2 Flashcards
- Surgeon has asked you do grade a pre-op patient on the ASA mortality scale. He has asthma which is well controlled. What ASA grading? 1,2,3,4,5.
2
ASA Grades
• ASA 1: A normal healthy patient
o Healthy, non-smoking, minimal alcohol
ASA 2: A patient with mild systemic disease
o Smoking
o BMI 30
o Social alcohol drinker
o Pregnancy
o Well controlled DM/HTN
o Mild lung disease
ASA 3: A patient with severe systemic disease
o Poorly controlled DM/HTN
o COPD
o BMI 40
o EtOH dependence/abuse
o Implanted pacemaker
o Moderate reduction EF
o ESRD on dialysis
o MI, CVA >3mo ago
ASA 4: A patient with severe systemic disease that is a constant threat to life
o MI, CVA, TIA <3 mo ago
o Severe valve dysfunction
o Sepsis
o DIC
o ARD
o ESRD no dialysis
ASA 5: moribund
o Will not survive without operation
o Ruptured aneurysm
o Massive trauma
o Cranial bleed with mass effect
o Ischaemic bowel + cardiac/multi-system pathology
ASA 6:
o Declared brain dead
- Patient on a LOAD of different drugs and experiences urinary retention. What is the drug causing it?
Amitriptyline
- Ring and little finger tingling - which nerve has been damaged? Ulnar nerve damage, median nerve damage
Ulnar
- Deltoid wasting, weakness of flexion and supination - Upper brachial plexus damage, Lower brachial plexus damage, Ulnar nerve damage, Median nerve damage
Upper brachial plexus damage,
- Man in office had episodes of smelling something funny and then went into a daze or a ‘trance like state’. No headache. Options: Migraine, cerebral vasculitis, idiopathic epilepsy
idiopathic epilepsy
- Crushing pain for an hour and collapsed, young guy.
VF
- He just started chemo for Burkitt’s, high K
tumour lysis syndrome
o Hyperuricaemia
o Hyperphosphataemia
o Hyperkalaemia
o Hypocalcaemia, magnesaemia
o Acute renal failure
o Metabolic acidosis
- She was on dialysis, missed a dialysis session due to diarrhoea and has now developed cramps. What electrolyte is causing this?
Potassium, Sodium, Calcium
Up to date says sodium?
- Widened mediastinum. Erythema nodosum. High Ca.
Sarcoidosis
- Diabetic due for inguinal hernia surgery taking both gliclazide and metformin - HbA1c < 69mmmol/L. Omit gliclazide and keep metformin, start IV insulin infusion, omit metformin and keep gliclazide, omit both
Omit gliclazide and keep metformin,
Metformin – take as normal if BD, if TDS, omit lunch dose
Sulphonylurea – take PM dose if BD, omit all if OD
Start VRIII if
• T1DM and missing >1 meal
• T1DM and no BG insulin
• Poor control HbA1c >69 mmol
• T2DM and missing >1 meal and BM >12
• Emergency surgery
If BM >12 mmol:
• T1DM: SC insulin e.g. novorapid 1U drops by 3 mmol
• T2DM: 0.1U/kg rapid insulin
- Patient has swelling not separate to testis. Translluminates. Options: hydrocele, varicocele
Hydrocele
- 40 year old patient whacked by football 2 days ago, noticed swelling in left groin, diffuse swelling at upper pole of left testes, does not transluminate, right one normal. Options: epidiomo-orchitis, seminoma, teratoma, spermatocoele
Seminoma
o Average age 40
o May secrete hCG and LDH
Non-seminoma (teratoma, yolk sac, choriocarcinoma)
o Age 20-30
o AFP, hCG elevated
- Intermittent swelling in groin, now stays and is tender. Options: inguinal hernia, epididymal cyst
Inguinal hernia
- Desaturation on exertion, perihilar hazing
PCP
- Lateral epicondylitis question, pain on wrist extension. Options: Golfers elbow, tennis elbow.
Tennis Elbow
(Medial is golfers)
- Which drug causing hyperkalaemia
??
- Has lumbar pain. Popliteal and foot pulses missing.
??
- Man has footdrop after hip fracture. Which nerve was damaged? Options: common peroneal, sciatic, gluteal etc.
Answer: Sciatic.
- Loss of vision every now and then in right eye which resolves, and weakness in arm. Carotid artery stenosis
? MI. (I think this is a TIA?)
- Lateral medullary syndrome picture. Which artery? Posterior inferior cerebellar artery, posterior cerebral, inferior cerebral
PICA or vertebral
- A patient with PKD has a bleed. What is the most likely cause? Sub arachnoid haemorrhage, intercerebral bleed, extradural haematoma
Sub arachnoid haemorrhage
- A woman’s right arm keeps banging into door, can’t read whole page of a book i.e. hinting she has homonymous hemianopia-. Which artery is affected? MCA, PCA, ACA
Isolated HH = PCA stroke
- A man is getting worried that the gaps in his teeth are getting wider and his chin is becoming more prominent. What does he have?
Acromegaly
Woman with postural hypotension, which test would give you the diagnosis? Short synthacten, glucose tolerance, dex suppression
Short synthacten
- Patient with hyponatremia, has bronchogenic carcinoma. IV furosemide, vasopressin receptor antagonist
Fluid restrict
Vaptans
Demeclocycline
- Infective endocarditis. Which investigation would give a definitive diagnosis? Echo (TTE), Blood cultures, sputum culture
Criteria: Duke’s
• 2 major
• 1 major + 3 minor
• 5 minor
Major
• Blood cultures: 2 cultures, or 3 >12h apart
• Echo: vegetation, abscess, dehiscence, new regurg (needs to be TOE not TTE so think cultures would be answer)
Minor:
• Fever: >38
• Risk factors: cardiac, IVDU
• Microbiological: not meeting major
• Vascular: splinters, Janeway lesions
• Immunological: GN, osler nodes, Roth spots
- Dry eye and dry mouth. Bilateral parotid swelling. Which investigation? Anti-Ro, sialography, biopsy
Definitive: biopsy
Anti-Ro and La: +ve in 90%
- Ank spond. NSAIDs not working. What to give next? Prednisolone, Methotrexate, Infliximab, other monoclonal antibody
Infliximab
- He had paracetamol 1g TDS for pain. What to give next?
Codeine phosphate
- Man about to have hip replacement. Already been given TEDs, which other DVT prophylaxis should you give? Dibagatran, Enoxaparin (LMWH), Unfractionated heparin
Enoxaparin (LMWH),
- Suspected DVT, calf was not tender or swelling. He had pitting oedema up to his knee in one foot. Started amlodipine a month ago. D-dimer normal. What do you do? Reassure and discharge, IV frusemide, put on ace inhibitor
put on ace inhibitor
- Sats 90%, unwell (nauseous) for a week. ECG sinus tachy. No chest pain. Which Ix: CTPA, Echo, Coronary angiogram
CTPA
- Patient recently had an MI. Has already been started on ramipril, atorvastatin. What is another drug that should be added? ARB, Bisoprolol, hydralazine, digoxin
Bisoprolol
- Patient has increasing breathlessness on exertion, which resolves with GTN spray. It’s getting worse. What is an appropriate drug to start to relieve his symptoms? Isosorbide nitrate, Nicorandil
Angina Mx
• Bb or CCB
• Increase dose to max
• Bb + CCB
• Nicorandil, ranolazine, long acting nitrate, ivabridine
- Patient on beclametasone inhaler and salbutamol inhaler and now has pain on swallowing (i.e. he got oesophageal candidiasis). What advice do you give him? Advice to take beclometasone with spacer, switch beclametasone to fluticasone, swap beclametasone for salmetrol, advise to take his salbutamol and beclamethasone inhaler an hour apart,
• Stop smoking
• Rinse mouth after using
• Advise spacer (reduces particles in mouth)
- Alcoholic with long standing ascites, has been abstinent for 6 months. Increasing confusion. Is on regular thiamine and spironolactone. Has recently been started on oral furosemide. Has been feeling unwell and has some worsening of ascites. Na: low, BP low (can’t remember other figures). What is the most important IV therapy to start: furosemide, pabrinex, 500mL of Hartmann’s, antibiotics.
Antibiotics
SBP: tazocin
- 18 month old boy drinks paracetamol 2 hours ago, and mum has now brought him into A&E. What time is it best to measure his paracetamol levels? Measure paracetamol level in 2 hours, measure paracetamol level in 4 hours, immediately, in 24 hours
Measure paracetamol level in 2 hours
- 30 year old, night sweats, weight loss, pyrexia. Right iliac fossa pain. No change in abdo. Histology shows caseating granulomas. Tuberculosis, Crohn’s, UC, Coeliac
TB
- Patient with normal duodenal and jejunal biopsies. Has had a year of intermittent constipation and diarrhoea. What is the diagnosis? Coeliac disease, IBS, Crohn’s, UC
IBS
Consider if for 6 mo:
• Abdo pain
• Bloating
• Change in bowels
Dx
• Abdo pain relieved by defecation / frequency / form AND 2/4:
o Altered passage (straining)
o Bloating
o Sx worse with eating
o Mucus
Ix
• FBC
• ESR/CRP
• Coeliac screen
Mx
• Dietary
• 1st line: antispasmodics, laxatives (not lactulose), loperamide
o 2nd line (constip): linaclotide (at least 12mo Sx)
• 2nd line pharm: TCA, then SSRI
• 3rd line: not resp 12 mo pharm Tx = CBT, hypno, psychological
- What is the likely diagnosis when there is bronchial breathing? Pneumonia, pneumothorax, pleural effusion
pneumonia
- Patient 10 weeks pregnant has urinary frequency and urgency. What is the most appropriate antibiotic? Amoxicillin, nitrofurantoin, trimethoprim
Nitrofurantoin
UTI
• 1st trimester: nitrofurantoin (not in third)
• 2nd trimester: nitro/trimethoprim
• Persistent symptoms: amoxicillin
• NB. always send for culture, repeat at 7 days for test of cure
NB: asymptomatic bacteriuria
• Needs two cultures to confirm before treatment
• 1st line: amoxicillin
• 2nd line: nitrofurantoin
- 81y lady with 30y history of RA. Cannot have a bath for herself and finding increasing difficulty eating with knife and fork. What is the next line of management? Refer to rheum OP, care package three times a day, physio and home OT assessment, admit to hospital for comprehensive geriatric assess
physio and home OT assessment
- 40 year old fit and well patient with displaced intracapsular fracture. What is the most appropriate management? Hemiarthroplasty, cannulated screws, dynamic hip screw
Cannulated Screws
• Undisplaced: always screw
• <55 years: try to screw
• >65 and displaced: arthroplasty
o Criteria for total: not cognitive impairment, walks with stick only, fit for anaesthesia
- 70 year old patient has 2 cm irregular, mobile lump in upper outer quadrant of breast. What is the most likely diagnosis? DCIS, LCIS, invasive ductal carcinoma, invasive lobular carcinoma, medullary carcinoma
invasive ductal carcinoma
- COPD patient is on salmeterol and tiotropium, but his symptoms are not well controlled. FEV1 is 65%. What to do next? Switch to LAMA + ICS, Substitute LABA for LAMA, Add LAMA
NICE guidelines
• SABA or SAMA
• SABA + ICS (asthmatic) OR LAMA + LABA
• ICS + LABA + LAMA
• Home nebs
• Theophylline
• Mucolytics
• LTOT
- Patient has inguinal lymphadenopathy. Lymph node biopsy finds sheets of RAPIDLY GROWING moderately sized B cells. What is the diagnosis? Burkitt’s lymphoma, CLL, CML, AML, ALL
Burkitt’s lymphoma
- Patient has low platelets, low Hb, low WCC. Bone marrow biopsy shows dry tap with some odd shaped red cells.. (Edit if you remember). Positive JAK2 mutation. What is the diagnosis? Myelofibrosis, Essential thrombocythemia, Polycythaemia rubra vera, myelodysplastic syndrome
Myelofibrosis
• Leukoerythroblastic film
• Tear drop poikilocytes
• Cytopenias
• Dry tap
• 50% Jak2 +ve
• Mx: supportive, blood products, splenectomy, BMT if younger
- Patient has weight loss, haemoptysis (symptoms of lung cancer). What is the most appropriate initial investigation? CXR, CT thorax
CXR
- A patient with ascites, and widespread abdo tenderness. No guarding no peritonitis. Ascitic tap reveals 500mm3 neutrophils. What does he have? Spontaneous bacterial peritonitis, hepatocellular carcinoma
SBP
- A rheumatoid patient who is taking pred and methotrexate has a sudden onset lower back pain. What is the cause? Osteoporotic fracture, acute pancreatitis
Osteoporotic fracture
- Patient with BRCA1 mutation. She is worried that her kids (son + daughter) and sister might have it. Options: Sister and daughter have 50% chance of getting it and son has 25% chance, Kids and sister all have 25% chance of getting it, kids and sister have 50% chance of getting it, kids have 50% chance of getting it and sister has 25% chance
kids and sister have 50% chance of getting it
- Histopathological findings: summary was villous atrophy. Diagnosis? Coeliac, IBS, Crohn’s, UC
Coeliac,
- So there was one about a tongue deviating to the left. Which nerve is damaged? Left hypoglossal, left glosopharyngeal, left something else, Right hypoglossal, right glossopharyngeal
Left hypoglossal
- Old patient wishes to be cared for at home. He has no living family. He understands that he is refusing hospital treatment. What is the most appropriate way to fulfil his wishes? Fill out a DNAR form, advance request, advance request for refusal of treatment, appoint a LPA
Fill out a DNAR form
Advance requests are for patients who will lose capacity
- A woman is worried about her mother whose memory is getting worse and her personality is changing. Not much else info given. What is the cause? Alzheimers, frontotemporal, lewy body, parkinson’s
Alzheimers
- Patient has a sore throat a few weeks ago. Now has ascending limb paralysis. Loss of plantar reflexes. Options: GBS, Motor neurone disease…?
GBS
- Patient (with cancer maybe..) is having severe pain. Already on oral morphine solution. What is the most appropriate pain relief? Morphine subcutaneous infusion continuous, morphine subcut prn, fentanyl transdermal patch
Morphine subcutaneous infusion continuous
- COPD patient with high Hb: options were secondary polycythemia, renal failure, polycythemia rubra vera
secondary polycythemia
- In a randomised controlled trial, what is the most likely form of bias? Attrition, Recall, selection
Attirition
- Patient has a oesophageal carcinoma (didn’t they specify adenocarcinoma?) in the lower part of oesophagus. What is the most likely cause? Alcohol, smoking, barrett’s oesophagus, H Pylori
barrett’s oesophagus
- Old COPD patient already on salbutamol, tiotropium etc. Having increasing breathlessness at rest, and has carers come to her place twice a day. What is the most appropriate treatment? Home oxygen, Nebulised salbutamol,
??
- Patient has progressive dysphagia to solid foods and weight loss. What is the diagnostic investigation? Barium swallow, Endoscopy
Endoscopy
- Angina… (edit if you remember). What is the best investigation? Coronary angiography, Perfusion scintigraphy
• 64 slice CT angio: typical angina, ECG changes
o >70% stenosis
o >50% main stem
• Functional testing eg perfusion scinti, stress echo, stress MR: known CAD unsure if current disease cardiac
• Invasive angio: functional testing inconclusive
- Abdominal pain 20 mins after meal. Weight loss. Options: mesenteric angina, gastric carcinoma
mesenteric angina
- Loin pain for a few months. Progressive worsening haematuria. No pain. Options: renal cancer, bladder cancer, ureteric colic
renal cancer
- Alcoholic with symmetrical clawed (basically can’t move fingers- dupotryen’s picture). What is the pathophysiology? thickened palmar fascia, thickened flexor tendon sheaths,
thickened palmar fascia
- Someone with absent breath sounds in upper right lobe?
??
- Which cells responsible for uptake of fat in fatty plaque formation- macrophages, neutrophils, platelets
macrophages
- Woman with SOB, ecg- sinus tachy, 35 year olds overall well, ascultation- pleural rub on right side- viral pericarditis, pulmonary emoblism, viral pleurisy
PE
- How is Hepatitis A spread- fecal oral route, blood products
fecal oral
- A guy who experiences night time coughing and then pleuritic pain or was SOB(?), no other symptoms
sarcoid?
- Eye that has industrial liquid splashed on his eye after workplace accident. Eye is now red and painful. What to do next? 0.9 NaCl saline wash out, neomycin drops, chloramphenicol drops
• NaCl wash out
- Red flag signs for someone with back pain- pain at night, pain while coughing, can’t get out of bed
Pain at night must disturb sleep
Pain while coughing
- Women with mobile, smooth breast lump
fibroadenoma
- Guy has sore throat, hard to swallow, tonsils were symmetrical and of a normal size., painful- quinsy, acute laryngitis, acute tonsillitis, mono infec?
??
- Woman lost 6 kg, diplopia in every direction, can see sclera on downward gaze (?), difficulty with most movements of eyes (except medial direction i think)- what do you do- MRI head, CT, check thyroid function
check thryoid function
- A patient has 6 month smoking history (lung cancer picture) and hyponatremia- what hormone caused this?
ADH
- Woman has pneumonia- breathless, 90% on room air, low BP, tachycardic, symptoms of sepsis. Already given IV fluids- what do you do next? Give broad spectrum Abx, call ITU, non invasive ventilation,
Give broad spectrum Abx
- FAP q- 18 yr old guy with hundreds of polyps, dad and grandfather had colorectal cancer- what do you do- Total colectomy, panproctocolectomy + ileal anastomosis, panproctocolectomy + ileostomy
panproctocolectomy + ileal anastomosis
IPAA is preferred option
- Guy comes back from travelling a month ago- had headaches and one week ago started getting diarrhea/ fever? Long time since travel- amoebiasis, salmonella, shigella, giardia
Salmonella typhi / amoeba?
- Women getting pain after eating, fat, middle aged- now she has obstructive jaundice what was cause
gallstones
- Guy has had 3 black outs, most recent one while washing car- goes pale, LOC, arm jerks while on ground, wakes up and feels fine/fast recovery. ECG is normal. What is next most appropriate investigation?
24 ECG, tilt table test, EEG, Echo
24 ECG
- Something about woman on predisilone and keeping track of risk of fractures?
DEXA
- Guy with heart failure gets pulmonary edema, you give him oxygen, sit him up, furosemide- what is appropriate to do next? Beta blocker and Ace inhibitor (ramipril) were both options
??
- Guy gets posterior hip dislocation, what is he most at risk of- sciatic nerve injury, AVN necrosis
sciatic nerve injury
femoral head osteonecrosis?
- pain relieved by eating, worse at night
Another duodenal ulcer question
- Chest pain worse on breathing- it sounded like rib fracture but no trauma so
costochondritis
- What in an ABG of a COPD person indicates a state of chronic respiratory acidosis?-
high bicarbonate
- A woman brings in her boyfriend who has starting getting hallucinations (?) long term alcoholic and just stopped alcohol 3 days ago. GP started him on acamprosate. What is causing symptoms? Delirium Tremens, Korsakoff, side effect of acamprosate, encephalopathy
Delirium Tremens
- A colonoscopy q that had skip lesions
crohns
- Has an eosinophilia, iron deficiency anaemia, and bloody diarrhoea. Which infection? Hookworm, shigella, salmonella
hookworm
