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Medicine Year 3 > Academic Week 1 > Flashcards

Academic Week 1 Flashcards

1
Q

Define sepsis

A

Sepsis is a dysregulated response to infection. The main cause is bacterial infection but viral, fungal and protozoan illnesses can also be responsible.

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2
Q

How does sepsis cause sepsis?

A

Infection can cause problems such as systemic inflammation which can develop into sepsis where there is reduced blood flow, Multi-organ failure and death.

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3
Q

What is the SIRS criteria?

A

The systemic Inflammatory Response Score which can only be used for severe sepsis.

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4
Q

What is septic shock?

A

This is a patient with sepsis and hypotension or a serum lactate greater than 4mmol despite adequate intravenous fluid replacement. Any lactate above 2 is high.

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5
Q

What are the main types of infections that cause sepsis?

A

Meningitis, encephalitis, endocarditis, pneumonia, empyema, UTIs, appendicitis, diverticulitis, cellulitis and infections associated with implantable devices.

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6
Q

What are the symptoms of sepsis?

A

Shivering, fever, extreme pain, pallor, sleepy, confusion, sense of impending doom, and shortness of breath. NEWS2 greater than 5 is indicative of sepsis.

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7
Q

The Sepsis Six are what?

A
  1. Take blood cultures
  2. Take a urine measurements and monitor vitals
  3. Take a serum lactate
  4. Give IV fluid resuscitation
  5. Give IV antibiotics
  6. Give high flow oxygen
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8
Q

When should fluid resuscitation be provided?

A

To treat hypotension or elevated lactate levels. The initial 1000ml should be delivered by Hartmann’s STAT and the aim is 1L within an hour and start the second titre. Smaller fluid challenges should be provided if there is poor LV function.

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9
Q

Give some examples of broad spectrum antibiotics used to treat sepsis

A

Teicoplanin, Gentamicin and Metronidazole

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10
Q

What antibiotic should be used with MRSA associated sepsis

A

IV ceftriaxone

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11
Q

What is the most common cause of community acquired Pneumonia?

A

Streptococcus Pneumoniae. This can be treated with penicillin.

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12
Q

What compounds are macronutrients?

A

Carbohydrates, proteins and fats

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13
Q

What compounds are micronutrients?

A

This encompasses trace elements (Fe, Cu, Zn, Mn, CO and Se) and vitamins. Generally micronutrients are essential but toxic in high doses.

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14
Q

Describe the physiological and detrimental effects of copper

A

Copper is a co-factor for oxidase enzymes.

Deficiency causes anaemia and poor collagen and elastin production.

Toxicity is seen in Wilson’s disease which is life threatening.

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15
Q

Describe the physiological and detrimental effects of zinc

A

Zinc is a co-factor or a component in over 200 metalloenzymes and is vital for prostate function.

Deficiency causes growth failure, hypogonadism, reduced immune function, impaired wound healing and hair-loss.

Toxicity causes GI irritation, vomiting and renal toxicity.

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16
Q

Describe the physiological and detrimental effects of selenium

A

Selenium is a component of GPx, an enzyme which breaks down byproducts of respiration.

Deficiency causes increased oxidative damage, poor muscle function and reduced thyroid function.

Toxicity causes hepatocellular damage.

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17
Q

Describe the physiological and detrimental effects of manganese

A

Manganese is a constituent of many metalloenzymes.

Deficiency causes impaired growth and reproductive function. It also causes skeletal abnormalities.

Toxicity causes neurological symptoms known as manganism.

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18
Q

Describe the physiological and detrimental effects of chromium

A

Chromium is used in the metabolism of of glucose.

Deficiency causes glucose intolerance

Toxicity can be carcinogenic

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19
Q

Describe the physiological and detrimental effects of cobalt

A

Cobalt is a vital component of Vitamin B12. Deficiency causes anaemia (B12 deficiency)

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20
Q

Describe the physiological and detrimental effects of lead

A

This has no physiological role. Toxicity causes abdominal pain, anaemia and peripheral neuropathy.

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21
Q

Describe the physiological and detrimental effects of cadmium

A

This has no physiological role. Toxicity causes nausea, vomiting and diarrhoea.

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22
Q

Describe the physiological and detrimental effects of aluminium

A

This has no physiological role. Toxicity causes neurological and bone damage

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23
Q

What is the function of Vitamin A

A

Vitamin A is a fat soluble vitamin which is used in vision, growth and reproduction. Deficiency causes keratomalacia and xerophthalmia

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24
Q

What is the function of Vitamin D?

A

Vitamin D is a fat soluble vitamin involved in calcium metabolism. Deficiency causes rickets and osteomalacia

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25
Q

What is the function of Vitamin E?

A

Vitamin E is a fat soluble vitamin that is an antioxidant. Deficiency causes lipid peroxidation.

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26
Q

What is the function of Vitamin K?

A

Vitamin K is vital in the activation of platelets and so deficiency causes hemorrhagic disease. It is a fat soluble vitamin.

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27
Q

What is the function of B1 (Thiamine)?

A

It is involved in carbohydrate metabolism. Deficiency causes Beriberi and Wernicke-Korsakoff aphasia.

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28
Q

What is the function of B2 (Riboflavin)?

A

B2 is involved in oxidation-reduction reactions and deficiency causes dermatitis.

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29
Q

What is the function of B6 (Pyridoxine)?

A

B6 is involved in amino acid metabolism. Deficiency causes convulsions and dermatitis.

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30
Q

What is the function of Niacin?

A

Niacin is involved in oxidation-reduction reactions. Deficiency causes pellagra.

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31
Q

What is the function of Folic Acid?

A

Folic acid is vital for nucleic acids. Deficiency causes Megaloblastic anaemia.

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32
Q

What is the function of B12?

A

B12 is vital for general metabolism. Deficiency causes burning feet.

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33
Q

What is the function of Vitamin C?

A

Vitamin C is involved in connective tissue formation and deficiency causes scurvy.

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34
Q

Define malnutrition

A

This is an imbalance of energy and deficiency in one or more nutrients. This can be acute or chronic.

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35
Q

What is Marasmus?

A

This is the loss of lean fat mass resulting in deficiency of both calories and protein. This is a form of malnutrition.

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36
Q

What is Kwashiorkor?

A

This is deficiency of protein but adequate calories and is associated with inflammation, oedema, dermatitis, fatty liver and infection. It is a form of malnutrition.

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37
Q

What is pellagra?

A

This is a disease caused by lack of Niacin (B3). Symptoms include inflamed skin, diarrhoea, dementia and sores in the mouth.

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38
Q

What does hyper metabolism cause?

A

This leads to protein catabolism (increased urine nitrogen excretion), insulin resistance, reduced triglyceride clearance, release of cytokines by macrophages and release of hormones such as cortisol and catecholamines. Illness leads to changes in all these pathways.

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39
Q

What ways can body weight/fat be measured?

A

BMI, Skinfold measurement, Mid-arm circumference and body fat scales.

40
Q

What are useful biomarkers of nutritional status?

A

Pre-albumin and nitrogen balance. Albumin is not a marker of nutritional status because it has a 20 day life span. Nitrogen balance test is the GOLD standard.

41
Q

What is the MUST score?

A

The Malnutrition Universal Screening Tool (MUST)

  1. BMI (0-2)
  2. Percentage of unexplained weight loss in the past 6 months (0-2)
  3. There has been or likely to be no nutritional intake for more than 5 days (0-2)

Any patient who scores above 2 should be treated for malnutrition

42
Q

What does the parenteral nutrition scheme involve?

A

20-30 KCAL/KG/DAY, 1g of protein per kilo, 30-35ml/KG fluid and standard amounts of electrolytes and minerals.

Metabolic complications can include refeeding syndrome, glucose intolerance, mild hyponatraemia, hypercalcaemia, abnormal LFTs and hypertriglyceridaemia.

43
Q

What is refeeding syndrome?

A

This classically presents following a prolonged period of starvation. Potential complications include generalised muscle weakness, tetany, myocardial dysfunction, arrhythmias, seizures, sodium and water retention, haemolytic anaemia, phagocyte dysfunction and death from cardiac or respiratory failure. Electrolyte replacement should be carefully monitored especially K and phosphate.

44
Q

What is abnormal urine output?

A

Less than 0.5/ml/kg/hr

45
Q

What are the types of shock?

A

Hypovolaemic, cardiogenic (Pump failure), vasodilatory (septic, neurogenic and anaphylactic)

46
Q

How is shock treated?

A

Any hypoxic patient will need oxygen. A fluid bolus will increase preload which improves hypovolaemic, cardiogenic and vasodilatory shock. It will reduce HR and increase blood pressure. Adrenaline improves cardiac output and breathing.

47
Q

What are the red flags for septic shock?

A

Acute confusion, tachypnoeic, tachycardia greater than 130, systolic BP below 90 or a drop of 40, recent chemotherapy, cyanosis, mottled skin, non-blanching rash and not passing urine in the last 18 hours.

48
Q

What are the amber flags for septic shock?

A

Relatives expressing concerns, acute deterioration in functional ability, immunosuppression, trauma/surgery in the last 6 weeks, rest rate between 21-24, systolic BP between 91-100, signs of skin infection, temperature below 36 and no urine output in the last 12-18 hours.

49
Q

What is the most common cause of bacteraemia?

A

Staphylococcus aureus

50
Q

How is bacteraemia defined?

A

This can be intravascular or extravascular. Intravascular causes are more serious and include endocarditis and through intravascular catheters. Persistent bacteraemia is almost always caused by intravascular infections.

51
Q

How is bacteraemia diagnosed?

A

Two blood cultures in a 24 hour period will detect 90% of cases. The sample should be taken before antibiotics are given

52
Q

What are the risk factors for infective endocarditis?

A

Endocardial damage through congenital heart disease, acquired heart disease such as rheumatic fever or previous endocarditis, replacement heart valves and pacemakers. Other risk factors include IVDU, long term intravenous catheters and invasive procedures.

53
Q

What are the symptoms of infective endocarditis?

A

Fever, chills, weakness, dyspnoea, sweats, anorexia, weight loss, malaise, cough, skin lesions, stroke, headache, myalgia, chest pain delirium and haemoptysis

54
Q

What are the clinical findings of infective endocarditis?

A

Fever, new or changing murmur, embolic phenomenon and signs of sepsis. Janeway lesions, Osler’s nodes and splinter haemorrhages.

55
Q

What score is used to assess infective endocarditis?

A

The DUKE criteria requires two blood cultures which show typical endocarditis organisms or 1 culture showing coxiella burnetii. There must also be evidence such as a positive endocarditis or new valvular regurgitation.

56
Q

What are the minor criteria for DUKE?

A

Any predisposing heart condition, IVDU, fever above 38, positive blood culture for atypical bacteria, vascular phenomena (Janeway lesions and emboli) or immunological phenomena (Osler’s nodes or glomerusclerosis)

57
Q

What antibiotics should be given for endocarditis prophylaxis?

A

This should only be given to people with heart abnormalities and the antibiotics used are amoxicillin and teicoplanin.

58
Q

What is an endogenous infection?

A

This is an infection which is caused by an agent already present in the body (normal flora). This is seen in staph aureus and neisseria meningitidis.

59
Q

What is the definition of a healthcare associated infection?

A

These are infections which present 48 hours after admission to a medical facility when it was not present on admission. These are usually LRTIs and UTIs.

60
Q

Give some examples of Gram positive resistant bacteria?

A

MRSA (methicillin resistant Staphylococcus aureus) have an altered binding site (PBP2) which confers resistance to all beta lactam antibiotics so should be treated with teicoplanin and vancomycin.
GRE (Glycopeptide resistant enterococci) which are found in the bowels and have variable resistance patterns to vancomycin and teicoplanin.

61
Q

Give some examples of Gram negative resistant bacteria?

A

CPE (Carbapenemase producing enterobactiaceae) are enteric bacteria.

62
Q

Describe Clostridium Difficile pathogenesis?

A

Clostridium difficile usually follows antimicrobial exposure and causes severe diarrhoea, colitis, toxic megacolon and even bowel perforations. Stool samples should be taken and tested for glutamate dehydrogenase (specific antigen for C.diff) and c difficile toxins.

63
Q

What is the definition of a fever?

A

A core temperature over 38 degrees. Axillary fever is above 37.3 and oral above 37.5. Core temperature can be taken via the rectum or tympanic membrane.

64
Q

What are the causes of fever?

A

Infection, inflammation/autoimmune, neoplasm, drugs, endocrine and psychosomatic causes. Inflammatory disorders such as vasculitis are common causes of non-infective PUO.

65
Q

What drugs can cause fever?

A

Erythromycin, penicillins, hypertensives of methylodopa and captopril. Ibuprofen, heparin and carbamazepine are other possibilities.

66
Q

What are the red flags associated with fever?

A

Weight loss, drenching night sweats (haematological malignancy), unilateral headache or jaw claudication which may indicate giant cell arteritis.

67
Q

What symptoms associated with fever are indicative of particular illnesses?

A

Fever +
Back pain = spondylitis, TB/ Bone mets
Headache = Chronic meningitis or giant cell arteritis
RUQ pain = Liver abscesses
LUQ pain = Splenic abscesses
Oral and genital ulcers = Bechcets disease
Jaw claudication = Temporal arteritis
Changes in behaviour = Granulomatous meningitis

68
Q

What are the main causes of fever in the returning traveler?

A

Malaria, typhoid, Lyme, Brucella, Chagas, Zika and Toscana virus.

69
Q

How should a returning traveler from central/west Africa in the last 21 days with a fever be treated?

A

They should be treated as a viral haemorrhage fever until proven otherwise.

70
Q

Where is legionella found?

A

Air conditioning systems and showers

71
Q

What illnesses are associated with caving?

A

Histoplasmosis and rabies

72
Q

What illnesses are associated with fresh water exposure and the returning traveler?

A

Schistosomiasis and leptospirosis

73
Q

What causes of fever also cause jaundice?

A

Viral hepatitis, malaria and leptospirosis

74
Q

What causes of fever also causes bloody diarrhoea?

A

Shigella, salmonella and amoebiasis

75
Q

What causes of fever also cause urticaria?

A

Acute schistosomiasis (Katayama fever) and strongyliodes

76
Q

What important information about malaria should you know?

A

The most worrying form of malaria is falciparum which can be fatal. Most cases of all malaria present within six months or a year.

77
Q

What are the symptoms of malaria?

A

Vague presentation including fever, malaise, myalgia, headache, diarrhoea, cough, jaundice, confusion and in rare cases lymphadenopathy.

A reduced GCS implies cerebral malaria or hypoglycaemia

78
Q

What is the GOLD standard test for malaria?

A

Malaria blood film. Thick films are the best for testing.

On a blood film, falciparum shows multiple parasites within one RBC with a headphone appearance.

79
Q

What symptoms imply severe malaria?

A

GCS, shock, renal impairment, parasite count above 2%, hypoglycaemia, Hb above 8, pH above 7.3, DIC, pulmonary oedema (ARDS) and haemoglobulinuria (Black urine)

80
Q

What is enteric fever?

A

This is typhoid and paratyphoid which is found in Asia and Africa. . They often present with fever and bardycardia. Types include salmonella type/paratyphi. It is carried asymptomatically in the gallbladder. Early antibiotics reduces mortality.

Rose spots and bradycardia are often seen.

81
Q

What does forehead sparing mean?

A

Upper motor neurone lesions such as stroke cause contralateral face weakness but the forehead is spared. Whole lower motor neurone lesion cause complete loss of the ipsilateral face

82
Q

What is leukoplakia?

A

This is a condition in which one or more white patches or spots form inside the mouth. This can develop into oral cancer.

The patches are not painful, irregular shaped, slightly raised, slightly red within the patch and cannot be scrubbed off like thrush.

Hairy Leukoplakia is caused by Epstein Barr virus and is often seen in people with HIV or other immunosuppression. This is not a cancer risk and can be treated with antiviral medications.

83
Q

What is disseminated intravascular coagulation? (DIC)

A

This is a condition where blood clots form throughout the body, blocking small blood vessels. This may present with chest pain, shortness of breath, leg pain, dysphasia and dyspraxia.

As platelets become depleted there may be more bleeding and blood in the urine and stool. This causes organ failure.

This is very serious and is seen in sepsis, post surgery, cancer and complications of pregnancy. Patients need platelet replacements. Purpura fulminans is a very bad sign.

84
Q

What is pitting oedema?

A

This is when a mark is left on the skin after pressure has been applied. This is often caused by excess water and so responds well to elevation and diuretics. Non-pitting oedema is more difficult to drain.

85
Q

What is lymphedema?

A

A chronic condition that causes swelling usually in the arms and legs. It is caused by failure of the lymphatic drainage system. Primary is genetic, secondary is caused by trauma, radiotherapy, cellulitis, inflammation, DVT, obesity and immobility. Initially it will pit but over time it will become non-pitting as fat is deposited and there is fibrosis. It is extremely painful.

86
Q

What is the emergency treatment for meningococcal septicaemia?

A

IM injection of benzylpenicillin or trephciaxone

87
Q

How does diverticulitis present?

A

Lower left quadrant pain, tenderness, abdominal distention and fever. Anorexia, constipation, nausea, dysuria and diarrhoea are also common.

88
Q

What are the red flags for abdominal pain?

A

Persistent pain, nocturnal pain, rectal bleeding, weight loss, fatigue, new medications and family history of abdominal disease.

89
Q

What are the criteria for 2ww for suspected colorectal cancer?

A
  • Aged 40 and over with unexplained weight loss and abdominal pain
  • Aged 50 and over with unexplained rectal bleeding
  • Aged 60 and over with iron deficiency anaemia or changes in their bowel habit or tests show occult blood in their faeces
90
Q

What other considerations should be taken into account when considering a two week referral for colorectal cancer?

A

Anyone with a rectal or abdominal mass.

Anyone under 50 with rectal bleeding and abdominal pain, change in bowel habit, weight loss or iron deficiency anaemia.

91
Q

What is feacal calprotectin?

A

This is used in patients under 30 with altered bowel habits when IBS is suspected but IBD needs to be ruled out.

This gives a quantitive test for bowel inflammation. It is sensitive but not specific but in this age group any pathology is likely to be IBD. It does not rule out bowel cancer.

92
Q

What are urinary storage symptoms?

A

Urgency, frequency and nocturia

93
Q

What are urinary voiding symptoms?

A

Hesitancy, poor flow, straining, intermittent flow and incomplete emptying

94
Q

What are the differentials for dysuria?

A

Pyelonephritis, cystitis, prostatitis and urethritis

95
Q

Why are urinary storage and voiding symptoms important?

A

Overactive bladder presents with storage symptoms whereas BPH presents with voiding symptoms. Prostate cancer may have both and red flags.

96
Q

What are the differentials for haematuria?

A

Cancer of the urinary-genital tract (TCC), UTI, renal calculi, haematological disorders, NSAIDs, rare causes such as BPH, prostate cancer and PCOS.

97
Q

What are the criteria for 2ww for renal malignancy?

A
  • Aged 45 or over and have unexplained visible haematuria without a UTI or visible haematuria that persists after treatment of a UTI
  • Aged 60 or over and unexplained non-visible haematuria with either dysuria or a raised white cell count.

Medicine Year 3 (22 decks)

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