Emergency And Ward Medicine

Question 1

Important differentials for acute lower abdo pain in any woman of childbearing potential?

Answer 1

GI stuff
Ectopic pregnancy
Ruptured ovarian cyst, ovarian torsion (ovarian accident)
(Miscarriage)

Question 2

5 step approach to ABGs?

Answer 2

Patients clinical picture
Oxygenation
pH
Respiratory component - CO2 as marker of ventilation
Metabolic component - bicarbonate and base excess

Question 3

What indicates respiratory involvement on an ABG? How?

Answer 3

CO2 - if it is in the ‘expected direction’ e.g. High in an acidosis then it is a respiratory acidosis, if in the ‘opposite’ direction it is a compensatory change for a metabolic disturbance

Question 4

Describe the role of base excess in ABGs?

Answer 4

Essentially the CO2 equivalent for metabolic disturbance - if in the ‘expected direction’ of pH change then it is a metabolic disturbance (e.g. Negative = metabolic acidosis)

Question 5

2 important causes of coma + sweating?

Answer 5

Sepsis

Hypoglycaemia

Question 6

What does the serum anion gap represent?

Answer 6

The unmeasured anions - albumin, phosphate, sulphate, lactate, ketoacids

Question 7

KLAPS of unmeasured anions?

Answer 7

Ketoacids
Lactate
Albumin
Phosphate
Sulphate

Question 8

2 causes of a low anion gap?

Answer 8

Lithium toxicity

IgM/IgG multiple myeloma

Question 9

5 causes of a raised anion gap?

Answer 9

Ketoacids - alcohol or DM
Lactate (sepsis)
Sulphate/phosphate - AKI
Uraemia

Question 10

Which type of bilirubin is water soluble and therefore detectable directly and visible in urine?

Answer 10

Conjugated

Question 11

What does bilirubinuria suggest?

Answer 11

Conjugated bilirubin (as this is the only type that is water soluble) - cholestasis

Question 12

3 causes of isolated raised ALP?

Answer 12

Paget’s disease
Normal pregnancy
Bony mets/blastic lesions e.g. Breast, prostate cancer

Question 13

2 causes of a low ALP?

Answer 13

Hypothyroidism

Pernicious anaemia

Question 14

Metabolic cause of a really really low ALP in the context of acute liver failure?

Answer 14

Willsons disease

Question 15

2 causes of an isolated raised AST?

Answer 15

Rhabdomyolysis

Acute MI

Question 16

What does a raised ALT and AST with a predominant AST suggest?

Answer 16

Alcoholic disease

Question 17

5 major causes of a macrocytic anaemia?

Answer 17

Pernicious
Other B12/folate def
Alcohol
Hypothyroidism
Reticulocytosis

Question 18

5 SIRS criteria?

Answer 18

HR > 90
RR > 20
Temp >38.3 or 12000 or

Question 19

What blood abnormality may be present in non-diabetics in the context of SIRS?

Answer 19

Raised BM

Question 20

What is severe sepsis?

Answer 20

SIRS + bacteraemia + end organ damage

Question 21

Signs of severe sepsis?

Answer 21

Hypotension and reduced urine output
Bounding pulse, increased CRT
Mottling, clotting dysfunction/DIC

Question 22

2 criteria for septic shock?

Answer 22

Persistent hypotension in spite of adequate fluid resus

Organ hypoperfusion as evidenced by lactate >4

Question 23

Warm vs cold shock?

Answer 23

Warm shock is early; bounding pulse, peripheral vasodilation and warmth
Cold shock is late; relative hypoperfusion and peripheral shutdown

Question 24

What type of shock is septic?

Answer 24

Distributive

Question 25

What is the sepsis 6?

Answer 25

``` High flow O2 via non-rebreathe mask IVT IVAbx Take blood cultures Take lactate Measure urine output ```

Question 26

Endocrine complication of septic (typically meningeal) shock?

Answer 26

Waterhouse-Friedrichson syndrome - bilateral adrenal haemorrhage

Question 27

Describe foot associated with autonomic neuropathy?

Answer 27

Dry (reduced sweating) | Bounding pulses due to peripheral vasodilation

Question 28

What is Charcot arthropathy?

Answer 28

Sensori-autonomic neuropathy | Hypervascularisation making unstable and easily fractured

Question 29

Describe an acute Charcot joint?

Answer 29

Hot, red, swollen in DM patient ddx septic, osteomyelitis, DVT, cellulitis, gout Warm with bounding pulses, 'painful' in a neuropathic foot

Question 30

Most important management of an acute Charcot joint?

Answer 30

Offload - air cast | To prevent arch collapse, subluxation of Ts and MTs, 'rocker bottom foot'

Question 31

How long do you have to wait post-bronchodilator to assess asthma reversibility via PEFR?

Answer 31

20 mins

Question 32

SPACESPIT for describing lumps?

Answer 32

``` Size and Shape Position Attachments and skin changes Consistency Edge Surface Pulsatile? Inflammation? Transillumination? ```

Question 33

3 crystalloid fluids?

Answer 33

Normal saline Dextrose/dexsaline Hartmanns

Question 34

2 colloid fluids?

Answer 34

Albumin | Blood products

Question 35

Extrinsic RFs for pressure ulcers?

Answer 35

``` Heat Friction and shearing Uniaxial pressure Moisture Posture ```

Question 36

Intrinsic RFs for pressure ulcers?

Answer 36

``` Immobility Infection Incontinence Sensory loss Old age Poor nutrition Chronic disease ```

Question 37

What is a grade 1 pressure ulcer?

Answer 37

Intact skin with patch of non-blanching erythema, typically over bony prominence

Question 38

What scoring systems are used to assess RFs for pressure ulcers?

Answer 38

Braden score | Waterlow

Question 39

What is a grade II pressure ulcer?

Answer 39

Partial thickness skin loss, involving epidermis and or dermis Or intact/open blister

Question 40

What is a grade 3 pressure ulcer?

Answer 40

Full thickness skin loss, damage or necrosis of subcutaneous tissue down to but not through underlying tissue

Question 41

What is a grade 4 pressure ulcer?

Answer 41

Skin loss through full thickness of skin, extensive destruction and necrosis to underlying bone, tissue muscle or joint capsule. +/- Slough and eschar

Question 42

What is erythema nodosum?

Answer 42

Painful raised rash on lower limbs

Question 43

Normal QRS interval length?

Answer 43

Less than 0.12s

Question 44

Drop of BP by how much is postural hypotension?

Answer 44

At least 20/10

Question 45

When should BP be measured when checking for postural hypotension?

Answer 45

Lay down for 5 mins then measure Stand up for 1 min then measure Measure after 3 mins of standing

Question 46

How long is a urine sample valid to be tested for after it is produced?

Answer 46

4 hours

Question 47

How big suggests small bowel dilatation? How do you know it's small bowel?

Answer 47

Over 3cm | Valvulae coniventes thoughout thickness

Question 48

How big suggests large bowel dilatation? Caecum? How do you know it's large bowel?

Answer 48

6cm normally, 9cm for caecum | Has haustra transversely (makes little houses) not through full thickness and taenia coli longitudinally (big long worm)