Elderly care

Question 1

How should someone on warfarin be treated with excessive bleeding?

Answer 1

INR > 8.0 (minor bleeding) - stop warfarin, give intravenous vitamin K 1-3mg, repeat dose of vitamin K if INR high after 24 hours, restart when INR < 5.0

Question 2

What is the threshold for T2DM?

Answer 2

Diabetes mellitus - HbA1c of 48 mmol/mol (6.5%) or greater is now diagnostic (WHO 2011)

Question 3

What are the features of MULTI SYSTEM ATROPHY?

Answer 3

There are 2 predominant types of multiple system atrophy

1) MSA-P - Predominant Parkinsonian features
2) MSA-C - Predominant Cerebellar features

Shy-Drager syndrome is a type of multiple system atrophy.

Features

parkinsonism

autonomic disturbance

erectile dysfunction: often an early feature

postural hypotension

atonic bladder

cerebellar signs

Question 4

What are the features of acute intermittent porphyria?

Answer 4

Acute intermittent porphyria typically presents with abdominal, neurological and psychiatric symptoms

Question 5

What are the features of multiple myeloma?

Answer 5

Multiple myeloma is a neoplasm of the bone marrow plasma cells. The peak incidence is patients aged 60-70 years.

Clinical features

bone disease

bone pain

osteoporosis + pathological fractures (typically vertebral)

osteolytic lesions

lethargy

infection

hypercalcaemia

primary factor: due primarily to increased osteoclastic bone resorption caused by local cytokines (e.g. IL-1, tumour necrosis factor) released by the myeloma cells

much less common contributing factors: impaired renal function, increased renal tubular calcium reabsorption and elevated PTH-rP levels

renal failure

other features: amyloidosis e.g. Macroglossia, carpal tunnel syndrome; neuropathy; hyperviscosity

Question 6

What are the features of HUS?

Answer 6

Haemolytic uraemic syndrome is generally seen in young children and produces a triad of:

acute kidney injury

microangiopathic haemolytic anaemia

thrombocytopenia

Most cases are secondary (termed ‘typical HUS’):

classically Shiga toxin-producing Escherichia coli (STEC) 0157:H7 (‘verotoxigenic’, ‘enterohaemorrhagic’). This is the most common cause in children, accounting for over 90% of cases

pneumococcal infection

HIV

rare: systemic lupus erythematosus, drugs, cancer

Question 7

What is an infection that can cause foul smelling diarrohea when people go abroad?

Answer 7

Giardiasis

Question 8

What are the features of Giardiasis?

Answer 8

Giardiasis is caused by the flagellate protozoan Giardia lamblia. It is spread by the faeco-oral route.

Risk factors

foreign travel

swimming/drinking water from a river or lake

male-male sexual contact

Features

often asymptomatic

lethargy, bloating, abdominal pain

flatulence

non-bloody diarrhoea

steatorrhoea

chronic diarrhoea, malabsorption and lactose intolerance can occur

Question 9

What is the qSOFA score?

Answer 9

qSOFA score
Respiratory rate > 22/min
Altered mentation
Systolic blood pressure < 100 mm Hg

Question 11

What is a drug for myasthesia gravis?

Answer 11

Pyridostigmine

Question 12

What are treatments for idiopathic intracranial hypertension?

Answer 12

Management

weight loss

diuretics e.g. acetazolamide

topiramate is also used, and has the added benefit of causing weight loss in most patients

repeated lumbar puncture

surgery: optic nerve sheath decompression and fenestration may be needed to prevent damage to the optic nerve. A lumboperitoneal or ventriculoperitoneal shunt may also be performed to reduce intracranial pressur

Question 13

How is the PR interval defined?

Answer 13

Start of P-wave to the start of the QRS complex

Question 14

A patient presents with NSTEMI, what medications should they have? This patient has gastric ulcers

Answer 14

Aspirin 300mg, Clopidogrel 300mg and Glyceryl Trinitrate spray.

Do not give foandparinox

Question 15

What are the guidelines for HTN?

Answer 15

Question 16

What are some features of cardiac pacing?

Answer 16

Pacing spikes preceding the QRS complexes. Broad QRS complexes with an RSR pattern in V5-6.

Question 17

What are some features of wolf parkinson white?

Answer 17

Patients may present with:

No symptoms - WPW is often asymptomatic

Palpitations

Dizziness

Syncope

Question 18

What medications can cause complete heart block?

Answer 18

Verapamil is a negative inotrope as it blocks calcium channels mainly in the SAN and AVN. Bisoprolol has a similar mechanism but the site of action is the adrenergic receptors and when used in conjunction can cause AV block

Question 19

What are the features of aortic dissection?

Answer 19

Stanford classification of aortic dissections

Stanford Type A: Involves the ascending aorta, arch of the aorta

Stanford Type B: Involves the descending aorta.

Clinical features

Usually presents in men over the age of 50

Sudden onset ‘tearing’ chest pain or interscapular pain radiating to the back.

It can also present with (depending on how far the dissection extends):

Bowel/limb ischaemia

Renal failure

Syncope

Clinical signs on examination

Radio-radial delay

Radio-femoral delay

Blood pressure differential between arms

Question 20

What won’t be seen in atrial fibrillilation in regards to the JVP?

Answer 20

The A-wave signifies atrial contraction. As a result of uncoordinated atrial activity, the A-wave will not be seen.

Question 21

What is a sign of digoxin?

Answer 21

downsloping ST segments characteristic of digoxin. It indicates that a patient is taking the drug and not a sign of digoxin toxicity.

Question 22

How should someone be treated with an ejection fraction of <35% on enalapril?

Answer 22

Sacubitril-valsartan is considered in heart failure patients with a LVEF < 35% who are still symptomatic on ACE-inhibitors & beta-blockers

Question 23

What infection has a short incubation period for gastroenteritis?

Answer 23

Staphylococcus aureus gastroenteritis is characterised by a short incubation period and severe vomiting

Question 24

How is COPD treated?

Answer 24

SABA required

LAMA or LABA regularly

OR

SAMA or SABA

LABA + ICS

Question 25

How do you manage pneumothorax of less than 2cm and no problems breathing?

Answer 25

Management in primary pneumothorax without shortness of breath, and <2cm in size, is discharge and review

Question 26

What is a problem with the following drugs:

Bisoprolol

Nicorandil

Isosorbide mononitrate

Answer 26

Bisoprolol - sexual dysfunction, libido

Nicorandil -Ulceration and perforation

Isosorbide mononitrate - tolerance

Question 27

What are the signs of pericarditis?

Answer 27

PR innterval depressed

Widespread ST elevation - saddle

Question 28

What time of STI causes painful ulcers?

Answer 28

Herpes is painful (her pain), painless is syphyllis

Question 29

How should steroids be given for patients with Addisons?

Answer 29

Patients with Addison’s disease require steroid replacement therapy to manage their condition. This usually takes the form of standard-release hydrocortisone for glucocorticoid replacement and fludrocortisone for mineralocorticoid replacement. Standard-release hydrocortisone is usually given as two doses, with the larger dose being given in the morning as this more closely resembles the natural daily variation in cortisol secretion from the adrenal glands. A smaller dose is given in the evening. Some patients take hydrocortisone three times a day in which case a lunchtime dose may be added.

Question 31

What are the different categories of AKI?

Answer 31

StageCreatinineUrine production

1Increase 1.5-1.9x baseline< 0.5ml/kg/h for >6 consecutive hours

2Increase 2.0-2.9x baseline< 0.5ml/kg/h for >12 consecutive hours

3Increase > 3x baseline or >354 µmol/L< 0.3ml/kg/h for > 24h or anuric for 12h