Deck 1 Flashcards
Pathology of Psoriasis
Cytokines trigger keratinocyte hyperplasia. Leads to elongated club shaped rete ridges, paraketosis and mild spongiosis
Presentation of Psoriasis
Itchy, flaky layers of dead keratinocytes. Inflammation and rapidly dividing celss
Rx for Psoriasis
Topical steroids and photosystemic therapy. Adherence affected by work, side effects, cost, attitude etc.
Non-pharm: stress mgmt, increased sun exp, reduced weight, stop smoking and also moisturising.
Inflamm arthritis presentation
affects synovial membrane, tendon insertion poitns around joints (enthesitis) and also red, hot, swollen etc.
Cause of psoriatic arthropathy
degradation of synovial membrane. Similar to RA. Causes fatigue and stiffness. Need to start of DMARDs
Technique for IACI
Clean technique: informed consent, prep equipment and patient, be skilled, dispose of sharps and other hazardous waste post procedural advice.
Structure of synovial joints anxtrd normal synovial fluid
Synovial membrane, articular cartilage and joint capsule. Fluid should clear, viscous with no fibrin clots (-ve culture and normal WBC count)
Extra articular manifestations of RA
fatigue, weight loss, hair falling out and heart problems. Amyloidosis of kidney, scleritis of eye and fibrosis of lung.
Pharmacology of Rx for Ra
Increased proliferation of T-cells causes Ra and can either use methotrexate (blocks antigen presentation/activation of macrophages). Also TNF-a inhibitor
non-pharm mgmt of RA
weight control, OT, exercise, hydrotherapy
Diagnosis for RA
use anti-CCP AB (produced by inflammation of synovium) Also ultrasound for early RA
Describe feedback and feedforward control
Visual and somatosensory and vestibular input into central command. Feedforward accompany voluntary movements and feedback= reflex response evoked by sensory inputs following loss of balance
List the 6 ways fracture can be classified
anatomical location, direction of fracture( oblique or transverse), linear or comminuted, impacted, open or closed and if its pathological
5 factors for fracture healing
Immobilisation, Good reduction, good vascular supply, minimal necrosis and lack of infection
6 stages of bone healing
Haematoma–> inflammation–> granulation tissue–> Soft callus–> Hard callus–> Remodelling
What are the types of osteoporosis
Type 1: post-menopausal
Type 2: low peak bone mass, age related
Secondary: endocrine diseases, drugs, malabs, physical inactivity
Rx for osteoporosis
Bisphosphonates, bone strengthening exercise
What are the risk factors for falls
Age>80, peripheral neuropathy, postural hypertension, Poor footwear, hypoglycaemia, urinary incontinene
Prevention: balance, strength training, med review, hazard intervention
Depression DSM-V criteria
One of the first two and a total of 5 symptoms from the list below in the past few weeks:
1) Lack of interest in performing activities
2) Low mood
3) Changes in sleep patterns- disturbed sleep
4) Distressed/Impairment on social life
5) Psychomotor agitation/retardation
6) feelings of guilt/worthlessness
7) Appetite changes
What is the difference between an episode and a disorder
Episode= over a period of time and usually one or more of depressive, manic or hypomanic
Disorder: pattern of illness due to an abnormal mood
What disorder is this: Over 2 years, no high phases and lasts much longer than typical major depressive disorder. Not severe enough to be depression
Persistant depressive disorder or dysthymia
Name the disorder: Major depressive moods characterised by classic symptoms of severe depression. Awake early, feeling worse than they do later in the day, los appetite and weight, guilty
Major depression with melancholic features
Describe symptoms in major depression with psychotic features
Manic and major episodes can be accompanied by delusions which can be mood congruent or incongruent.
Describe Bipolar disorder
manic and depressive episodes. Manic episodes for atleast one week
Name the suicide assesment tool
SAD PERSONS S: Sex M>F A: Age (teen and elderly) D: Depression P: Prev attempt E: Ethanol abuse R: Rationale thinking loss S: Social support (none) O: Organised plan N: No spouse S: sickness
What are the 2 types of headache
Tension type and migraine headache
What are the red flags of a headache
Exacerbated by coughing, provoked by postural hypertension, ass with eye movement, thunderclap, headache with stiff neck, general aches and pains.
Also dramatic change in quality and site as well as failure to response to appropriate therapy
What is the mechanism of SSRI
Blocks re-uptake, increasing serotonin (5-HT) in the synapse.
What are some things you need to warn patients about before placing them on SSRI?
Side effects ie they will get worse before they get better.
What are the 3 classic symptoms of Parkinson’s
Bradykinesia, Cogwheel rigidity and Tremor
What are the non-motor symp of PD
mood disturbance, neuropsychiatric symp, cognitive impairment, sense of smell altered, speech altered, acting out dreams in sleep.
What would you see on examination of PD
Gait, standing tests, tone. Also axial rigidity, mask face, increased tone, rapidly alternating movements, absence of humour.
Name 4 causes of an altered mental state
CNS ie trauma.
Physchological condition
drugs
non-CNS ie hypoglycaemia
Describe the GCS
Looks at Eye-opening, Verbal and Motor movements. 4,,5 and 6 scores.
Comatose is 8 or less. 3= totally unresponsive
What are some anatomical consequences of head trauma?
Haemorrhage, raised ICP, coma, loss of motor/sensory fn
What is the sequelae of traumatic brain injury
Confusion, collapse, coma and death
What are the classifications of seizure?
Partial (simple partial, complex partial or secondary) and generalised (grand mal)
What can ECG be used for?
Confirmation of brain death
spatial+ temporal resolution
investigating unexplained collapse
NOT to diagnose sleep abnormalities
What epileptic drugs would you give to:
Pregnant womn
Child
Someone with generalised seizures
Preg: NO valproate.
Child:Benzo
Generalised: Valproate
What are pros and cons of MMSE
Good: quick, no training req, can be done anywhere, cheap, way of communication
Bad: low sensitivity for fronto-temporal impairment. Lot of recall and NO cognition
What are functions of the frontal lobe
motor cortex: calling forth info and using it–> goal
working memory
exacerbation of though
Name the 4 ECG rhythms in order of most–> least alertness
Gamma: high cog state B: normal everyday, alert and consious. Dreaming in REM A; Eyes closed but awake and relaxed D: Deep sleep GBAD
What are the structures penetrated during a LP?
dura, skin, fat, supraspinatus lig, interspinous lig, lig flavum
Where would you inject an epipen in leg?
Inject at vastus lateralis away from femoral artery, vein and nerve
Where would you inject something in arm? Name a common condition due to incorrect technique
Deltoid muscles used for <2 y.o. In the deltoid triangle. Can hit the radial nerve.
Which subtypes of meningitis are common in neonates, kids and elderly
ALL have N.meningitidis and S.pneumoniae
Neonates: Group B strep, E.coli, protons, Pseudomonas, Listeria
Kids: HiB
Elderly: S.aureus, enterobact and listeria
What are some viral causes of meningitis?
Arbovirus (Murray, West Nile), mumps, measles, HIV
Clinical features of meningitis are?
fever, inflamm of meninges, headache, photophobia, neck stiffness, possible confusion. Can also cause seizures, infections in arachnoid and CF.
Hearing loss due to affect on vestibulo-chochlear nerve is due to what condition?
Meningitis. Ossicles are damaged in Otitis media
Name the 3 ligaments of the pelvis
Iliofemoral lig, catyloid lig and pubofemoral lig
Difference between ischaemia and infarction
Ischaemia is reduced bloody supply to the tissue. Infarction is death of tissue due to hypoxia.
What are causes and symptoms seen in Osteomylelitis
Causes: post trauma/surgery, haematogenous, continous with other infections.
Symp: fever, unexplained limp, trouble weight bearing on affected side
What are the causes of septic arthritis
> 70% haematogenous, surgery, spread from adjacent osteomyelitis
What are some causes of avascular necrosis of bone
Alcohol abuse, atherosclerosis, increased corticosteroid use, radiotherapy, sickle cell disease
How many vertebrae are in each section of the spine?
Cervical: 7 Thoracic:12 Lumbar: 5 Sacral:5 Cocys: fused
What are the primary and secondary curvatures of the spine
Kyphotic=primary. And Lordotic
What stimuli is carried by alpha-delta and C fibres?
Mechanical heat
What stimuli is carried by C fibres
Cold and chemicals
Difference between nociceptive and neuropathic pain?
Nociceptive is due to pain mediators and source of injury/damage. Neuropathic is due to membrane excitability/hypersensitivity to pain
What are the two types of NSAIDs
COX1: normal constituent and acts as gastric protector, renal sodium/water balance and platelet aggregation
COX2: More specific locations. Inducible constituent in pain, inflammation and pain.
What structures do the following supply: ACA, MCA and PCA
ACA: frontal and temporal mode (esp on the medial surface)
MCA: majority of cortex. inc Wernicke’s, Broca’s, Auditory area as well
PCA: Occipital and parietal
Name the tract: arises in motor cortex and crosses at medulla. Control of skilled motor activity
Lateral corticospinal tract
Name the tract: In motor area and uncrossed. Controls axial muscles
Anterior corticospinal tract
Name the tract: Arises in contralateral red nucleus of the midbrain. Control of flexor tone
Rubrospinal tract
Name the tract: Arses in the ipsilateral vestibular nucleus of the pons and controls extensor tone
Vestibulospinal tract
What happens in an UMN lesion
contralateral increase in tone. Clonus and Babinski’s positive
What happens in LMN lesion
Ipsilateral reduced tone
Describe effect of UMN and LMN lesion of facial nerve
UMN: Affects only 1/4 of face
LMN: 1/2 of face ie Bell’s Palsy
Name the stroke classifications
Haemorrhagic and Ischaemic. 85% Ischaemic
Haemorrhagic= bleed IN brain
Risk factors for stroke
Non-modifiable: age>55, gender and fam Hx
Modifiable: Hypertension, CVD, smoking, alcohol, diet, overweight, physical inactivity
Medical condition related: prev episode of TIA, atrial fib, blood clotting disorder
Steps in MGMT of stroke
- Rapid initial stroke screen
- Urgent CT/MRI
- Aspirin as soon as possible (if ischaemic)
- Monitor nuero status
What is the ABCD2 score?
A: age>60, BP, Clinical features of TIA, Duration (TIA>60 mins) and DIabetes
Describe the pathology of SLE
due to formation of immune complexes ( Type 3 hypersensitivity). These are usually broken down by complement activation but here can deposit at various sites. Complex deposition–>complement activation–> inflamm cell influx–> mediator release
What investigations would you perform for SLE
Look for ANA AB and then diff tests conducted for the different symptoms present ie Coomb’s test for haemolytic anaemia
What does the acronym VITAMIN CDEF stand for and what is its use
Used for formulating DDx/ V: vascular I: infective T: trauma A: autoimmune M: MSK I: idiopathic N: neural C: congenital D: Developmental E: endocrine/environment F: functional ie sleep
What investigations would you perform for haemolytic anaemia
Looking for normocytic or macrocytic anaemia so look at blood smear.
Also positive DAT and increased bilirubin
Name this test: RBC+ antigen placed in a solution. AB added and test for agglutination
Direct antigen test
Name the test: AB and antigen RBC in solution, bind and then anti-AB added to bind the complexes
indirect DAT
Describe the general scheme of iron transport around the body
oral iron in lumen–> blood–> either used or stored as ferritin. Can also be sent to macrophages for recycling
What is ferroportin
Iron transporter. Allows iron to exit lumen and enter blood
What is the fn of transferrin
Binds to iron which allows it to bind to transferrin receptor on erythroid progenitor cells
What are the 3 types of anaemia and name one example of each
Macrocytic: B12 and Folate, hypothyroidism
Normocytic: renal failure, combined nutritional def
Microcytic: iron def, anaemic of chronic disease
What are symptoms of IDA
tiredness, faitgue, PICA, pallor, hair loss, britlle nails, pallor of palmar creases, chest pain and tachycardia
What are the 3 measurements that can be performed for IDA
Serum iron: iron in blood and reflective of intake
Ferritin: amount stored in body, usually low
Total iron binding capacity: measurement of the protein that carries iron
What are the 3 factors affecting iron abs
concomitant consumption of inhibitors, GIT disorder and non-compliance
What are the symptoms of iron OD
Nausea, abdominal discomfort, vomiting and diarrhoea
What are haemantinics
Factors required to increased Red cell/blood cell productions ie EPO. Can be used in IDA but not recommended
Name the 4 steps in primary haemostasis
Unstable platelet plug (at time of injury)–>Coagulation cascade–> fibrin formation–> fibrin stabilised platelet plug
What is the role of vWF
Carrier of factor VIII and involved in primary haemostasis
Symptoms of vWF disease?
Epitaxis, mucosal bleeding, menorrhagia and easy bruising
What is the mgmt for vWF
IV infusion of desmopressin. Increased breakdown of vWF storing granules in platelets and endothelium
Biostate can be used for those that dont respond to desmopressin
What is the function of the lymphatic system
aids the immune system in removing and destroying waste, debris, dead blood cells, toxin and cancer cells.
What are the primary lymphoid organs and their fn
Bone marrow and thymus. They provide appropriate environment for development and maturation of lymphocytes
What are secondary lymphocytes and their fn
Spleen, MALT, appendix, tonsils and lymph nodes. Trap antigens and site of antigen presentation. Generally from nearly tissues/fluids where lymphocytes can interact with antigens
What are the developmental changes in the immune system
Start off with maternal AB protection and then after 6 months, innate and adaptive IS start to develop. Adaptive takes longer to develop with new exposures and vaccines
What is the difference between innate and adaptive immunity
Innate: immediate and acts within 0-96 hours. No specific response. Includes neutrophils and complement system
Adaptive: more specialised response, tailored to the microorg after antigen presentation from APC. Divided into cell mediated and humoural immunity.
Name the disease: fever, sore throat and runny nose. Begins on face and neck–> neck, trunk and extremities. Lasts 5 days. Behind ear and back of neck
Rubella
Name the disease: Itchy rash of red papules–> vesicles (blisters)–> other parts of body. Blisters can also arise in mouth. Others can get high fever, headache, cold like symp, vomitting and diarrhoea. Most experience cold-like symptoms before breaking out in a rash
Variecella!
Name the disease: associated with splenomegaly, hepatitis and arthritis. Diffuse lymphadenopathy present and most common= faint, widespread, non-itchy rash for one week.
HHV or EBV
Name the disease: Non-specific viral symp is mild fever and headache. Rash appears a few days later with red red cheeks. Lasts 2-4 days and causes polyarthropathy in adults
Parvovirus B19
Name the disease: increased fever for 3-5 days and URT symptoms ie sore throat, cough, runny nose. Rash appears day 3-5 with small rose-pink raised spots that blanch when touches. Similar spots on uvula and soft palate
HHV-6
What do you look for in an examination for severe lymphadenopathy
Tender? Enlarged? Growing? Symmetrical? mobile? Also look for systemic symptoms
What are some signs of a serious illness in a child
reduced BP, high fever, unresponsive/ not eating. BP maintained in young children until last straw so any change= sig pathology
What situations is safety netting important in?
Case of missed/uncertainty of diagnosis, ruling out serious disease, parentral cancer, illness that can progress rapidly etc
What are the steps of the Calgary Cambridge Framework
Open session–> Gather info–> physical exam–> explanation and planning–> close session. All the while providing structure and building rapport
What are the valves of the heart and their location
A: aortic. Parasternal, 2nd intercostal space on the right
P: Pulmonary. Parasternal and 2nd intercostal space on the left
T: tricuspid valve. 5th intercostal space, parasternal
M: mittral. 5th intercostal space on the left
What are the mechanical events of the heart during a cardiac cycle
Late systole Atrial systole Isovolumetric contraction Ventricular ejection Isovolumetric relaxation
What happens in late diastole
both chambers relaxed and passive ventricular filling
What happens in atrial systole
Atria contract, forcing a small amount of additional blood into the ventricles
Isolvolumetric contration
First phase of ventricular contraction. Pressure in ventricle rises with the A-V valves closed but NOT enough to open the semilnar valves
Ventricular ejection
Pressure eventually reaches high enough to open the semilunar valves–> ejection of blood
Isovolumetric relaxation
The semilunar valves close as ventricles relax and pressure drops
What are the major features of RHF
Subcutaneous nodules, erythema marginatum, Sydenham’s chorea, pancarditis and polyarthritis
What are the minor symp of RHF
Raised CRP and ESR, fever, fatigue, athralgia
Name the sequelae of RHF
Group A strep infection–> normal AB response–> develops into an autoAB response –> secondary infection–> exacerbates autoimmune response–> inflammation and effect on the heart
What is the mgmt for RHF
single dose penicillin or oral erythromycin is allergic. [need monthly penicillin injections as prevention]
Describe the compensatory mechanism of RHD
Chronic mittral regurg–> increased return to left atria-> left ventricular hypertrophy and increased stroke volume–> left atrial distension–> normal cardiac output and minimal pulmonary congestion
Using the baroreceptor reflex, explain why atrial fib presents as head spins
Reduced blood outflow due to non-synchronous contraction of the heart–>sensed as a reduction in bp by receptors in the aortic arch– CV control centre–> increased output–> effectors which return homeostasis
Explain presyncope from AF
AF–> rapid ventricualr response–> reduced diastolic duration–> reduced LV filling–> reduced CO–> baroreceptors cant compensate–> presyncope
Why do you need anti-coagulants for patients with AF?
Turbulent blood flow one of the factors in Virchow’s triad for hypercoagulability
What are the two ways to control AF and in what situation would you use either?
Can control rhythm or rate
Younger: rhythm
Older: rate
What medication can be used to control heart rate in AF
Beta blockers, alpha blockers, diuretics, ACE inhibitors or ARBs
Describe HF due to MR
Valvular insufficiency from MR–> volume overload of the heart–> heart working too hard and cant compensate–> failure. Results in SOB, tachycardia, cough etc
What are 3 DDx for dizziness
HF, iron def, pulmonary hypotension, dehydration, heart attack
What can be a cause of pain in calves in a patient with high cardiac risk factors?
Intermittent claudication–> MI
Name this condition: set of signs and symptoms due to reduced blood flow meaning coronary part of heart muscle is unable to fn properly and dies
Acute coronary syndrome
What are atypical and typical symptoms of MI
Typical: left arm pain, crushing pain
Atypical: pain in jaw, nausea, vomitting, back pain and discomfort, dysopnea
Name the Rx for anyone with MI
First: aspirin ASAP unless contraindicated Then ABCDE A: ACE inhibitors B: Beta blockers C: Clopidogrel (anti-platelet, anti-ADP) D: Diet (Statins) E: exercise
What are the 5 steps in the physiology of respiration
Ventilate lungs with air, diffusion of gases between air and blood, transfer of gases in blood, diffusion of gases from blood to tissues
What are the physical barriers to protect the resp system
Nose hairs, cilia and mucus producing goblet cells. Cough reflex from the larynx. Upper airway branching (providing muco-cilliary clearance) Then alveolar macrophages and the innate IS
What are the 3 ways an infection can develop in the RT
Haematogenous spread, aspirations, spread from adjacent site or inhalation from environment
Pathophysiology of CAP
Inhalation of microrog, aspiration of oropharyngeal or gastric contents, haematogenous deposition or invasion of infection contigous structures, direct inoculation or reactivation
Presentation of CAP?
Fevers, rigors, dysopnea, cough, haemoptysis, pleuritic chest pain
What does CURB-65 stand for
C: Confusion U: urinary fn R: resp rate (>30bpm) B: BP (<90 systolic and <60 diastolic) Age>65
What does CORB stand for
C: Confusion, O:Oxy sat 90% , R: Resp rate (>30) and B: BP
What appears white on an x-ray
Consolidation, Fluid, solid tumour or foriegn body and collapsed lung
Name the 4 divisions of the resp tract and the histological features of each
Trachea: Psuedostrat epithelium and C-shaped cartilage
Bronchi: More elastic, less smooth muscle. Patchy cartialge
Bronchioles: more smooth muscle, less elastic
Alveoli: Simple squamous epithelium with no cartilage
What is the pathophysiology of asthma
antigen–> APC–> Th2 cells–> IL-4–> B cells–> plasma cells IgE production–> IgE–> mast cells and binding via epsilon receptors–> release of histamine, leukotrines. Then cytokines, chemokines and enzymes.
What is the result of the immune response in asthma
Smooth muscle contraction, sneezing, nasal discharge, redness. Oedema and bronchoconstriction as well as remodelling
Lists the steps in the cough reflex
irritant–> mechanoreceptors in the throat–> vagus nerve–> medulla–> cough reflex (closure of epiglottis and pressure builds up in the lungs as expiratory muscles contract. Then the epiglottis opens and the irritant is violently expelled
What is the mechanism of a wheeze
Contraction of smooth muscles reduces the diametre of airways (from the larynx to small bronchi) hence making it harder for air to leave the lungs. This produces a wheezing sound as the air travels through the resp tract
List the 4 causes of airway narrowing
Smooth muscle contraction, mucosal oedema, abnormal mass or external compression
What are some precipitating factors for asthma
Smoking, allergies.
What are the signs and symptoms of poorly controlled asthma
Daytime symp for >2days/week which can be partially or fully relived by a bronchodilator.
>3 symp of partial control in the same week ie limitation of activity, symp during the night and when they wake up
What are the clinical features of astham
Wheeze, cough, SOB, tight chest. Reduced FEV1
What is the Rx for asthma?
Short term: bronchodilators ie SABAs (salbutamol). Work for 4-6 hours
Long term: need LABAs and inhaled corticosteroids. Inhaled corticosteroids are the number one controllers and often combined with LABAs. These are preventors!!!
What education advice can you give to an adult about spacers? Should they use them?
Yes! Spacers dilute the dose in the container and increase the delivery of the medication to the lungs hence more effective! Young children use it due to lack of co-ordination but highly recommended in older individuals as well. Reduces the amount of medication stuck at the back of the throat (sore throat)
Why is an action plan neecesary for asthma?
To be able to recognise deterioration and respond properly. Also aims to enable early intervention and prevent severity of attack
What happens to FEV1/FVC, lung volumes, resp rate and gas transfer in intersitial lung disease?
FEV1/FVC usually maintained Lung volumes reduced Impaired gas transfer Increased resp rate also worsening breathlessness
What happens to FEV1/FVC in obstructive vs restrictive disease?
Obstructive: reduced
Rest: increased or normal because BOTH parameters change
What are the goals and risks of oxygen therapy
Goal is tor relive hypoxaemia
Risks: fire, reduced resp drive and not enough oxygen
List 5 aspects of a good death
Patient should know and understand what’s coming
It should be in a location of their choice
Offer digniity and privacy
Available expertise on whatever info required
They should be able to retain control of what happens
