acute medicine Flashcards
What rest can confirm anaphylaxis?
Serum tryptase
Adult dose of for anaphylaxis
500 micrograms (0.5ml 1 in 1000) if older than 12
How long can you confirm serologically that anaphylaxis occurred
Serum tryptase are raised for up to 12 hours
What drug is used to treat adrenaline induced ischaemia
local injection of phentolamine, a short acting alpha blocker
features of carbon monoide poisoning
headache (90%), N&V (50%), vertigo 50%, confusion (30%), pink mucosas,
Sats may be falsely high due to similarities between oxyhaemoglobin and carboxyhaemoglobin
So do ABG
typical carboxyhaemoglobin levels < 3% non-smokers < 10% smokers 10-30 symptomatic >30 severe
features of Anti-NMDA receptor encephalitis
visual/auditory hallucinations, agitation,
Paraneoplastic syndrome related to ovarian ca
Electrolyte abnormality that increased risk of torsades
Hypocalcemia, hypokalemia, hypomag
What is G6PD deficiency
X linked recessive disease that triggers haemolytic crises following oxidative stress… I.e. ciprofloxacin or broad beans or henna
STEMI thrombolysis two options of meds
tenecteplase is cheaper and easier than TPA
Management after thrombolysis of stemi
ECG after 90 minutes, if less than 50% reduction in ST elevation then PCI, but PCI also beneficial for both
Child with neck swelling, biopsy shows starry sky microscopy, diagnosis and causative pathogen
Burkitt’s lymphoma and ebv
reduced vision and poorly reactive pupils, homeless gentleman. What has he taken?
Methanol
Features of Lambert Eaton syndrome
Associated with small cell lung cancer, sometimes breast cancer, or independently
Repeated muscle contraction leads to increased strength … Then weakness (legs then arms), hyporeflexia, autonomic symptoms: dry mouth, impotence, difficultly micturating
Antibody associated with Lambert Eaton syndrome
Voltage gated sodium antibodies affecting pre synapses in peripheral nervous system
Antibody is myasthenia gravis
Acetylcholine receptor antibody in 85-90%
In renal transplant what is the most important HLA antigen to match
DR > B > A
Mechanism of action of N-Acetylcysteine
Replenishes glutathione
-it’s a precursor, and glutathione then conjugates and denatures the toxins. Conjugation of paracetamol is saturated in overdose)
When do you treat paracetamol overdose
If staggered (taken over longer than an hour), or unsure of time. Or if level is above 100mg/l at 4hr, or 15 at 15
What virus causes rabies
RNA rhabdovirus - lyssavirus , a bullet-shaped cspsid
Normal anion gap
10-18 mmol/L
Causes of raised anion gap metabolic acidosis
Caused by impaired H+ excretion
Lactate (shock, hypoxia eg PE)
toxins (methanol),
Ketones (DKA)
Renal
Causes of normal anion gap metabolic acidosis
Addison’s
Bicarbonate loss ( GI or renal)
Chloride excess
Diuretics
Treatment of serotonin syndrome
supportive, IV fluids, benzos, in severe cases : Cyproheptadine (h1 and 5HT antagonist)
Causes of absent radial pulse
Takayasu’s arteritis (malaise headache, intermittent claudication)
Aortic dissection with subclavian involvement
Peripheral arterial embolus
Trauma
Iatrogenic (postcath)
What are staghorn calculi usually composed of
Magnesium ammonium phosphate - struvite
Two radiolucent calculi types
Urate, xanthine
cystine is semi opaque .. Ground glass
Management of tricyclic antidepressants overdose
Iv bicarb may reduce risk of seizures
IV lipid emulsion is being used to bind free drug and reduce toxicity
DIALYSIS IS INEFFECTIVE
Management of high altitude cerebral oedema
Decent and dexamethasone
Features of dengue fever
Headache, fever myalgia, pleuritic pain, Mac pap rash
Treatment for shigella
Cipro
Diagnosis following a discrete episode of antero/retrograde amnesia and repetitive questioning without other impairment… But can remember their own name and DOB
Transient global amnesia
Features of amoebiasis
Bloody diarrhoea, stool microscopy trophozoites if 15min or kept warm! Can cause liver abscess.
Metro
Non nitrate producing bacturia
Gram positive effect staphylococcus
causes of toxoplasmosis
cat faeces, but also rat. and undercooked meat
important test to do if suspecting toxo
pregnancy, due to congenital toxoplasmosis
classic symptoms of infective mononucleosis of low-grade fever, generalised lymphadenopathy with prominent cervical lymph nodes and malaise…but EBV negative??
consider acute toxoplasmosis infection in an immunocompetent patient
remember to then consider pregnancy, due to congenital toxoplasmosis
classical features of cyanide poisoning
‘classical’ features: brick-red skin, smell of bitter almonds
Investigation for thyphoid
Large volume blood culture
Can use Widal test by low sensitivity and specificity
Features of typhoid
Fevers, headaches, arthralgia, Abdo pain constipation , rose spots in trunk… Encephalitis
features of Typhus
black eschar and site of entry. fever, headache… treat with doxy
Features of drug inducted lupus
Typical features, without renal or neuro
Recurrent DVT inr
3.5
What do you give to asthmatic with SVT
verapamil because adenosine is contraindicated
Treatment for Cryptosporidium
Supportive
Features of Wiskott-Aldrich syndrome
recurrent bacterial infections (e.g. Chest)
eczema
thrombocytopaenia
X linked recessive
Low IgM
What factor is good prognostically for sarcoid
erythema nodosum and not being black (!)
lateral femoral cutaneous nerve (LFCN) origin
L2/3
meralgia paraesthetica.
Diagnosis of meralgia paraesthetica
Pelvic compression test induces symptoms
Patient presenting with auricular chondritis, saddle nose, bilat hearing loss, arthralgia, hoarseness…
Relapsing polychondritis - a multi-systemic condition characterised by repeated episodes of inflammation and deterioration of cartilage… Most commonly ears
Saddle nose and deafness are also caused by congenital syphilis… And saddle nose can be seen in Granulomatosis with polyangiitis (Wegener’s granulomatosis)
Saddle nose deformity… diagnoses
Relapsing polychondritis -reduced hearing and auricular chondritis, all cartilage inflammation
Congenital syphilis… Child with deafness, peg shaped upper incisors
Granulomatosis with polyangiitis (Wegener’s granulomatosis)… Haematuria and cANCA
Woman came back from Turkey, seizure, after having headaches. multiple calcified lesions on the CT hea
Neurocysticercosis
Thick dense bones prone to fracture…bone pains… Normal calcium ALP and phosphate. Diagnose and mechanism
Osteopetrosis
Defect in osteoclasts activity
Patient with meningitis. When do you give dex?
Give with first dose of cefotaxime
Continue for 4 days if pneumococcal meningitis suspected
This reduces the risk of neurological sequela
Patient back from Tanzania, odd behaviour, pyrexial, reversed sleep wake cycle
African trypanosomiasis
Aka African sleeping sickness
American trypanosomiasis is Chagas. Mostly asym but can get myocarditis
Woman fit and well has cats, gets fever and lymphadenopathy. Raised ESR and positive IgG and IgM for toxo. What’s management?
Reassure! Immunocompetent patients with toxoplasmosis don’t usually require treatment, unless severe
Would treat with pyrimethamine, sulfadiazine and folinic acid for 4 to 6 week
Patient with peritonsilar abscess develops neck pain…
Patients with peritonsillar abscesses can develop Lemierre’s syndrome (thrombophlebitis of the internal jugular vein)- this can present with neck pain and can result in septic pulmonary embolism
macroscopic haematuria in young people days after an upper respiratory tract infection… Diagnosis
IgA nephropathy (raised c3) Weeks after is post-strep glumerulonephritis (and low compliment levels)
Patient presents with dissection of descending aorta. What is management
IV labetalol only
What is heerfordt syndrome
Subset of sarcoidosis
Parotid enlargement, fever, anterior uveitis
Bilat hilar lymphadenopathy and erythema nodosum
Treatment for cyanide poisoning
hydroxocobalamin (intravenously)
Management of torsades de pointes
IV magnesium sulfate is used to treat torsades de pointes
Commonest bacteria cause of otitis media
Stept pneumoniae
Commonest bacterial cause of tonsillitis
Stept pyogenes
Features of Whipple’s disease
Middle aged man, with malabsorption (diarrhoea/weight loss), arthralgia, hyperpigmentation and lymphadenopathy
Infection… Most common in hla b27 +ve middle aged men
Patient presents with rapid weight gain, diplopia in mornings and before meals, and intermittent sweating. What is likely diagnosis
Insulinoma
Diplopia related to hypoglycemia
What investigation diagnoses obstructive sleep apnea
Polysomnography
Features of cholesterol embolism
Eosinophilia (in 70%)
Purpura
Renal failure
Livedo reticularis… net-like rash
Often post vascular surgery or angio
Definitive management for patient with endocarditis and severe congestive cardiac failure
emergency valve replacement surgery
Other indications are overwhelming sepsis despite Abx
Recurrent embolic episodes
Pregnancy
Young female, hypertension and asymmetric kidney… diagnosis
fibromuscular dysplasia (90% female) Flash pulmonary oedema and kidney failure following ACEi
brown/bluish pigment of the ear cartilage or sclera, arthropathy, renal stones, cardiac valve involvement and coronary calcification.. diagnosis
Alkaptonuria
Features of leptospirosis
Bilateral conjunctivitis, bilateral calf pains and high fevers in a sewage worker, farmers vets, abbertoire or rat urine
Renal failure in 50% jaundice…..
Treat with benpen or doxy
How long do you monitor someone post anaphylaxis
should be observed for 6–12 hours from the onset of symptoms, as it is known that biphasic reactions can occur in up to 20% of patients
management of listeria meningitis
usually under 3m or over 60yr /immunosup
IV amoxicillin + gentamicin
prophylactic management of contacts of meningitis
Rifamp or Cipro for contacts of meningococcus meningitis
patient allergic to latex. What food allergy are they most likely to have?
Latex-Fruit syndrome…so particularly banana, pineapple, avocado, chestnut, kiwi fruit, mango, passion fruit and strawberry
patient presents who is eating clay. Diagnosis?
geophagia (ingesting clay/soil) can occur in Zinc deficiency, iron def, pregnancy
what blood result would you expect in a diagnosis of cholesterol embolism?
Eosinophilia is seen in around 70% of cases of cholesterol embolisation.
Management of witnessed cardiac arrest while on a monitor, which shows VF
up to three successive shocks before CPR for VF or pulseless VT
Amiodarone 300mg is administered after the third shock (in shockable rhythms)
Management of oesophageal varices…. acute and prevention
Acute; terlipressin
Prevention: propranolol
Treatment for local anaesthetic toxicity
IV 20% lipid emulsion
Management of severe hypocal
IV calcium gluconate 10ml of 10% over 10 minutes
Patient presents with chronic abdo pain, psychiatric issues like depression, and neuropathy. Mum had same. Diagnosis?
Acute intermittent porphyria
Auto dom
Urine turns deep red on standing
Active ingredient in anti freeze poisoning
Ethylene glycol
USED to be methanol…… So you don’t get loss of vision with antifreeze
Mx toxicity with - fomepizole, ethanol is second line
Skin necrosis after starting warfarin. Diagnosis
Protein c Def
Auto dom, thrombosis
Mx of aspirin OD
Charcoal if within an hour,or IV sodium bicarbonate
Most common infective cause of haemolytic uraemic syndrome
E coli 0157:h7 accounts for 90% of cases in children
Single most important factor to indicate the need for a liver transplant post paracetamol od
pH < 7.3 , 24hr after ingestion
Or all of:
PT>100
Cr >300
Grade 3 or 4 enceph
How do you distribution TRALI and TACO
hypotension in TRALI vs hypertension in TACO
Fever and leukopenia in TRALI
Patient just started chemo and they develop low calcium, high phosphate, AKI.. diagnosis
Tumour lysis syndrome
Patient who is Turkish, Armenian, or Arabic Presents with pyrexia, arthralgia, abdo pain and pleurisy
Familial Mediterranean fever
Management of high altitude pulmonary oedema and of high altitude cerebral oedema
HAPE Descent and acetazolamide, nifidipine, dexamethasone
HACE descent and dexamethasone
Patient on warfarin for AF, intracranial haemorrhage
Stop warfarin
IV vit K 5mg
Prothrombin complex concentrate
Abdo pain, blue lines on gum, motor neuropathy, constipation
.
What poison?
Lead poisoning
Lead > 10 mcg/dl are considered significant
Give D-penicillamine
Or DMSA
