Conditions

Question 1

Presenting features in history for aspirin overdose

Answer 1

Ingestion: formulation, dose, time, co-ingestants, accidental or intentional

Symptoms: initially minimal with severe toxicity not until 6-12 hours later
- CNS: Tinnitus, vertigo, confusion
- GIT: Nausea and vomiting

Question 2

Features in examination of aspirin overdose

Answer 2

Resp: Hyperventilation
CVS: Dehydration
CNS: Agitation, lethargy, seizures, coma
Other: Hyperthermia

Question 3

What ix would you do in suspected aspirin overdose?

Answer 3

Blood gas
Urea & electrolytes, creatinine
Capillary glucose (hypoglycaemia)
Serum salicylate concentration
At presentation: 2-4 hourly if symptomatic or enteric coated preparation, until declining

Question 4

Aspirin overdose mx

Answer 4

A-E resus and supportive care
- ABG
- discuss with National Poisons unit
- notify ICU

Decontamination
- activated charcoal

Correct fluids and electrolytes

Enhance elimination and treat acidosis
- urinary alkalisation via IV bicarbonate
- haemodialysis in severe cases

Observe for at least 6 hours before discharge

Question 5

Signs of severe aspirin posioning

Answer 5

Cardiac dysrhythmias
Acute non-cardiogenic pulmonary oedema
Cerebral oedema
Convulsions
Confusion
Coma
Hyperpyrexia
Heart failure
Acute kidney injury
Worsening metabolic and lactic acidosis

Question 6

What would you see on aspirin poisoning ABGs?

Answer 6

Phase 1: Respiratory stimulation - hyperventilation and respiratory alkalosis with alkaluria

Phase 2: Paradoxical aciduria (pH <6) and respiratory alkalosis.

Phase 3: Metabolic acidosis & hypokalaemia (± ongoing respiratory alkalosis)

Question 7

Red flags for infection in pt presenting with lower back pain

Answer 7

Fever
Tuberculosis, or recent urinary tract infection
Diabetes
History of intravenous drug use
HIV infection, use of immunosuppressants, or the person is otherwise immunocompromised

Question 8

What infection could be present in the lower back?

Answer 8

Discitis
Vertebral osteomyelitis
Spinal epidural abscess

Question 9

Cauda equina syndrome red flags

Answer 9

Severe or progressive bilateral neurological deficit of the legs

Recent-onset urinary retention (caused by bladder distension because the sensation of fullness is lost) and/or urinary incontinence (caused by loss of sensation when passing urine)

Recent-onset faecal incontinence (due to loss of sensation of rectal fullness)

Perianal or perineal sensory loss (saddle anaesthesia or paraesthesia)

Unexpected laxity of the anal sphincter

Question 10

Spondylodiscitis vs discitis

Answer 10

Discitis is inflammation of the vertebral disc space

Spondylodiscitis describes infection of both the intervertebral disc space and the adjacent vertebrae

Question 11

Most common pathogen and area affected by discitis

Answer 11

Staph aureus

Lumbar region

Question 12

Potential findings on X ray of suspected discitis

Answer 12

Disc space narrowing
End-plate irregularities
Annulus calcification

Question 13

When may a nephrostomy be indicated?

Answer 13

Ureter obstructed by a stone, blood clot, tumour, damage to the urinary system or infection

Can also be inserted at the time of an operation on a large kidney stone to protect the urinary tract

Question 14

What causes carpal tunnel syndrome?

Answer 14

Compression of median nerve in the carpal tunnel

Question 15

Signs of severe carpal tunnel syndrome

Answer 15

Wasting of the thenar muscles

Sensory loss in the median nerve distribution (the thumb, index finger, middle finger, and radial half of the ring finger)

Reduced hand grip and pinch grip strength.

Question 16

Who gets carpal tunnel syndrome?

Answer 16

Commonly affects women in middle age but
can occur at any age in either sex

Can also occur with pregnancy, diabetes,
thyroid problems, rheumatoid arthritis

Question 17

Hallux valgus aka

Answer 17

Bunion

Question 18

When would you refer a bunion?

Answer 18

Referral to an orthopaedic or podiatric surgery specialist should be considered if:
- Progressive symptoms and/or deformity
- Sx persist after three months of conservative mx
- Second toe involvement
- Significant impact on daily functioning
- Unable to wear suitable footwear

Urgent referral to an appropriate specialist should be arranged if:
- Impending or non-healing foot ulcer present
- Suspected peripheral limb ischaemia

Referral to a diabetic foot protection service if the person has diabetes mellitus, the urgency depending on clinical judgement

Specialist referral is not indicated for cosmetic or prophylactic reasons alone!!

CKS NICE

Question 19

Medial knee pain, esp when climbing stairs
O/E contracting hamstring against resistance
Dx?

Answer 19

Pes anserine tendinopathy/bursitis

Question 20

Sharp pain at lateral condyle at 45-degree squat (bend/flexion)
O/E Tender at this angle when lateral condyle pressed on

Answer 20

Iliotibial band syndrome

Question 21

Swelling in the popliteal fossa ddx

Answer 21

Baker’s cyst
Popliteal aneurysm

Question 22

What causes foot drop?

Answer 22

Damage/compression to the common peroneal/fibular nerve

Question 23

O/E right foot cannot dorsiflex, cannot evert foot with total loss of sensation of foot

Which nerve is affected?

Answer 23

Right common peroneal/fibular nerve

Question 24

Describe a +ve McMurray’s test and what it indicates

Answer 24

Painful click obtained as knee brought from flexion to extension in either an internal or external rotation

Suggestive of a meniscal tear

Question 25

Which imaging confirms a meniscal tear?

Answer 25

MRI knee

Question 26

Meniscus tear tx

Answer 26

Most tears do not heal spontaneously and are treated arthroscopically by meniscus repair (if torn in a clear, clean pattern) or, less commonly, partial meniscectomy (if torn in a complex pattern)

Question 27

45 yo male presents with sudden pain back of left ankle, unable to fully weight bear on left leg and cannot planter flex What test confirms the dx?

Answer 27

Simmond's test - achilles tendon rupture - ask pt to knell on chair, squeeze calves, observe plantar flexion in feet - if ruptured, less flexion in affected side

Question 28

Intracapsular neck of femur fracture tx

Answer 28

Replacement arthroplasty (hemi/ or total hip) for displaced Total hip if: 1. able to walk independently out of doors with no more than the use of a stick 2. not cognitively impaired 3. medically fit for anesthesia and operation

Question 29

Extracapsular neck of femur fracture tx

Answer 29

Extramedullary implants - sliding hip screw for trochanteric fractures above and including the lesser trochanter Intramedullary - pin and plate - extramedullary internal fixation for subtrochanteric fractures

Question 30

When is a primary percutaneous coronary intervention indicated?

Answer 30

Acute STEMI presentation within 12 hours of onset of sx AND primary PCI can be delivered within 120 minutes (compared to fibrinolysis)

Question 31

When is a coronary angiography indicated in acute STEMI presentations?

Answer 31

Pt presents more than 12 hours after onset of sx and continuing myocardial ischaemia

Question 32

When is fibrinolysis indicated in acute STEMI presentations?

Answer 32

Within 12 hours of onsent of sx if primary PCI cannot be delivered within 120 minutes compared to fibrinolysis

Question 33

What test must be completed before discharge of a pt who has had a STEMI?

Answer 33

ECHO to assess left ventricular function

Question 34

Which additional medication is required with reperfusion therapy for STEMI pts?

Answer 34

1. Primary PCI - prasugrel + aspirin if not on oral anticoagulant - clopidogrel + aspirin if on oral anticoagulant 2. Fibrinolysis - antithrombin given at same time - ticagrelor + aspirin unless HIGH risk bleed - clopidogrel +/or aspirin if high risk bleed

Question 35

Which additional medication is required with reperfusion therapy for STEMI pts?

Answer 35

1. Primary PCI - prasugrel + aspirin if not on oral anticoagulant - clopidogrel + aspirin if on oral anticoagulant 2. Fibrinolysis - antithrombin given at same time - ticagrelor + aspirin unless HIGH risk bleed - clopidogrel +/or aspirin if high risk bleed

Question 36

First medication for STEMI mx

Answer 36

300-mg loading dose of aspirin and continue indefinitely unless contraindicated

Question 37

Immediate medical mx of STEMI pts

Answer 37

M – IV morphine O – oxygen if sats < 94% RA N – sublingual nitroglycerin A – oral aspirin 300mg + IV metoclopramide 10mg (anti-emetic for opiate AE)

Question 38

What medication should a MI pt be discharged with?

Answer 38

Clopidogrel 75mg OD Bisoprolol 2.5mg OD Aspirin 75mg OD Ramipril 5mg OD Atorvastatin 80mg OD The NICE guidelines for the secondary prevention of MI recommend that all patients should be offered an ACEi, dual antiplatelet therapy, a beta-blocker and a statin.

Question 39

Signs of aortic stenosis

Answer 39

Slow rising pulse Narrow pulse pressure Ejection systolic murmur radiating to the neck

Question 40

Signs of mitral regurgitation

Answer 40

Atrial fibrillation Displaced hyperdynamic apex Pansystolic murmur at the apex radiating to the axilla *The more severe the larger the ventricle*

Question 41

When do you give alteplase in acute ischaemic stroke?

Answer 41

Within 4.5 hours of onset of stroke sx AND Intracranial haemorrhage excluded via CT head (assumes unit trained to prescribe and monitor it)

Question 42

When do you offer thrombectomy and IV thrombolysis in acute ischaemic stroke?

Answer 42

Within 6 hours of sx onset AND Confirmed occlusion of proximal anterior circulation via CTA/MRA

Question 43

Do you give aspirin to stroke patients?

Answer 43

YES if haemorrhagic stroke EXCLUDED and must be done within first 24 hours ideally Aspirin 300 mg orally if no dysphagia Aspirin 300 mg rectally/enteral tube if dysphagia - give with PPI if associated dyspepsia Continue aspirin daily until 2 weeks after onset of stroke - then will start long-term antithrombotic tx

Question 44

Do you give statins to stroke patients?

Answer 44

Do not start immediately, give after 48 hours If patient already on it, you may continue statin tx

Question 45

Overall mx of ischaemic stroke

Answer 45

A to E Thrombolysis/thrombectomy Antiplatelet - aspirin within 24 hours Assess swallowing within 24 hours Nutritional support if risk of malnutrition Optimise positioning and early mobilisation VTE prophylaxis if immobile

Question 46

What aspect of a patient's clinical status should be monitored to guide supportive care?

Answer 46

Level of consciousness Blood glucose Blood pressure Oxygen saturations Hydration Temperature Cardiac rhythm and rate

Question 47

When may an ischaemic stroke pt be considered for thrombectomy alone?

Answer 47

Presents between 6 to 24 hours stroke sx

Question 48

Bamford Stroke Classification categories

Answer 48

Total anterior circulation stroke Partial anterior circulation stroke Posterior circulation stroke Lacunar syndrome

Question 49

CT findings of stroke

Answer 49

Hypoattenuation (darkness) of the brain parenchyma Loss of grey matter-white matter differentiation, and sulcal effacement Hyperattenuation (brightness) in an artery indicates clot within the vessel lumen

Question 50

Total anterior circulation stroke

Answer 50

1. Unilateral hemiparesis and/or hemisensory loss of face, arm, leg 2. Homonymous hemianopia 3. Higher cognitive dysfunction, e.g. dysphagia Middle and anterior cerebral arteries

Question 51

Partial anterior circulation stroke

Answer 51

2 of the following: 1. Unilateral hemiparesis and/or hemisensory loss of face, arm, leg 2. Homonymous hemianopia 3. Higher cognitive dysfunction, e.g. dysphagia Smaller anterior arteries, i.e. upper/lower division of MCA

Question 52

Posterior circulation stroke

Answer 52

1 of the following: 1. Cerebellar or brainstem syndrome 2. Loss of consciousness 3. Isolated homonymous hemianopia Involves vertebrobasilar arteries, cerebellar or PCA vessels

Question 53

Lacunar syndrome

Answer 53

1 of the following: 1. Unilateral weakness (and/or sensory deficit) of face and arm, arm and leg or all three 2. Pure sensory stroke 3. Ataxic hemiparesis Involves perforating arteries around internal capsule, thalamus and basal ganglia

Question 54

Most common drugs to cause or exacerbate kidney injury

Answer 54

NSAIDS Aminoglycosides ACE inhibitors Angiotensin II receptor antagonists Diuretics Iodine-based contrast media

Question 55

Simple care bundle for AKI

Answer 55

STOP AKI Sepsis screen (sepsis 6) Toxin exposure (review drugs) Optimise volume status and BP (crystalloid taking into account electrolyte imbalances, escalate to critical care for vasopressors if not responding) Prevent harm (treat reversible causes/complications, review medications in line with kidney injury)

Question 56

When do you refer for emergency renal replacement therapy?

Answer 56

Refractory hyperkalaemia (potassium >6.5 mmol/L) Refractory metabolic acidosis (pH <7.15) Refractory volume overload with or without pulmonary oedema End-organ complications of uraemia (e.g., pericarditis, encephalopathy, uraemic bleeding) or other end-organ involvement (e.g., neuropathy, myopathy) Severe AKI and poisoning/drug overdose (e.g., ethylene glycol, lithium).

Question 57

What complications may arise from a subarachnoid haemorrhage?

Answer 57

Vasospasm (stroke like sx) Hyponatraemia (?SIADH) Re-bleed (high mortality) Seizures Hydrocephalus

Question 58

How would you manage a bowel obstruction?

Answer 58

A-E approach Drip and suck - NBM, IV fluids, Riles tube, analgesia Refer to surgeons

Question 59

Which medications improve the prognosis for heart failure patients?

Answer 59

ACE inhibitors SGLT-2 inhibitors (dapagliflozin) Spironolactone Beta blockers

Question 60

Oesophageal varices mx

Answer 60

Band ligation or sclerotherapy Transjugular intrahepatic portosystemic shunt can be considered if bleeding is not controlled by band ligation Sengstaken-Blakemore tubes should only be used as a last resort (pt risk of death) Non-cardioselective beta-blokers are the first line treatment of prevention of variceal bleeding

Question 61

How does DKA mx change based on blood glucose levels after initial fluid and insulin management?

Answer 61

Once blood glucose falls to <14.0 mmol/L: 1. Add 10% glucose with normal saline to correct the dehydration 2. Consider reducing intravenous insulin infusion rate to 0.05 units/kg/hour to avoid the risk of developing hypoglycaemia and hypokalaemia

Question 62

IV Fluid mx in DKA - consider BP in your answer - consider which pt groups you may be cautious in

Answer 62

Question 63

Potassium mx in DKA - consider mmol/L

Answer 63

Must have confirmed K+ level before adding to fluids

Question 64

Insulin mx in DKA

Answer 64

Continue long-acting basal insulin if the patient is already taking this If this is the first presentation of diabetes, start a long-acting basal insulin as soon as possible

Question 65

When is a DKA considered to be resolved and what further mx may be needed?

Answer 65

Involve the specialist diabetes team as soon as possible and definitely within 24 hours Counsel patients about causes and early warning symptoms of DKA Provide access to psychological support

Question 66

When do you switch a DKA pt from fixed-rate to subcutaneous insulin?

Answer 66

DKA has resolved and pt is drinking and eating Specialist diabetes team will start subcutaneous insulin with a meal and continue the fixed-rate intravenous insulin infusion for 30 to 60 minutes after this

Question 67

When may you switch a DKA pt from fixed-rate to variable rate intravenous insulin infusion?

Answer 67

DKA is resolved but the patient is not eating and drinking

Question 68

Medical mx of acromegaly

Answer 68

Cabergoline (dopamine receptor antagonist) Bromocriptine (dopamine receptor antagonist) Octreotide (somatostatin analouge)

Question 69

Sick day rules for type I diabetics

Answer 69

1. Never stop or omit insulin 2. Check blood glucose more frequently, for example every 1–2 hours including through the night 3. Consider checking blood or urine ketone levels regularly, for example every 3–4 hours including through the night, and sometimes every 1–2 hours depending on results 4. Maintain their normal meal pattern (where possible) if appetite is reduced 5. If blood glucose levels are normal or high, water or sugar-free fluids are probably most appropriate in the majority of cases 6. Seek urgent medical advice if they are violently sick, drowsy, or unable to keep fluids down 7. When feeling better, continue to monitor their blood glucose carefully until it returns to normal