Case of Screaming Agony

Question 1

caput medusae

Answer 1

dilated superficial epigastric veins radiating from central large venous varix

Question 2

filtration/reabsorption rate rate equation?

Answer 2

Qf= Peff (difference between hydrostatic/blood pressure minus oncotic pressure) x Kf (permeability x exchange area)
effective filtration pressure Peff
filtration coefficient Kf

Question 3

transudate vs exudate?

Answer 3

transudate- plasma filtrate with low protein content- change in hydrostatic/oncotic pressure

exudate- unfiltered plasma with high protein count
change in vascular permeability or exchange area

Question 4

causes of ascites?

Answer 4

portal hypertension- liver cirrhosis, alcoholic hepatitis, constrictive pericarditis, congestive heart failure

hypoalbuminaemia- nephrotic syndrome, protein losing enteropathy malnutrition
peritoneal disease- malignancy carcinomatosis, infectious TB, fungal vasculitis peritonitis

Question 5

how to work out cause of ascites?

Answer 5

SAAG serum albumin - ascites albumin

if more than 1.1g/dl then portal hypertension transudate effusion with low protein count

if less than that then not portal hypertenion

Question 6

contraindications for drainage

Answer 6

pt factors- acute abdomen, bowel obstruction
abnormal clotting/platelets

Question 7

seldinger technique?

Answer 7

introduce needle
guide wire
needle removed
skin incision
drain passed over wire
guidewire removed

Question 8

pouch between kidney and liver is called?

Answer 8

morrisons pouch

Question 9

how do mesothelial cells look?

Answer 9

grouped, clusters, balls with windows and microvilli
malignancy- high nuclear to cytoplasm ratio

Question 10

eosinophil rich tissue?

Answer 10

CHARCOT LEYDEN CRYSTALS

Question 11

ferruginous body?

Answer 11

seen in asbestosis- macrophages trying to eat

Question 12

adenocarcinoma of ovary?

Answer 12

huge calcification within cells

Question 13

granuloma?

Answer 13

central collection of histiocytes macrophages surrounded by lymphocytes mainly t lymphocytes

Question 14

squamous marker?

Answer 14

p63

Question 15

LEVOTHYROXINE?

Answer 15

once a day, given on empty stomach for improved absorption, half life 7 days

1.6-1.8 mcg/kg/day

Question 16

liothyronine?

Answer 16

short half life 24-48 hours
avoid in cardiac disease

Question 17

what percent of t3 is derived from t4?

Answer 17

80%

Question 18

major site of degradation of t3/4?

Answer 18

liver

Question 19

what is myxodema coma?

Answer 19

severe hypothyroidism GCS low

Question 20

in myoxedema coma you give?

Answer 20

warming, intravenous t4/t3 and iv hydrocortisone

Question 21

treatment of myxodemea come?

Answer 21

iv levothyroxine 300-400mcg then 50-100mcg daily oral levothyroxine

if no improvement iv liothyronine 10mch 8 hourly

slow rewarming 0.5c/hour

iv hydrocortisone in cortisol deficiency

Question 22

what happens in pregnancy to levothyroxine?

Answer 22

bound to plasma proteins, beta hcg is like tbg, tbg increases

hence increase by 20-30%
25mcg/day

Question 23

treatment for hyperthyroidism

Answer 23

carbimazole 40 mg od
beta blockers- symptoms

Question 24

how does carbimazole work?

Answer 24

reduces concentration and uptake of iodine by thyroid, prevents thyroid peroxidase enzyme from coupling iodine and thyroglobulin

Question 25

propylthiouracil peripherally inhibits?

Answer 25

t4 to t3 conversion

Question 26

carbimazole side effects?

Answer 26

hair loss arthralgia agranulocytosis- sore throat mouth ulcers, fever teratogenic- aplasia cutis (problems with developing skin)

Question 27

propythiouracil similar side effects to carbimazole but includes?

Answer 27

fulminant liver failure

Question 28

in thyroid storm lab results will show?

Answer 28

leukocytosis, elevated ALP and high t4 and t3

Question 29

thyroid storm treatment?

Answer 29

underlying cause, itu, PTU 600-1000mg loading dose thne 200-300mg 4 hourly via NG, potassium iodide after PTU to inhibit thyroid hormone release, beta blockers for symptom control, steroids prevent t4 to t3 conversion

Question 30

normal level of cortisol?

Answer 30

over 300

Question 31

potency of steroids?

Answer 31

dexamethasone then prednisolone then hydrocortisone dexamethasone has no mineralocorticoid activity whereas hydrocortisone has equal

Question 32

sick day rule?

Answer 32

double dose im/iv if vomiting or cannot take orally

Question 33

steroids side effects?

Answer 33

thinning skin/bruising iatrogenic cushings

Question 34

role of fludrocortisone?

Answer 34

sodium reabsorption and potassium excretion 50-100mcg

Question 35

in pituitary apoplexy you should give?

Answer 35

hydrocortisone 100mg iv stat and 0.9% NaCl

Question 36

in acromegaly check for?

Answer 36

IGF1 and cortisol

Question 37

gold standard test for growth hormone?

Answer 37

OGTT, if growth hormone not suppressed

Question 38

if giving testosterone monitor?

Answer 38

CHECK PSA AND FBC

Question 39

how does metformin work?

Answer 39

decreases gluconeogenesis and increases peripheral utilisation of glucose

Question 40

side effects of metformin

Answer 40

lactic acidosis gi symptoms- pain, nausea d/v decreased b12 absorption

Question 41

avoid metformin in?

Answer 41

GFR less than 30ml/min, and stop in dehydration or AKI occurs

Question 42

how do sulphonylureas work?

Answer 42

increase inculin secretion from pancreas

Question 43

side effects of sulphonylureas?

Answer 43

weight gain, hypoglycaemia

Question 44

DPP4 inhibitors work by?

Answer 44

incretins- glucose through mouth causes increase of insulin dpp4 inactivates GIP, GLP hormones so DPP4 inhibitors, increase insulin secretion and lower glucagon secretion

Question 45

side effects of DPP4 inhibitors?

Answer 45

pancreatitis stevens johnson

Question 46

GLP1 agonist?

Answer 46

binds to activate GLP1 receptor to increase insulin secretion induce weight loss impact satiety and stomach motility

Question 47

GLP1 agonist side effects?

Answer 47

GI side effects pancreatitis

Question 48

SGLT 2 inhibitors?

Answer 48

inhibit SGLT2 sodium glucose cotransporter, reduces glucose reabsorption

Question 49

side effects of SGLT2 inhibitors?

Answer 49

genital infections hypoglycaemia euglycaemic DKA

Question 50

glitazones?

Answer 50

reduced peripheral insulin resistance, liver fat, insulin requirements

Question 51

side effects of glitazones?

Answer 51

bladder cancer, heart failure, bone fractures,weight gain

Question 52

hypoglycaemis GCS 3?

Answer 52

glucagon im 1mg

Question 53

DKA protocol?

Answer 53

iv fluids, fixed rate insulin, potassium replacement 10% dextrose- glucose less than 14 dont omit long acting insulin