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Phase 3 > Acute > Flashcards

Acute Flashcards

1
Q

Excluding pain and pallor, give other clinical features of an acutely ischaemic limb

A 
Pulseless
Paralysis
Paraesthesia/numbness 
Cold
Fixed staining /mottling of skin 
Capillary refil time over 2 secs
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2
Q

Give examination findings of a patient that may indicate embolic source of ischaemic limb

A 
AF/irregularly irregular pulse 
AAA
Popliteal artery aneurysm 
Mechanical heart valve
New or changed murmur 
Femoral bruits
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3
Q

Give features of an affected limb which would suggest irreversible ischaemia

A

Fixed staining /mottling of skin
Gangrene / necrosis
Profound paralysis
Severe sensory deficit

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4
Q

How do you calculate an ankle brachial pressure index?

A

BP in leg / BP in arm

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5
Q

What does an ABPI result of 0.4 show?

A

Severe arterial disease

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6
Q

In a patient with an ABPI of 0.4 and symptoms and signs of a critically ischaemic limb, give mediation which should be immediately prescribed and route of administration

A

IV heparin or subcutaneous LMWH

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7
Q

What is phlegmasia cerulea dolens?

A

Severe form of DVT which results from extensive thrombotic occlusion of major and collateral veins of an extremity

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8
Q

What are characteristic features of phlegmasia cerulea dolens?

A

Sudden severe pain
Swelling
Cyanosis
Oedema of affected limb

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9
Q

What is there a high risk of with phlegmasia cerulea dolens?

A

PE
Venous gangrene
Underlying malignancy

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10
Q

What are signs and symptoms of TCA overdose?

A 
Tachycardia/arrhythmia 
Tachypnoea due to metabolic acidosis 
Urinary retention
Dilated pupils
Pyrexia
Hyperreflexia 
Hypotension
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11
Q

What problems can occur if c diff goes untreated?

A

Dehydration
Perforation
Obstruction

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12
Q

A 38 year old female attends ED after falling onto muddy path in park. She has grazes on both knees and a very deep wound to her left thenar eminence. An X-ray of hand confirms presence of foreign body. The patient says she is fully immunised against tetanus. According to the Department of Health guidance, what should be done?

A

Immediate dose of tetanus immunoglobulin

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13
Q

A 24 year old man presents with left chest trauma. A CT thorax shows multiple fractured ribs and a lung contusion. On the second day he develops worsening dyspnoea and hypoxia. What is the likely pathology?

A

Acute respiratory distress syndrome

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14
Q

What is acute respiratory distress syndrome?

A

Lungs begin to fill with fluid due to activation of the inflammatory cascade resulting in impaired gas exchange

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15
Q

A 74 year old man develops oliguria following an emergency open abdominal aortic aneurysm repair. Despite aggressive fluid resuscitation, his serum creatinine rises to 600. What is going on?

A

Acute kidney injury

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16
Q

A 24 year old alcoholic man with severe acute pancreatitis ha been admitted to intensive care. Despite aggressive management he has developed cardiac, respiratory and renal failure. What is going on?

A

Multi organ dysfunction syndrome

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17
Q

A 19 year old lady is admitted to ITU with severe meningococcal sepsis. She is on maximal inotropic support and a CT scan of her chest and abdomen is performed. The adrenal glands show evidence of diffuse haemorrhage. What is the diagnosis?

A

Waterhouse Friderichsen syndrome

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18
Q

A 38 year old man is noted to have a blood pressure or 175/110 on routine screening. On examination there are no abnormalities of note. CT scan shows a left sided adrenal mass. Plasma metanephrines are elevated. What is the diagnosis?

A

Phaeochromocytoma

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19
Q

What are clinical features of a thoracic aorta rupture?

A

Mechanism of injury - RTA, fall from height
Contained haematoma - persistent hypotension
CXR changes: widened mediastinum, tracheal deviation to right, depression of left main stem bronchus, widened paratrachal stripe, space between aorta and pulmonary artery obliterated
Rib fracture/ left haemothorax

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20
Q

What percentage body surface area burns should be transferred to a burns unit in children and adults?

A

Adults >20%
Children and elderly >10%
As soon as they are stabilised

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21
Q

What methods can be used to get IV access in burns if percutaneous access cannot be obtained?

A

IV cutdown in cubital fossae or long saphenous vein (anterior to medial malleolus or groin)
In children less than 6, intraosseous approach in tibia

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22
Q

In the absence of IV access what is the next preferred route of administration of adrenaline during cardiac arrest?

A

Intraosseous

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23
Q

What is the dose of adrenaline given in a cardiac arrest?

A

1 mg of 1:10000 adrenaline IV every 3-5 mins

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24
Q

What are the surviving sepsis guidlines?

A

TO BE COMPLETED WITHIN 3 HOURS OF TIME OF PRESENTATION:
1. Measure lactate level
2. Obtain blood cultures prior to administration of antibiotics
3. Administer broad spectrum antibiotics
4. Administer 30ml/kg crystalloid for hypotension or lactate 4mmol/L or more
TO BE COMPLETED WITHIN 6 HOURS OF TIME OF PRESENTATION:
5. Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to
maintain a mean arterial pressure (MAP) 65mmHg
6. In the event of persistent hypotension after initial fluid administration (MAP < 65 mm Hg) or if initial lactate was 4 mmol/L or more, re-assess volume status and tissue perfusion and document findings. Place a central line and aim for CVP greater than 8 and ScvO2 greater than 70
7. Re-measure lactate if initial lactate elevated

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25
Q

What causes Kussmaul breathing in DKA?

A

Ketone bodies produce acidosis which causes deep rapid breathing

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26
Q

Why do patients with DKA get dehydrated?

A

Ketones and glucose produce osmotic diuresis

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27
Q

A 65 year old man presents to ED with a sudden onset tender mass in the left lower quadrant. His PMH includes valve replacement for rheumatic heart disease and he takes regular warfarin. He has also recently been on a course of erythromycin for a chest infection as he has a penicillin allergy. On examination there is a tender mass to the left of the midline which appears to become more prominent on lifting the patient’s head from the bed. His Hb is 89 and his INR is 7.2. What is the diagnosis?

A

Rectus sheath haematoma

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28
Q

If you suspect a PE in a patient, what should be done while waiting for the CTPA to be done?

A 
ABG
FBC
CRP 
CXR 
Place patient on LMWH
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29
Q

What are causes of traumatic pneumomediastinum after penetrating trauma? How do you investigate?

A

Injury to pharynx, larynx, trachea and oesophagus

Multislice spiral CT or contrast study endoscopy

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30
Q

What is the management for salicylate poisoning?

A

ABCDE
Gastric lavage
Blood levels
Encourage high fluid intake - may need resus and maintenance IVI
Monitor urine volume and pH
Forced alkaline diuresis induced with bicarbonate infusion
If coagulopathy - vitamin K administration

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31
Q

Which bug causes cat scratch disease?

A

Bartonella henselae

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32
Q

Which bugs are responsible for reactive arthritis?

A

Ureaplasma urealyticum

Mycoplasma genitalium

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33
Q

Which bug is responsible for Lyme disease?

A

Borrelia burgdorferi

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34
Q

What is the typical skin lesion seen in Lyme disease?

A

Erythema migrans

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35
Q

Which bug causes necrotising fasciitis?

A

Group A streptococcus

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36
Q

Which bug typically causes cold agglutinin production and autoimmune haemolytic anaemia?

A

Mycoplasma pneumoniae

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37
Q

How do you treat organophosphate poisoning?

A

Pralidoxime

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38
Q

What are features of organophosphate poisoning?

A

Hypersalivation
Sweating
Bradycardia
Due to increased cholinergic activity

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39
Q

What should be given to treat methanol poisoning?

A

Ethanol - inhibit build up of toxic metabolite products of methanol

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40
Q

What problems can methanol consumption cause?

A

Blindness
Lactic acidosis
Liver failure

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41
Q

What should be done to treat a child who has taken an excessive amount of ferrous sulphate?

A

Desferrioxamine

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42
Q

Which organisms does the BCG vaccine protect against?

A

Mycobacterium tuberculosis

Mycobacterium leprae

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43
Q

What is a Mantoux?

A

Tuberculin sensitivity test - screen for TB

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44
Q

What dose of adrenaline should be given for a PEA arrest?

A

1mg IV

10 ml of 1:10000

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45
Q

How often should adrenaline be given in a PEA arrest?

A

Immediately then after every 2 cycles (roughly once each 3-5 mins)

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46
Q

What are GI symptoms of iron overdose in a child?

A

Vomiting
Diarrhoea
Abdominal distension
Symptoms of intestinal haemorrhage

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47
Q

What can be a long term complication of iron overdose in a child?

A

Pyloric stenosis

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48
Q

What are non GI features of iron overdose in a child? Why?

A

Hepatic toxicity - jaundice, deranged liver function and clotting abnormalities
Metabolic acidosis
Hypoglycaemia
Iron is absorbed and accumulated into the mitochondria

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49
Q

Why is gastric lavage no longer used in iron overdose?

A

Iron tablets are large and sticky so it is unlikely to be of benefit

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50
Q

What are you at risk of if being bitten by an IV drug user?

A

Hep B, C and HIV

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51
Q

How is Lyme disease diagnosed?

A

Clinical picture

ELISA

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52
Q

How is malaria diagnosed?

A

Clinical picture

Blood film stained with Giemsa to identify Plasmodium infections

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53
Q

What is the treatment for someone presenting with haemoptysis who’s sputum sample shows Aspergillus fumigatus?

A

IV amphotericin B

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54
Q

In patients with isolated nasal injuries, which are the 3 major exceptions where the patients will need admission?

A

Septal haematoma
Compound nasal fracture
Associated epistaxis

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55
Q

When is it best to review patients with uncomplicated isolated nasal injuries?

A

After 5 days in ENT clinic when swelling has subsided and it can be determine whether manipulation is appropriate

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56
Q

A 30 year old man who works in a lab which handles animal products presents to ED with a skin ulcer with a black area in the centre. The patient explains that this started with a small itchy pimple that began to ulcerate a couple of days later. What is the diagnosis?

A

Bacillus anthracis - anthrax

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57
Q

What are the 3 main types of anthrax?

A

Cutaneous: direct contact with skin or tissue of infected animals
Inhalation: spores, sore throat, cough, fever. Abrupt resp failure 2-4 days
Intestinal: swallowing spores, nausea, bloody diarrhoea, pain

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58
Q

How does aciclovir work?

A

Via thymidine cycle
Phosphorylated by this pathway, then further phosphorylated by cellular enzymes to triphosphate, then competes with deoxyguanosine triphosphate for a position in viral DNA

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59
Q

Which drug is effective against CMV?

A

Ganciclovir

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60
Q

What is the commonest adult muscular dystrophy?

A

Myotonic dystrophy

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61
Q

What are features of myotonic dystrophy?

A

Frontal baldness in men
Atrophy of temporalis, masseters and facial muscle
Cardiac abnormalities including first degree heart block and complete heart block

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62
Q

What is progressive multifocal leucoencephalopathy?

A

Rapidly progressing demyelinating disease related to infection of oligodendrocytes by papovirus
AIDS defining illness

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63
Q

Which enzyme is essential in duplication of the HIV genome which cleaves RNA strands during transcription?

A

Ribonuclease H

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64
Q

Which enzyme in HIV helps in forming the DNA strand from viral RNA?

A

Reverse transcriptase

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65
Q

What form of meningitis is commons in HIV infected patients?

A

Cryptococcal meningitis

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66
Q

What is a an important feature of cryptococcal meningitis for which the treatment is CSF drainage?

A

Raised intracranial tension

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67
Q

What is the treatment for cryptococcal meningitis?

A

Amphotericin B 0.7-1mg/kg daily IV

5-flucytosine 100mg/kg oral daily

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68
Q

What are different types of polycythemia?

A

Primary
Secondary: chronic hypoxia
Relative: reduced plasma volume, normal red cell mass
Inappropriate: excess EPO production

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69
Q

What are features of legionella?

A 
Flu like symptoms 
Dry cough
Bradycardia 
Confusion
Lymphopenia 
Hyponatraemia 
Deranged LFTs 
Pleural effusion
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70
Q

How is a diagnosis of legionella made?

A

Urinary antigen

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71
Q

How is legionella treated?

A

Erythromycin

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72
Q

What are causes of a metabolic acidosis with a raised anion gap?

A

Lactic acid - sepsis, ischaemia
Urate - renal failure
Ketones - DKA
Drugs/toxins - salicylates, methanol, ethylene glycol

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73
Q

What are causes of a metabolic acidosis with normal anion gap?

A 
Renal tubular acidosis 
Diarrhoea 
Addison's disease
Diarrhoea, ureterosigmoidostomy, fistula 
Acetazolamide
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74
Q

What is the management for starvation ketosis?

A

IV pabrinex if alcohol related

IV dextrose

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75
Q

What are complications of ecstasy use?

A

Arrhythmia
Seizures
Water intoxication
Acute hyponatraemia

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76
Q

What are features of tricyclic antidepressant overdose?

A 
Reduced conscious level 
Tachycardia
Urinary retention
Dilated pupils 
Seizures
Ventricular arrhythmias
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77
Q

What does ecstasy cause?

A 
Increased alertness and self confidence
Euphoria
Extrovert behaviour
Increased talkativeness and rapid speech
Lack of desire to eat or sleep
Tremor
Dilated pupils
Tachycardia
Hypertension
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78
Q

What does a more severe ecstasy intoxication cause?

A 
Excitability
Agitation
Paranoid delusions
Hallucinations and violent behaviour
Hypertonia
Hyperreflexia 
Convulsions
Rhabdomyolysis 
Hyperthermia
Cardiac arrhythmia 
DIC
Renal failure 
Hyponatraemia
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79
Q

What are causes of high anion gap metabolic acidosis?

A 
CAT MUDPILES
Carbon monoxide
Aminoglycosides
Theophyline/toluene 
Methanol
Uraemia
Diabetic ketoacidosis/alcoholic/starvation
Paracetamol
Iron/isoniazid 
Ethanol/ethylene glycol
Salicylates
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80
Q

Which fluid should be given for resuscitation in the setting of acute kidney injury?

A

500ml 0.9% saline over 15 mins as it does not contain potassium and hyperkalaemia is a concern

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81
Q

How can streptococci be subdivided?

A

Alpha haemolytic: partial haemolysis. Strep pneumoniae and viridans
Beta haemolytic: complete haemolysis. Groups A, B, D. Group A strep pyogenes (impetigo, cellulitis, Nec fasc, pharyngitis, rheumatic fever, scarlet fever. Group B strep agalactiae neonatal meningitis, sepsis. Group D enterococcus

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82
Q

What are red flag signs of sepsis?

A 
Systolic blood pressure <90 or >40 from baseline
Mean arterial pressure <65
Heart rate >131
Resp rate >25
AVPU: V P or U
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83
Q

What doses of adrenaline, hydrocortisone and chlorphenamine are required in an adult or child >12 anaphylaxis?

A

Adrenaline 500mcg
Hydrocortisone 200mg
Chlorphenamine 10mg

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84
Q

What doses of adrenaline, hydrocortisone and chlorphenamine are required in an child age 6-12 anaphylaxis?

A

Adrenaline 300mcg
Hydrocortisone 100mg
Chlorphenamine 5mg

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85
Q

What doses of adrenaline, hydrocortisone and chlorphenamine are required in an child age 6m to 6y anaphylaxis?

A

Adrenaline 150mcg
Hydrocortisone 50mg
Chlorphenamine 2.5mg

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86
Q

What doses of adrenaline, hydrocortisone and chlorphenamine are required in an child age less than 6 months anaphylaxis?

A

Adrenaline 150 mcg
Hydrocortisone 25mg
Chlorphenamine 250mcg

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87
Q

What steps do you take for acute pulmonary oedema?

A 
Loop diuretic 40-80mg IV
Morphine
Nitrate 2 sublingual 
Oxygen 
Position upright
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88
Q

What are main indications for emergency dialysis?

A

Severe hyperkalaemia >7 resistant to medical therapy
Pulmonary oedema resistant to medical therapy
Metabolic acidosis <7.2 or BE

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89
Q

What are the causes of malignancy associated hypercalcaemia?

A

Lytic bony metastasis
Myeloma
Production of osteoclast activating factor or PTH-like hormone by the tumour

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90
Q

What can be presenting symptoms of hypercalcaemia?

A 
Nausea 
Polydipsia
Polyuria
Constipation
Confusion 
Weakness
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91
Q

What is the important first line management of malignancy associated acute hypercalcaemia?

A

Rehydration with IV 0.9% saline 3-4L/day
IV pamidronate to lower serum calcium
Calcitonin if resistant to bisphosphonates

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92
Q

An underweight 21 year old female comes to ED with palpitations. Her ECG shows first degree heart block, tall P waves and flattened T waves. An ABG shows pH 7.55, HCO3 30, Cl 85. What is the underlying cause of the presentation?

A

Bulimia nervosa
ECG shows hypokalaemia causing palpitations
ABG shows metabolic acidosis - hypochloraemic

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93
Q

What is Gitelman syndrome?

A

Autosomal recessive kidney disorder characterised by hypokalaemic metabolic alkalosis with hypocalciuria and hypomagnesaemia
Loss of function mutations of thiazide sensitive sodium chloride symporter in the distal convoluted tubule

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94
Q

What is Bartter syndrome?

A

Inherited defect in thick ascending limb of loop of Henle characterised by low potassium, alkalosis and normal to low blood pressure
Neonatal and classic forms

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95
Q

What are features of lead poisoning?

A 
Anorexia 
Hyperirritability
General apathy
Vomiting
Colicky abdominal pain
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96
Q

What are features of superior vena cava obstruction?

A 
Dyspnoea
Swelling of face, neck and arms 
Headache
Visual disturbance
Pulseless jugular venous distension
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97
Q

What are causes of superior vena cava obstruction?

A 
Small cell lung cancer
Lymphoma
Metastatic seminoma
Kaposis sarcoma 
Beast cancer
Aortic aneurysm 
Mediastinal fibrosis
Goitre
SVC thrombosis
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98
Q

What is the management of superior vena cava obstruction?

A 
Dexamethasone 
Balloon venoplasty 
Stenting
Small cell: chemo and radio 
Non small cell: radiotherapy
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99
Q

What is the management for acute stroke?

A

Blood glucose, hydration, O2 sats and temp maintained within normal limits
Blood pressure shouldn’t be lowered in acute phase unless complications - hypertensive encephalopathy
Aspirin 300mg orally or rectally given asap if haemorrhagic stroke excluded
Thrombolysis: if within 4.5 hours of onset of symptoms and haemorrhage has been excluded - alteplase

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100
Q

What are absolute contraindications to thrombolysis?

A 
Previous intracranial haemorrhage
Seizure at onset
Intracranial neoplasm
Suspected SAH
Stroke or traumatic brain injury in previous 3 months
Lumbar puncture in previous 7 days
GI bleeding in preceding 3 weeks
Active bleeding
Pregnancy 
Oesophageal varices
Uncontrolled HTN >200/120
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101
Q

What are relative contraindications to thrombolysis?

A

Concurrent anticoagulation INR >1.7
Haemorrhagic diathesis
Active diabetic haemorrhagic retinopathy
Suspected intracardiac thrombus
Major surgery/trauma in preceding 2 weeks

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102
Q

What are criteria for liver transplantation in paracetamol overdose?

A 
Arterial pH <7.3, 24 hours after ingestion 
Or all of:
Prothrombin time > 100 secs
Creatinine >300
Grade III or IV encephalopathy
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103
Q

What is required for a diagnosis of DKA?

A

Glucose >11
pH <7.3
Bicarbonate <15
Ketones > 3 or urine ketones ++

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104
Q

What are features of DKA?

A

Abdominal pain
Polyuria, polydipsia, dehydration
Kussmaul respiration
Acetone smelling breath

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105
Q

What are the most common precipitating factors of DKA?

A

Infection
Missed insulin
Myocardial infarction

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106
Q

What is the management of DKA?

A

Fluid replacement: isotonic saline 5-8L
Insulin: IV infusion 0.1 unit/kg/hour. Once glucose <15, 5% dextrose started
Correction of hypokalaemia

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107
Q

What is a good fluid replacement regime for a patient with systolic BP of 90 and over in DKA?

A
  1. 9% NaCl 1L over 1 hr
  2. 9% NaCl 1L with KCl over 2 hr
  3. 9% NaCl 1L with KCl over 2 hr
  4. 9% NaCl 1L with KCl over 4 hr
  5. 9% NaCl 1L with KCl over 4 hr
  6. 9% NaCl 1L with KCl over 6 hr
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108
Q

What are complications of DKA and it’s treatment?

A

Gastric stasis
Thromboembolism
Arrhythmia secondary to hyperkalaemia/hypokalaemia
Iatrogenic due to incorrect fluid therapy: cerebral oedema, hypokalaemia, hypoglycaemia
Acute respiratory distress syndrome
Acute kidney injury

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109
Q

What are guidelines on potassium correction in DKA?

A

Potassium over 5.5: no correction
Potassium 3.5-5.5: 40 mmol/L
Below 3.5: senior review

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110
Q

How is low molecular weight heparin activity measured?

A

Anti factor Xa levels

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111
Q

What is the organism that causes Lyme disease?

A

Borrelia burgdorferi

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112
Q

What are symptoms of Lyme disease?

A 
Joint pains
Facial nerve palsy
Palpitations 
Headache 
Fever
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113
Q

What are causes of a prolonged prothrombin time?

A

Warfarin
Unfractionated heparin
DIC
Liver disease

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114
Q

What is the recommended antibiotic for neutropenic sepsis?

A

Tazocin

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115
Q

What are features of leptospirosis? (Weils disease)

A 
Fever
Flu like symptoms
Renal failure
Jaundice
Subconjunctival haemorrhage 
Headache 
Sewage workers, farmers, vets
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116
Q

What is the management for leptospirosis?

A

High dose benzylpenicillin or doxycycline

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117
Q

What are the stages of AKI?

A

1: creatinine 1.5-1.9x, urine <0.5ml/kg/h for >6h
2: creatinine 2-2.9x, urine <0.5ml/kg/h for >12 h
3: creatinine 3x or >354, urine <0.3ml/kg/h for >24 h or anuric for 12h

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118
Q

What are the BNF recommendations for management of hyperkalaemia?

A

If K+ is >6.5 or ECG changes
Administer calcium gluconate 10% 10-20ml by slow IV injection titrated to ECG response
Give 10 units actrapid in 50ml 50% glucose over 10-15 ml IV
Consider nebulised salbutamol
Consider correcting acidosis with sodium bicarbonate

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119
Q

What is the management for acute heart failure in a patient who is haemodynamically stable?

A

Oxygen
Morphine 2.5-10mg IV 2-6h
Furosemide 40-160mg IV increase by 20-40 mg every 6-12 h according to response. Max 600mg
GTN 5 micro grams/min IV. Increase by 5-20 micro grams/min every 3-5 mins. Max 200 micro grams
CPAP

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120
Q

What investigations should be done for acute heart failure?

A 
ECG
CXR
Hb
TFT 
Troponin 
BNP 
Echo
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121
Q

What is the PEP for hep A?

A

Human normal immunoglobulin or hep A vaccine

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122
Q

What is the PEP for hep B?

A

HBsAg positive source: booster dose of vaccine, if in process of vaccination or non responder - hep B immune globulin and vaccine
Unknown source: booster dose, non responder - HBIG and vaccine, in process of vaccination - accelerated course

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123
Q

What is the PEP for hep C?

A

Monthly PCR

If seroconversion then interferon and ribavirin

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124
Q

What is PEP for HIV?

A

Oral antiretrovirals: tenofovir, emtricitabine, lopinavir, ritonavir
Can be started up to 72h following exposure for 4 weeks
Serological testing at 12 weeks following completion of PEP

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125
Q

By how much does PEP reduce risk of transmission in HIV?

A

80%

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126
Q

What is PEP for varicella zoster?

A

VZIG for IgG negative pregnant women or immunosuppressed

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127
Q

What is the estimated risk of transmission of hep B, C and HIV from a needle stick?

A

Hep B: 20-30%
Hep C: 0.5-2%
HIV: 0.3%

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128
Q

What are complications of acute heart failure?

A

Arrhythmia
Complication of GTN: headache and hypotension
Complication of diuretics: worsening of renal function, hypotension, hypokalaemia

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129
Q

What are features of salicylate poisoning?

A 
Fever
Sweating
Hyperventilation
Tachycardia
Nausea and vomiting
Dehydration
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130
Q

What does the treatment of amitriptyline involve?

A

ABC resus
Gastric lavage followed by activated charcoal in severe cases
Treatment of arrhythmias and seizures as necessary

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131
Q

What are features of stage 1 shock?

A 
Volume loss <750ml
Urine output >35ml/hr
Pulse <100
Cap refil normal
Blood pressure normal 
Resp 14-20
Mental state alert
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132
Q

What are features of stage 2 shock?

A 
Volume loss 750ml to 1.5L
Urine output 20-35 ml/hr
Pulse >100
Cap refil prolonged
SBP normal
DBP raised 
Resp 20-30
Mental state anxious
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133
Q

What are features of stage 3 shock?

A 
Volume loss 1.5 to 2L
Urine output 5-15 ml/hr
Pulse >120
Cap refil prolonged
SBP reduced
DBP reduced 
Resp 30-40
Mental state confused, anxious
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134
Q

What are features of stage 4 shock?

A 
Volume loss >2L
Urine output <5ml/hr
Pulse >140
Cap refil absent 
SBP severely reduced 
DBP severely reduced 
Resp rate >35
Mental state drowsy unresponsive
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135
Q

What are examination findings in aortic artery dissection?

A

Hypertension
Aortic regurgitation
Pleural effusion
Inferior lead ECG changes if right coronary is compromised

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136
Q

What are the 4 main derangements seen in Reye’s syndrome?

A

Raised ICP
Hypoglycaemia
Coagulopathy
Hyperammonaemia

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137
Q

What is Reye’s syndrome?

A

Acute non inflammatory encephalopathy and hepatotoxicity caused by ingestion of aspirin in under 12s

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138
Q

How is Reye’s syndrome managed?

A

Give activated charcoal as soon as possible
Measure salicylate level
Treat pathological derangements

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139
Q

What are clinical features of organophosphate poisoning?

A 
Miosis
Blurred vision
Hypersalivation
Expectoration of frothy secretions
Nausea
Vomiting
Abdominal cramps
Diarrhoea
Bronchospasm
140
Q

What are antidotes to organophosphate poisoning?

A 
Atropine 
Pralidoxime (cholinesterase reactivators)
141
Q

What are clinical features of mild abuse of ecstasy?

A 
Agitation
Tachycardia
HTN 
Widely dilated pupils
Trismus
Sweating
142
Q

What are features of severe ecstasy abuse?

A

Hyperthermia
DIC
Rhabdomyolysis
Acute renal failure

143
Q

In a patient who is on warfarin who is haemorrhaging and has an INR greater than 8, what is the emergency management?

A 
A to E approach
Fluid resus and cross match 
Prothrombin complex concentrates (FFP if not available)
Vitamin K IV 5mg 
Stop warfarin
144
Q

In patient on warfarin who has an INR over 8 but only minor bleeding, what is the management?

A 
A to E approach 
Stop warfarin 
Give IV vitamin K 1-3mg 
Repeat dose of Vit K if INR still too high after 24 hours
Restart warfarin when INR <5
145
Q

In patient on warfarin who has an INR over 8 but NO bleeding, what is the management?

A

Stop warfarin
Give Vit K 1-5mg by mouth
Repeat dose of Vit K if INR still too high after 24 hours
Restart warfarin when INR <5

146
Q

In patient on warfarin who has an INR between 5-8 but only minor bleeding, what is the management?

A

Stop warfarin
Give IV Vit K 1-3mg
Restart warfarin when INR <5

147
Q

In patient on warfarin who has an INR between 5-8 but NO bleeding, what is the management?

A

Withhold 1-2 doses of warfarin

Reduce subsequent maintenance dose

148
Q

A patient with long alcohol history, presenting with palpitations has an irregular tachycardia (165 bpm) with broad QRS complex (155ms). His potassium is 2.1. There are no signs of shock, heart failure or syncope. What is the differential diagnosis and how should it be managed?

A

Polymorphic VT - most likely torsades due to hypokalaemia
Pre-excited AF
AF with bundle branch block
Manage: 2g magnesium

149
Q

Which scoring system is used to determine need to anticoagulate a patient in AF?

A

CHA2DS2VASc

150
Q

Which scoring system is a prognostic score used to risk stratify patients who have had a suspected TIA?

151
Q

Which scale is used to determine severity of heart failure?

A

New York heart association

152
Q

Which scale is used to measure disease activity in rheumatoid arthritis?

153
Q

Which scale is used to assess severity of liver cirrhosis?

A

Child Pugh classification

154
Q

What is a wells score for?

A

Estimate risk of patient having a DVT

155
Q

What is an epworth sleepiness scale?

A

Assessment of suspected obstructive sleep apnoea

156
Q

What is a Gleason score?

A

Indicate prognosis in prostate cancer

157
Q

What is an APGAR score?

A

Assess health of a newborn immediately after birth

158
Q

What is a bishop score?

A

Assess whether the induction of labour will be required

159
Q

What score is used to assess the risk of a patient developing a pressure sore?

A

Waterlow score

160
Q

What is a FRAX tool?

A

Risk assessment tool calculates 10 year risk of developing osteoporosis related fracture

161
Q

What is the ranson criteria used for?

A

Acute pancreatitis

162
Q

What is a MUST score used for?

A

Malnutrition

163
Q

What is the treatment for severe ecstasy abuse?

A

IV fluids

Dantrolene 1mg/kg

164
Q

How is severe warfarin toxicity managed?

A

Whole blood
Fresh frozen plasma
Clotting factor concentrates
Vitamin K

165
Q

What are potential complications of opioid toxicity?

A 
Coma
Respiratory depression
Pin point pupils
Convulsions
Hypotension
Peripheral circulatory failure
Cardiac arrhythmia 
Conduction defects
Hypothermia
Pulmonary oedema
Renal failure
Rhabdomyolysis
166
Q

Which electrolyte abnormalities increase the risk of digoxin toxicity?

A

Hypokalaemia

Hypomagnesaemia

167
Q

What is the management for beta blocker overdose?

A

0.5mg IV atropine
IV glucagon
IV isoprenaline
Transvenous temporary cardiac pacemaker

168
Q

Which local anaesthetic is used for cleaning, exploring and suturing wounds in ED? What is the maximum dose?

A

1% lidocaine

Max dose 3mg/kg or 200mg (20ml of 1%)

169
Q

If lidocaine with adrenaline is used for wound local anaesthetic, what is the maximum dose?

A

7mg/kg or 500mg

170
Q

What is the single most important factor in determining need for liver transplant according to the kings college hospital criteria in paracetamol overdose? What are the other factors?

A

Arterial pH <7.3, 24 h after ingestion

All of: prothrombin time >100, creatinine >300, grade III or IV encephalopathy

171
Q

What is the parkland formula for calculating fluid requirements in burns?

A

4x body weight and burn percentage
First half given in 8 h
Remaining over 16 h

172
Q

Why does tricyclic overdose lead to metabolic acidosis?

A

Acidity of drug
Rhabdomyolysis
Renal failure

173
Q

An 18 year old male with sickle cell disease presents with severe abdominal pain, his BP is 105/80 HR 110, temp 38. What is your first action?

A

IV normal saline
Opiate analgesia
Consider antibiotics: ceftriaxone, erythromycin and cefuroxime

174
Q

What may be features of aspirin ingestion in a child?

A 
Fever and sweating
Hyperventilation 
Tachycardia 
Nausea and vomiting 
Dehydration 
Lethargy
Seizures
175
Q

Why is aspirin absolutely contraindicated in children under 12?

A

Side effects

Potential risk of Reye’s syndrome

176
Q

What is Reye’s syndrome? What are the main derangements?

A 
Acute non inflammatory encephalopathy and hepatotoxicity 
Raised ICP
Hypoglycaemia 
Coagulopathy 
Hyperammonaemia
177
Q

What are the essentials of management in paracetamol overdose?

A

Check paracetamol level four hours after ingestion against Rumack Matthew nomogram
Gastric lavage if large dose ingestion (>7.5g) or presenting within 8 hours, consider oral charcoal
Give N acetylcysteine or methionine
Hourly BMs monitored
Check INR 12 hourly

178
Q

What are signs associated with a poor prognosis and indicating transfer to liver unit in paracetamol overdose?

A 
INR >2 within 48 hours 
INR >3.5 within 72 hours
Creatinine >200 
pH <7.3
Signs of encephalopathy 
Hypotension
179
Q

What type of bug causes cholera?

A

Vibrio cholerae
Aerobic
Comma shaped
Gram negative bacillus

180
Q

What are features of enteric fever?

A 
Chills
Diaphoresis 
Cough
Headache 
Myalgia 
Delirium
Fever 
Constipation due to swollen peyers patches 
Rose spots
181
Q

A man weighing 75kg requires maintenance fluids as he is not able to drink. What fluids should be prescribed and at what rate?

A

500ml 0.9% sodium chloride at 100ml/hr

182
Q

In a patient presenting with typhoid type symptoms, what name is given to the erythematous rash that is irregular and discrete?

A

Rose spots

183
Q

What are features of typhoid fever?

A 
Systemic upset
Relative bradycardia
Abdo pain, distension
Constipation 
Rose spots
184
Q

What are possible complications of typhoid?

A 
Osteomyelitis 
GI bleed/perforation
Meningitis
Cholecystitis
Chronic carriage
185
Q

Which organism is responsible for kaposis sarcoma?

A

Human herpes virus 8

186
Q

What is rheumatic fever?

A

Immunological reaction to recent (2 to 6 weeks ago) streptococcus pyogenes infection

187
Q

What are major diagnostic criteria for rheumatic fever?

A 
Erythema marginatum
Sydenham's chorea
Polyarthritis
Carditis
Subcutaneous nodules
188
Q

What evidence is required of a streptococcus pyogenes infection in order to diagnose rheumatic fever?

A

ASOT >200
History of scarlet fever
Positive throat swab
Increase in DNase B titre

189
Q

What are minor criteria for diagnosis of rheumatic fever?

A

Raised ESR or CRP
Pyrexia
Arthralgia
Prolonged PR interval

190
Q

What are 4 diagnostic criteria for hereditary haemorrhagic telangiectasia?

A

Epistaxis
Telangiectasia: lips, oral cavity, fingers, nose
Visceral lesions: GI, pulmonary AVM, hepatic AVM, cerebral AVM, spinal AVM
Family history in first degree relative

191
Q

What are symptoms of dengue fever?

A 
Fever 
Headache
Retro orbital pain
Myalgia 
Nausea and vomiting
Skin rash 
Mild bleeding
192
Q

What are complications of opioid misuse?

A

Viral infection: HIV, hep B and C
Bacterial infection: infective endocarditis, septic arthritis, septicaemia, necrotising fasciitis
VTE
Overdose: resp depression, death
Psychological problems
Social problems: crime, prostitution, homelessness

193
Q

What is a curlings ulcer?

A

Acute peptic ulcer of duodenum as a complication of severe burns when reduced plasma volume leads to ischaemia and cell necrosis of the gastric mucosa

194
Q

What are complications of infectious mononucleosis?

A 
Splenic rupture/infarction
Upper airway obstruction 
Immune mediated pneumonia
Rash with ampicillin 
Viral meningitis
Guillain Barre
195
Q

What psychiatric disturbances can occur with acute intermittent porphyria?

A 
Delirium
Depression
Emotional lability
Schizophreniform psychoses
Hysteria
196
Q

What are causes of atypical lymphocytosis?

A 
EBV
Chicken pox
Cytomegalovirus
Rubella
HIV 
Toxoplasmosis
197
Q

Which antidote is used for arsenic poisoning?

A

Dimercaprol or penicillamine

198
Q

What should be used parenterally as a chelating agent for iron overdose?

A

Desferrioxamine

199
Q

What causes gas gangrene?

A

Clostridium perfringens

200
Q

How does clostridium tetani cause motor symptoms?

A

Produces a neurotoxin called tetanospasmin which acts at synapses resulting in disinhibition

201
Q

What are some benign causes of SVC obstruction?

A 
Fibrotic disease
Infections
Thoracic aortic aneurysms
Central venous catheters 
Pacemaker wires
202
Q

In what time span does a GP have to have seen a patient before their death in order to issue a death certificate?

A

They have to have seen the deceased within 14 days of the death

203
Q

What does a whirl pool sign on USS suggest?

A

Ovarian torsion

Volvulus

204
Q

Which organisms most commonly cause post splenectomy sepsis?

A

Strep pneumoniae
Haemophilus influenzae
Meningococci

205
Q

What are features of dengue fever?

A 
Headache
Fever
Myalgia 
Pleuritic pain
Facial flushing
Maculopapular rash
206
Q

What are features of Lyme disease?

A

Erythema chronicum migrans
Systemic features: fever, arthralgia
CVS: heart block, myocarditis
Neuro: cranial nerve palsies, meningitis

207
Q

How is toxoplasmosis investigated?

A

Antibody test

Sabin Feldman dye test

208
Q

What is the treatment for severe toxoplasmosis infection in immunosuppressed patients?

A

Pyrimethamine plus sulphadiazine for 6 weeks

209
Q

What physiological response accounts for the sensory symptoms experienced during a panic attack?

A

CO2 is blown off due to increased RR
This leads to respiratory alkalosis
This causes a decrease in plasma ionised calcium concentration which leads to sensory symptoms of tingling in fingertips and around mouth

210
Q

Why might a patient with chronic diarrhoea present short of breath?

A

Loss of HCO3 and K ions from gut
Kidneys compensate by conserving K at the expense of H
This generates HCO3 ions but if it continues then a metabolic acidosis predominates
A compensatory respiratory alkalosis and kussmaul respiration ensues resulting in low PaCO2 and SOB

211
Q

Over what time period is a patient with rubella infectious?

A

Eight days prior and nine days after onset of rash

212
Q

What is the most useful test to establish whether an episode is due to anaphylaxis?

A

Serum tryptase

213
Q

What is the advice to give to someone regarding playing sports after having glandular fever?

A

Avoid contact sports for 8 weeks

214
Q

What is cushings triad?

A

Widening of pulse pressure
Respiratory changes
Bradycardia

215
Q

Which antibiotics are best for ESBL bugs?

A

Carbapenems

216
Q

What are classic differential diagnoses for rigors?

A

Biliary sepsis
Pyelonephritis
Visceral abscess
Malaria

217
Q

What are clinical findings of dehydration?

A 
Prolonged cap refil
Dry mucous membranes
Reduced skin turgor
Tachycardia 
Tachypnoea 
Reduced urine output
Sunken eyes
Low blood pressure 
Thready/weak pulse 
Decreased consciousness
218
Q

What is required to pronounce an individual dead?

A

Fixed dilated pupils
No respiratory effort for 3 mins
No pulse or heart sounds for 1 min

219
Q

What are clinical features of adult onset stills disease?

A 
High spiking fever (X1/day with return to normal)
Arthralgia/arthritis 
Sore throat
Transient maculopapular rash
Lymphadenopathy
Hepato splenomegaly 
Pleuritis/pericarditis
220
Q

What is the kings college criteria for identifying patients with poor prognosis and needing transplant after paracetamol overdose?

A

Arterial pH <7.3

Or all 3 of: INR >6.5, creatinine >300, HE grade 3-4

221
Q

What are some neurological complications of HIV?

A 
Cerebral toxoplasmosis
Lymphoma
TB
Encephalitis - CMV, HIV, HSV
Cryptococcus 
Progressive multi focal leukoencephalopathy
AIDS dementia complex
222
Q

What is the cause of a sudden anaemia and a low reticulocyte count in a patient with sickle cell disease?

A

Parvovirus infection

223
Q

What is the parkland formula for fluid resuscitation in burns?

A

Fluid requirement in 24 hours:
4ml x ((total burn surface area%) x body weight (kg))
50% given first 8 hours
50% given next 16 hours

224
Q

What are duke criteria for endocarditis?

A

Positive blood cultures
Evidence of endocardial involvement - echo, murmur
Coxiella burnetii infection
Minor: predisposing factor or IV drug use, fever, vascular phenomena, immune (oslers nodes, Roth spots, glomerulonephritis), microbiological evidence

225
Q

What are the kings college criteria for liver transplant after paracetamol overdose?

A

Arterial pH <7.3 24 hours after

Or all of: prothrombin time >100, creatinine >300, grade III or IV encephalopathy

226
Q

What is first line management for severe falciparum malaria?

A

IV artesunate

227
Q

What is the abortive management for cluster headaches?

A

100% oxygen at least 12L/min via non rebreathe mask

Subcutaneous/nasal triptan

228
Q

What is first line management for prevention of cluster headache?

229
Q

What are differentials for hyperamylasaemia?

A 
Acute pancreatitis
Pancreatic pseudocyst
Mesenteric infarct
Perforated viscus
Acute cholecystitis
Diabetic ketacidosis
230
Q

What is the Mackler triad for boerhaave syndrome?

A

Vomiting
Thoracic pain
Subcutaneous emphysema

231
Q

What is the most common cause of diarrhoea in hiv patients?

A

Cryptosporidium

232
Q

In a postmenopausal woman presenting with a fracture, what is the next management step?

A

Bisphosphonates and calcium supplements (no need for dexa scan)

233
Q

What are contraindications to lumbar puncture?

A

Signs suggesting raised intracranial pressure: Relative bradycardia and hypertension, Focal neurological signs, Abnormal posturing, Unequal, dilated or poorly responsive pupils, Papilloedema, Abnormal ‘doll’s eye’ movements, Reduced or fluctuating level of consciousness (Glasgow Coma score less than 9 or a drop of 3 or more)
Shock
Extensive or spreading purpura
After convulsions until stabilised
Coagulation abnormalities: Platelet count below 100, Receiving anticoagulant therapy
Local superficial infection at lumbar puncture site
Respiratory insufficiency (lumbar puncture is considered to have a high risk of precipitating respiratory failure in the presence of respiratory insufficiency)

234
Q

How do different depths of burn present?

A

Superficial / 1st Degree - Erythema, pain, no blisters
Partial thickness / 2nd Degree - Mottled, Blisters, Wet and pain
Full thickness / 3rd Degree - Pale, dark, leathery, dry and no pain

235
Q

What are the different zones of a burn?

A

Zone 1: zone of coagulation
Zone 2: zone of stasis
Zone 3: zone of hyperaemia

236
Q

What counts as a major and minor burn?

A

Minor < 10% children or 15% adults

Major >10% children or 15% adults

237
Q

What are signs that a patient may have experienced an inhalational burn?

A 
Fire in an enclosed/confined space
Face and neck burns
Singeing of eyebrows and nasal hair
Hoarse voice
Dyspnea
Carbonaceous sputum
Brassy cough
Carboxyhemoglobin (HbCO) >10%
238
Q

Which burns victims require fluid resuscitation?

A

Indicated in Burns >10% in children and >15% in adults

239
Q

How should burn wounds be dressed and managed?

A

Deroof blisters if possible
Adequate wound cleaning before dressing
Flamazine, Mepitel or Urgotul SSD
Face - leave exposed (Polyfax or Chloramphenicol ointment)
Hand - Flamazine hand bag or light Mepitel dressing. The fingers must move
In transfer use cling film or sterile sheet
Review all dresings within 48 hrs

240
Q

What might be signs that a patient has suffered an electrical burn?

A

History of fit/thrown over
Unconsciousness or depressed GCS
Entry and Exit wounds
Changes in ECG, myoglobinuria or abnormal CK/Troponin

241
Q

Which patients should be referred to burns services?

A 
Suspected airway involvement
Any full thickness burn
Partial thickness burns greater than 10% adult and 5% in children
Burns to special areas (hands, face, neck, feet, perineum)
Electrical burns
Chemical burns
Suspected NAI
Associated major trauma
Associated co-morbidities
Circumferential burns
242
Q

What CSF findings would you expect in viral meningitis?

A

Cells: predominantly lymphocytes
Gram stain: negative
Protein: normal or slightly raised
Glucose: usually normal

243
Q

What CSF findings would you expect in bacterial meningitis?

A 
Cells: mainly polymorphs
Gram stain: positive
Bacterial Ag detection
Protein: high
Glucose: less than 60% of serum
244
Q

What CSF findings would you expect in TB meningitis?

A 
Cells: mainly lymphocytes
Gram stain: positive
Protein: high/very high 
Glucose: <60% serum 
Lactate: raised
245
Q

How do you adjust WCC in bloody CSF?

A

For every 500-700 RBCs deduct 1 white cell from WCC

246
Q

Who is most at risk of meningococcal meningitis?

A

> 1 year old

247
Q

Who is most at risk of pneumococcal meningitis?

A

Children
Elderly
Immunocompromised

248
Q

Who is most at risk of beta haemolytic streptococcus group B meningitis?

249
Q

Who is most at risk of listeria meningitis?

A

Neonates
Immunocompromised
>60 years old
Pregnant women

250
Q

Who is most at risk of cryptococcal meningitis?

A

HIV

Immunocompromised

251
Q

Who is most at risk of TB meningitis?

A

HIV
Immunocompromised
Concurrent TB infection

252
Q

Which antibiotics are appropriate to use against meningococcal meningitis/pneumococcal/haemophilus influenzae?

A

Ceftriaxone/cefotaxime
Meropenem
Chloramphenicol

253
Q

Which antibiotics are appropriate to use for pneumococcal meningitis?

A

Ben pen

Vancomycin

254
Q

Which antibiotics are appropriate to use for listeria meningitis?

A

Amoxicillin
Ben pen
Co trimoxazole

255
Q

Which antiviral is used to treat HSV/VZV encephalitis?

256
Q

Which drug should be used to treat cryptococcal meningitis?

A

Amphotericin with flucytosine then fluconazole

257
Q

What bugs can cause septic arthritis?

A

Staph aureus
Beta haemolytic strep
Coagulase negative staph (prosthetic joints)
Alpha haemolytic strep (prosthetic joints)

258
Q

What antibiotics are used to treat septic arthritis?

A

Flucloxacillin
Clindamycin if pen allergic
Vancomycin
Co amoxiclav

259
Q

Which bugs can cause UTI?

A

Coliforms: E. coli, proteus, klebsiella
Enterococci
Staph saprophyticus
Pseudomonas aeruginosa (catheter)

260
Q

What clinical findings are consistent with a diagnosis of necrotising fasciitis?

A

Septic shock
Extreme pain out of proportion to clinical findings
Lack of pain in area which previously had extreme pain
Skin infection with vesicles or bullae
Woody feel to tissues and crepitus

261
Q

What causes necrotising fasciitis?

A

Type 1: immunosuppression, chronic disease, staph aureus, coliforms, anaerobes
Type 2: beta haemolytic strep group A (strep pyogenes), staph aureus

262
Q

How is alcoholic ketoacidosis managed?

A

Infusion of saline and thiamine

263
Q

What are symptoms of hypoglycaemia?

A 
Autonomic: Sweating, Palpitations 
Tremor 
Hunger
Neuroglycopenia: confusion, clumsiness, behavioural change 
Headache
Nausea
264
Q

What are causes of fasting hypoglycaemia?

A 
Pituitary failure
Liver disease
Addison’s 
Islet cell tumours 
Retroperitoneal fibrosarcoma
265
Q

What is the management of a hypo in a patient who is conscious and able to swallow?

A

15-20g quick acting carbohydrate: glucotabs, lucozade, fruit juice
Repeat blood glucose 10-15 mins later
If less than 4, repeat carbs
If still less than 4 after 3 cycles/30 mins, consider 1mg glucagon or IV glucose
Once glucose over 4: long acting carb

266
Q

What is the management of a hypo in a patient who is conscious but confused/unable to cooperate but able to swallow?

A

1.5-2 tubes glucogel/dextrogel between teeth and gums
Glucagon 1mg IM if ineffective
If glucose <4 after 10/15 mins repeat (only 1mg glucagon in total)

267
Q

What is the management of a patient with a hypo who is unconscious/having seizures/aggressive?

A 
A to E
20% glucose 75-100ml IV over 15 mins 
Or 10% 150-200ml 
Or glucagon 1mg IM 
Repeat if needed 
Once glucose over 4, long acting carb
268
Q

What is the management for hypercalcaemic crisis?

A

IV fluids: 3-4L isotonic saline in 24 hours
Furosemide 40mg IV 6 hourly after hydration
Bisphosphonates
Calcitonin 100 units SC or IM every 6-8 hours
Steroids
Denosumab
Dialysis

269
Q

What are common causes of hypercalcaemic crisis?

A

Malignancy
Granulomatous disease
Primary hyperparathyroidism
Drug induced

270
Q

What complication can occur if sodium is corrected too quickly? What are symptoms of this?

A 
Central pontine myelinosis 
Quadriplegia 
Pseudobulbar palsy 
Aspiration
Seizures
Coma/death
271
Q

Which vessels bleed in epistaxis?

A

Anterior (80-90%), Little’s area anterior nasal septum – Keisselbach plexus of vessels
Posterior from branches of sphenopalatine artery in posterior nasal cavity

272
Q

What are local traumatic causes of epistaxis?

A 
Nosepicking
Nasal fractures
Septal ulcers / perforation
Foreign body
Blunt trauma e.g. falls
273
Q

What are local inflammatory causes of epistaxis?

A

Infection
Allergic rhinosinusitis
Nasal polyps

274
Q

What are some local causes of epistaxis?

A 
Trauma
Inflammation
Topical drugs: cocaine, nasal decongestants
Vascular: hereditary haemorrhagic telangiectasia, Wegeners granulomatosis
Post-operative: ENT, max fax, ophthalmic
Benign tumours: angiofibroma
Malignant tumours: squamous cell
Nasal oxygen
275
Q

What are some general causes of epistaxis (not local)?

A

Hypertension
Atherosclerosis
Increased venous pressure from mitral stenosis
Alcohol
Environmental: temperature, humidity, altitude
Haematological: Thrombocytopaenia, Platelet dysfunction, Leukaemia, Haemophilia, Anticoagulant drugs, antiplatelet drugs e.g aspirin, clopidogrel

276
Q

What is important in a history of a nosebleed?

A 
Duration
Which nostril
Estimated blood loss
Any home management / packing
Previous epistaxis and management
PMH –likely underlying causes
Surgery
Trauma
Symptoms suggestive of tumour: Nasal obstruction, Rhinorrhoea, Facial pain, Facial numbness, double vision
Drugs
FH bleeding disorders
Environmental
277
Q

What investigations might be required for epistaxis?

A

FBC if heavy or recurrent bleeding or clinically anaemic
Coagulation – if on warfarin or bleeding diathesis suspected
Group and save / cross match - if bleeding heavy, shock, severe anaemia

278
Q

What are possible management options for epistaxis? Describe details of each

A

Naseptin (chlorhexidine and neomycin) qds for 10 days, Avoid in peanut allergy – use mupirocin instead, Reduces crusting and vestibulitis, Very useful in young children as cautery inappropriate
Nasal cautery: Use if first aid unsuccessful, not for young children, Need appropriate expertise and equipment, Blow nose, Anaesthetic spray preferably with vasoconstrictor (lignocaine and phenylephrine), Allow 3-4 mins for anaesthetic to work, Identify bleeding point, Apply silver nitrate stick to bleeding point for 3-10 seconds until grey-white colour develops, Only one side of septum to avoid septal perforation, Avoid touching area not requiring treatment
Nasal packing: If bleeding not controlled, Local anaesthetic and vasoconstrictor, Nasal tampon (merocel), Inflatable packs (rapid rhino), Impregnated ribbon gauze – needs specific expertise, Position sitting forward mouth open, Secure pack to cheek, Check no pressure on cartilage around nostril, Check oropharynx for bleeding, may need to pack both nostril, Admit ENT

279
Q

What self care advice can be offered after epistaxis?

A

Avoid blowing or picking nose
Avoid heavy lifting
Avoid strenuous exercise
Avoid lying flat
Avoid alcohol and hot drinks ( cause vasodilation)
If further bleeding unresponsive to first aidmeasures, return to ED

280
Q

What are possible complications of nasal packing?

A

Sinusitis
Septal haematoma /abscess (from traumatic packing)
Pressure necrosis (from excessively tight packing)
Toxic shock syndrome (prolonged packing)
Airway obstruction

281
Q

When is an ENT referral required for epistaxis?

A

Uncontrolled bleeding
Posterior bleeding
Nasal pack
Significant comorbidities clotting disorder, anaemia
Recurrent with high risk of underlying cause

282
Q

What more advanced treatment options may be offered by ENT for epistaxis?

A 
Formal packing
Endoscopy and electrocautery
EUA and surgical intervention e.g. Arterial ligation
Radiological arterial embolisation
IV or oral tranexamic acid
283
Q

What are examples of third space losses?

A 
Pleural cavity: effusion, oedema 
Pancreatitis
Burns
Major fractures
Obstruction
Peritoneal cavity: ascites
284
Q

What are normal fluid requirements for a 70kg man per day?

A

1.5 ml/kg/h - 2.5L

285
Q

What are normal sodium requirements for a 70kg male per day?

A

1-2 mmol/kg/24h - 100mmol

286
Q

What is the daily potassium requirement for a 70kg male?

A

0.5 mmol/kg/24h - 50mmol

287
Q

What should be the daily urine output for a 70kg male?

A

> 0.5 ml/kg/h - 800ml

288
Q

What problems may increase a person’s fluid requirements?

A

Fever/Sweating. Increase by 100 to 150 mL/day for each C degree body temperature increase
Burns
Tachypnoea
Surgical drains
Polyuria
Gastrointestinal losses (eg vomiting or diarrhoea)

289
Q

What are some benefits of IV fluids?

A

Immediate / Therapeutic effect
Control over the rate of administration
Patient cannot tolerate drugs / fluids orally
Some drugs cannot be absorbed by any other route
Pain and irritation is avoided compared to some substances when given SC/IM

290
Q

What are some disadvantages of IV fluids?

A 
Cannot recall drug/Reverse action of drug/may lead to toxicity
Phlebitis: Mechanical/chemical irritation
Microbial contamination/Infection
Extravasation
Circulatory overload / can cause shock
Anaphylaxis/Allergic reactions 
Administration time
Serious Technical problems (Air in line)
291
Q

What are the electrolyte components of Hartmanns solution?

A

Na: 131
Cl: 111
K: 5
HCO3: 29 as lactate

292
Q

What are causes of rhabdomyolysis?

A

Muscle injury: Trauma, burns, electrocution, immobilisation (long lie), DKA, ischaemia, compression, vascular injury, compartment syndrome
Medications/Toxins: Alcohol, cocaine, amphetamines, statins, major tranquillizers, tetanus, venom
Increased muscular activity: Sport, seizures, status asthmaticus, inflammatory/inherited myopathies

293
Q

What are symptoms of lithium toxicity?

A

CVS arrhythmias

CNS eg, tremor, confusion, coma

294
Q

Which drugs can cause ANCA vasculitis?

A 
Hydralazine
Ciprofloxacin
Sulphonamides
Phenytoin
Allopurinol
Some PPIs
Propylthiouracil
Minocycline
Penicillamine
295
Q

What is the treatment for digoxin toxicity?

A

Supportive: Correction of electrolyte imbalances, Atropine for bradycardia, Avoid cardio stimulants because arrythmogenic
Limitation of absorption: Charcoal effective within 8 hours (or cholestyramine)
Specific measures: DIGIBIND = Fab digoxin specific antibodies. Binds plasma digoxin and complex eliminated by kidneys (used when OD is high/near arrest)
Enhanced elimination: Dialysis is ineffective. Charcoal/cholestyramine interrupt enterohepatic cycling

296
Q

Why does rhabdomyolysis lead to decreased phosphate and calcium?

A

Injury to muscles causes phosphate release which then binds to calcium

297
Q

What are causes of neutropenia?

A

Drugs: Cytotoxic chemotherapy, Bone marrow transplantation
DMARDs, Antithyroid drugs (carbimazole), Antipsychotic drugs (clozapine)
Infections: HIV/ TB, Overwhelming sepsis leading to bone marrow suppression and increased destruction of neutrophils, Transient neutropenia after viral infections (measles/ EBV)
Nutritional deficiency: B12, Folate
Medical conditions: Aplastic anaemia, acute leukaemia, Hypersplenism (Felty’s syndrome)

298
Q

What are risk factors for neutropenic sepsis?

A

Rate of decline of neutrophil count and duration of neutropenia
Hypophosphataemia and hypoproteinaemia
Inpatient chemotherapy regimens (especially for haematological malignancies)
Exposure to prior chemotherapy or current immunosuppression e.g.oral steroids
Pre-treatment elevations in ALP, bilirubin or AST levels
Reduced eGFR

299
Q

What is SIRS?

A

Systemic inflammatory response syndrome
2 of the following in response to an insult:
T > 38 C or < 36 C
HR > 90 bpm
RR > 20 bpm or PaCO2 < 32 mmHg
WBC > 12 000 cells/mm3 , < 4 000 cells/mm3 or >10 % bands

300
Q

What infections can group A beta haemolytic strep cause?

A 
Pharyngitis
Impetigo
Cellulitis
Pneumonia
Osteomyelitis
Necrotizing fasciitis
301
Q

What are complications of group A strep infection?

A

Scarlet fever – Erythrogenic toxin
Rheumatic fever – Molecular mimicry
Post-streptococcal glomerulonephritis –Molecular mimicry

302
Q

What are examples of group A strep?

A

Streptococcus pyogenes

Streptococcus dysgalactiae

303
Q

Which bugs can cause meningitis in neonates?

A

E. coli and other Gram negative bacillus
Streptococcus agalactiae
Listeria monocytogenes

304
Q

Which bugs can cause meningitis in infants?

A

Neisseria meningitidis
Haemophilus influenzae
Streptococcus pneumoniae

305
Q

Which bugs can cause meningitis in children?

A

Streptococcus pneumoniae

Neisseria meningitidis

306
Q

What features of CSF are measured from a lumbar puncture and what are normal values?

A

Glucose – Along with a peripheral glucose just before LP (Normal - 2/3 of peripheral glucose)
Protein (Normal – up to 45mg/dl)
Culture
Cell count (Normal - up to 5 cells/microL)

307
Q

What are the drugs of choice in treating meningitis?

A

Amoxicillin if treating Listeria meningitis
Benzyl penicillin or cefotaxime in neonates depending on causative agent
Ceftriaxone in children

308
Q

What is the sepsis six?

A 
Administer high flow oxygen
Take blood cultures
Give broad spectrum antibiotics
Give intravenous fluid challenges
Measure serum lactate and haemoglobin
Measure accurate hourly urine output
309
Q

What should target sodium reduction be in hypernatraemia?

A

<12 mmol/day

310
Q

Which patients are at increased risk of developing hepatotoxicity following paracetamol overdose?

A

Liver enzyme inducing drugs: rifampicin, phenytoin, carbamazepine, chronic alcohol excess, St. John’s wort
Malnourished patients: anorexia, CF, hep C, alcoholism, HIV
Patients who have not eaten for a few days

311
Q

What is trousseaus sign?

A

Carpal spasm on inflation of BP cuff to pressure above systolic due to hypocalcaemia

312
Q

What is chovsteks sign?

A

Tapping over parotid CN7 causes facial muscles to twitch due to hypocalcaemia

313
Q

What organisms can cause UTI?

A

E.coli: Gram negative rod, Facultative anaerobe, Gut commensal
Klebsiella
Proteus
Enterococcus

314
Q

What are different methods of microbiologically confirming a UTI?

A

Mid Stream Urine (MSU)
Clean catch specimen
Supra pubic puncture
Collection using a catheter

315
Q

What is a Jarisch Herxheimer reaction?

A

Acute febrile reaction due to rapid release of treponema antigen with associated allergic reaction
Caused by anti syphilitic treatment, especially penicillin

316
Q

Which is the antibiotic of choice in osteomyelitis?

A

Clindamycin

317
Q

Which is the antibiotic of choice in bacterial endocarditis with penicillin allergy?

A

Vancomycin

318
Q

Which antibiotics are used to manage bite wounds from human or animal bites?

A

Co amoxiclav

319
Q

Which antibiotic is used to manage malignant otitis externa?

A

Ciprofloxacin

320
Q

What are features of yellow nail syndrome?

A 
Lymphatic hypoplasia
Bronchiectasis
Pleural effusions
COPD
Carcinoma 
Dystrophic nails
321
Q

Which bugs are post splenectomy patients susceptible to? What prophylaxis is therefore required?

A

Capsulated bacteria - streptococcus pneumoniae
Spleen important in sequestration and phagocytosis, and production of antibodies
Prophylaxis: pneumococcal vaccine, penicillin

322
Q

What are features of kartageners syndrome?

A 
Dextrocardia
Situs invertus
Otitis media
Sinusitis 
Infertility
Bronchiectasis 
Frontal sinus dysplasia
323
Q

Which burns need referral to secondary care?

A

Deep dermal and full thickness
Superficial burns more than 3% TBSA in adults or 2% children
Superficial burns on face, hands, feet, perineum, genitals, flexures
Circumferential burns of limb, torso, neck
Inhalation injury
Electrical or chemical burn
Suspicion of NAI

324
Q

Why is there no benefit to giving paracetamol for the hyperthermia seen in serotonergic syndrome?

A

Caused by sustained isotonic muscle contractions

Not hypothalamically mediated

325
Q

What are features of serotonin syndrome?

A 
Extremes of temperature 
Mental agitation and confusion
Hypertonia
Hyperreflexia
Clonus 
Dilated pupils 
Sweaty 
Metabolic acidosis 
Rhabdomyolysis 
Hyperkalaemia
326
Q

Which drugs could cause serotonin syndrome?

A 
SSRI
MAOI
TCA 
Antipsychotics 
Tramadol 
Pethidine 
St. John's wort
Triptans 
Ondansetron 
Linezolid 
Recreational drugs: cocaine, ecstasy, LSD, amphetamines, GHB
327
Q

What are symptoms of giant cell arteritis?

A 
Headaches
PMR features: shoulder/hip pain, weakness
Temporal artery tenderness 
Jaw claudication
Amaurosis fugax
Blindness
328
Q

What blood test abnormalities might you expect in giant cell arteritis?

A

Raised ESR and CRP
High alk phos
Low Hb

329
Q

How does thiamine deficiency lead to peripheral oedema/pleural effusions (wet beriberi)?

A

Thiamine is essential cofactor for pyruvate dehydrogenase
Without thiamine, pyruvate formed from glycolysis cannot be converted to acetyl co A to enter Krebs cycle
This leads to impaired glucose metabolism with accumulation of lactate and pyruvate resulting in vasodilation and oedema

330
Q

How should anti HBs levels be interpreted after a vaccine to check response?

A

Level >100: adequate response. No further testing required. Should still receive booster at 5 years
Level 10-100: suboptimal response, one additional vaccine dose should be given. If immunocompetent, no further testing required
Level <10: non responder. Test for current or past infection. Give further vaccine course (3 doses again) then retest. If still fails to respond then HBIG required for protection if exposed

331
Q

What are absolute contraindications to thrombolysis?

A 
Active internal bleeding
Suspected aortic dissection
Recent head trauma/intracranial neoplasm
Previous haemorrhagic stroke at any time
Previous ischaemic stroke in past year
Previous allergic reaction to fibrinolytic agent
Trauma/surgery in past 2 weeks
332
Q

Which pathogen causes owls eye appearance in infected cells?

A

Cytomegalovirus due to intranuclear inclusion bodies

333
Q

What are features of CMV retinitis? What is the management?

A

HIV: CD4 count <50
Visual impairment
Retinal haemorrhages and necrosis (pizza retina)
IV ganciclovir

334
Q

What can cause haemolysis in G6PD?

A

Fava beans
Antimalarial drugs
Nitrofurantoin

335
Q

What biochemical abnormalities are found in rhabdomyolysis?

A 
Myoglobinuria 
Elevated CK
Elevated K
Elevated urate
Elevated calcium intracellularly in myocytes, can be normal or low in blood but increases as disease progresses 
Acidosis
336
Q

What is Kala azar?

A 
Visceral leishmaniasis (protozoa transmitted by sandfly) 
Black fever - skin darkens
337
Q

What is the wells score for a PE?

A

Clinical signs of DVT (leg swelling and pain on palpation) 3
Alternative diagnosis less likely 3
Heart rate >100 1.5
Immobilisation for more than 3 days or surgery in previous 4 weeks 1.5
Previous DVT/PE 1.5
Haemoptysis 1
Malignancy 1
PE likely if more than 4 points - immediate CTPA, if delay, treat with LMWH until scan

338
Q

What are criteria for severe falciparum malaria?

A 
High parasitaemia >2%
Hypoglycaemia
Severe anaemia
Renal failure
Pulmonary oedema
Metabolic acidosis
Abnormal bleeding
Multiple convulsions
Seizures 
Shock
339
Q

What is the management of severe falciparum malaria?

A

IV artesunate

340
Q

What is the most common cause of osteomyelitis in patients with sickle cell anaemia?

A

Salmonella

341
Q

Which infections are HIV patients susceptible to with a CD4 count of 200-500?

A

Hairy leukoplakia
Shingles
Kaposi sarcoma
Oral thrush

342
Q

Which infections are HIV patients susceptible to with a CD4 count of 50-100?

A

Oesophageal candidiasis
Cryptococcal meningitis
Primary CNS lymphoma
Aspergillosis

343
Q

What is Ludwig’s angina?

A

Cellulitis which occurs on floor of mouth

Spreads in fascial spaces of head and neck

344
Q

What drugs are sickle cell patients likely to be on?

A

Hydroxyurea
Folic acid
Penicillin

345
Q

What is samters triad?

A

Asthma
Aspirin sensitivity
Nasal polyposis

346
Q

What is the triad of features of haemolytic uraemic syndrome?

A

Haemolytic anaemia
Renal failure
Thrombocytopenia

347
Q

Which bug is associated with haemolytic uraemic syndrome?

A

Ecoli 0157

Phase 3 (23 decks)

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