16/12/20

Question 1

What are the signs of subacute combined degeneration of the spinal cord?

Answer 1

Ataxia

Absent ankle reflexes

Loss of vibration sensation

B12 deficiency is a known complication of total and sub-total gastrectomy, a consequence of removing of the intrinsic factor secreting cells that reside in the fundus and body of the stomach.

Question 2

What are the complications of gastrectomy?

Answer 2

Dumping syndrome

early: food of high osmotic potential moves into small intestine causing fluid shift
late: (rebound hypoglycaemia): surge of insulin following food of high glucose value in small intestine - 2-3 hours later the insulin ‘overshoots’ causing hypoglycaemia

Weight loss, early satiety

Iron-deficiency anaemia

Osteoporosis/osteomalacia

Vitamin B12 deficiency

Other complications

increased risk of gallstones

increased risk of gastric cancer

Question 3

Blood transfusion products - complications

What are the features of non-febrile haemolytic reaction?

How is it managed?

Answer 3

Fever and chills

(most likely to be caused by platelets)

Management:

• Slow down or stop the transfusion
• Give paracetamol
• Monitor

Question 4

Blood transfusion products - complications

What are the features of a minor allergic reaction?

What is the management?

Answer 4

Pruritus

Urticaria

Management: Temporarily stop the transfusion, antihistamine, monitor

Question 5

Blood transfusion products - complications

What is the cause of anaphylaxis

Answer 5

Seen in patients with IgA deficiency who have anti-IgA antibodies.

Question 6

Blood transfusion products - complications

What are the features of anaphylaxis

Answer 6

Hypotension

Dyspnoea

Wheezing

Question 7

Blood transfusion products - complications

What is the treatment of anaphylaxis?

Answer 7

Stop the transfusion

IM adrenaline

ABC support

oxygen

fluids

Question 8

What are the features of an acute haemolytic reaction?

Answer 8

Fever, abdominal pain, hypotension

Question 9

What is the management for acute haemolytic reaction?

Answer 9

Stop transfusion

Confirm diagnosis

check the identity of patient/name on blood product

send blood for direct Coombs test, repeat typing and cross-matching

Supportive care

fluid resuscitation

Question 10

What are the features of transfusion associated circulatory overload?

Answer 10

Pulmonary oedema, hypertension

Question 11

What is the management of a TACO?

Answer 11

Slow or stop transfusion

Consider intravenous loop diuretic (e.g. furosemide) and oxygen

Question 12

What is the mechanism of TACO?

Answer 12

Excessive rate of transfusion, pre-existing heart failure

Question 13

What causes a TRALI?

Answer 13

Non-cardiogenic pulmonary oedema thought to be secondary to increased vascular permeability caused by host neutrophils that become activated by substances in donated blood

Question 14

What are the features of TRALI?

Answer 14

Hypoxia, pulmonary infiltrates on chest x-ray, fever, hypotension

Question 15

What is the management of TRALI?

Answer 15

Stop the transfusion

Oxygen and supportive care

Question 16

What is the cause of acute haemolytic reaction?

Answer 16

Acute haemolytic transfusion reaction results from a mismatch of blood group (ABO) which causes massive intravascular haemolysis. This is usually the result of red blood cell destruction by IgM-type antibodies.

Question 17

What are the complications of actue haemolytic transfusion reaction?

Answer 17

Complications include disseminated intravascular coagulation, and renal failure

Question 18

What is the cause of cervical myelpathy?

Answer 18

Dorsomedial herniation of a disc and the development of transverse bony bars or posterior osteophytes may result in pressure on the spinal cord or the anterior spinal artery, which supplies the anterior two-thirds of the cord

Can occur after trauma - ezpecially hyperextension injury

Question 19

What are the features of degenerative cervical myelopathy?

Answer 19

Pain (affecting the neck, upper or lower limbs)

Loss of motor function (loss of digital dexterity, preventing simple tasks such as holding a fork or doing up their shirt buttons, arm or leg weakness/stiffness leading to impaired gait and imbalance

Loss of sensory function causing numbness

Loss of autonomic function (urinary or faecal incontinence and/or impotence) - these can occur and do not necessarily suggest cauda equina syndrome in the absence of other hallmarks of that condition

Hoffman’s sign: is a reflex test to assess for cervical myelopathy. It is performed by gently flicking one finger on a patient’s hand. A positive test results in reflex twitching of the other fingers on the same hand in response to the flick.

Question 20

What is the investigation for cervical myelopathy?

Answer 20

MRI (or rarely myelography) will direct surgical intervention. MRI also provides information on the state of the spinal cord at the level of compression.

Question 21

What is the managment for cervical myelopathy?

Answer 21

Decompressive surgery (laminectomy or anterior discectomy)

Manual manipulation of the cervical spine is of no proven benefit and may precipitate acute neurologi- cal deterioration.

Question 22

What is a post-operative complication of laminectomy/anterior discectomy for cervical myelopathy?

Answer 22

Postoperatively, patients with cervical myelopathy require ongoing follow-up as pathology can ‘recur’ at adjacent spinal levels, which were not treated by the initial decompressive surgery. This is called adjacent segment disease. Furthermore, surgery can change spinal dynamics increasing the likelihood of other levels being affected. Patients sometimes develop mal-alignment of the spine, including kyphosis and spondylolisthesis, and this can also affect the spinal cord. All patients with recurrent symptoms should be evaluated urgently by specialist spinal services.

Question 23

What are the differentials for hypokalaemia and hypertension?

Answer 23

The differential for hypertension with low potassium includes Conn’s, Cushing’s, renal artery stenosis and Liddle’s

Question 24

What are the causes of hypokalaemia without hypertension?

Answer 24

diuretics

GI loss (e.g. Diarrhoea, vomiting)

renal tubular acidosis (type 1 and 2**)

Bartter’s syndrome

Gitelman syndrome

Question 25

What is the inheritance pattern of beta thalassaemia?

Answer 25

autosomal recessive condition

Question 26

What type of anaemia is beta thalassaemia?

Answer 26

mild hypochromic, microcytic anaemia. It is usually asymptomatic

mild hypochromic, microcytic anaemia - microcytosis is characteristically disproportionate to the anaemia

HbA2 raised (> 3.5%)

Question 27

What type of organism is chlamydia?

Answer 27

obligate intracellular pathogen

Question 28

What are the features of chlamydia?

Answer 28

asymptomatic in around 70% of women and 50% of men

women: cervicitis (discharge, bleeding), dysuria
men: urethral discharge, dysuria

Question 29

What are the potential complications of chlamydia?

Answer 29

epididymitis

pelvic inflammatory disease

endometritis

increased incidence of ectopic pregnancies

infertility

reactive arthritis

perihepatitis (Fitz-Hugh-Curtis syndrome)

Question 30

What is the investigation for chlamydia?

Answer 30

traditional cell culture is no longer widely used

nuclear acid amplification tests (NAATs) are now the investigation of choice

urine (first void urine sample), vulvovaginal swab or cervical swab may be tested using the NAAT technique

for women: the vulvovaginal swab is first-line

for men: the urine test is first-line

Chlamydiatesting should be carried out two weeks after a possible exposure

Question 31

What is the management of chlamydia?

Answer 31

7 days course of doxycycline

if doxycycline is contraindicated / not tolerated then either azithromycin (1g od for one day, then 500mg od for two days) should be used

if pregnant then azithromycin, erythromycin or amoxicillin may be used. The SIGN guidelines suggest azithromycin 1g stat is the drug of choice ‘following discussion of the balance of benefits and risks with the patient’

Question 32

What are the requirements for maintenance fluids?

Answer 32

25-30 ml/kg/day of water and

approximately 1 mmol/kg/day of potassium, sodium and chloride and

approximately 50-100 g/day of glucose to limit starvation ketosis

Question 33

What is the holliday-segar formula?

Answer 33

Question 34

What is the maintenance fluid for a child weighing 28 kilos

Answer 34

Calculation for patient weighing 28 kg:

First 10 kg x 100 ml/kg = 1000 ml

Second 10 kg x 50 ml/kg = 500 ml

Last 8 kg x 20 ml/kg = 160 ml

so 1660

Question 35

What are the valves most commonly affected by infective endocarditis?

Answer 35

mitral valve, aortic valve, combined mitral and aortic valve, tricuspid valve, pulmonary valve (rare).

Question 36

Which patients get infective endocarditis?

Answer 36

previously normal valves (50%, typically acute presentation)

the mitral valve is most commonly affected

rheumatic valve disease (30%)

prosthetic valves

congenital heart defects

intravenous drug users (IVDUs, e.g. typically causing tricuspid lesion)

others: recent piercings

Question 37

What are the infective agents that cause infective endocarditis?

Answer 37

Staphylococcus aureus is now the most common cause of infective endocarditis

Staphylococcus aureus is also particularly common in acute presentation and IVDUs

If post prosthetic valve surgery - then staph epidermis is likely - Staph aureus becomes the likely organism after 2 months

Endocarditis caused by strep viridens is linked with poor dental hygiene or following a dental procedure. Additionally it is more prevalent in developing countries.

Streptococcus bovis is associated with colorectal cancer

non-infective: systemic lupus erythematosus (Libman-Sacks), malignancy: marantic endocarditis

Culture negative causes

prior antibiotic therapy

Coxiella burnetii

Bartonella

Brucella

HACEK: Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella)