EMCC Flashcards

Question

Inguinal hernia presetation

Answer 1

If inguinoscrotal swelling; cannot 'get above it' on examination Cough impulse may be present May be reducible

Answer 2

Often history of dysuria and urethral discharge Swelling may be tender and eased by elevating testis Most cases due to Chlamydia Infections with other gram negative organisms may be associated with underlying structural abnormality

Answer 3

Single or multiple cysts May contain clear or opalescent fluid (spermatoceles) Usually occur over 40 years of age Painless Lie above and behind testis It is usually possible to 'get above the lump' on examination

Answer 4

Non painful, soft fluctuant swelling Often possible to 'get above it' on examination Usually contain clear fluid Will often transilluminate May be presenting feature of testicular cancer in young men

Answer 5

Varicosities of the pampiniform plexus Typically occur on left (because testicular vein drains into renal vein) May be presenting feature of renal cell carcinoma Affected testis may be smaller and bilateral varicoceles may affect fertility bag of worms

Answer 6

Suxamethonium

Answer 7

Hypotension Muffled heart sounds Raised JVP

Answer 8

Nimodipine

Answer 9

Sport injury Mechanism: high twisting force applied to a bent knee Typically presents with: loud crack, pain and RAPID joint swelling (haemoarthrosis) Poor healing Management: intense physiotherapy or surgery

Answer 10

PCL damage .= tibia displaces posteriorly on application of a force.

Answer 11

Staphylococcus aureus

Answer 12

an inflammatory disorder causing symmetrical, proximal muscle weakness and characteristic skin lesions may be idiopathic or associated with connective tissue disorders or underlying malignancy (typically ovarian, breast and lung cancer, found in 20-25% - more if patient older). Screening for an underlying malignancy is usually performed following a diagnosis of dermatomyositis polymyositis is a variant of the disease where skin manifestations are not prominent

Answer 13

``` Risk factors haemochromatosis hyperparathyroidism acromegaly low magnesium, low phosphate Wilson's disease ```

Answer 14

Increased airways resistance – COPD/asthma Reduced breathing effort – drug effects (e.g. opiates)/brain stem lesion/extreme obesity A decrease in the area of the lung available for gas exchange – chronic bronchitis Neuromuscular problems – Guillain-Barré syndrome/motor neuron disease Deformity – ankylosing spondylitis/flail chest

Answer 15

Anxiety – panic attack Pain – causing increased respiratory rate Hypoxia – often seen in ascent to altitude Pulmonary embolism Pneumothorax Iatrogenic (excessive mechanical ventilation)

Answer 16

vomitting | diarrhoea

Answer 17

hyperchloraemic, normal anion gap metabolic acidosis

Answer 18

dorsal carpal branch of the radial artery

Answer 19

valvular effects are tricuspid insufficiency and pulmonary stenosis

Answer 20

phenytoin, ciclosporin, calcium channel blockers and AML

Answer 21

used to identify patients at risk of pressure sores

Answer 22

female patients who develop AKI after initiation of an ACE inhibitor, Features hypertension chronic kidney disease or more acute renal failure e.g. secondary to ACE-inhibitor initiation 'flash' pulmonary oedema

Answer 23

Blatchford score

Answer 24

triad of CVD, high lactate and soft but tender abdomen

Answer 25

Common predisposing factors increasing age atrial fibrillation - particularly for mesenteric ischaemia other causes of emboli: endocarditis, malignancy cardiovascular disease risk factors: smoking, hypertension, diabetes cocaine: ischaemic colitis is sometimes seen in young patients following cocaine use

Answer 26

Internal fixation (especially if young)

Answer 27

Hemiarthroplasty

Answer 28

total hip arthroplasty (healthy) Hemiarthroplasty in immobile or over 70

Answer 29

Dynamic hip screw

Answer 30

morbidities affect management Usually intramedullary device

Answer 31

Idarucizumab

Answer 32

radioactive iodine is the treatment of choice

Answer 33

``` thyroid dysfunction: both hypothyroidism and hyper-thyroidism corneal deposits pulmonary fibrosis/pneumonitis liver fibrosis/hepatitis peripheral neuropathy, myopathy photosensitivity 'slate-grey' appearance thrombophlebitis and injection site reactions bradycardia lengths QT interval ```

Answer 34

decreased metabolism of warfarin, therefore increased INR | increased digoxin levels

Answer 35

amlodipine nifedipine diltiazem verapamil Avoid in HF Verapamil shouldn't be used with atenolol

Answer 36

ramipril caoripril imidapril

Answer 37

bispronalol atenolol metoprolol

Answer 38

under 55 1st line -ACE inhibitor 2nd ACE inhibitor + Calcium channel blocker or thiazide diuretic 3rd ACE inhibitor + Calcium channel blocker + thiazide diuretic 4th K+ > 4.5mmol/l - add an alpha- or beta-blocker K+ below 4.5mmol/l- low-dose aldosterone antagonist (spironolactone)

Answer 39

1st line -Calcium channel blocker 2nd ACE inhibitor + Calcium channel blocker or thiazide diuretic 3rd ACE inhibitor + Calcium channel blocker + thiazide diuretic (ACE I in diabetes)

Answer 40

``` 1. lifestyle 2 . medication - GTN, 3. beta blocker or CBB first line 4. antiplate (apsirn 75mg) ACEi if has diabetes ```

Answer 41

candesartan Losartan use with ACEi aren't tolerated

Answer 42

onn's, Cushing's, renal artery stenosis and Liddle's. The first step in this case should be further simple investigations. Quantifying the renin and angiotensin levels will help to distinguish the cause here, before going on to more specialised tests.

Answer 43

weight loss there after 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 pressure

Answer 44

``` Chlorothiazide (Diuril) Chlorthalidone. Hydrochlorothiazide (Microzide) Indapamide. Metolazone. ``` contraindicated due to the history of gout,

Answer 45

admit for specialist assessment

Answer 46

Clinic BP >= 140/90 mmHg and subsequent ABPM daytime average or HBPM average BP >= 135/85 mmHg treat if < 80 years of age AND any of the following apply; target organ damage, established cardiovascular disease, renal disease, diabetes or a 10-year cardiovascular risk equivalent to 10% or greater in 2019, NICE made a further recommendation, suggesting that we should 'consider antihypertensive drug treatment in addition to lifestyle advice for adults aged under 60 with stage 1 hypertension and an estimated 10-year risk below 10%. '. This seems to be due to evidence that QRISK may underestimate the lifetime probability of developing cardiovascular disease

Answer 47

Clinic BP >= 160/100 mmHg and subsequent ABPM daytime average or HBPM average BP >= 150/95 mmHg Offer drug treatment regardless of age

Answer 48

Weight loss Fevers, night sweats Age at onset <20 years or > 55 years Traumatic mechanism of injury Constant, progressive, unrelated to activity Sleep disturbance and night pain Thoracic distribution - commonest site for metastasis Urinary habit - retention, incontinence, loss of sensation Faecal incontinence PMH of malignancy (active or previous) Evolving neurology - motor +/- sensory

Answer 49

Epidural haematoma - esp post lumbar puncture Metastatic spinal cord compression Often joint medical / surgical care as up to 30% are CUP Myeloma workup Traumatic injuries Manage as per ATLS principles Epidural abscess Often radiologically aspirated to guide microbiological therapy +/- surgery

Answer 50

Sensory loss over anterior thigh Weak quadriceps Reduced knee reflex Positive femoral stretch test

Answer 51

Sensory loss anterior aspect of knee Weak quadriceps Reduced knee reflex Positive femoral stretch test

Answer 52

Sensory loss dorsum of foot Weakness in foot and big toe dorsiflexion Reflexes intact Positive sciatic nerve stretch test

Answer 53

Sensory loss posterolateral aspect of leg and lateral aspect of foot Weakness in plantar flexion of foot Reduced ankle reflex Positive sciatic nerve stretch test

Answer 54

Usually gradual onset Unilateral or bilateral leg pain (with or without back pain), numbness, and weakness which is worse on walking. Resolves when sits down. Pain may be described as 'aching', 'crawling'. Relieved by sitting down, leaning forwards and crouching down Clinical examination is often normal Requires MRI to confirm diagnosis

Answer 55

Pain on walking, relieved by rest Absent or weak foot pulses and other signs of limb ischaemia Past history may include smoking and other vascular diseases

Answer 56

fever, jaundice and right upper quadrant pain classically linked to ascending cholangitis.

Answer 57

Management intravenous antibiotics endoscopic retrograde cholangiopancreatography (ERCP) after 24-48 hours to relieve any obstruction

Answer 58

GET SMASHED Gallstones Ethanol Trauma Steroids Mumps (other viruses include Coxsackie B) Autoimmune (e.g. polyarteritis nodosa), Ascaris infection Scorpion venom Hypertriglyceridaemia, Hyperchylomicronaemia, Hypercalcaemia, Hypothermia ERCP Drugs (azathioprine, mesalazine*, didanosine, bendroflumethiazide, furosemide, pentamidine, steroids, sodium valproate)

Answer 59

CT abdo is the definitive diagnostic

Answer 60

Sudden onset of pain (usually epigastric). Often preceding history of upper abdominal pain. Soon develop generalised abdominal pain. On examination may have clinical evidence of peritonitis.

Answer 61

``` Unilateral: PACT Pelvic-ureteric obstruction (congenital or acquired) Aberrant renal vessels Calculi Tumours of renal pelvis ``` ``` Bilateral: SUPER Stenosis of the urethra Urethral valve Prostatic enlargement Extensive bladder tumour Retro-peritoneal fibrosis ```

Answer 62

Management Remove the obstruction and drainage of urine Acute upper urinary tract obstruction: nephrostomy tube Chronic upper urinary tract obstruction: ureteric stent or a pyeloplasty

Answer 63

chronic alcohol, HIV, anorexia or P450 inducers

Answer 64

Extra-renal manifestations liver cysts (70% - the commonest extra-renal manifestation): may cause hepatomegaly berry aneurysms (8%): rupture can cause subarachnoid haemorrhage cardiovascular system: mitral valve prolapse, mitral/tricuspid incompetence, aortic root dilation, aortic dissection cysts in other organs: pancreas, spleen; very rarely: thyroid, oesophagus, ovary

Answer 65

inability to generate acid urine (secrete H+) in distal tubule causes hypokalaemia complications include nephrocalcinosis and renal stones causes include idiopathic, rheumatoid arthritis, SLE, Sjogren's, amphotericin B toxicity, analgesic nephropathy

Answer 66

decreased HCO3- reabsorption in proximal tubule causes hypokalaemia complications include osteomalacia causes include idiopathic, as part of Fanconi syndrome, Wilson's disease, cystinosis, outdated tetracyclines, carbonic anhydrase inhibitors (acetazolamide, topiramate)

Answer 67

reduction in aldosterone leads in turn to a reduction in proximal tubular ammonium excretion causes hyperkalaemia causes include hypoaldosteronism, diabetes

Answer 68

education and lifestyle measures such as adequate hydration and salt intake discontinuation of vasoactive drugs e.g. nitrates, antihypertensives, neuroleptic agents or dopaminergic drugs if symptoms persist, consider compression garments, fludrocortisone, midodrine, counter-pressure manoeuvres, and head-up tilt sleeping

Answer 69

Easiest option May be supplemented by calorie rich dietary supplements May contra indicated following certain procedures

Answer 70

Usually administered via fine bore naso gastric feeding tube Complications relate to aspiration of feed or misplaced tube May be safe to use in patients with impaired swallow Often contra indicated following head injury due to risks associated with tube insertion

Answer 71

Avoids problems of feed pooling in stomach (and risk of aspiration) Insertion of feeding tube more technically complicated (easiest if done intra operatively) Safe to use following oesophagogastric surgery

Answer 72

Surgically sited feeding tube May be used for long term feeding Low risk of aspiration and thus safe for long term feeding following upper GI surgery Main risks are those of tube displacement and peritubal leakage immediately following insertion, which carries a risk of peritonitis

Answer 73

Combined endoscopic and percutaneous tube insertion May not be technically possible in those patients who cannot undergo successful endoscopy Risks include aspiration and leakage at the insertion site

Answer 74

dyspnoea and hypoxaemia, which progress to acute respiratory failure. Common causes are pneumonia, sepsis, aspiration, and severe trauma. 1. oxygen and ventilation 2. Prone positioning can improve oxygenation in patients with ARDS

Answer 75

``` Rapid assessment High flow oxygen Nebulised salbutamol 2.5-5mg Nebulised ipratropium bromide 500mcg Steroids - IV hydrocortisone 100mg IV magnesium sulphate 1-2g ITU review Intubation and ventilation for life threatening asthma ```

Answer 76

give metaraminol (as is an alpha agonist)

Answer 77

Medication overuse headaches occur in patients who use analgesics such as paracetamol, NSAIDs and weak opiates to manage existing headaches. Paradoxically, they develop frequent, almost daily headaches which worsen with the frequent use of these drugs. It is thought to be due to down-regulation of pain receptors, leading to a lack of efficacy of analgesics when they are used. The most appropriate treatment is to withdraw the offending drugs, and start the patient on an agent such as gabapentin or a tricyclic once the withdrawal period is over.

Answer 78

rapid sequence induction

Answer 79

Smoking Family history Marfan's syndrome Male Lung disease e.g COPD, malignancy, cystic fibrosis Previous pneumothorax

Answer 80

large bore cannula in the 2nd intercostal space, mid-clavicular line on the same side, and following this a chest drain needs to be inserted.

Answer 81

Diagnosis can be clinical or with a FAST scan, and urgent treatment with pericardiocentesis or surgery is required.

Answer 82

1.Switch oral steroids to 50-100mg IV hydrocortisone. If there is associated hypotension then fludrocortisone can be added. For minor operations oral prednisolone can be restarted immediately post-operatively. If the surgery is major then they may require IV hydrocortisone for up to 72 hours post-op.

Answer 83

Pre-hospital Rectal diazepam 10-20mg Buccal midazolam 10mg In hospital Intravenous lorazepam 4mg, repeated every 10-20min Anesthetic review Status epilepticus Phenytoin infusion Consider propofol and thiopentone Intubation and ventilation

Answer 84

nflammation of the vagina as a result of the mucosa becoming thinner and fragile. This is due to a fall in the level of oestrogen, hence is most common after menopause. The reduced mucosa leads to vaginal dryness and itching. As the mucosa is more fragile, it is more likely to be damaged such as during sexual intercourse. Hence some women experience dyspareunia and post-coital bleeding. The inflammation can also lead to the production of vaginal discharge. In regard to differentials, post-menopausal bleeding should be investigated to exclude endometrial cancer. Itching and discharge may be due to genital infections.

Answer 85

Subcutaneous hematoma CSF rhinorrhea: leakage of CSF from the anterior nares (nostrils) Subcutaneous hematoma around the orbitae (“raccoon eyes”) CSF otorrhea: leakage of CSF from the external auditory meatus Hemotympanum Subcutaneous hematoma behind the ear (Battle sign) Subcutaneous emphysema. Cranial nerve palsies: arise 1–3 days after the trauma

Answer 86

Nasopharyngeal airways are contraindicated in these patients as they can cause further damage to the patient. A head tilt chin lift is contraindicated in trauma patients at risk of a C-spine injury as it can cause further instability and damage.

Answer 87

lassical triad of features is seen urinary incontinence dementia and bradyphrenia gait abnormality (may be similar to Parkinson's disease)

Answer 88

Management ventriculoperitoneal shunting around 10% of patients who have shunts experience significant complications such as seizures, infection and intracerebral haemorrhages

Answer 89

``` Contraindications to thrombolysis active internal bleeding recent haemorrhage, trauma or surgery (including dental extraction) coagulation and bleeding disorders intracranial neoplasm stroke < 3 months aortic dissection recent head injury severe hypertension ```

Answer 90

most common upper limb injury in children under the age of 6. This is due to the fact that the distal attachment of the annular ligament covering the radial head is weaker in children at this age group. Signs include elbow pain and limited supination and extension of the elbow. The child usually refuses examination on the affected elbow due to the pain. Management analgesia and passively supination of the elbow joint whilst the elbow is flexed to 90 degrees

Answer 91

hypertension and bradycardia

Answer 92

Extradural = lucid period, usually following major head injury. Subdural = fluctuating consciousness, often following trivial injury in the elderly or alcoholics

Answer 93

fall on an outstretched wrist and leads to a distal radial fracture with dorsal displacement of the distal fragment. It occurs mostly in older women with osteoporotic bones. management = manipulation in order to reduce the fracture. If good reduction is not achieved or precise alignment is needed (e.g. in those who use their wrists for work/skills e.g. sportsmen) then open reduction and internal fixation with plates and screws can be performed.

Answer 94

Mal/non-union Sudek's atrophy/complex regional pain syndrome Extensor pollicis longus rupture Median nerve injury Carpal tunnel syndrome Frozen shoulder (a result of the mechanism of the fall causing shoulder injury rather than directly due to the fracture).

Answer 95

weak pronation of the forearm, weak flexion and radial deviation of wrist, with thenar atrophy and inability to oppose or flex the thumb ; - sensory distribution includes thumb, radial 2 1/2 fingers, and the corresponding portion of palm.

Answer 96

proximal third of the ulnar shaft and anterior dislocation of the radial head at the capitellum. MUGGER M- ulnar

Answer 97

which involve the distal third of the radial shaft and dislocation at the radio-ulnar joint.

Answer 98

The most important clinical sign is pain on palpation of the anatomical snuffbox. There may also be pain whilst telescoping the thumb. Management Management involves requesting a scaphoid series of X-rays. If scaphoid fracture is confirmed then the wrist should be placed in the 'beer glass position' and casted. If highly suspicious of scaphoid fracture, treatment should commence even if there is no initial radiological evidence of fracture, with repeat X-rays/MRI after 10 days.

Answer 99

semi-flexed position, with tenderness and swelling. They are classified as either extension (most common) or flexion type. Assessing for neurovascular status is the most important aspect of examination. Local structures that may be damaged are the brachial artery, median nerve and radial nerve.

Answer 100

Numbness from the triceps down to the fingers. Problems extending the wrist or fingers. Pinching and grasping problems. Weakness or inability to control muscles from the triceps down to the fingers. Wrist drop – when the wrist hangs limply and the patient cannot lift it.

Answer 101

Management If there is any evidence of vascular damage then the patient should urgently be taken to theatre for reduction and potential on-table angiogram to assess brachial artery patency. Non-displaced fractures can be managed with a collar and cuff whereas displaced fractures will require manipulation under anaesthesia with Kirschner wire fixation and then a collar and cuff.

Answer 102

Compression of the brachial plexus leads to neurological symptoms (neurogenic thoracic outlet syndrome) Compression of the subclavian vein leads to swelling and decreased venous return, especially during and after strenuous upper limb exercise (venous thoracic outlet syndrome) Compression of subclavian artery leads to ischaemic pain and a cold limb - rarest form, approximately 1% of cases (arterial thoracic outlet syndrome)

Answer 103

little finger loss of sensation thumb abduction travels in the medial aspect the condyle

Answer 104

SCFE causes pain and discomfort in the hip joint, especially on movement. Internal rotation and abduction are particularly painful. Pain can also be referred to the knee. There may be a history of precipitating minor trauma.

Answer 105

For very high lesions, the cause is commonly impingement e.g. due to crutches or ‘Saturday night palsy’. Here, there will be wrist drop and triceps weakness For high lesions, the cause is normally a humeral shaft facture. This will give wrist drop, reduced sensation in the anatomical snuffbox but no triceps weakness For low lesions, the cause is normally a fracture in the forearm e.g. the head of the radius. This leads to finger drop with no sensory loss.

Answer 106

Features pain and tenderness localised to the lateral epicondyle pain worse on wrist extension against resistance with the elbow extended or supination of the forearm with the elbow extended episodes typically last between 6 months and 2 years. Patients tend to have acute pain for 6-12 weeks ``` Management options advice on avoiding muscle overload simple analgesia steroid injection physiotherapy ```

Answer 107

Erb palsy Injury to the upper trunk of the brachial plexus (C5–C6) Clinical features Weakness of muscles in the C5 and C6 myotomes → flexed wrist with an extended forearm and internally rotated and adducted arm (waiter's tip posture) Weak biceps brachii, brachialis and brachioradialis → impaired flexion and supination of the forearm; absent biceps reflex Weak infraspinatus → impaired external rotation of the arm Weak deltoid and supraspinatus → impaired arm abduction Weak wrist extensors → impaired wrist extension Asymmetric Moro reflex in infants (absent or impaired on the affected side) Sensory loss in the C5 and C6 dermatomes (thumb and lateral surface of the forearm and arm

Answer 108

Treatment Immobilization in flexion and external rotation with an abduction brace Physiotherapy Surgery for severe nerve damage or prolonged cases

Answer 109

Paralysis of the deltoid muscle → impaired arm abduction Paralysis of the teres minor muscle → impaired external rotation of the arm Muscle atrophy: flattened deltoid

Answer 110

Paralysis of gluteus maximus → impaired thigh extension Difficulty standing from a sitting position and climbing stairs Backward lurching gait (an abnormal gait in which the trunk tilts backwards during the heel strike phase in the limb with the weak hip extensor) Forward pelvic tilt

Answer 111

Paralysis of hamstring muscles → impaired knee flexion Motor deficits of tibial nerve injury and common peroneal nerve injury

Answer 112

TIPPED = tibial nerve injury versus peroneal nerve injury: TIP = Tibial → damaged foot Inversion, Plantarflexion; PED = Peroneal → damaged foot, Eversion, Dorsiflexion

Answer 113

``` Dizzy spells Syncope Chest pain Palpitations Angina Low output heart failure Note that sick sinus syndrome describes an intrinsic pathology, and drug causes should be excluded before the diagnosis is made. ``` Sinus bradycardia Sinoatrial block Periods of sinus arrest Abnormally long pauses after a premature beat

Answer 114

Class I - no limitation in physical activity, and activity does not cause undue fatigue, palpitation or dyspnoea. Class II - slight limitation of physical activity, and comfort at rest. Ordinary physical activity causes fatigue, palpitation and/or dyspnoea. Class III - marked limitation in physical activity, but comfort at rest. Minimal physical activity causes fatigue (less than ordinary). Class IV - inability to carry on any physical activity without discomfort, with symptoms occurring at rest. If any activity takes place, discomfort increases.

Answer 115

If the BNP is raised, the patient should be referred for trans-thoracic echocardiogram. If BNP>2000ng/L the patient needs an urgent 2 week referral for specialist assessment and an ECHO. If BNP 400-2000ng/L the patient should get a 6 week referral for specialist assessment and an ECHO.

Answer 116

Pharmacological management ACE-inhibitor and beta-blocker (these improve mortality) Consider angiotensin receptor blocker (ARB) if intolerant to ACE inhibitors Consider hydralazine and a nitrate intolerant to ACE-I and ARB. Loop diuretics such as furosemide or bumetanide improve symptoms (but NOT mortality) If symptoms persist and NYHA Class 3 or 4 consider: Aldosterone antagonists such as spironolactone or eplerenone. These drugs also improve mortality. Hydralazine and a nitrate for Afro-Caribbean patients Ivabradine if in sinus rhythm and impaired ejection fraction Angiotensin receptor blocker Digoxin - useful in those with AF. This worsens mortality but improves morbidity.

Answer 117

Patients should be assessed using the ABCDE approach. If the patient shows adverse features (shock, syncope, heart failure, or myocardial ischaemia), emergency synchronised direct current (DC) cardioversion is indicated. In haemodynamically stable patients management differs according to whether there is a broad (QRS duration >120 ms) or narrow (QRS duration <120 ms) QRS complex. In regular narrow complex tachycardias (SVTs) the first step is to trial vagal manoeuvres (carotid sinus massage or Valsalva manoeuvre). If vagal manoeuvres fail, adenosine should be administered (initially as a 6 mg intravenous bolus, and if this fails 12 mg followed by a further 12 mg is trialled). In irregular narrow complex tachycardias the most likely diagnosis is atrial fibrillation. Atrial fibrillation with onset <48 hours is typically managed with rhythm control (LMWH followed by flecainide if there is no structural heart disease, or amiodarone if there is structural heart disease). Atrial fibrillation with onset >48 hours is typically managed with rate control (i.e. metoprolol or bisoprolol or verapamil, or digoxin if there are signs of heart failure) and anticoagulation.

Answer 118

QRS complexes are polymorphic and irregular

Answer 119

Management is according to the Advanced Life Support guidelines: The initial priorities will be as for the Basic Life Support: ensure the airway is patent, check for signs of life (pulse and breathing), and commence CPR. Ventricular fibrillation is a shockable rhythm: the next step is to administer defibrillation (unsynchronised cardioversion using a 200 J biphasic shock). Chest compressions should then be resumed. 1 mg adrenaline (10 ml 1:10 000) plus 300 mg amiodarone should be administered after the 3rd shock. Adrenaline should subsequently be administered every 3-5 mins (after every alternate shock).

Answer 120

Tachycardia (>100 beats per minute), plus Absent P waves, plus Monomorphic regular broad QRS complexes (>120 ms).

Answer 121

f there is no pulse the patient should be managed according to the Advanced Life Support algorithm: VT is a shockable rhythm so a 200 J bi-phasic (unsynchronised) shock should be administered. CPR should be resumed for 2 minutes before re-checking the rhythm. Intravenous adrenaline (1 mg of 10 ml 1:10 000 solution) and amiodarone (300 mg) should be administered after delivery of the 3rd shock. Adrenaline should be administered every 3-5 minutes thereafter (after every alternate shock).

Answer 122

Management of TdP in haemodynamically unstable patients If the patient displays adverse features (shock, syncope, myocardial ischaemia, or heart failure) emergency synchronised direct current shock should be administered, followed by intravenous amiodarone. Management of TdP in haemodynamically stable patients In haemodynamically stable patients, initial management is with intravenous magnesium sulphate (2 g over 10 minutes). Offending drugs such as drugs that prolong the QT interval should be stopped and electrolyte abnormalities (particularly hypokalaemia and hypomagnesaemia) should be corrected. Isoprenaline infusion and temporary or permanent pacing may be considered. These may be used in patients with recurrent TdP despite initial therapy with magnesium sulphate.

Answer 123

``` Radiofrequency ablation of the accessory pathway Drug treatment (such as amiodarone or sotalol) to avoid further tachyarrhthmias. These are contraindicate din structural heart disease. Surgical (open heart) ablation - rarely done and only used in complex case ```

Answer 124

Hypertension Connective tissue disease e.g. Marfan's syndrome Valvular heart disease Cocaine/amphetamine use

Answer 125

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

Answer 126

CT angiogram is used to diagnose dissection but other investigations can suggest the diagnosis and/or its complications: ECG - May show ischaemia in specific territories if dissection extends into coronary arteries. Echocardiogram - May demonstrate pericardial effusion and aortic valve involvement. Chest x-ray - May show a widened mediastinum Bloods: Troponin may be raised D-dimer may be positive

Answer 127

Mechanism of action It inhibits the sodium potassium adenosine triphosphatase ([Na+/K+ ATPase) ion pump in the myocardium and also has parasympathetic effects on the AV node. It is therefore negatively chronotropic and positively ionotropic (i.e. slows heart rate but increases contractility). Digoxin effects on ECG ``` Downsloping ST depression T-wave changes (inversion) Biphasic/flattened and shortened QT interval Slight PR interval prolongation Prominent U-waves ```

Answer 128

Mechanism of action It inhibits the sodium potassium adenosine triphosphatase ([Na+/K+ ATPase) ion pump in the myocardium and also has parasympathetic effects on the AV node. It is therefore negatively chronotropic and positively ionotropic (i.e. slows heart rate but increases contractility). Digoxin effects on ECG ``` Downsloping ST depression T-wave changes (inversion) Biphasic/flattened and shortened QT interval Slight PR interval prolongation Prominent U-waves ```

Answer 129

e condition is usually diagnosed by characteristic ECG changes and at least one clinical criterion. Examples include: ``` VF or polymorphic VT Family history of sudden cardiac death under the age of 45 Syncope, ECG signs in the family Inducible VT Nocturnal agonal breathing ```

Answer 130

``` Myocardial infarction Pericarditis Myocarditis Arrythmias Defibrillation Acute heart failure Pulmonary embolus Type A aortic dissection Chronic kidney disease Prolonged strenuous exercise Sepsis ```

Answer 131

Targeted oxygen therapy (aiming for sats >94%) Loading dose of PO aspirin 300mg Note that some hospital protocols will also call for a loading dose of a second anti-platelet agent such as clopidogrel (300mg) or ticagrelor (180mg) Sublingual GTN spray - for symptom relief IV morphine/diamorphine - in addition this causes vasodilation reducing preload on the heart Primary percutaneous coronary intervention (PPCI) for those who: Present within 12 hours of onset of pain AND Are **<2 hours** since first medical contact

Answer 132

Targeted oxygen therapy (aiming for sats >94%) Loading dose of PO aspirin 300mg Patients should have their 6 month mortality score (often the GRACE score) calculated as early as possible - all those who are anything other than lowest risk should also be given PO clopidogrel 300mg Sublingual GTN spray - for symptom relief IV morphine/diamorphine - in addition this causes vasodilation reducing preload on the heart Start antithrombin therapy such as treatment dose low molecular weight heparin or fondaparinux Patients with high 6 month risk of mortality should be offered an angiogram within 96 hours of symptom onset. Those at high risk should be offered early angiography (within 96 hours of symptoms onset)

Answer 133

ALL patients post-MI patients should be started on the following four drugs: Aspirin 75mg OM Beta blocker (normally bisoprolol) ACE-inhibitor (normally ramipril) High dose statin (e.g. Atorvastatin 80mg ON)

Answer 134

Mitral regurgitation - loudest at the apex, radiating to the axilla and loudest in expiration Tricuspid regurgitation - heard loudest at the lower left sternal edge, in inspiration Ventricular septal defect

Answer 135

``` Aortic Stenosis Aortic Sclerosis Flow murmur (anaemia, pregnancy, thyrotoxicosis) Hypertrophic obstructive cardiomyopathy Pulmonary stenosis ```

Answer 136

Echocardiography is the primary test for the diagnosis and evaluation of severity in aortic stenosis (AS).

Answer 137

Indications for intervention Intervention in aortic stenosis is indicated in the following patients: All patients with symptomatic aortic stenosis Asymptomatic patients with a left ventricular ejection fraction (LVEF) < 50% Asymptomatic patients with an LVEF > 50% who are physically active, and who have symptoms or a fall in blood pressure during exercise testing Asymptomatic patients with an LVEF > 50% who have the following risk factors Aortic valve peak velocity > 5.5 m/s^2 Severe calcification and peak velocity progression >= 0.3 m/s^2 Markedly elevated BNP levels without other explanation Severe pulmonary hypertension (pulmonary artery systolic pressure > 60mmHg)

Answer 138

Management Choices of intervention are transcatheter aortic valve implantation (TAVI) or surgical aortic valve replacement (SAVR). TAVI is favoured with patients with severe comorbidities, previous heart surgery, frailty, restricted mobility, and those older than 75 years of age. SAVR is favoured for patients who are low risk and less than 75 years of age.

Answer 139

Treat concurrent complications: AF - rate control and anticoagulation Thromboembolism - anticoagulation Heart failure - Diuretics, ACE-Inhibitors, beta-blockers The definitive management for symptomatic MR is surgery - there are two main options: Mitral valve repair (mitral valvuloplasty) - this is preferable as is preserves all components of the native valve and avoids use of prostheses. Mitral valve replacement - offers the choice between a mechanical valve (lifelong anticoagulation but long-lasting), and a bioprosthetic valve (limited durability but no need for anticoagulation)

Answer 140

``` Sinus tachycardia (most common) Right ventricular strain pattern (ST depression and T wave inversion in right ventricle and inferior leads) RBBB Right axis deviation P pulmonale S1Q3T3 Atrial arrhythmias ```

Answer 141

Examination findings Peripheral findings: "Waterhammer" pulse (Corrigan's pulse) De Musset's sign - bobbing of the head in synchrony with the beating of the heart Quincke's sign - Pulsation of the nail beds Traube's sign - "Pistol shot" like bruit heard on auscultation of the femoral pulse Müller's sign - Pulsation or bobbing of the uvula Widened pulse pressure (low diastolic pressure) is usually present Auscultation findings Early diastolic murmur Heard best in the aortic area whilst the patient is leant forward and on exhalation Soft S1 and occasionally an ejection flow murmur

Answer 142

Investigations Echocardiogram is the definitive investigation for aortic regurgitation (AR). Cardiac MRI is indicated in patients with moderate to severe AR, with suboptimal or inconclusive Echocardiogram findings. Invasive cardiac catheterisation and angiography can finally be used when noninvasive tests are inconclusive, and can give detailed information on severity of the AR, aortic valve movement, determination of left ventricular size, function and pressures, and dimensions of the aortic root.

Answer 143

low molecular weight heparin anticoagulation followed by either electrical direct current cardioversion or pharmacological cardioversion.

Answer 144

chemical cardioversion (using intravenous amiodarone). An alternative is with electrical direct current cardioversion.

Answer 145

progressive lengthening of the PR interval which results in a P wave that fails to conduct a QRS. reversible conduction block at the AV node

Answer 146

he PR interval is constant and there may no pattern or fixed ratios such as 2:1 or 3:1 block. distal block in the His-Purkinje system and many patients have pre-existing left bundle branch block/ bifascicular block.

Answer 147

It is generally asymptomatic and does not require any specific management as the risk of high AV block/ complete heart block is low. If symptoms do arise, ECG monitoring may be required, exclude precipitating drugs and if bradycardic may require atropine.

Answer 148

Management of Mobitz Type II Definitive management is with a permanent pacemaker as these patients are at risk of risk of complete heart block and becoming haemodynamically unstabl

Answer 149

improves the synchronisation of ventricular and atrial contraction, and is helpful in patients with symptomatic heart failure despite optimum medical therapy, left ventricular ejection fraction (< 35%), and are in sinus rhythm with a prolonged QRS (> 130ms).

Answer 150

Inferior | II, III, aVF

Answer 151

V1-2 septal

Answer 152

Anterior LAD

Answer 153

Distal LAD/ LCx/ RCa apex

Answer 154

Stage I (stage of analgesia or disorientation): From beginning of induction of general anaesthesia to loss of consciousness • Stage II (stage of excitement or delirium): From loss of consciousness to onset of automatic breathing Eyelash reflexes disappear but other reflexes remain intact and coughing and vomiting may occur; respiration can be irregular with breath holding • Stage III (stage of surgical anaesthesia): From onset of automatic respiration to respiratory paralysis It is divided into four planes: • Plane I – From onset of automatic respiration to cessation of eyeball movements Eyelid reflex is lost, swallowing reflex disappears • Plane II - From cessation of eyeball movements to beginning of paralysis of intercostal muscles. Laryngeal reflex is lost although inflammation of the upper respiratory tract increases reflex irritability, secretion of tears increases (useful sign 17 of light anaesthesia), respiration is automatic and regular, movement and deep breathing as a response to skin stimulation disappears • Plane III - From beginning to completion of intercostal muscle paralysis. Diaphragmatic respiration persists but there is progressive intercostal paralysis, pupils dilated and light reflex is abolished. This was the desired plane for surgery when muscle relaxants were not used • Plane IV - from complete intercostal paralysis to diaphragmatic paralysis (apnoea)

Answer 155

Be fully conscious - responding to voice or light touch • Be able to maintain a clear airway and have a normal cough reflex • Have a satisfactory respiration rate and oxygen saturations • Be cardiovascularly stable with a normal (or back to preoperative) pulse and blood pressure • Have pain and emesis adequately controlled, with suitable analgesic and anti-emetic regimens charted • Have oxygen and fluid therapy appropriately prescribed where required

Answer 156

1. Tachycardia 2. Vasoconstric&on 2. ↓ Cardiac output 2. Narrow pulse pressure 3. ↓ Mean arterial pressure 3. ↓ Blood flow

Answer 157

α1 - vasoconstriction, mydriasis ! α2 - cardiac muscle relaxation, platelet activation ! β1 - ↑ heart rate and ↑ contractility ! β2 - smooth muscle relaxation, bronchodilation

Answer 158

β1 agonist - ↑ heart rate and contractility ! Acts indirectly by increasing release of endogenous NA ! May be ineffective in presence of β-blockers ! Treats ↓BP associated with ↓HR ! Dose = 3-9mg IV bolus

Answer 159

``` Inhibits parasympathetic transmission via vagus nerve ! Anticholinergic ! Treats bradycardia due to: - anaesthetic agents - heart block - prior treatment with β-blockers - hypoxia - vagal stimulus e.g. peritoneal or anal stimulation, pneumoperitoneum ! Dose = 300-600mcg IV bolus ```

Answer 160

``` ! α1 agonist - ↑SVR ∴ ↑ BP ! Acts directly on the receptor ! Treats ↓BP associated with ↑HR ! Induces a reflex bradycardia (baroreceptor reflex) mediated by carotid sinus ! Dose = 0.5mg IV bolus ```

Answer 161

ACCIRUED acid load, chronic renal failure, carbonic anhydrase inhibitors, renal tubular acidosis [RTA], ureteroenterostomy, expansion/extra-alimentation, diarrhea

Answer 162

MUDPILES: Methanol; uremia; diabetic ketoacidosis (DKA); paraldehyde, phenformin; iron, isoniazid; lactic (ie, carbon monoxide [CO], cyanide

Answer 163

cor pulmonale in the case of isolated RHF of pulmonary origin Symptoms of fluid retention and increased CVP Jugular venous distention: visible swelling of the jugular veins due to an increase in CVP and venous congestion Kussmaul sign Hepatosplenomegaly: may result in cardiac cirrhosis and ascites

Answer 164

divided into systolic (heart doesn’t pump out blood ) or diastolic (doesn't fill fully) Dyspnea , orthopnea Pulmonary edema Paroxysmal nocturnal dyspnea Nocturnal bouts of coughing and acute shortness of breath Caused by reabsorption of peripheral edema at night → increased venous return Find crackles Laterally displaced apical heart beat (precordial palpation beyond the midclavicular line) Coolness and palor of lower extremities

Answer 165

consider imaging and sodium (may have hyppnaterium due to dilution) Ultrasound-guided diagnostic paracentesis Indications: first diagnosed ascites, worsening ascites or suspected complication Ascitic fluid analysis

Answer 166

General measures Treatment of the underlying disease (e.g., using anticoagulation in case of a thrombosis or tuberculostatics in case of a tubercular peritonitis) Sodium restriction Regular weight control Water restriction or avoiding overhydration Spironolactone in PORTAL hypertensive ascites drainage if tense ascites (therapeutic abdominal paracentesis) large-volume paracentesis for the treatment of ascites requires albumin 'cover'. paracentesis induced circulatory dysfunction can occur due to large volume paracentesis (> 5 litres)

Answer 167

``` Cirrhosis Alcoholic hepatitis Cardiac ascites Mixed ascites Massive liver metastases Fulminant hepatic failure Budd-Chiari syndrome Portal vein thrombosis Veno-occlusive disease Myxoedema Fatty liver of pregnancy ```

Answer 168

``` Peritoneal carcinomatosis Tuberculous peritonitis Pancreatic ascites Bowel obstruction Biliary ascites Postoperative lymphatic leak Serositis in connective tissue diseases ```

Answer 169

Evidence suggests this reduces paracentesis-induced circulatory dysfunction and mortality

Answer 170

Clinical Features ``` Malaise and fatigue Nausea and vomiting Right upper quadrant pain diarrhoea (may have pale stools and dark urine) Jaundice Hepatomegaly Splenomegaly and lymphadenopathy Liver failure: characterized by hepatic encephalopathy, jaundice, ascites and abnormal clotting. ```

Answer 171

Flu-like symptoms followed by jaundice, pale stools (in some), dark urine and abdominal pain. Incubation period of 2-6 weeks Complete recovery can take up to 6 months. test for IgM and IgG antibodies to HAV. Supportive management

Answer 172

jaundice, fever, malaise, and darkening of urine and lightening of stool. Some develop fulminant liver failure with decompensation (ascites, encephalopathy etc.). Risk of developing chronic disease is low (<5%). HBsAg is detected 3-5 weeks after infection. If present for >6 months, this defines carrier status (5-10% of infections). Antibodies to HBsAg (anti-HBs) indicate previous vaccination Antibodies to hep B core antigen (anti-HBc) indicate past infection. Only adults who are HBsAg-positive, have compensated liver disease, are pregnant or of young age may be referred for treatment Peginterferon alfa-2a is the first line, with tenofovir and entecavir as second-line alternatives.

Answer 173

Symptomatic treatment in the early stages of the disease Drug therapy should be considered for all patients and depends on the genotype of the virus. Nucleoside analogs are generally preferred e.g. Sofosbuvir and often lead to undetectable viral loads Antivirals of proven benefit in basically every patient irrespective of the amount of cirrhosis and fibrosis Manage any underlying cirrhosis

Answer 174

may present with signs of chronic liver disease acute hepatitis: fever, jaundice etc (only 25% present in this way) amenorrhoea (common) ANA/SMA/LKM1 antibodies, raised IgG levels liver biopsy: inflammation extending beyond limiting plate 'piecemeal necrosis', bridging necrosis Management steroids, other immunosuppressants e.g. azathioprine liver transplantation

Answer 175

Posterior ankle pain Pain on palpation of the Achilles tendon Swelling and thickening of the Achilles tendon Treatment is conservative, with rest and analgesia (non-steroidal anti-inflammatory drugs are most useful)

Answer 176

extension of the knee synovium that develops between the medial head of gastrocnemius and the semi-membranous muscle. essential to rule out a venous thrombosis in rupture In children - Consider referral: To a paediatric orthopaedic surgeon, if symptomatic or the cyst is very large. To a paediatric rheumatologist or paediatrician, if an underlying condition (such as inflammatory joint disease) is suspected. To a paediatric orthopaedic surgeon or paediatrician, if diagnosis is unclear. If no underlying disease is suspected, and the diagnosis is confirmed on ultrasound scan, reassure the child (and the parents or carers) that primary Baker's cysts usually resolve without treatment. If symptoms are troublesome: Consider simple analgesia (such as paracetamol or ibuprofen) and physiotherapy

Answer 177

Osteosarcoma is the commonest primary bone malignancy and occurs mainly in adolescent males. It presents with a warm, painful swelling and most commonly at the knee. X-ray shows periosteal reaction with codman's triangle and a sunburst appearance.

Answer 178

Ewing's Sarcoma occurs in adolescents and presents as a painful, warm, enlarging mass along long bone diaphysis. The patient will have systemic symptoms such as fever and anaemia, with a raised ESR and WCC. X-ray shows onion skin periosteal reaction.

Answer 179

Chondrosarcoma is cartilaginous malignancy at occurs in older patients (>40) with pain and a lump. Many of these arise from previous chondromas that have undergone malignant change. X-ray shows a lytic lesion with 'fluffy popcorn calcification'.

Answer 180

MEDIAN NERVE tingling/pain in the first three digits, worse at night and relieved by shaking/ hanging out the hand at night. There may also be clumsiness in hand movements and decreases sensation in the first three digits. Management Carpal tunnel syndrome can be treated through splinting, local steroid injections and treatment of the underlying cause if it is secondary. If these fail, then decompression surgery is used- performed by dividing the tunnel roof (flexor retinaculum).

Answer 181

fall on an outstretched wrist and leads to a distal radial fracture with dorsal displacement of the distal fragment Risk of non-union, medial nerve injury

Answer 182

``` Posterior hip dislocations (treat with manual reduction or open reduction if this fails) Surgical site infection Injury to blood vessels/nerves Leg-length discrepancy Fracture ```

Answer 183

heterotopic ossification within large muscles. It can be inherited but typically occurs 2-6 weeks after trauma, with the most common sites being the elbow and the thigh. It can mimic osteal malignancy and can even histologically appear like osteosarcoma, leading to incorrect management. radiologically ->circumferential calcification with a lucent centre and a radiolucent cleft (string sign) that separates the lesion from the cortex of the adjacent bone.

Answer 184

ORIF and cancellous screws in grade 1 or 2 grade 3/4 young - ORIF middle and healhty - total hip old and co morbid - hemi-arthroplasty

Answer 185

pen repair and internal fixation (ORIF) with dynamic hip screw

Answer 186

need CT | reatment involves close ophthalmology follow up +/- antibiotics or surgery.

Answer 187

blood supply of bone is interrupted, leading to bone and cartilage detaching from the area and being able to move freely in the joint space. It commonly occurs in young adults at the knee, elbow and ankle. bone debris in the joint and include: swelling after exercise; joint locking, and decreased range of movement.

Answer 188

Less common | Ass/w epilepsy, electrocution and trauma.

Answer 189

For very high lesions, the cause is commonly impingement e.g. due to crutches or 'Saturday night palsy'. Here, there will be wrist drop and triceps weakness For high lesions, the cause is normally a humeral shaft facture. This will give wrist drop, reduced sensation in the anatomical snuffbox but no triceps weakness For low lesions, the cause is normally a fracture in the forearm e.g. the head of the radius. This leads to finger drop with no sensory loss.

Answer 190

semi-flexed position, with tenderness and swelling. They are classified as either extension (most common) or flexion type. Assessing for neurovascular status is the most important aspect of examination. Local structures that may be damaged are the brachial artery, median nerve and radial nerve. any evidence of vascular damage then the patient should urgently be taken to theatre for reduction and potential on-table angiogram to assess brachial artery patency.

Answer 191

weakness of the intrinsic muscles of the hand and give rise to a 'claw hand'. Clinical signs include finger weakness in both abduction and adduction, as well as sensory loss over the fifth digit. Froment's sign will be positive (flexion of thumb when holding a piece of paper between thumb and second digit; due to weak adductor pollicis). Patients will also be unable to cross their fingers in a 'good luck' sign. The ulnar paradox describes greater clawing in the hand when there is a lesion at the wrist compared to the elbow. This is because higher lesions will cause weakness of flexor digitorum profundus- hence an inability to flex the digits.

Answer 192

winging of scapula bruising on the left posterior aspect of the thoracic cage Shoulder flexion and abduction is limited.

Answer 193

inital abduction of shoulder injury - inability to initiate active abduction Jobe/empty can = suprspinatus muscle which is innervated by this

Answer 194

= ULNAR nerve palsy | 4th and 5th digit isssues

Answer 195

think Knee in active kids | 1st line = xray (big tib tubule )

Answer 196

rep work in rotator cuff injury | maybe difficult to sleep on the right shoulder and finds it difficult to comb his hair using his right hand due to pain.

Answer 197

unilateral headache that is typically worse around the eye. A bloodshot or teary eye Vomiting Severe headache Management Treatment of cluster headaches acutely is with 100% oxygen and sumatriptan. Prophylactic treatment may have some effect, and includes verapamil and steroids.

Answer 198

Nasopharyngeal airways are contraindicated in these patients as they can cause further damage to the patient. A head tilt chin lift is contraindicated in trauma patients at risk of a C-spine injury as it can cause further instability and damage.

Answer 199

``` Facial burns Vomiting Untreated pneumothorax Severe co-morbidities Haemodynamically unstable Patient refusal ```

Answer 200

``` Medical treatment includes; carbamazepine (first line) phenytoin lamotrigine gabapentin Surgical options include; microvascular decompression treatment of the underlying cause and alcohol injections ```

Answer 201

Management of the conscious patient Encourage the patient to cough 5 back blows with the heal of hand aiming centrally between shoulder blades 5 abdominal thrusts performed from behind the patient, with a fist placed between the umbilicus and xiphisternum, grasping it with the other hand and pulling upwards and inwards sharply Continue these motions until the obstruction is dislodged, or the patient becomes unconscious Management of the unconscious patient If unconscious, call for help and start ABC

Answer 202

``` Lethargy Ataxia Slurred speech Coma Respiratory depression ```

Answer 203

Bradycardia Hypotension Mild hypoglycaemia Mild hyperkalaemia

Answer 204

``` Nausea and vomiting - if small doses Rapid loss of consciousness Apnoea Seizures Cardiac arrest ```

Answer 205

``` Agitation Tachycardia Hyperthermia Acute renal failure Hypo/hypertension Mydriasis ```

Answer 206

``` PEF <33% SO2 <92% or PO2 <8 Cyanosis Hypotension Exhaustion, altered consciousness Silent chest Tachyarrhythmias ``` raised PCO2 is an indication of near fatal asthma.

Answer 207

mmediate management: Sit-up 100% O2 via non-rebreathe mask (aim for 94-98%) Nebulised salbutamol (5mg) and ipratropium (0.5mg) Hydrocortisone 100mg IV or prednisolone 50mg PO If Life-threatening: Inform the intensive care team Mangesium sulphate 2g IV over 20 minutes Nebulised salbutamol every 15min Monitoring: Peak flow measurement every 15-30min pre- and post-Salbutamol SpO2: keep >92% Consecutive Arterial blood gas measurements

Answer 208

Unstable angina = critical narrowing of coronary artery causing ischaemia Chest pain at rest or minimal exertion lasting >15 minutes ECG changes (new ST-depression or T wave inversion) NO rise in troponin: no myocardial necrosis

Answer 209

Chest pain at rest or minimal exertion lasting >15 minutes ECG changes (new ST-depression of T wave inversion) Rise in troponin: myocardial necrosis

Answer 210

To diagnose a STEMI on ECG, there should be new ST-segment elevation in 2 or more contiguous leads. The ST elevation should be ≥2mm in the precordial leads or ≥1mm in the limb leads.

Answer 211

MMONAC can be used to remember the initial treatment for STEMI. It stands for: ``` Morphine Metoclopramide Oxygen (if sats <94%) Nitrates (GTN spray) Aspirin 300 mg Clopidogrel 300 mg ```

Answer 212

Oxygen Therapy Sit-up 24% O2 via Venturi mask: SpO2 88-92%, Vary FiO2 and SpO2 target according to Arterial Blood Gas Nebulised Bronchodilators (Air Driven) Salbutamol 5mg/4h Ipratropium 0.5mg/6h Steroids Hydrocortisone 200mg IV Prednisolone 40mg PO for 7-14d Antibiotics (if evidence of infection)

Answer 213

``` Remove trigger if possible Call for help early ABCDE assessment Administer oxygen and Lie patient flat and raise legs Administer adrenaline (Adult dose is 500 micrograms IM) Administer chlorphenamine and hydrocortisone IV fluid challenge if hypotensive ```

Answer 214

Beck's triad (raised JVP, hypotension and muffled heart sounds) Kussmaul's sign (rise of JVP with inspiration) Pulsus paradoxus (drop in systolic blood pressure with inspiration) An ECG may show electrical alternans (alternating height of QRS complexes) and an Echocardiogram is the most useful diagnostic investigation.

Answer 215

Management Gastric lavage or NG aspiration if <1 hour since ingestion Fomepizole (competitive inhibitor of alcohol dehydrogenase) - prevents metabolism of ethylene glycol into toxic metabolites. Alcohol (ethanol) can be used if Fomepizole is unavailable. Haemofiltration can be used in severe cases

Answer 216

If the patient is NOT short of breath AND the pneumothorax is <2 cm on a chest x-ray conservative management is sufficient. The patient can be discharged and reviewed in the outpatient department in 2-4 weeks. If the patient IS short of breath OR the pneumothorax is >2 cm the pneumothorax should be aspirated with a 16-18G cannula under local anaesthetic. If this is successful the patient can be discharged. If this fails an intercostal drain is necessary (and the patient must be admitted).

Answer 217

If the patient is NOT short of breath AND the pneumothorax is <1 cm on the chest x-ray they do not require further invasive intervention but should be admitted for observation for 24 hours and administered oxygen as required. If the patient is NOT short of breath and the pneumothorax is 1-2 cm on the chest x-ray aspiration is required. If this is successful the patient can be admitted for 24 hours of observation. If this is unsuccessful and intercostal drain is necessary. If the patient IS short of breath OR the pneumothorax is >2 cm on the chest x-ray an intercostal drain is necessary (and the patient should be admitted).

Answer 218

ABCDE approach Oxygen Ensure IV access Arterial Blood gas Bloods for glucose, FBC/UE/CRP,Calcium/Phosphate/Magnesium, drug levels if the patient is on anti-epileptic medications Anaesthetic review to ensure the airway is managed IV lorazepam 4mg A second dose of lorazepam should be given if no response In the absence of IV access, PR diazepam or buccal midazolam can be administered. If the initial benzodiazepine fails, further anti-convulsants can be used: Leviteracetam Phenytoin Valproate

Answer 219

Treatment of any upper GI bleed is as follows: ABCDE assessment Insert 2 large bore IV cannulae and take bloods for FBC, U+E, LFT, clotting, cross match IV fluids - fluid challenge if hypotensive Catheterise Correct clotting if needed Urgent endoscopy

Answer 220

IV Amiodarone

Answer 221

1. reducing dietary sodium - fluid restriction is sometimes recommended if the sodium is < 125 mmol/L 2. aldosterone antagonists: e.g. spironolactone 3. drainage if tense ascites - large-volume paracentesis for the treatment of ascites requires albumin 'cover'. Evidence suggests this reduces paracentesis-induced circulatory dysfunction and mortality

Answer 222

Injury to the AC joint is relatively common and typically occurs during collision sports such as rugby following a fall on to the shoulder or a FOOSH (falls on outstretched hand). AC joint injuries are graded I to VI depending on the degree of separation. Grade I and II injuries are very common and are typically managed conservatively including resting the joint using a sling. Grade IV, V and VI are rare and require surgical intervention. The management of grade III injuries is a matter of debate and often depends on individual circumstances.

Answer 223

Investigations Assessment of the patient includes imaging with CT scanning Management surgery a craniotomy is performed and the abscess cavity debrided the abscess may reform because the head is closed following abscess drainage. IV antibiotics: IV 3rd-generation cephalosporin + metronidazole intracranial pressure management: e.g. dexamethasone

Answer 224

Headache (typically worse in the morning, when lying down and during valsalva) Nausea and vomiting Papilloedema Coma (in severe cases)

Answer 225

accounts for around 50% of cerebral lesions in patients with HIV constitutional symptoms, headache, confusion, drowsiness CT: usually single or multiple ring-enhancing lesions, mass effect may be seen management: pyrimethamine plus sulphadiazine for at least 6 weeks

Answer 226

Overview a cause of horizontal disconjugate eye movement due to a lesion in the medial longitudinal fasciculus (MLF) controls horizontal eye movements by interconnecting the IIIrd, IVth and VIth cranial nuclei located in the paramedian area of the midbrain and pons Features impaired adduction of the eye on the same side as the lesion horizontal nystagmus of the abducting eye on the contralateral side Causes multiple sclerosis vascular disease

Answer 227

characterised by a raised pC02 and/or requiring mechanical ventilation with raised inflation pressures.

Answer 228

PEFR 50-75% best or predicted Speech normal RR < 25 / min Pulse < 110 bpm

Answer 229

PEFR 33 - 50% best or predicted Can't complete sentences RR > 25/min Pulse > 110 bpm

Answer 230

``` PEFR < 33% best or predicted Oxygen sats < 92% 'Normal' pC02 (4.6-6.0 kPa) Silent chest, cyanosis or feeble respiratory effort Bradycardia, dysrhythmia or hypotension Exhaustion, confusion or coma ```

Answer 231

``` analgesia good fluid intake consider antibiotic therapy if patients: are systemically very unwell have pre-existing co-morbidities have a CRP of 20-100mg/L (offer delayed prescription) or a CRP >100mg/L (offer antibiotics immediately) doxycycline first-line ```

Answer 232

21 percent

Answer 233

features such as: a transient rise in serum aminotransferases / jaundice fatigue arthralgia

Answer 234

HCV RNA is the investigation of choice to diagnose acute infection whilst patients will eventually develop anti-HCV antibodies it should be remembered that patients who spontaneously clear the virus will continue to have anti-HCV antibodies

Answer 235

``` chronic hepatitis (5-10%). 'Ground-glass' hepatocytes may be seen on light microscopy fulminant liver failure (1%) hepatocellular carcinoma glomerulonephritis polyarteritis nodosa cryoglobulinaemia ```

Answer 236

pegylated interferon-alpha used to be the only treatment available. It reduces viral replication in up to 30% of chronic carriers. A better response is predicted by being female, < 50 years old, low HBV DNA levels, non-Asian, HIV negative, high degree of inflammation on liver biopsy whilst NICE still advocate the use of pegylated interferon firstl-line other antiviral medications are increasingly used with an aim to suppress viral replication (not in a dissimilar way to treating HIV patients) examples include tenofovir, entecavir and telbivudine (a synthetic thymidine nucleoside analogue)

Answer 237

RNA hepevirus spread by the faecal-oral route incubation period: 3-8 weeks common in Central and South-East Asia, North and West Africa, and in Mexico causes a similar disease to hepatitis A, but carries a significant mortality (about 20%) during pregnancy does not cause chronic disease or an increased risk of hepatocellular cancer a vaccine is currently in development, but is not yet in widespread use

Answer 238

``` flu-like prodrome abdominal pain: typically right upper quadrant tender hepatomegaly jaundice cholestatic liver function tests ```

Answer 239

diffuse hepatic injury resulting from acute hypoperfusion (sometimes known as 'shock liver'). It is not an inflammatory process. It is diagnosed in the presence of an inciting event (e.g. a cardiac arrest) and marked increases in aminotransferase levels (exceeding 1000 international unit/L or 50 times the upper limit of normal). Often, it will occur in conjunction with acute kidney injury (tubular necrosis) or other end-organ dysfunction.

Answer 240

Features may present with signs of chronic liver disease acute hepatitis: fever, jaundice etc (only 25% present in this way) amenorrhoea (common) ANA/SMA/LKM1 antibodies, raised IgG levels liver biopsy: inflammation extending beyond limiting plate 'piecemeal necrosis', bridging necrosis Management steroids, other immunosuppressants e.g. azathioprine liver transplantation

Answer 241

``` Hs Hypoxia Hypovolaemia Hyperkalaemia, hypokalaemia, hypoglycaemia, hypocalcaemia, acidaemia and other metabolic disorders Hypothermia ``` ``` Ts Thrombosis (coronary or pulmonary) Tension pneumothorax Tamponade – cardiac Toxins ```

Answer 242

by 2 minutes of CPR, rather than a series of 3 shocks followed by 1 minute of CPR

Answer 243

if the cardiac arrested is witnessed in a monitored patient (e.g. in a coronary care unit) then the 2015 guidelines recommend 'up to three quick successive (stacked) shocks', rather than 1 shock followed by CPR

Answer 244

adrenaline 1mg should be given as soon as possible. Should be treated with 2 minutes of CPR prior to reassessment of the rhythm

Answer 245

If the patient has adverse signs (systolic BP < 90 mmHg, chest pain, heart failure, syncope) then immediate cardioversion is indicated. Drug therapy amiodarone: ideally administered through a central line lidocaine: use with caution in severe left ventricular impairment procainamide

Answer 246

Acute management vagal manoeuvres: e.g. Valsalva manoeuvre, carotid sinus massage intravenous adenosine 6mg → 12mg → 12mg: contraindicated in asthmatics - verapamil is a preferable option electrical cardioversion

Answer 247

Response to question 'Are you choking?' victim speaks and answers yes Other signs victim is able to speak, cough, and breathe f mild airway obstruction encourage the patient to cough

Answer 248

Response to question 'Are you choking?' victim unable to speak victim may respond by nodding ``` Other signs victim unable to breathe breathing sounds wheezy attempts at coughing are silent victim may be unconscious ``` If severe airway obstruction and is conscious: give up to 5 back-blows if unsuccessful give up to 5 abdominal thrusts if unsuccessful continue the above cycle

Answer 249

if the rim of air is < 2cm and the patient is not short of breath then discharge should be considered otherwise, aspiration should be attempted if this fails (defined as > 2 cm or still short of breath) then a chest drain should be inserted patients should be advised to avoid smoking to reduce the risk of further episodes - the lifetime risk of developing a pneumothorax in healthy smoking men is around 10% compared with around 0.1% in non-smoking men

Answer 250

if the patient is > 50 years old and the rim of air is > 2cm and/or the patient is short of breath then a chest drain should be inserted. otherwise aspiration should be attempted if the rim of air is between 1-2cm. If aspiration fails (i.e. pneumothorax is still greater then 1cm) a chest drain should be inserted. All patients should be admitted for at least 24 hours

Answer 251

``` Causes infection: sepsis, pneumonia massive blood transfusion trauma smoke inhalation acute pancreatitis cardio-pulmonary bypass ```

Answer 252

dyspnoea elevated respiratory rate bilateral lung crackles low oxygen saturations

Answer 253

orally or rectally should be given as soon as possible if a haemorrhagic stroke has been excluded

Answer 254

it is administered within 4.5 hours of onset of stroke symptoms (unless as part of a clinical trial) haemorrhage has been definitively excluded (i.e. Imaging has been performed)

Answer 255

Offer thrombectomy as soon as possible and within 6 hours of symptom onset, together with intravenous thrombolysis (if within 4.5 hours), to people who have: acute ischaemic stroke and confirmed occlusion of the proximal anterior circulation demonstrated by computed tomographic angiography (CTA) or magnetic resonance angiography (MRA) OR 6 hours and 24 hours potential to salvage brain tissue, as shown by imaging such as CT perfusion or diffusion-weighted MRI sequences showing limited infarct core volume

Answer 256

Contralateral hemiparesis and sensory loss, lower extremity > upper

Answer 257

Contralateral hemiparesis and sensory loss, upper extremity > lower Contralateral homonymous hemianopia Aphasia

Answer 258

Contralateral homonymous hemianopia with macular sparing | Visual agnosia

Answer 259

Ipsilateral CN III palsy | Contralateral weakness of upper and lower extremity

Answer 260

Ipsilateral: facial pain and temperature loss Contralateral: limb/torso pain and temperature loss Ataxia, nystagmus

Answer 261

Associations | diabetes mellitus: up to 20% of diabetics may have an episode of frozen shoulder

Answer 262

Features typically develop over days external rotation is affected more than internal rotation or abduction both active and passive movement are affected patients typically have a painful freezing phase, an adhesive phase and a recovery phase bilateral in up to 20% of patients the episode typically lasts between 6 months and 2 years

Answer 263

Management no single intervention has been shown to improve outcome in the long-term treatment options include NSAIDs, physiotherapy, oral corticosteroids and intra-articular corticosteroids

Answer 264

Lung fibrosis

Answer 265

Cardiomyopathy

Answer 266

Myelosuppression, mucositis, liver fibrosis, lung fibrosis

Answer 267

Myelosuppression, mucositis, dermatitis

Answer 268

hydrocortisone + fludrocortisone

Answer 269

Most commonly due to laceration of lung, intercostal vessel or internal mammary artery Haemothoraces large enough to appear on CXR are treated with large bore chest drain Surgical exploration is warranted if >1500ml blood drained immediately

Answer 270

Most common potentially lethal chest injury Arterial blood gases and pulse oximetry important Early intubation within an hour if significant hypoxia

Answer 271

Risks It can cause maternal hypotension resulting in foetal and maternal distress. Additionally, there is risk of dural puncture, resulting in a severe postural headache. Other risks include epidural haematoma.

Answer 272

Management Stop administration of local anaesthetic! ABCDE approach including ECG monitoring Lipid emulsion (20% intralipid) 1mL/kg every 3 minutes up to a dose of 3mL\kg Initiate lipid emulsion infusion at a rate of 0.25mL\kg\min Maximum total dose = 8mL\kg

Answer 273

Preparation Involves ensuring the environment is optimised, equipment is available and staff are ready Preoxygenation Involves the administration of high flow oxygen for 5 minutes prior to the procedure Pretreatment May involve administration of opiate analgesia or a fluid bolus to counteract the hypotensive effect of anaesthesia Paralysis The administration of the induction agent (e.g. Propofol or Sodium Thiopentone) and paralysing agent (e.g. Suxamethonium or Rocuronium) Protection and positioning Cricoid pressure should be applied to protect the airway following paralysis. In line stabilisation may be required in some cases. Placement and proof Intubation is performed via laryngoscopy, with proof obtained (direct vision, end-tidal CO2, bilateral auscultation) Post-intubation management Taping or tying the endotracheal tube, initiating mechanical ventilation and sedation agents

Answer 274

Scoring Motor Response 6- obeys commands 5 - localises to pain 4 - withdraws to pain 3 - flexor response to pain 2 - extensor response to pain 1 - no response to pain Scoring Verbal Response 5 - oriented 4 - confused conversation 3 - inappropriate speech 2 - incomprehensible 1 - none Scoring Eye Opening 4 - spontaneous 3 - open in response to speech 2 - opens to pain 1 - no eye opening Therefore, the lowest GCS is 3/15.

Answer 275

Clinical features Posterior ankle pain Pain on palpation of the Achilles tendon Swelling and thickening of the Achilles tendon Management Treatment is conservative, with rest and analgesia (non-steroidal anti-inflammatory drugs are most useful)

Answer 276

ABCDE approach Full immobilisation until C-Spine 'cleared' Detailed history and examination Imaging as required

Answer 277

result of a shoulder injury, particularly anterior dislocation and proximal humeral fractures weakness of shoulder abduction due to disruption in the motor supple to deltoid and teres minor. may also be weakness in shoulder flexion, extension and external rotation There may also be sensory disturbance to the lateral deltoid, around the 'regimental patch'. Management is typically conservative, with reconstructive surgery reserved for those who do not respond to non-surgical management.

Answer 278

``` Head injury Reduced consciousness Battle's sign = bruising of the mastoid process Raccoon eyes = bruising around the eyes Rhinorrhoea = CSF leaking from the ear Cranial nerve palsy Bleeding from the nose/ears Haemotympanum = blood visible behind the tympanic membrane ```

Answer 279

fracture of the base of the thumb, commonly caused by forced abduction injuries. It is diagnosed via x-ray. Stable fractures are managed with a cast for 3-4 weeks followed by physiotherapy. Unstable fractures require surgery with an open reduction and fixation using screws or k-wires.

Answer 280

Biceps tendon tears are injuries to the biceps muscle that result in the complete or partial severing of the tendon from the bone. It can be caused by minimal trauma in elderly patients with pre-existing degenerative shoulder disease or secondary to eccentric loading of the muscle.

Answer 281

Osteosarcoma is the commonest primary bone malignancy and occurs mainly in adolescent males. It presents with a warm, painful swelling and most commonly at the knee. X-ray shows periosteal reaction with codman's triangle and a sunburst appearance.

Answer 282

Ewing's Sarcoma occurs in adolescents and presents as a painful, warm, enlarging mass along long bone diaphysis. The patient will have systemic symptoms such as fever and anaemia, with a raised ESR and WCC. X-ray shows onion skin periosteal reaction.

Answer 283

fracture of the neck of the 4th or 5th metacarpal. = transverse fracture Pain and swelling over the metacarpophalangeal joints of the 4th and 5th fingers.

Answer 284

Surgery is required if there is: Significant rotation or angulation of the affected fingers. Articular involvement of the fracture Multiple metacarpal fractures Open fractures

Answer 285

. Symptoms include heel pain and inability to weight bear. CT is the gold standard for diagnosis. Management of a non-displaced fracture is with cast immobilisation and non-weight-bearing for 6-12 weeks.

Answer 286

Patient with clinical features suggestive of spinal cord compression or cauda equina syndrome should have an urgent WHOLE spine MRI, with an aim (in appropriate cases) to surgically decompress within 48 hours. In patients where malignancy is demonstrated on MRI, or in patients where clinical suspicion is high, administration of dexamethasone 16 mg daily in divided doses (with PPI cover) is indicated.

Answer 287

Treatment of closed uncomplicated clavicle fractures is with initial sling immobilisation for 2 weeks, following by range of motion exercises

Answer 288

Mal/non-union Sudek's atrophy/complex regional pain syndrome Extensor pollicis longus rupture Median nerve injury Carpal tunnel syndrome Frozen shoulder (a result of the mechanism of the fall causing shoulder injury rather than directly due to the fracture).

Answer 289

Injury causes a 'foot drop' due to paralysis of the foot extensors (tibialis anterior, extensor digitorum longus and extensor hallucis longus). Foot inversion may also occur as the common peroneal nerve also innervates the foot evertor muscles.

Answer 290

``` Anaesthetic complications Infection Loosening of the joint Hip dislocation Leg length disparity Thrombosis Nerve damage ```

Answer 291

``` Sudden painful 'popping' sensation with rapid swelling Inability to return to activity Lateral knee and joint line tenderness Lachman test often positive Anterior drawer test may be positive ```

Answer 292

Mechanism of posterior cruciate ligament injury Mechanism usually direct blow to proximal tibia when knee flexed Symptoms and signs of PCL injury May be asymptomatic, or have posterior or anterior knee pain Posterior drawer test may be positive Posterior sag test may be positive

Answer 293

'ulnar nerve entrapment' is compression or irritation of the ulnar nerve as it passes through the cubital tunnel at the elbow. It manifests with pain at medial elbow or forearm and sensory disturbance of the 4th and 5th digits, hypothenar eminence and ulnar side of the dorsum of the hand. Treatment is with conservative treatment with the use of an elbow splint, with surgical decompression reserved for those with inadequate improvement with splinting, or with symptoms of moderate weakness.

Answer 294

inflammation of the extensor pollicis longus and extensor pollicis brevis tendons at the base of the thumb Symptoms typically include pain at the base of the thumb, which is exacerbated by abduction of the thumb, gripping and ulnar movement of the wrist. There may be tenderness of the anatomical snuffbox and weakness of the hand. Splinting and analgesia are the mainstay of treatment, with corticosteroid injections or surgery reserved for those in whom non-surgical treatment has failed.

Answer 295

heterotopic ossification within large muscles. can be inherited but typically occurs 2-6 weeks after trauma It can mimic osteal malignancy and can even histologically appear like osteosarcoma, leading to incorrect management.

Answer 296

synovial fluid filled swelling that commonly occurs at the wrist. Ganglions may be asymptomatic, or may present with pain. Treatment is recommended for symptomatic ganglions and is with aspiration or excision of the cyst.

Answer 297

typically occur as a result of direct trauma to the base of the thumb and often present weeks after the initial injury. Diagnosis is via plain x-ray, with a 'carpal tunnel' view most useful for visualisation of hamate fractures.

Answer 298

chronic condition presenting with pain at the site of insertion of the forearm extensors at the lateral epicondyle of the humerus. It typically presents in those over the age of 35 in those who perform repetitive activities involving elbow extension. Symptoms typically resolve with rest.

Answer 299

presence of blood and fat in the joint space. This occurs due to fracture and escape of blood and bone marrow into the joint cavity . It commonly occurs in fractures of large joints e.g. knee and can be identified on plain x-ray by the presence of a fluid-fat level.

Answer 300

dislocation of the tarsometatarsal joint between the medial cuneiform bone and base of the second metatarsal in the mid foot Symptoms include midfoot pain and inability to weight bear.

Answer 301

thoracic nerve is derived from the brachial plexus and runs distal to the clavicle, superficial to the first two ribs innervate serratus anterior muscle. damage = scapula winging This nerve can be damaged by repetitive stretching, e.g. in sports requiring overhead activity e.g. basketball, or can be damaged acutely by trauma to the chest or neck. Treatment is typically conservative, including rest and physiotherapy.

Answer 302

spiral fracture of the proximal fibula, together with an unstable ankle injury and is typically caused by external rotation and pronation of the foot. Management is typically surgical and may involve fixation of the ankle injury, and reduction and stabilisation of the proximal fibula fracture.

Answer 303

Tendinopathy of the wrist flexor tendons which attach to the medial epicondyle of the distal humerus. . Patients typically report gradual-onset medial elbow pain exacerbated by activity, particularly flexion of the wrist. There may also be weakness of wrist flexion. Diagnosis is typically clinical, and the condition is usually treated conservatively with rest and guided rehabilitation. Surgical debridement of damaged tissue may be indicated in cases which do not respond to 6 months non-surgical management.

Answer 304

All women aged over 65 should be assessed and men aged over 75. Younger patients should be assessed if they have risk fractures e.g. a previous fragility fracture of frequent use of oral corticosteroids. Depending on this score they may be offered a bone density scan of the spine and hip. A score which shows a 10 year fracture risk of greater than 10% requires further assessment using a bone density scan. T-scores compare the patient's bone density with that of a young patient of the same gender. A score of 0 is average. A positive or negative score indicates how many standard deviations away from the mean the patient's bone density is. Osteoporosis is diagnosed when patients have a T-score of less than 2.5 standard deviations below the mean. A score of between -1 and -2.5 indicates osteopenia.

Answer 305

or very high lesions, the cause is commonly impingement e.g. due to crutches or 'Saturday night palsy'. Here, there will be wrist drop and triceps weakness For high lesions, the cause is normally a humeral shaft facture. This will give wrist drop, reduced sensation in the anatomical snuffbox but no triceps weakness For low lesions, the cause is normally a fracture in the forearm e.g. the head of the radius. This leads to finger drop with no sensory loss.

Answer 306

One of the most common causes of shoulder pain. Occurs when the tendons of the rotator cuff muscles become compressed between the humeral head and the acromion. Presents with pain and stiffness, particularly when performing overhead activities. Plain x-ray may be useful in evaluating the acromiohumeral joint space. Treatment is usually non-operative, with analgesia and physiotherapy. Subacromial decompression surgery may be indicated if non-operative management fails.

Answer 307

semi-flexed position, with tenderness and swelling. Assessing for neurovascular status is the most important aspect of examination. Local structures that may be damaged are the brachial artery, median nerve and radial nerve.

Answer 308

Compression of the brachial plexus leads to neurological symptoms (neurogenic thoracic outlet syndrome) Compression of the subclavian vein leads to swelling and decreased venous return, especially during and after strenuous upper limb exercise (venous thoracic outlet syndrome) Compression of subclavian artery leads to ischaemic pain and a cold limb - rarest form, approximately 1% of cases (arterial thoracic outlet syndrome)

Answer 309

Compression between the anterior and middle scalene muscles (most common cause) Compression by a cervical rib is the (second most common cause). a cervical rib is a normal anatomical variant. It is an extra rib that comes off the 7th cervical vertebra. They are present in almost 0.5% of the population, more often bilateral and more common in females.

Answer 310

Symptoms include: lateral hip pain (worse at night and aggravated by physical activity) swelling A positive Trendelenberg (single leg stance) test

Answer 311

Ulnar nerve lesions will lead to weakness of the intrinsic muscles of the hand and give rise to a 'claw hand'. Clinical signs include finger weakness in both abduction and adduction, as well as sensory loss over the fifth digit. Froment's sign will be positive (flexion of thumb when holding a piece of paper between thumb and second digit; due to weak adductor pollicis). Patients will also be unable to cross their fingers in a 'good luck' sign.

Answer 312

radial - Brachioradialis

Answer 313

Lumbar disc herniation

Answer 314

supraspinatus, infraspinatus, teres minor and subscapularis.

Answer 315

Cozen's test used to diagnose lateral epicondylitis. Lateral epicondylitis is a tendinopathy involving the common origins of the extensor muscles of the forearm. The muscle most commonly involved is the extensor carpi radialis brevis (ECRB). Pain is on the lateral aspect of the elbow and is worsened by movements that place stress on the tendon of the ERCB such as resisted wrist extension.

Answer 316

It is performed with the patient positioning the affected arm in internal rotation. The examiner then passively brings the affected shoulder to full flexion. A positive test is if there is pain. Shoulder impingement is a tendonitis of the rotator cuff muscles as they pass through the subacromial space. When the arm is raised, the subacromial space narrows causing impingement of the tendon and pain to the patient.

Answer 317

Open repair with internal fixation and cancellous screws

Answer 318

require surgical fixation

Answer 319

Quervain's tenosynovitis

Answer 320

Swelling over the posterior aspect of the elbow. There may be associated pain, warmth and erythema. It typically affects middle-aged male patients.

Answer 321

back pain, neuropathic pain and symptoms mimicking claudication. Sitting is better than standing and patients may find it easier to walk uphill rather than downhill.

Answer 322

verapamil is contraindicated - likely to precipitate severe hypotension, ventricular fibrillation or cardiac arrest

Answer 323

polycystic kidney disease

Answer 324

should never be taken concurrently - possibility of heart block and fatal arrest