How does isoniazid affect warfarin metabolism?
Isoniazid is a hepatic enzyme inhibitor, which leads to a decrease in the metabolism of Warfarin and therefore an increase in the International Normalised Ratio.
86
In what condition is anti-mitochondrial antibody M2 subtype (AMA M2) positive?
Primary biliary cholangitis
87
Where do you find cherry red skin? How do we treat the condition?
CO poisoning
| Hyperbaric oxygen
88
How does hyposplenism present on blood film?
Howell-Jolly bodies, monocytosis, lymphocytosis, and increased platelet counts
Think coeliac diseasE?
89
What do we advise to patients taking doxycycline?
Doxycycline is an antibiotic used in the treatment of pneumonia that is also associated with the development of oesophagitis due to its direct chemical irritant effect on the mucosa. Patients should be advised to take Doxycycline with a large glass of water whilst in an upright position.
90
How do we treat antifreeze overdose?
Fomepizole inhibits alcohol dehydrogenase. At a sufficiently high concentration, ethanol saturates alcohol dehydrogenase, preventing it from acting on ethylene glycol, thus allowing the latter to be excreted unchanged by the kidneys. Historically, this has been done with intoxicating doses of ethanol. However, ethanol therapy is complicated by its own toxicity. Fomepizole inhibits alcohol dehydrogenase without producing serious adverse effects.
Large amounts of ethylene glycol in antifreeze
91
Which antibodies are raised in autoimmune hepatitis?
This patient is presenting with signs and symptoms that may be consistent with autoimmune hepatitis, which tends to present in pre-menstrual females with jaundice, fatigue and anorexia. Anti-smooth muscle antibodies and Anti-nuclear antibodies are likely to be positive in this individual.
92
How do we treat C. difficile infection?
Vancomycin
93
Do we give vancomycin IV or orally in C difficile infection?
Vancomycin does not cross the blood-gut barrier so is most effective when administered orally.
94
How does Addisonian crisis present?
To do
95
How do we treat Addisonian crisis?
IV hydrocortisone
96
How do we manage torsades de pointes?
IV Magnesium Sulphate is the most appropriate treatment for TDPs, which is what this patient has on ECG. Antipsychotics can cause a prolonged QT interval, which can develop into TDP.
97
In which patients are ACEi contraindicated?
Those with AKI
98
Where do we use faecal occult blood testing?
is offered to (asymptomatic) people aged 55 and over to screen for bowel cancer, rather than used to investigate symptomatic people.
99
What is ischaemic hepatitis?
Ischaemic hepatitis describes diffuse hepatic injury secondary to acute hypoperfusion of the liver. This pattern is typically seen in patients who become acutely hypotensive or have a cardiac arrest.
100
Where do you find organophosphates, and what do they cause?
Organophosphates (found in pesticides) cause over-activity of the cholinergic system giving the symptoms described in this scenario.
Difficulty breathing, diarrhoea, urinary frequency and muscle spasms.
On examination his eyes are watering and he appears sweaty. He is also bradycardic.
101
Which organism can likely cause GBS?
C. jejuni
102
Which cancers are patients with coeliac's disease more likely to suffer from?
atients are at increased risk of small bowel lymphoma and adenocarcinoma. The risk is thought to normalise within a few years of a gluten free diet.
103
Too much to do
An irregular broad complex tachycardia is assumed to be ventricular fibrillation. The patient should be managed according to the Advanced Life Support guidelines. If there are no signs of life, the resuscitation team should be called and CPR commenced. Shockable rhythms (VF or VT) are managed with unsynchronised DC cardioversion.
Synchronised DC cardioversion is used in the management of haemodynamically unstable patients with a tacchyarrhythmia, who show signs of life (i.e. have a pulse). Synchronised cardioversion delivers a low energy shock in time with a specific point in the QRS complex, to avoid inducing ventricular fibrillation. Unsychronised cardioversion (defibrillation) delivers a high energy shock at any point in the cardiac cycle when there is no coordinated intrinsic myocardial activity, with the aim to allow the heart's intrinsic rhythm to regain control.
104
How does acute-on-chronic renal failure present?
These include hyperkalaemia (tented T-waves on ECG, best seen in precordial leads), acute pulmonary oedema (bi-basal crepitations and Type I respiratory failure on an ABG) and uraemia (confusion and uremic pericarditis).
105
How do we treat hyperkalaemia?
It would be most important to start an intravenous infusion of Calcium gluconate, which stabilises the myocardium and prevents the development of ventricular tachyarrhythmias.
106
Give two alternatives to clopidogrel.
Ticagrelor and prasugrel
107
What should all patients be offered following MI?
All patients following a myocardial infarction (MI) should be offered dual antiplatelet therapy, ACE inhibitor, beta-blocker and statin.
108
How does rheumatic fever present?
This woman presents with evidence of previous group A streptococcal infection (positive ASO titre, recent sore throat), along with core features of rheumatic fever: carditis (a new murmur), arthralgia, a characteristic rash (erythema marginatum), and raised inflammatory markers.
109
What ECG changes do you see in hypothermia?
A J-wave/Osborne wave is classically associated with hypothermia. This is when a positive deflection is seen occurring at the junction between the QRS complex and the ST-segment.
110
Do we give bisoprolol or propanolol as rate control in the management of fast AF
Bisoprolol is cardioselective, propanolol is non-cardioselective
111
Treating thyroid storm
To do
Symptom control:
IV propanolol
IV digoxin if propanolol fails or is contraindicated (e.g. asthma, low BP)
Reduce thyroid activity:
Propylthiouracil - preferred because it inhibits peripheral thyroxine conversion
Lugol's iodine 4 hours later
Methimazole/carbimazole is considered second-line
IV hydrocortisone to reduce thyroid inflammation
Treat complications: (e.g. heart failure, hyperthermia)
112
Which fluid do we use for initial resuscitation, and why?
Crystalloid IV fluid not colloid due to risk of anaphylaxis
113
What is the commonest cause of sudden cardiac death in young people?
Hypertrophic cardiomyopathy
114
How does eosinophilic granulomatosis with polyangitis present?
adult-onset asthma, symptoms of nasal obstruction and bilateral nasal polyps classical features of this condition.
115
How does vestibular schwannoma present?
Rinne's and Weber's tests reveal sensorineural deafness of the left ear. This and the tinnitus reveal palsy of cranial nerve (CN) VIII. Loss of corneal reflex points to CN V palsy. These are in keeping with vestibular schwannoma (previously termed acoustic neuroma), which is a tumour of Schwann cells of CN VIII that is located in the cerebellopontine angle (CPA). As the tumour enlarges, it can compress local nerves including CN V (leading to loss of corneal reflex) and/or the brainstem. Late in the disease course, it can rarely affect CN VII (which may cause unilateral lower motor neuron palsy manifesting in inability to bear teeth on one side and change in taste). The enlarging tumour can also cause a headache due to mass effect, which is most frequently occipital in location.
116
What can epistaxis be the result of in middle-older aged men?
Liver disease
117
Describe the signs you would see in tension pneumothorax
Tracheal deviation to the left, reduced chest expansion, hyperresonant percussion on the right, decreased vocal resonance on the right
A tension pneumothorax may be large enough to shift the trachea to the opposite side. Due to the collection of air in the pleural space, percussion will appear hyperresonant and vocal resonance will be decreased on the same side as the pneumothorax. Other findings may include signs of haemodynamic instability and crepitus over the skin from surgical emphysema.
118
How does Meniere's disease present?
Ménière's disease presents with sudden, unpredictable attacks of vertigo lasting between 20 minutes and 12 hours, often with fatigue and dysequilibrium afterwards. According to the AAO-HNS criteria, it is associated with low- to mid-frequency sensorineural hearing loss and fluctuant aural symptoms (hearing, tinnitus, or fullness) in the affected ear.
119
Describe the signs seen in aortic regurgitation
early diastolic murmur, widened pulse pressure, soft S1 and a history of previous rheumatic fever, which are all associated with aortic regurgitation
120
How does cardiac tamponade present?
This lady also displays Beck’s triad - the combination of raised JVP, hypotension and muffled heart sounds
She has Kussmaul’s sign (rise in JVP with inspiration) and pulsus paradoxus (drop in systolic blood pressure of about 15 mmHg with inspiration), which are also features of cardiac tamponade.
121
How do we treat cardiac tamponade?
Pericardiocentesis involves the insertion of a needle into the pericardial sac to relieve over-accumulation of fluid. A needle is usually inserted just left to the xiphoid process, aiming towards her left shoulder.
122
Give common complications of myocardial infarct
Common complications resulting from a myocardial infarct that can result in a murmur include mitral regurgitation secondary to rupture of the papillary muscle/chordae tendineae as well as ventricular septal defect due to rupture of the inter-ventricular wall. In both cases, they result in a pan-systolic murmur.
123
What investigation should patients with strep bovis endocarditis have?
Screening colonoscopy
124
How does digoxin toxicity present?
This patient most likely takes Digoxin for congestive heart failure. The abdominal pain, nausea and vomiting may be explained by gastroenteritis, or due to the effects of Digoxin toxicity itself. Hypokalaemia (which can result from vomiting and diarrhoea) worsens Digoxin toxicity - allowing it to occur in therapeutic concentrations. The downsloping ST segment is the characteristic 'Salvador Dali's moustache' or reverse tick sign - this does not necessarily indicate toxicity, but is seen with Digoxin use. Note, yellow discolouration of vision (xanthopsia) is a classic but rare sign of Digoxin toxicity.
125
What is the ORBIT score used for?
To do
126
What is a cholesteatoma?
This is a rare but important condition. Cholesteatoma is a misnomer; it is not a tumour and is not related to cholesterol. Instead, it is a destructive, expansive mass of keratinised squamous epithelium that requires surgical removal, because it has the potential to invade medially into the ear ossicles and beyond.
127
How does amyloidosis present in cardiology?
esults in amyloid protein deposition in various tissues in the body, such as kidneys and the heart. It can lead to a restrictive cardiomyopathy that appears “sparkling” on an echocardiogram. This man has presented with symptoms of heart failure with a preserved ejection fraction (HFpEF). Amyloid deposition also causes arrhythmias and conduction disturbances.
128
What is suxamethonium apnoea?
It occurs when a patient does not possess the enzymes (plasma cholinesterase) to metabolise suxamethonium leading to sustained action of the drug on the post-synaptic membrane of the neuromuscular junction.
129
How do we treat hypotension in the major haemorrhage protocol?
Blood transfusion - NOT fluids
130
How do we treat hypotension when a epidural is in-situ?
A well-recognised side effect of epidural anaesthesia is hypotension due to local anaesthesia of sympathetic nerves. This leads to unopposed parasympathetic activity and therefore the only method of counteracting profound hypotension is removal of the epidural.
131
Are you allowed microgynon prior to surgery?
Combined contraceptive preparations increase a patient's thromboembolic risk which is significant at the time of surgery. Therefore, it is recommended to stop combined preparations 4 weeks before surgery and use barrier contraception in this period.
132
What can treatment with a dopamine antagonist present with?
This describes an acute dystonic reaction most likely secondary to metoclopramide. Reactions to metoclopramide, an antidopaminergic anti-emetic, can cause acute dystonic reaction, clasically in patients younger than 30 years old and when doses of greater than 30 mg per day are administered. Metoclopramide should be discontinued. An anticholinergic agent, such as procyclidine or biperiden, can be administered to alleviate the acute dystonic reaction.
133
How do we use warfarin prior to surgery?
Stop. If at high risk of further thromboembolic events, bridging with a LMWH is recommended.
134
How do we treat hyperthermia after rapid sequence induction?
The patient has developed malignant hyperthermia secondary to suxamethonium use during rapid sequence induction. Initial treatment should be an immediate 2mg/kg bolus of dantrolene.
135
What percentage of traumatic tympanic membrane perforations heal within 8 weeks?
90%
136
How do we treat trigeminal neuralgia?
Carbamazepine, this patient has symptoms of trigeminal neuralgia, which causes severe pain in the distribution of the trigeminal nerve, particularly in response to light touch
137
How does metformin cause lactic acidosis? How do we treat it?
Metformin can cause a lactic acidosis by impairing lactic acid metabolism in the liver. A lactic acidosis is initially managed with a fluid bolus. This will improve the renal component to his acidosis although it may not fully treat the liver component.
138
Patients on long term steroids must be covered during surgery due to the risk of adrenocortical insufficiency. IV hydrocortisone alone is sufficient for this during surgery, and oral steroids may be started again 48-72 hours post-op provided the patient is eating and drinking again. An increased dose of steroid is required to account for the stress response to surgery.
To do
139
What is the first line treatment of diabetic neuropathy?
Duloxetine, amitriptyline, pregabalin and gabapentin for the treatment of chronic pain.
140
What is duloxetine?
Duloxetine is a serotonin and noradrenaline re-uptake inhibitor
141
How do we treat acute cluster headaches?
first line treatment for which is a triptan and 100% oxygen.
142
What is the difference betewen CPAP and BiPAP?
CPAP is commonly used in patients with type I respiratory failure - hypoxia with a normal CO2. This allows the patients to experience a positive pressure throughout respiration, allowing further gas exchange to take place.
BiPAP is used to treat type II respiratory failure, which presents with hypoxia and hypercapnia. A higher inspiratory pressure is used compared to the expiratory pressure, and BiPAP is commonly used in patients with COPD.
143
How do we treat suspected tricyclic antidepressant overdose?
Patients with a suspected tricyclic antidepressant overdose, who are acidotic or have an arrhythmia should be managed according to the ABCDE algorithm and also with sodium bicarbonate.
144
What is amitriptyline?
Tricyclic antidepressant
145
What is Lyme disease spread by?
Spread by tick bites
146
Where does psoriasis predominantly affect?
Psoriasis most commonly presents on the scalp and extensor surfaces of the knees and elbows.
147
What is the first line treatment for acne vulgaris?
Topical Benzoyl peroxide
148
Where would you see topical vitamin D analogues used in dermatology?
Topical vitamin D analogues are commonly used in the management of Psoriasis to help reduce the rate of skin turnover. It is reported to cause an exacerbation of eczema and hence is not indicated.
149
What is vitiligo?
Vitiligo is a a cutaneous depigmentation disorder that occurs as a result of loss of normal melanocytes. It typically affects the extremities as well as areas around the body orifices
150
What is bullous pemphigold?
Bullous Pemphigoid is an autoimmune blistering skin condition which affects the elderly. It is more common in those with neurological diseases such as Parkinson's Disease or dementia. Bullous Pemphigoid is caused by autoantibodies against antigens between the epidermis and dermis, resulting in a sub-epidermal split. Initially, it presents as pruritic, tense, fluid-filled bullae (large blisters) on an erythematous base. In the image shown, some of the bullae have ruptured, leaving post-inflammatory hyperpigmentation. The lesions can be localised or widespread, often occurring in skin folds.
151
How does staphylococcal scalded skin syndrome present?
The age of this patient, the de-squamation, the positive Nikolsky sign and the sparing of the oral mucosa points towards staphylococcal scalded skin syndrome (SSSS)
152
How do squamous cell carcinomas present? How do they differ form basal cell carcinomas?
An SCC typically appears as an irregular, ill-defined red nodule with scale and ulceration. They often occur on sun exposed skin such as the face, scalp, ears, hands and shins. Also, SCCs can cause pain or bleeding and grow over weeks or months.
BCCs are also often located on areas of skin exposed to sun, particularly the head and neck. However, a BCC usually presents as a small, skin-coloured nodule with a pearly rolled edge, surface telangiectasia and possibly a necrotic or ulcerated center
153
How do we treat diabetic retinopathy?
Mild? Glycaemic control
| Severe? Pan-retinal photocoagulation
154
What is the difference between dry age related macular degeneration and wet AMD?
Dry - progressive loss of central vision over years/decades
Wet - progressive loss of central vision over months
155
How do we treat wet AMD?
When treating wet ARDM, prevention of further neovascularisation is essential. This is achieved through anti-VEGF agents such as Bevacizumab, which can be injected directly into the vitreous to increase its bioavailability to the choroid.
156
A red eye post eye surgery indicates...
Endopthalmitis - infection inside the pt's eye
157
Give an explanation for the purpose of a fluorescein eye drop test
Fluorescein is an orange/yellow eye drop which turns green with stimulation by blue light. The fluorescein accumulates in defects in the corneal epithelium and thus these areas of damage are more apparent when blue light is shone on to the cornea.
158
What is the purpose of tropicamide?
To dilate the pupil prior to formal fundoscopy exam owing to its relatively short half life (roughly 4 hours).
159
How does scleritis differ from episcleritis?
Painful ocular movement suggest scleritis as the extra-ocular muscles insert into the sclera.
Inflammation of the episclera (the layer underneath the conjunctiva). Patients present with red eye and tenderness over the inflamed area. In episcleritis pain is often mild, severe pain should raise the suspicion of scleritis.
160
How does anterior uveitis present?
- Moderately painful eye
- Slight blurring of vision
- Photophobia
- Associated with ankylosing spondylitis = back pain
161
What is Hutchinson's sign?
Nose-tip involvement in herpes zoster ophthalmicus is known as Hutchinson’s sign. Presence of this sign makes it likely that the eye will be affected.
162
How does molluscum contagiosum present?
Small, pink nodules with a central umbilication that occur in clusters is the classical description of molluscum contagiosum, caused by a poxvirus
163
Where would you see dendritic ulcers?
Dendritic ulcers seen under slit lamp with fluorescein applied suggest active herpes simplex virus replication. These ulcers are pathognomonic for herpes simplex keratitis.
164
What disease is rare but likely in a contacts wearer who went swimming? What is it characterised by?
Acanthamoeba keratitis. Amoebae invade the cornea of the eye. Contact lens wearers become exposed to the organism through contaminated water. It is a potentially blinding condition and is characterised by pain out of proportion to the findings, which include eye redness and decreased visual acuity.
165
How does temporal arteritis present?
- Blurring of vision in one eye
- Tenderness over the one side of face
- Finding chewing painful
- On fundoscopy, unilateral pale and swollen optic disc
166
How does dermatomyositis present?
Proximal muscle weakness and pain is indicative of myositis and the skin signs described are the heliotrope rash and Gottron’s papules.
167
How do we diagnose dermomyositis?
Muscle biopsy
168
How does psoriatic arthritis present?
Psoriatic arthritis typically affects the interphalangeal joints and spares the metacarpophalangeal joints. In addition, it appears the patient has psoriatic plaques on her scalp which is one of the most common places for them to appear.
169
How do we differentiate between seborrheic keratosis and squamous cell carcinomas?
Like squamous cell carcinomas, seborrheic keratosis are found on areas of sun exposed skin but are not malignant. They are common in elderly individuals and do not have an ulcerated core.
170
What do we use ciclosporin for?
Tx of psoriasis
171
What are the five side effects of ciclosporin
```
Hypertrophy of the gums
Hypertrichosis
HTN
Hyperkalaemia
Hyperglycaemia
```
172
What is dermatitis herpetiformis?
An extremely itchy, autoimmune, chronic, blistering, disease. It is a cutaneous manifestation of coeliac disease, which explains the abdominal symptoms this patient is suffering from
173
What is the first line tx of mild acne vulgaris?
Topical benzoyl peroxide
174
How does erythema multiforme present?
Erythema multiforme can have multiple aetiologies including bacterial and viral infections and drug reactions. It presents as target-like lesions on the peripheries that can eventually blister.
175
What is the most common nail manifestation of psoriasis?
Pitting
176
What must you council a pt starting systemic retinoids for their acne/
Teratogenicity
177
What is actinic keratosis?
Actinic Keratosis (also known as Solar Keratosis) is a premalignant skin condition which can precede the development of a Squamous Cell Carcinoma (SCC). Actinic Keratoses are thought to be caused by sunlight causing DNA damage and hence are found on sun exposed areas of skin, such as the backs of hands
178
How do we treat actinic keratosis?
Actinic Keratoses are treated to prevent them developing into an SCC. For larger areas (such as in this case), topical therapies are used. These include 5-Fluorouracil (a cytotoxic agent), a non-steroidal anti-inflammatory (NSAID) or Imiquimod (which modifies immune response). For localised lesions, cryotherapy, curettage and surgical excision can be used.
179
What is eczema herpeticum?
A serious complication of Atopic Eczema (and less commonly other skin conditions). It is caused by Herpes Simplex Virus (HSV). Urgent tx with IV aciclovir.
180
What is HSP?
Henoch-Schonlein purpura (HSP) is a small vessel vasculitis that usually affects children.
181
How does HSP present?
Classical triad of purpura over the extensor surfaces of the lower limb, abdominal pain and arthritis
182
What are haemangiomas?
benign proliferations of the vascular endothelium seen in early infancy. They usually clear spontaneously.
183
How does small-cell lung cancer present?
Can secrete ACTH, causing Cushing's syndrome
| Central lesion
184
How do we diagnose bronchiectasis?
High resolution CT scan of the chest
185
How do we pharmacologically treat IPF?
Pirfenidone - slows disease progression
186
What is primary ciliary dyskinesia?
An autosomal recessive disorder of dysfunctional cilia
187
How does PCD present?
Bronchiectasis and recurrent infections
188
What is the standard length of treatment for provoked PEs?
3 months
189
Give a respiratory SE of methotrexate
Pneumonitis (can lead to PF)
190
What is hyoscine butylbromide SC used for?
Hyoscine butylbromide is an anticholinergic agent that can improve respiratory secretions in end of life care.
191
In which respiratory condition would you see a swinging fever?
Empyema
192
What is the most common cause of cancer deaths in the male population?
Lung ca
193
Describe the pathophysiology behind tumour lysis syndrome?
The administration of chemotherapy can cause significant cell death in mitotically active tumours, resulting in the extravasation of intracellular contents such as nucleic acids into the circulation. These are then broken down into uric acid and phosphate. Uric acid can precipitate in renal tubules leading to an acute kidney injury, which may cause the anuria as reported by this patient. Raised phosphate levels sequester free Ca2+ ions in the bloodstream, leading to hypocalcaemia and its characteristic symptoms, such as tetany (cramps) and vomiting.
194
How do we treat fever in chemotherapy patients?
If they present unwell or with a fever, any patient who has recently had chemotherapy should be presumed to have neutropaenic sepsis.
Hospital for broad-spectrum IV abx
195
What is a common side effect of vincristine
Peripheral neuropathy is a significant and common side effect of Vincristine, which acts by inhibiting microtubule formation at the mitotic spindle.
196
What is Pemberton's test?
Pemberton's test involves asking the patient to lift their arms above their head. If this causes facial plethora, the patient has Pemberton's sign (i.e. a positive Pemberton's test).
197
How do we treat SVC syndrome?
Superior vena cava syndrome caused by compression of the superior vena cava by a tumour (Non-Hodgkin lymphoma can cause superior vena cava syndrome)
Dexamethasone can reduce swelling and oedema associated with the tumour
198
Give four causes of raised AFP
Hepatocellular carcinoma
Liver mets
Neural tube defects
Germ cell tumours
199
What is the most frequently used agent to treat N&V post chemotherapy?
Ondansetron - 5HT3 antagonist
200
What is the triad of serotonin syndrome?
```
Mental state changes
Autonomic hyperactivity (diarrhoea and pupil dilatation)
Tremor
```
201
Where do you find Orphan-Annie cells?
Pathognomonic of papillary thyroid cancers
202
What is the most common mechanism of breast cancer spread?
Haematogenous through blood vessels to distant sites, e.g. lung, liver and brain
203
How does SVC obstruction present?
To do
204
How do we manage sore throat in a patient on immunosuppressant medication e.g. azathioprine?
Urgent full blood count, to exclude neutropenia
205
What is Meig's syndrome? What is the triad?
Meig's syndrome is the triad of an ovarian benign tumour, ascites and pleural effusion. It is usually treated with a mixture of thoracentesis and paracentesis to drain off excess fluid and resection of the ovarian fibroma to correct the underlying cause. Meig's syndrome is a cause of a transudative pleural effusion.
206
What is ipratropium bromide? What is it used for?
Ipratropium bromide is a anti-muscarinic inhaler (short acting anti-muscarinic agent, sometimes abbreviated to SAMA). It is often used first line in helping patients with COPD to manage their symptoms in the short term (rapid acting).
207
How do we diagnose COPD?
Spirometry
208
Define pneumothorax
The presence of air or gas in the pleural cavity which is the potential space between the visceral and parietal pleura. Insertion of a chest drain will therefore penetrate the parietal pleura but not the visceral pleura.
209
How do restrictive patterns show on spirometry?
Pulmonary fibrosis is a restrictive lung disease, hence the reduced FVC and FEV1 (resulting in a normalised FEV1/FVC ratio)
210
Where do you find reduced Diffusion capacity of the lungs for carbon monoxide (DLCO) ?
Pulmonary fibrosis
211
What is the most common lung cancer not caused by smoking?
Adenocarcinoma
212
Give the three features of hypertrophic pulmonary osteoarthropathy
This is a presentation of the paraneoplastic syndrome hypertrophic pulmonary osteoarthropathy (HPOA) secondary to an underlying lung malignancy. The three classic features of HPOA; periostitis (inflammation of the periosteum, the connective tissue layer surrounding bone), digital clubbing and painful arthropathy of large joints are present in the history.
213
Define cor pulmonale
Hypertrophy and subsequent failure of the right ventricle of the heart
214
In which lung cancer would you find SIADH?
SIADH is a characteristic paraneoplastic phenomenon of small cell lung cancer.
215
What nail condition is most associated with psoriasis?
Nail pitting
216
How does tuberous sclerosis present?
Angiofibromas in the butterfly distribution, ash-leaf macules and shagreen patch.
217
Give hte main side effect of isotretinoin, an oral retinoid used to treat severe acne
Teratogenic
218
How does lichen planus present?
Autoimmune, chronic inflammatory condition
Wickham's striae are lacy white lines seen on the surface of skin lesions or on the oral mucosa. Lichen Planus also presents with a rash most commonly located on the neck, flexor aspects of the wrist or forearm, thigh, genitalia, shin and upper back. It is often symmetrically distributed. The appearance of Lichen Planus can be remembered by the 5 Ps; Purple, Pruritic, Papular, Polygonal, Planar (flat topped).
219
How do we treat staphylococcal scalded skin syndrome?
IV flucloxacillin with topical fusidic acid
220
What is eosinophilic folliculitis?
Any papular/pustular rash around hair follicles
221
What pathogen causes acne?
Cutibacterium (Propionibacterium) acnes
222
Which skin lesions have a pearly rolled edge?
BCCs
223
CREST syndrome
Anti-centromere antibodies - TO DO
224
Pityriasis rosea
TO DO
225
What is an haemangioma?
TO DO It is common in young children and will typically regress with age. They rarely require medical intervention.
226
How do we treat scabies?
Topical permethrin 5% + treat household members
227
In what condition would you see pruritic wheals? How is it treated?
Urticaria. Give oral cetirizine
228
How does bullous pemphigoid present?
TO DO
229
Give a common trigger for psoriasis
Skin trauma
230
How does systemic lupus erythematosus present?
It results in a variety of systemic symptoms including myalgia, arthralgia, fevers, mouth ulcers, lymphadenopathy and rashes. The exact cause is not identified but it is thought to involve genetics and environmental factors.
231
Give a risk factor for developing BCC
Immunosuppression
232
What is tinea pedis otherwise known as?
Athlete's foot
233
What is Koebner phenomenon?
This case describes the Koebner phenomenon, which is the presence of a new skin lesion on previously healthy skin following injury. Injury can include (but is not limited to) lacerations, burns, bites, sunburn, chemical irritation, surgery or cryotherapy. Koebner's phenomenon occurs primarily in Psoriasis, Vitiligo and Lichen Planus but can occur in others skin conditions less commonly.
234
How does shingles present?
Shingles is a cutaneous infection by the herpes zoster virus that resides in the basal root ganglia, hence the dermatomal distribution of the rash. It is known to be extremely painful and can remain so for some time after the blisters have cleared. This is known as post-herpetic neuralgia.
235
What causes shingles?
Varicella-zoster virus
236
How do arterial and venous ulcers present?
Arterial is cold, punched-out and is worse at night
| Venous is warm to touch and usually found above the medial malleolus
237
What is a pyogenic granuloma?
A Pyogenic Granuloma is a reactive overgrowth of capillary blood vessels. It is a benign lesion, but can cause discomfort and bleeding. Pyogenic Granulomas are rapidly growing and typically appear as described in the case above. The fingers and hands are particularly common sites. The cause of Pyogenic Granulomas is not fully understood, but minor trauma, infection and pregnancy are all associated with their development.
238
What is the pathophysiology of acne?
The pathology of acne involves distended pilosebaceous follicles with surrounding cellular infiltrate in the dermis. This can develop further into granuloma formation, granulation tissue and scar formation.
239
How does eczema herpeticum present?
Eczema Herpeticum is a serious complication of Atopic Eczema (and less commonly other skin conditions). It is caused by the Herpes simplex virus (HSV). It presents with widespread red, monomorphic blisters and erosions. Patients become systemically unwell with fever and malaise. Eczema Herpeticum requires immediate treatment with antivirals such as intravenous Aciclovir.
240
How does staphylococcal scalded skin syndrome present?
Staphylococcal scalded skin syndrome is a result of a Staphylococcus aureus infection from an injury such as a graze. It results in large blisters that cover most of the skin that eventually burst. It is extremely painful.
241
What is the first line treatment for plaque psoriasis?
Potent topical corticosteroid + topical vitamin D
242
In which lung cancer would you see hypercalcaemia?
Squamous cell lung cancer is associated with the ectopic production of parathyroid hormone related protein (PTHrP) which causes hypercalcaemia. The description of a cavitating lesion also points towards a histological diagnosis of squamous cell cancer.
243
Do you see clubbing in sarcoidosis?
No
244
How does cystic fibrosis present in adults?
Recurrent chest infections, sinusitis and pancreatic insufficiency (e.g. T2DM)
245
How do we treat sarcoidosis?
Oral prednisolone
246
What causes sarcoidosis?
Characterized by the growth of tiny collections of inflammatory cells (granulomas) in any part of your body — most commonly the lungs and lymph nodes
Experts think it results from the body's immune system responding to an unknown substance. Some research suggests that infectious agents, chemicals, dust and a potential abnormal reaction to the body's own proteins (self-proteins) could be responsible for the formation of granulomas in people who are genetically predisposed.
247
How does sarcoidosis present?
Fatigue, Swollen lymph nodes, Weight loss, Pain and swelling in joints, such as the ankles
Persistent dry cough, SOB, wheezing, chest pain
Erythema nodosum, uveitis (blurred vision)
248
How can we diagnose TB histologically?
Ziehl-Neelsen stain, as mycobacterium tuberculosis are acid fast bacilli
249
Which lung cancer is most strongly associated with smoking?
Squamous cell lung cancer
250
What do we use creon for?
Pancrelipase - replaces the exocrine enzymes that the pancreas would produce
251
Patients with severe COPD who remain breathless despite maximal medical therapy should be considered for...
Lung volume reduction surgery
252
Where would you see the pulmonary fibrosis with rheumatoid arthritis?
Lower lobes
253
What is cubital tunnel syndrome?
Compressive neuropathy of the ulnar nerve
254
What is Osgood Schlatter's disease? How is it diagnosed?
Osgood-Schlatter disease is a common cause of knee pain in growing adolescents. It is an inflammation of the area just below the knee where the tendon from the kneecap (patellar tendon) attaches to the shinbone (tibia).
Osgood-Schlatter disease most often occurs during growth spurts, when bones, muscles, tendons, and other structures are changing rapidly. Because physical activity puts additional stress on bones and muscles, children who participate in athletics — especially running and jumping sports — are at an increased risk for this condition.
Plain radiograph of the knee.
255
Give an MSK risk factor for ciprofloxacin use
Achilles tendon rupture
256
What is the female athletic triad? What can this lead to?
Osteoporosis, eating disorders and amenorrhoea.
Low oestrogen levels and poor nutrition in girls with eating disorders can lead to osteoporosis.
Osteoporosis is a risk factor for them to sustain stress fractures.
257
What does Jobe's test test for?
Jobe's test is the empty can test, which tests the supraspinatus muscle. Weakness on performing this movement would indicate a supraspinatus pathology as well.
258
How does osteomyelitis present on XR?
Regional osteopenia, focal cortical loss and periosteal changes.
259
Which imaging modality do we use to look at the soft tissues such as the menisci and the cruciate ligaments of the knee?
MRI
260
If the knee "gives way," after trauma, what might we be worried about?
Anterior cruciate ligament rupture
261
What is the mechanism of action of alendronate?
Bisphosphonate which inhibits the activity of osteoclasts, which are responsible for bone resorption
262
What is adhesive capsulitis? Which conditions is it linked to?
Frozen shoulder syndrome, adhesive capsulitis, is a painful and progressive disorder of unclear aetiology that leads to inflammation of the joint capsule of the shoulder. Movement becomes restricted often over the course of several weeks however it tends to be self limiting and usually resolves without invasive intervention.
Risk factors include strokes, diabetes and connective tissue diseases.
263
How does De Quervain's tenosynovitis present?
To do
264
When might scaphoid fractures become visible radiologically after trauma?
Pain in anatomical snuffbox but negative XR
May becomes visible in 10 days
265
Where would you see a Baker's cyst?
OA
266
What is jumper's knee?
Patellar tendinitis
267
How does patellar tendinitis present?
Anterior knee pain at the inferior pole of the patella that has a chronic course and often occurs in people who are keen runners or perform repetitive jumping movements.
268
What do you see in saturday night palsy?
This would give the appearance of wrist drop (paralysis or weakness of the hand and finger extensors), a finding seen in radial nerve neuropathy. Saturday night palsy occurs due to compression of the radial nerve to the prolonged pressure applied on the mid-arm. It is commonly seen in the setting of intoxication or anaesthesia.
269
How do we test for damage to the axillary nerve?
Test for sensation over the lower half of the right deltoid muscle
270
What is a greenstick fracture?
Greenstick fractures occur in paediatric patients when force is applied to a bone and it bends in such way that the structural integrity of the cortex surface is overcome. However, the bending force applied does not break the bone completely, breaking only the convex part of the bone whilst the concave surface remains intact.
271
What is a common complication of THR?
Posterior hip dislocation
272
Where might bony metastases arise from?
Breast, prostate, thyroid, kidney and bronchus
273
How does frozen shoulder syndrome present?
The absence of symptoms outside of the shoulder region is consistent with a frozen shoulder. Pain at night and on both active and passive movement of the shoulder are highly suggestive of frozen shoulder
274
What fracture is common after falling on an outstretched hand?
Colles' fracture
275
When might you see a Smith's fracture?
TO DO
276
How does damage to the common peroneal nerve present?
Also known as the common fibular nerve, this nerve wraps around the neck of the fibula and is commonly damaged by a fracture of the fibula or use of a tight plaster cast. The common peroneal nerve has motor and sensory functions. Damage to this nerve causes loss of the ability to dorsiflex and evert the foot causing a foot drop. Sensory functions of this nerve cover the skin on the anterolateral aspect of the leg and the dorsum of the foot.
277
How does complex regional pain syndrome present?
He subsequently undergoes carpal tunnel release surgery.
Two months after the operation, he presents with pain in the ipsilateral forearm, excruciating to even light touch. The arm also feels hot and sweaty at times.
Examination shows the skin to be shiny around the area.
278
What is the main risk with scaphoid fracture?
Avascular necrosis of the fractured part of the scaphoid. This is because the scaphoid is supplied in a retrograde manner (from the distal part of the bone to the proximal), mainly through the dorsal carpal branch of the radial artery.
Scaphoid fractures are the most frequent carpal bone fractures and account for up to 15% of wrist injuries.
279
What is the first line tx of non-severe carpal tunnel syndrome?§
A wrist splint would be the most suitable first line as her disease is in the mild to moderate stage as shown by the fact that there is no muscle wasting. The splint would help her keep her wrist in a fixed position at night and should be trialled for one month before other interventions are considered.
280
What is greater trochanteric pain syndrome?
Greater trochanteric pain syndrome is also known as trochanteric bursitis (inflammation of the bursa). The bursa becomes inflamed causing lateral hip pain worse at the extremes of hip rotation, abduction and adduction. Trochanteric bursitis is the most common cause of lateral hip pain. Autoimmune disease such as rheumatoid arthritis is a risk factor for trochanteric bursitis.
281
What is trigger finger?
This lady describes a classic history of trigger finger, a tendonitis of the digital flexor tendon at the A1 pulley leading to catching and locking of the digit.
282
Which organism causes gas gangrene? What is it?
C. perfringens is a gram-positive anaerobic bacteria found in the soil. Infections due to C. perfringens cause tissue necrosis, bacteraemia and gas gangrene. The gas produced is an exotoxin produced by the fermentation of glucose. Gas gangrene is a medical emergency that can rapidly progress to a severe clinical course with multi-organ failure.
283
What is pathognomonic for posterior shoulder dislocation?
The lightbulb sign
284
What is Golfer's Elbow?
Medial epicondylitis
usually affects patients in the 40-50 year old age range with a history of activities that involve repetitive use of the anterior forearm muscles such as working at a desk or playing golf. The pain is on the medial aspect of the elbow and worse on flexion and gripping. Patients typically report resolution of symptoms with non-steroidal anti-inflammatory drugs (NSAIDS) use and rest of the arm.
285
If a patient can plantarflex their foot, are we worried about an Achilles tendon fracture or a calcaneal fracture
With this mechanism of injury, it is highly likely that the fall has led to a fracture of the calcaneus. The symptoms of pain and swelling and tenderness on the medial aspect of the heel are consistent with this diagnosis.
The patient is able to plantar flex her foot which means the Achilles tendon is intact.
286
What is a hemiarthroplasty? When is it indicated?
TO DO
The radiograph demonstrates a basicervical fracture of the femoral neck which is intracapsular. The management option here would be hemiarthroplasty or total hip replacement but the patient's age, cognitive status and performance status would all favour the former.
287
How do bowing fractures differ from greenstick fractures?
Bowing fractures are common in children and can present similarly to greenstick fractures. However, bowing fractures do not produce actual fractures of the bone, so there would not be an actual fracture line or cortical injury to the bone.
288
What is the Garden classification?
The Garden classification is helpful for grading intra-capsular fractures of the femoral neck. The system allows the severity of the fracture to be graded as well a standardised treatment pathway to be followed. Grade 1 and 2 fractures are often treated using a dynamic hip screw. Grade 3 and 4 fractures are treated using open reduction and internal fixation or a hip arthroplasty.
289
How do Colles' fractures and fractures of the hamate bone differ?
Colles' fracture also occurs after falling on an outstretched hand, but this is a fracture of the distal radius. The patient would present with pain, tenderness and swelling in the forearm rather than over the hypothenar eminence.
In this case, the tenderness over the hypothenar eminence corresponds anatomically to the area where the hamate bone is.
290
How does a fat embolus present/
Fat embolus usually manifests 24 to 72 hours after the insult, which can be trauma or surgery.
Patients typically develop a classic triad - hypoxaemia, neurological abnormalities (confusion in this case) and petechial rash.
291
What is a Monteggia fracture?
Monteggia fractures involve the proximal third of the ulnar shaft and anterior dislocation of the radial head at the capitellum.
292
What is a Galeazzi fracture?
This differs from Galeazzi fractures, which involve the distal third of the radial shaft and dislocation at the radio-ulnar joint.
293
What is Cozen's test?
TO DO
Cozen's test used to diagnose lateral epicondylitis. Lateral epicondylitis is a tendinopathy involving the common origins of the extensor muscles of the forearm. The muscle most commonly involved is the extensor carpi radialis brevis (ECRB). Pain is on the lateral aspect of the elbow and is worsened by movements that place stress on the tendon of the ERCB such as resisted wrist extension.
294
What is the other name for tennis elbow?
Epicondylitis
295
How does osteochondritis dissecans present?
The history of swelling and pain after exercise with joint locking points to a diagnosis of osteochondritis dissecans. The joint can be unlocked through movement of the knee to displace the obstructing material.
296
What causes frozen shoulder syndrome?
Frozen shoulder is caused by thickening and contraction of the glenohumeral joint capsule and formation of adhesions which cause pain and loss of movement.The diagnosis is confirmed by clinical findings and a normal shoulder x-ray.
297
What is a hemiarthroplasty?
Partial hip replacement
298
What is osteogenesis imperfecta? How does it present?
a hereditary condition caused by a decreased in the normal amount of collagen. The milder forms have autosomal dominant inheritance whereas the severe forms have autosomal recessive inheritance.
Orthopaedic manifestations include several fractures during childhood, with associated long bowing and short stature. Other non-orthopaedic manifestations are hearing loss, blue sclerae.
This boy has had several fractures, learning difficulties most likely due to hearing loss and a short stature, which are all consistent with the diagnosis.
299
What can cause scapular winging?
Scapular winging can be caused by a deficit in the serratus anterior muscle or an injury to the long thoracic nerve, which innervates the serratus anterior muscle
300
Where would you see an ill-defined lytic area with 'onion-skin' periosteal reaction?
Ewing's sarcoma
301
What does a positive Lachman's test indicate?
ACL tear
A positive anterior drawer test would also indicate an ACL tear but less specific and sensitive.
302
What would you see on XR in Perthes' disease?
Femoral head collapse and fragmentation suggestive of osteonecrosis
303
How does dry AMD present?
Dry age related macular degeneration
Patients are often elderly and present with a gradual loss of central vision over years. Fundoscopy reveals ‘drusen’, which are deposits of protein on the retina.
304
What are the features of primary open angle glaucoma?
Insidious symptom onset, raised cup:disc ratio and arcuate visual field defects are typical features of POAG.
Glaucoma is NOT a raised intraocular pressure. Glaucoma is an optic neuropathy which has characteristic features on examination. The main feature to be aware of is a raised cup:disc ratio. A normal cup:disc ratio is < 0.3.
305
What is the function of topical pilocarpine?
Topical pilocarpine constricts the pupil and increases trabecular outflow.
306
How does a hereditary retinoblastoma present?
Cannot see well. On examination at the slit lamp, the patient has a large cream coloured mass in the fundus of both eyes.
The red reflex is absent.
307
How does a carotid-cavernous fistula present?
TO DO
This a communication between the carotid artery and the cavernous sinus. All cranial nerves that run through the cavernous sinus may be affected which include (III, IV, V1, V2 and VI). The eye is usually proptosed with an injected conjunctiva and may be pulsatile.
308
Which anti-tuberculous medications can cause gout?
Pyrazinamide and ethambutol
309
How do we treat joint hypermobility syndrome?
Improve muscle strength to protect the joints
310
What is CREST syndrome?
```
Calcinosis
Raynaud's
oEsophageal dysmotility (difficulty swallowing)
Sclerodactyly
Telangiectasia
```
311
How does ankylosing spondylitis present?
```
Inflammatory back pain: often early morning stiffness with tenderness of the sacroiliac joints and limited range of spinal motion on examination
Peripheral enthesitis (Achilles tendonitis, plantar fasciitis) and peripheral arthritis may occur in up to 1/3 of patients
Extra-articular involvement can be severe and includes anterior uveitis, aortitis (which can lead to aortic regurgitation), upper lobe pulmonary fibrosis and reduced chest expansion
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312
Which antibodies are positive in SLE pts?
Anti-nuclear antibodies are positive in over 95% of SLE patients. Anti-dsDNA is positive in 60%.
313
Which test does all pts with SLE need to have on diagnosis?
Urine dipstick test to look for proteinuria (evidence of lupus glomerulonephritis)
314
Which antibodies are found in autoimmune hepatitis?
Anti-smooth muscle antibodies
315
How does Goodpasture's syndrome present?
This patient presents with a pulmonary-renal syndrome with acute/sub-acute onset of symptoms, which is classic of Goodpasture's syndrome. The classic presenting symptom is haemoptysis following by deterioration in renal function.
316
What antibodies are seen in Goodpasture's syndrome?
Anti-glomerular basement membrane antibodies
317
What is Felty syndrome?
TO DO
318
What is the other term for CREST syndrome?
Systemic sclerosis
319
How do we diagnose Takayasu's arteritis?
CT angiography
320
How do we treat GCA with vision loss?
IV Methylprednisolone (high dose pred not enough as vision loss)
321
How does pseudogout present on joint aspiration? How do we treat it?
positively birefringent, rhomboid shaped crystals
There is no specific treatment targeting the pathology in pseudogout, but naproxen is an NSAID which is an effective anti-inflammatory medication and should be effective in alleviating pain
