Emergency Medicine

Question 1

Local anaesthetic toxicity

Answer 1

Symptoms of LA Toxicity:
- Light headedness
- Tongue numbness
- Tinnitus
- Visual disturbance
- Circumoral numbness
- Muscular twitching
Signs of LA Toxicity:
- confusion
- Respiratory arrest/ Bradypnea
- Convulsions
- Hypotension, Bradycardia
- Decresed GCS/ COMA
- Tachycardia if with adrenaline
Rx = intralipid 1-1.5 ml/Kg

Question 2

Brown-Sequard syndrome?

Answer 2

Brown-Sequard syndrome:
Cause-transaction of lateral half of the spinal card by bullet or stab wound.
Ipsilateral upper motor neuron weakness
Ipsilateral loss of vibration, joint position; proprioception senses
Contra lateral loss of pain and temperature, often 1/2 levels below injury

Question 3

Central Cord Syndrome?

Answer 3

Central cord syndrome:
Most often seen in older people due to hyper extension of neck
May not have a fracture on X-rays
Caused by compromise of anterior spinal artery supplying central cord
Motor weakness of the arms in greater than lower limbs
Variable sensory loss, cape like
Upper limb areflexia
Horner’s syndrome- meiosis, loss of forehead sweating, ptosis

Question 4

Anterior cord syndrome?

Answer 4

Anterior Cord Syndrome:
Usually causes by vascular insufficiency(ASA) due to disc herniation or tumor
Bilateral para paresis
Loss of pain & temperature bilaterally
Preserved dorsal column function(proprioception & vibration)

Question 5

Features of neurogenic shock in spinal injury?

Answer 5

Neurogenic Shock features:
- Hypotension due to loss of vascular tone, sympathetic loss
- Bradycardia or lack of appropriate tachycardia
- Flaccid paralysis below level
- priapism, at least initially
- preserved anocutaneous and bulbocavernosus reflexes
- abdominal breathing if loss of diaphragm nerves, phrenic, C3C4C5

Question 6

Autonomic dysreflexia?

Answer 6

Autonomic Dysreflexia:
- occurs after spinal injury when reflexes are returning ie long after
- only seen in paraplegia with injury higher than T6 or tetra plegia
- Some stimulus starts it like: constipation/ bone fracture/ painful stimulus/ blocked urine cath
- features: Sudden severe Hypertension, Headache, flushing, sweating, Mydriasis
- Correct stimulus cause
- Treat HTN with nitrates, Nifedipine

Question 7

C spine assessment?

Answer 7

C spine assessment in trauma:
- Anterior vertebral line
- Anterior spinal Line
- Posterior spinal Line
- Spinous processes line
- Pre dental space < 3 mm
- Anterior to C3 space < 7mm
- Anterior to C7 space < 30 mm

Question 8

Rule of nine for burn estimation?

Answer 8

Rule of nine for estimation of burns:
Head = 9%
Each Arm = 9%
Each Leg = 18% (9 front, 9 back)
Front of trunk = 18%
Back of trunk = 18%
Perineum = 1%

Question 9

Depth of burns

Answer 9

Depth of burn estimation:
First Degree (Superficial):
- Damage to epidermis only
- Red and dry
- Blanch with pressure
- Very painful
- Heals within 10 days, no scarring

Second Degree (Partial thickness)
- Damage to epidermis and dermis
- Blisters and edema
- Painful
- Healing occurs in 14 days
- depigmentation may occur
- May require skin grafting

Third Degree (complete thickness):
- Loss of all layers of skin
- Dark and leathery or waxy white
- Painless, nerves lost
- No blanching
- skin grafting required

Question 10

Parkland formula for fluids in burns case?

Answer 10

Parkland formula for estimation of fluid resuscitation in first 24 Hrs of at least 15% or more burns is as:

Total fluid to give = % Burns x Wt (kg) x 4

Half given = in 8 Hrs
Rest Half given = over 16 Hrs

Example:
Fluid: = 30% x 70 (kg) x 4 = 8400 ml
Give 4200 ml in 8 Hrs i.e. at 525 ml/Hr for 8 Hrs
Then give 4200 in 16 hrs i.e. at 262.5 ml per hr for 16 hrs

Question 11

Complications of electrical burns?

Answer 11

Complications of electrical burns:
*Musculoskeletal = Fractures, dislocations, myonecrosis, compartment syndrome
*Neurological = Convulsions, coma, headache, transient paralysis, peripheral neuropathy
*Metabolic = rhabdomyolysis, renal failure
*Cardiac = arrhythmias, cardiac arrest, myocardial damage
*Ophthalmic = cataracts, Glaucoma

Question 12

Hydrofluoric acid burns

Answer 12

Hydrofluoric acid burns: symptoms, signs, treatment:
Symptoms: burns at site, delayed and prollonged due to deep penetration. Fluoride ions chelates calcium in tissues causing severe hypocalcemia leading to other effects.
Signs: of tetany, arrhythmia’s, tissue necrosis with severe pain, convulsions, CNS depression, myoclonus
Treatment: Opioids for analgesia, copious irrigation for 30 minutes, Local OR iv Calcium Gluconate 10%

Question 13

What is Muir-Barclay formula for fluid in burns?

Answer 13

Muir-Barclay formula gives amount of fluid to be given as one aliquot in burns:
Fluid = 1/2 x % Burns x Wt (kg) = one Aliquot fluid in ml
Example:
1/2 x 20% x 60 = 600 ml over 4, 4, 4, 6, 6, 12 Hours, (every time 600 ml)

Question 14

Gustilo classification of open fractures

Answer 14

Gustilo classification of open fractures:
Type I = open fracture + wound < 1 cm & clean

Type II = open # + wound > 1 cm & no avulsion/flaps or extensive soft tissue damage

Type III-A = High energy trauma responsible but bone is covered

Type III-B = Open # + extensive soft tissue loss, peri osteal stripping and loss of bone

Type III-C. = Open # + arterial injury requiring repair

Question 15

What are the 6P’s of compartment syndrome?

Answer 15

6 P’s of compartment syndrome:
- Pain out of proportion at rest and on passive stretch
- Paraesthesia (late sign)
- Pallor
- Paralysis (late signs)
- Pulse less limb (late sign)
- Poikilothermia
Note - if difference between intra compartmental pressure and diastolic blood pressure is < 30 mm Hg - then fasciotomy is required.

Question 16

What are various methods for reduction of dislocated shoulder?

Answer 16

External Rotation method: Hold arm in adduction and close to patient’s body - flex elbow to 90 degrees - hold wrist of patient and rotate externally while holding arm in adduction, close to body.

Kocher’s Method: flex the elbow to 90 degree and apply downward traction on humerus - EXTERNALLY rotate the shoulder to bring the head of humerus forward - Pull the elbow across the patient’s body adducting the shoulder and then internally rotate the arm.
# Milch Method: With the patient supine - arm is externally rotated - then abducted over the patient’s head while maintaining external rotation - gentle force can be applied over head of humerus by operators thumb in axilla
#Stimpson’s Method: Patient prone on trolley - with affected arm hanging off the bed - Apply a weight to the wrist to provide slow traction. - Gravity will reduce dislocation (posterior one)
# Cunningham method: Patient sitting with clinician sitting opposite to him - Rest the patient hand off the affected arm on the clinician’s shoulder - clinician rests one of their arm in patient anti-cubital fossa - gently massages shoulder area and patient is encouraged to pull their shoulder blades together thus moving their scapula out of way and thus aiding reduction.

Question 17

Monteggia fracture dislocation

Answer 17

Monteggia fracture dislocation:
Fracture of shaft of ulna with dislocation of radial head. A line through radial shaft should normally pass through capitellum and is disturbed in monteggia type ie doesnt pass throught capitellum. - needs ORIF.

Question 18

Galeazzi fracture dislocation

Answer 18

Galeazzi fracture dislocation:
fracture of shaft of radius with distal dislocation of radio-ulnar joint - needs ORIF.

Question 19

Colle’s fracture

Answer 19

Colle’s fracture:
distal radius bone fracture with dorsal angulation of distal piece. Happens when fall on out-stretched hand (FOOSH)- can be reduced in ER under hematoma block or Bier’s block.

Question 20

Smith’s fracture

Answer 20

Smith’s fracture:
fracture of distal end of radius (as in colle’s) but with volar displacement - needs ORIF.

Question 21

Jefferson Fracture of C1

Answer 21

Most common vertebral fracture of C1
Usual mechanism is axial loading which occurs when a large load falls vertically on head or patient lands on top of his head in a neutral position
Involves disruption of both anterior and posterior rings of C1 with lateral displacement of lateral masses. both seen in open mouth view of C1C2

Question 22

Barton’s Fracture

Answer 22

Barton’s fracture:
intra-articular fracture involving only the distal radius. Fractured piece of radius tends to displace in volar direction and is unstable - needs ORIF

Question 23

Lunate and perilunate dislocations?

Answer 23

Lunate and Peri-Lunate dislocations = Distal radius, lunate and capitate articulate with each other and all lie in straight line in lateral wrist xrays.

Lunate Dislocation:
- Lunate dislocates anteriorly
- concavity of lunate is empty on lateral view
- radius & capitate remain in straight line lateral view
- Lunate appears triagular on AP view
- Can leads to AVN, Median injury, complex pain syndrome

Peri-Lunate dislocation:
- whole carpus except lunate is displaced posteriorly
- radius and lunate remain in straight line
- hand is very swollen
- Scaphoid is usually fractured as well
- concavity of Lunate is empty

Question 24

Bennet’s fracture dislocation

Answer 24

Bennet’s fracture dislocation:
results typically from a fall onto thumb or from a blow onto closed fist around thumb - fracture through base of first ie thumb metacarpal with radial pull due to Abductor Pollicis Longus muscle.

Question 25

Garden classification of neck of femur fracture

Answer 25

Garden classification of femur neck fracture: Garden I: trabeculae angulated, but inferior cortex intact, no displacement Garden II: trabeculae in line but a fracture line visible from superior to inferior cortex, no displacement Garden III: obvious complete fracture line with slight displacement and/or rotation of femoral head Garden IV: Gross, often complete displacement of femoral head

Question 26

Ottawa knee rules and ankle rules

Answer 26

Ottawa knee rules: Do knee radiographs only if any of following is present - age 55 yrs or older - isolated patella tenderness - Tenderness of head of fibula - inability to bear weight immediately and in ED

Question 27

Monoarthritis differentials

Answer 27

Differentials to consider for monoarthritis: - Septic arthritis - Haemarthrosis - Crystal Synovitis: Gout, Pseudogout, Calcific, - Osteoarthritis - Reactive: with urethritis, Conjunctivitis, Skin rash, Enthesopathy - Neuropathic - Charcot's - Synovial: pigmented villonodular synovitis, - Enteropathic: with SLE, Sarcoidosis, IE, foreign body (thorn) - Monoarticular presentation of RA/Psoriasis, Ankylosis, etc

Question 28

Polyarthritis causes

Answer 28

Causes of polyarthritis: - Rheumatoid arthritis - Ankylosing spondylitis - Psoriatic arthritis - Reactive arthritis - Rheumatic fever - Gonococcal arthritis - Viral Arthritis - Gout

Question 29

Causes of septic Arthritis: SHANGS

Answer 29

SHANGS - mnemonic for septic Jts Staphylococcal aureus Haemophillus - 6 to 24 month olds Aerobic Gram negative rods Pseudomonas, Enterobacter Neisseria gonorrhea Group B streptococci Streptococcus viridans or pneumoniae

Question 30

Causes of Hyperuricemia

Answer 30

1. Increased Urate production: - Myeloproliferative disorders - High purines: beer, meat - Cytotoxic drugs - chemo - Trauma, Exercise, Alcholism 2. Decreased urate excretion: - Idopathic - Enzyme defect: Lesch-Nyhan syndrome - Renal Failure - Drugs: Diuretics, Low dose ASA

Question 31

Risk factor for PseudoGout development?

Answer 31

Pseudogout that is precipitation of calcium pyrophorphate in joints is seen with: - Hyper-para-thyroidism - Haemochromoatosis - Hypo-thyroidism - Hypo-magnesemia - Hypo-phosphatemia - Acromegaly - Diabetes mellitus - Any long standing arthritis-RA, AS, OA

Question 32

Sero-negative Arthritis

Answer 32

Sero-negative Arthritis conditions: (REAP-U) - Reactive arthritis - Enteropathic arthritis - Ankylosing spondylitis - Psoriatic arthritis - Undifferentiated spondyloarthropathy Common Features: = HLA B27 positivity = Axial spine, SA Jt involvement = Tendon insertion enthesitis = RA factor negatives

Question 33

Features of ankylosing spondylitis?

Answer 33

Ankylosing spondylitis: Presentation in low back pain in MEN 15-30 year old, - bamboo spine-fused spine with kyphosis - Q mark posture - Restrictive Pulmonary disease - Restricted neck movements, difficult intubation - Uveitis - Lung fibrosis - Aortitis - Plantar fascitis - achilles tendonitis

Question 34

Features of reactive arthritis (Reiter's syndrome)

Answer 34

Reactive Arthritis (reiter's): Urethritis: dysuria, frequency, urgency, urethral discharge, circinate balanitis Arthritis: asymmentric & arthralgia, Jt swelling of knees, ankle, feet Conjunctivitis+Uveitis: redness, pain, irritation, watering, photophobia Keratoderma blenorrhagicum: small hard nodules on palm, soles Mouth Ulcers: Cardiac: AR, Myocarditis

Question 35

Rheumatoid Arthritis featurres

Answer 35

**Features of RA: ** - 70% RA factor positive - MCP and PIP joint inflammation, ulnar deviation, volar subluxation at MCP jts - Boutonnier & swan nek deformity finger and Z thumbs - Degeneration of transnverse ligament of odointoid peg - more subluxation risk - Subcut rheumatoid nodules, mostly elbows - nail fold infarcts - livedo reticularis - Pulmonary fibrosis and plerisy - pericarditis, endocarditis - Anemia, spleenomegaly, scleritis

Question 36

Cauda Equina Syndrome

Answer 36

Features of cauda equina are according to nerve roots compressed, L1-L5 & S1-S5: L1:- Groin sensation loss L2:- Sensation to medial prox thigh, Hip flexion L3:- Distal thigh, knee, knee Jerk L4:- medial lower Leg, Knee jerk, Ankle Dorsiflex L5:- Lateral low Leg, Great Toe, Great Toe Ext S1:- Lat foot, Little toe, Ankle jerk, Plantar fkex S2:- Sensation to Posterior thigh Bladder disturbance: S2S3S4 Bowel disturbance: S2S3S4

Question 37

Anatomical Snuff Box

Answer 37

**Borders of Anatomical snuff Box: ** Ulnar side - EPL tendon Radial side - APB, APL tendons Proximally - Radial styloid process Distally - Base of thumb metacarpal Floor - scaphoid and trapezium Contents - radial artery

Question 38

Intrinsic Muscles of Hand

Answer 38

**Intrinsic Hand muscles: **- **Interossei** - 4 dorsal + 3 palmar (ulnar n) - flex MCP and extends IP joints, Palmar adducts, Dorsal ABducts (PAD DAB) - **Lumbricals** - 4, flexes MCP, extends IP, 1+2 by median nerve, rest ulnar nerve - **Thenar muscles**: APB, FPB, OP, adductor pollicis (first 3 by median, AddP by ulnar) - **Hypothenar muscles**: Abd digiti minimi, FDMinimi, OPDminimi, all by Ular nerve

Question 39

Carpal Tunnel anatomy

Answer 39

**Carpal Tunnel anatomy: **Flexor retinaculum runs from - **Ulnar side** - Pisiform, hamate **Radial side** - Scaphoid, Trapezium **Contents** -nine tendons + median nerve FDP - 4 tendons FDS - 4 tendons Flexor pollicis longus - 1 tendon Superficial to CT & Flexor retinaculum is Guyon's canal containing Ulnar nerve & artery.

Question 40

Median Nerve Injury

Answer 40

**Median Nerve injury** *at Thumb:* Loss of sensation on radial 3& 1/2 fingers (thenar eminence sensations preserved as palmar cutaneous branch doesnot pass through Carpal tunnel) Weakness of thenar muscles and loss of flexion at MCP + PIP + DIP joints - ape Hand (except at little finger) *in the Forerarm:* Hand of benediction,1, 2, 3 fingers do not flex Weakness of wrist flexion+ pronation Loss of flexion@ PIP jts of radial 4 fingers Loss of Flexion @ DIP jts of radial 4 fingers

Question 41

Kanavel's Signs | Signs of finger tendon sheath infection

Answer 41

Kanavel's Signs: 1. Tenderness along course of flexor tendon 2. symmetrical edema of the finger 3. Pain on passive extension of finger 4. Flexed resting posture of finger Tendon sheath of thumb & little fingers of continuous with radial & ulnar bursa & infections can go to carpal tunnel.

Question 42

Accidental digital injection of adrenaline

Answer 42

Managing accidental digital injection of adrenaline: - Insert finger in warm water - apply Topical or IV GTN - local infiltration of pentolamineC(Alfa blocker)

Question 43

Medical Cause of acute Abdomen

Answer 43

Medical Causes of Acute Abdomen: Cardio-respiratory: - Inferior STEMI - Pericarditis - Lower Lobe Pneumonia - Pulmonary embolism Metabolic: - DKA - Addison's crisis - Acute intermittent porphyria - Hyperlipidemia - Familial mediterranean fever Drug Induced: - opioid withdrawal - Lead poisoning Haematological: - Sickle cell crisis - Acute leukemia CNS conditions: - herpes zoster - Nerve Root compression

Question 44

What is Charcot's triad?

Answer 44

Charcot's Triad: Obstruction of the CBD leads to biliary stasis & a predisposition to the bacterial infection ascending from duodenal ampulla. Classic presentation of ascending cholangitis is charcot's triad and is: - Fever - Jaundice - RUQ Pain abdomen Note - approx 10% of GB stones are radio-opaque.

Question 45

Courvoisier's Law?

Answer 45

Courvoisier's Law states that - in the presence of jaundice, if gallbladder is palpable, the cause if UNLIKELY to be a GB stone. Suspect pancreatic carcinoma.

Question 46

Causes of Acute Pancreatitis - GET SMASHED

Answer 46

GET SMASHED - causes of pancreatitis G - Gallstones E - Ethanol consumption T - Trauma to abdomen S - Steroids M - Mumps + CMV, EBV A - Autoimmune S - Scorpion venom, rare H - Hyperlipid,Hypocalcemia,High Temp E - ERCP procedure side effect D - Drugs - Azathioprine, Statins, Estrogens, Thiazides, Valproate I - Idiopathic P - Pregnancy

Question 47

Glasgow scoring for acute Pancreatitis

Answer 47

Glasgow scoring for acute pancreatitis to predict severity of disease: Age - > 55 YRS WBC - > 15 K Glucose - > 10 mmols Urea - > 16 mmols PaO2 - < 8 kPa Corrected Calcium - < 2 mmols Albumin - < 32 Gms/Lit LDH Levels - > 600 Units/L AST/ ALT - > 100 Units/Lit

Question 48

Complication of Acute Pancreatitis

Answer 48

Complication of Acute Pancreatitis: 1. Local complications: - Pancreatic necrosis/ abscess - pancreatic pseudocyst - Ascites - Biliary obstruction - Portal vein thrombosis - paralytic ileus - GI Haemorrhage 2. Systemic complications: - ARDS - Hyperglycemia - Hypocalcemia - Acute Kidney injury, DIC - Sepsis, Multi-organ failure, Death

Question 49

Alvorado score for Appendicitis

Answer 49

Alvorado score: appendicitis: MANTRELL M = Migration of pain to RIF A = Anorexia N = nausea, vomiting T = tender RIF R = Rebound tenderness , 2 points E = Elevated Temp >37.3 L = Leucocytosis L = Left shift Leucocytosis 5/6 - maybe, 7/8 - probable, 9/10 - likley

Question 50

Causes of small bowel obstruction

Answer 50

Causes of small bowel obstruction: > 3 cm diameter in AXR centrally - Adhesions - Hernias - Crohn's disease - Gallstone ileus - Tumor - intussusception - Foreign boodies

Question 51

Causes of Large bowel obstruction

Answer 51

Causes of Large bowel obstruction: - Volvulus: Sigmoid or Caecal - Hernia's - Adhesions - inflammatory bowel disease - Tumor - Fecal impaction - Diverticulitis > 5 cm diameter in AXR peripherally

Question 52

Causes of functional bowel obstruction

Answer 52

Causes of Functional Bowel Obstruction - Hypokalemia - Hyponatremia - Hypomagnesemia - Intestinal Ischaemia - Intra-abdominal infection - Trauma - Pseudo-Obstruction - TCA's use

Question 53

AAA suspect, work up

Answer 53

AAA features: - pulsatile mass in abdomen, central - Left renal colic + hematuria like - Sudden Hypotension, PEA - Absent one or both femoral pulses - Retro peritoneal haemorrhage Aorta diameter at various levels: - at diaphragm: 2.5 cm - at Renal artery: 2 cm - At bifurcation level - 1.5 to 2 cm - Iliac arteries just distal - origin 1.5 cm CT Aortic diameter > 3 cm is aneurysm

Question 54

Aortic dissection types

Answer 54

Classification of aortic dissection: 1. Stanford System: Type A - involvement of ascending aorta and aortic arch Type B - descending aorta involvement distal to the origin of left subclavian artery 2. DeBakey System: Type I: - dissection originates in ascending aorta and spread to whole aorta Type II: - Originates & confined to ascending aorta/ arch Type III: - involves only descending aorta

Question 55

Risk factors for Aortic dissection

Answer 55

Risk factor for aortic dissection: - Hypertension - Connective tissue diseases- EDS, Marfan's - Bicuspid aortic valve - Coarctation of aorta - Cocaine abuse - Giant cell arteritis - Iatrogenic CAG, CABG

Question 56

Suspect Aortic dissection

Answer 56

Suspect aortic dissection if: - tearing interscapular, chest pain - unequal pulses - Pulsus paradoxus + Distended neck veins + Quiet heart sounds tamponade - AR murmur - More than 20 mmHg BP diff between arms - New neuro signs due to cord ischemia - complication signs

Question 57

Radiological signs of Aortic dissection

Answer 57

Radiological signs of Aortic dissection - widened mediastinum - Loss of aortic knuckle - Pleural cap - Pleural effusion - Right sided deviation of trachea - Right sided NGT deviation - Left mainstem bronchus pushed inferiorly - Calcium sign - separation of calcified aortic walls - Globular heart s/o hemopericardium - aortic wall thickening > 15 mm - ECG may show STEMI/ nonSTEMI/ LVH - Trans-esophageal ECHO confirms -

Question 58

Pre-renal & renal causes of Hematuria

Answer 58

Pre-renal causes of hematuria: - sickle cell disease - Leukemia - Anticoagulation - Exercise induced - Infective endocarditis Renal causes of Hematuria: - Glomerulonephritis - Malignancy - renal trauma - Calculus - Polycystic disease - Pyelonephritis - Ruptured AAA

Question 59

Other causes of Hematuria: Ureteric-Bladder-Urethral?

Answer 59

Ureteric causes of Hematuria: - Calculus, - Carcinoma - Schistosomiasis Bladder Causes of Hematuria: - UB, Prostate malignancy - BPH - Calculus, UTI, Trauma Urethral causes of hematuria: - Malignancy - Calculus - Foreign body

Question 60

Coloured Urine, no blood

Answer 60

Colored Urine without blood - Myoglobin - Porphyria - Beetroot - Rifampicin - Doxorubicin

Question 61

Hematuria in children

Answer 61

Hematuria in children - UTI - Trauma - Glomerulonephritis - Wilm's tumor - Bleeding diasthesis - Urinary tract stones - Exercise - Foreign bodies - Factitious

Question 62

Renal stones

Answer 62

Renal stones: - calcium oxalate 80% - HyperPTH, Oxaluria, RTA - Calcium Phosphate, - High PTH, RTA - Mg-NH3-Phosphate - Proteus UTI - Uric acid stones in Gout - Cystine stones

Question 63

Causes of priapism

Answer 63

Causes of Priapism: - Iatrogenic - papaverine, Alprostadil intracavernosal injections - Blood disorders: SCD, Myeloma, Leukemia - Pelvic Trauma - Spinal cord injury - Bladder/ prostate malignancy - Cocaine - Idiopathic 40% - Drugs: Chlorpromazine, Fluoxetine, Heparin used in dialysis Rx - Ice packs, Hydration, Oral pseudoephedrine, Oral Terbutaline, Phenylephrine inj in penis, Embolization or surgical ligation of ruptured artery

Question 64

LMN Facial Palsy

Answer 64

LMN Facial palsy causes: - Bell's palsy (idiopathic, viral) - Pontine tumors - Acoustic neuromas at CP angle - Ramsay-Hunt syndrome, Zoster of 7,8 - Trauma, # of base of skull - Middle ear infections, cholesteatoma - Sarcoidosis - Parotid Gland tumors

Question 65

Medications that can induced vertigo

Answer 65

Medicine Classs = Examples Analgesics = codeine Antibiotics = aminoglycosides, macrolides, minocycline, nitrofurantoin, sulfamethoxazole Anticonvulsants = levetiracetam, phenytoin, pregabalin Anti-inflammatories = celecoxib, parecoxib, naproxen, prednisone Antimalarials = mefloquine, quinine, hydroxychloroquine Antivirals = oseltamivir, raltegravir Anti-Parkinson’s drugs = lisuride Cardiovascular drugs = nifedipine, furosemide, indapamide, prazosin, terazosin, glyceryl trinitrate, isosorbide mononitrate, sotalol, timolol Gastroenterology drugs = omeprazole, lansoprazole, sucralfate Rheumatology drugs = zolendronic acid, alendronate Phosphodiesterase type-5 inhibitors: sildenafil, vardenafil Other medicines = lithium, haloperidol, benzodiazepines, desmopressin, melatonin

Question 66

Causes of vertigo

Answer 66

Peripheral vertigo: - BPPV - Vestibular neuritis - Acute Labrynthitis - Cholesteatoma - Otitis media - Menier's disease Central Vertigo: - Stroke, TIA - Acoustic neuroma - CP Angle tumors

Question 67

Dix-Hallpike Manoeuvre

Answer 67

Dix Hallpike Manoeuvre: Step 1 - Sit patient upright and ask to turn head to right side 45 degrees - examiner on right side to patient holding patient's head Step 2 - Quickly place patient in supine position with head extended down the edge of bed by 20 degrees Step 3 - Ask patient to fix vision on your nose - observe 30 seconds for nystagmus Step 4 - Sit the patient up and bring head to neutral position and observes eyes for 30 seconds Repeat Test on other side same way BPPV + if = nystagmus when affected ear is down (like right sided ear down with nystagmus means right BPPV)

Question 68

Epley Manoeuvre

Answer 68

Epley Manoeuvre: = Tilt your head to whichever side is causing vertigo. = Have you quickly lie flat on your back with your head slightly off the edge of the examination table in the same position. (Your vertigo symptoms may worsen during this portion of the procedure.) = Gradually move your head to the opposite side. Rotate the rest of your body so it’s in alignment with your head. = Ask you to remain on your side for a few moments. = Sit you upright.

Question 69

Head Impulse test

Answer 69

Head Impulse test for assessment of vestibular system: 01 - sit face to face in front of patient 02 - ask patient to fix eyes On your nose 03 - hold patient head & move side to side while he keeps eyes fixed onto you 04 - any deviation of eyes laterally along with head movements and then return to examiner’s nose = positive test = indicates vestibular dysfunction

Question 70

Acute angle closure Glaucoma

Answer 70

Features of Glaucoma, Acute angle: - History of blurred vision - Haloes around lights due to corneal edema - Headache and eye pain - Nausea, Vomiting - Decreased visual acuity - Mid dilated fixed pupil - Hazy edematous cornea - Circumferential erythema, ciliary - Raised IOP

Question 71

Iritis, Anterior Uveitis,

Answer 71

Iritis, Anterior uveitis Uveal tract comprises posterior choroid layer and anteriorly ciliary body + iris. - iritis is common with Ankylosing spondylitis, UC, sarcoidosis - also with trauma, surgery, keratitis - HLA B27 association - photophobia, consensual also - painful eye - accommodation increase pain - slit will show cell in AC

Question 72

Scleritis, Episcleritis

Answer 72

Outer Sclera has 3 layers - episclera, Tenon’s capsule and conjunctiva. Scleritis: - deep episcleral plexus inflammation - blueish sclera - pain deep within - painful eye movements - pain on digital palpation - reduced VA - can perforate Episcleritis: - inflamed episcleral plexus - irritation rather than pain - localised - less serious than scleritis Self limiting

Question 73

Orbital cellulitis

Answer 73

Orbital cellulitis - inflammation and infection behind orbital septum means involves orbit itself, commonest cause is streptococcus pneumoniae - painful eye movements - ophthalmoplegia - red desaturation due to neuritis - loss of vision - Proptosis - chemists - conjunctival Edema Complications- - systemic spread - cavernous sinus thrombosis - central retinal artery occlusion - secondary glaucoma - optic neuritis - meningitis - endophthalmitis - osteomyelitis - Death

Question 74

Peri-Orbital cellulitis

Answer 74

Peri-Orbital cellulitis, Involves eye lids & soft tissues anterior to orbital septum, less severe Follows URTI, trauma to lids - eyes features absent as mentioned in orbital cellulitis

Question 75

CRAO versus CRVO

Answer 75

CRAO - arterial - pale retina with cherry spot at fovea - Relative afferent pupillary defect - Rebreather CO2 to dilate retinal artery - sublingual GTN to dilate RetinalArt - massage globe to dislodge emboli - Timolol drops to reduce pressure - IV diamox to reduce eye pressure CRVO - venous: - sunset stormy fundus - dilated tortuous fundus veins - RAPD - risk factors reduction- HTN, chronic glaucoma, Polycythemia,

Question 76

Temporal arteritis

Answer 76

Temporal arteritis: - vasculitis - temporal headaches - scalp tenderness, temporal - Jaw clarification during chewing - red vision desaturation - RAPD - Unilateral blindness - pale swollen optic disc - PMR- malaise, myalgia in shoulders & thighs, weight loss, proximal muscle weakness (difficulty in getting up from chairs)

Question 77

Amaurosis fugax

Answer 77

Amaurosis fugax - is a temporary vision loss, usually 5-20 minutes, due to temporary arterial obstruction which can be due to: - emboli, stroke - atheromatous disease - acute angle closure glaucoma - raised ICT - hypercoagulability

Question 78

Le forte facial fracture classification

Answer 78

Classification of facial fractures Le forte 1 = involves tooth bearing portion of the maxilla. There may be associated split in hard palate, hematoma of the soft palate and malocclusion Le forte 2 = involves maxilla, nasal bone & medial orbit. Floating maxilla and possible airway obstruction. Le forte 3 = involves maxilla, zygoma, nasal bones, ethmoid and base of skull. Nasoethmoidal fractures results in splaying of the nasal complex and a saddle shape nose deformity. These will be significant pre orbital bruising & may be associated with supra orbital or supracochlear hypoesthesia

Question 79

Contraindications to LP include:

Answer 79

Contraindications to LP include: raised intracranial pressure coagulation abnormalities suspicion of spinal epidural abscess infection at the LP site uncontrolled convulsions ———————— The spinal cord ends at L3 in newborns, so the lumbar puncture should be performed at the top of the iliac crest, L3/4 or L4/5 intervertebral space. Usually, the L2/3 and L3/4 levels are preferred for LP in adults

Question 80

Tripod fractures of face Orbital fracture signs

Answer 80

Tripod fracture of face involves 3 sutures: = Zygomatico-temporal = Zygomatico-frontal = infra Orbital foramen Signs of orbital fracture due to direct trauma: Tear Drop Sign - tissue herniating from orbit into maxillary sinus roof seen in xrays as tear drop Eye Brow Sign - air around superior orbit due to maxillary sinus fracture noted in xrays around at at eye brow areas

Question 81

Zones of neck for injury assessment

Answer 81

Zones of neck and structures at risk: Zone 01 = clavicle to cricoid cartilage, structures at risk are: subclavian vessels, brachocephalic vessels, CCA, Aortic arch, Jugular veins, trachea, C spine, Lung apices, Spinal cord and nerve roots Zone 02 = Cricoid to angle of jaw = structures at risk are: Carotid arteries, vertebral arteries, Jugular veins, pharynx, larynx, trachea, esophagus, C spine, Spinal cord Zone 03 = from angle of mandible to skull base = structures at risk are = salivary, parotid glands, esophagus, trachea, vertebral bodies, carotid arteries, jugular veins, cranial nerves 9-12

Question 82

Features of PID

Answer 82

Features of PID: - Lower abd pain and tenderness, usually bilateral - Fever > 38c - abnormal vaginal discharge - cervical motion tenderness on bimanual exam - Deep dyspareunia - abnormal vaginal bleeding, intermenstrual, post-coital - Adnexal mass and tenderness - Fitz-Hugh-Curtis syndrome: peri hepatitis in PID, RUQ pain Rx - 1. Oflox 400 BD + Flagyl 400 BD x 14 days 2. IM Ceftriaxone 500 mg then Flagyl + Doxy x 14 days

Question 83

Emergency contraception

Answer 83

Emergency contraception options: 1. Oral - Levonorgestrel and Ulipristal Levonorgestrel - 1.5 mg upto 72 hrs Ulipristal - 30 mg upto 120 Hrs Contraindications: - severe Liver disease - Porphyria, Migraine, Pregnancy, Malabsorption 2. Cu-IUCD - upto 5 days (120 Hrs) - 98% effective - risk of uterine perforation, PID, Ectopics, etc

Question 84

Types of Miscarriages

Answer 84

Types of Miscarriages - Loss of pregnancy prior to 24 weeks. 1. Threatened Miscarriage - PV bleeding but cervical Os closed. 2. Inevitable Miscarriage - PV bleeding with open cervical Os 3. Incomplete Miscarriage - PV Bleed but not all products passed 4. Missed Miscarriage - silent loss of pregnancy and directly noted in Ultrasound only 5. Miscarriage with infection 6. Complete Miscarriage

Question 85

Gestational Tropoblastic Disease

Answer 85

Gestational trophoblastic disease - occasionally fertilized ovum may form abnormal ovum instead of fetus and has two forms: 1. Hydatidiform mole - bening 2. Choriocarcinoma, malignant - excessive beta HCG causes hyperemesis gravidarum - PV bleeding by 12-16 weeks - passage of frog spawn like PV tissue - USG: snowstorm appearance

Question 86

Placenta praevia

Answer 86

Placenta praevia - complete placenta in lower segment of the uterus, if it covers cervical os its called complete otherwise incomplete. Risks of having PP are: - Maternal age > 35 yrs - Multiparity history - Previous PP - Twin pregnancy - Uterine abnormalities Presentation- Bright red painless per vaginal bleeding in 3rd trimester + Labour. Vasa praevia - rare condition in which fetal blood vessels grown within the membranes and over the internal opening(os_) AND HAS RISK OF FETAL BLEEDING WHEN THE MEMBRANES RUPTURE.

Question 87

Kleihauer Test

Answer 87

The KB test is the standard method of quantitating fetal–maternal hemorrhage (FMH). It takes advantage of the differential resistance of fetal hemoglobin to acid. A standard blood smear is prepared from the mother's blood and exposed to an acid bath. This removes adult hemoglobin, but not fetal hemoglobin, from the red blood cells. Subsequent staining, using Shepard's method, makes fetal cells (containing fetal hemoglobin) appear rose-pink in color, while adult red blood cells are only seen as "ghosts". 2,000 cells are counted under the microscope and a percentage of fetal to maternal cells is calculated. In those with positive tests, follow up testing at a postpartum check should be done to rule out the possibility of a false positive. This could be caused by a hemoglobinopathy in the mother which causes persistent elevation of fetal hemoglobin, e.g. sickle cell trait.

Question 88

Cervical Shock

Answer 88

Cervical Shock - is a shock condition in which products of conception during miscarriage gets stuck at cervical Opening - causing intense vagal stimulation leading to bradycardia, hypotension and lower abdomen pain. They need removal of products from internal O S.

Question 89

Rule of 2 of Lumbar Plexus

Answer 89

Rule of 2 of Lumbar plexus 2 roots one supplies 1 action and next 2 other opposite action. At Hip Joint: Flexion by L2L3 - Iliopsoas muscle Extension by L4L5 - Glutes & Hamstrings ---------------------------------- At Knee Joint: Extension: by L3L4 - Quadriceps Flexion: by L5S1 - Hamstrings --------------------------------- At Ankle Joint: Flexion by L4L5 - Dorsiflexion, Posteriaris tibialis extensor Extension: S1S2 - Plantar flexion, Calf muscles

Question 90

Hyperemesis gravidarum

Answer 90

Complications of Hyperemesis gravidarum: - Hyponatremia, AKI - Wernicke's Encephalopathy, thiamine - Mallory weis tear of esophagus - Central pontine myelinolysis - B12, B6 deficiency - Foetal intra uterine growth retardation - Venous thromboembolism - Hypochloremic metabolic acidosis

Question 91

Pre-Eclampsia, Eclampsia

Answer 91

Pre-Eclampsia: triad of - Hypertension > 140/90 - Proteinuria - Leg edema, non specific Eclampsia - add convulsions to above Clinical features: = Malaise = Head ache, blurred vision = RUQ & epigastric pain (Liver edema) = Occipital Lobe Blindness = Clonus, Hyperreflexia = convulsions due to cerebral edema

Question 92

Anti D immunoglobulin guidance

Answer 92

Anti D, when to give: indications when mother is RhD negative blood grp = close trauma to tummy = Antepartum bleeding = IUD = INVASIVE PRE NATAL diagnostic tests = Ectopic pregnancy = Spontaneous miscarriage = Threatened miscarriage =Therapeutic termination of pregnancy = External cephalic versions How much to give: 500 IU at 28 and 34 weeks of gestation 250 IU prophylactic if< 20 wks gestation 500 IU prophylactic if > 20 wks

Question 93

Postpartum Haemorrhage

Answer 93

Primary Postpartum Hemorrhage: within 24 Hrs of delivery, minor 500-1000 ml, major if > 1000 ml = Uterine atony = Retained placenta = Genital tract trauma, cut = DIC ---------------------- Secondary PPH, 24 hrs to 12 weeks = Retained products = Intra-uterine infection = Genital tract trauma = Trophoblastic disease = DIC -------------------------- General Risk factors: - Placental abruption, praevia - Placenta accreta, adherant - Multipara - Pre-eclampsia - Past PPH - Haemophillia - Anti-coagulant use

Question 94

Arrhythmia - AVNRT

Answer 94

AVNRT -AV nodal re-entry tachycardia - accessory re-entery circuit within AV node - In typical AVNRT, retrograde P waves occur early, so we either don't see them (buried in QRS) or partially see them (pseudo R' wave at terminal portion of QRS complex) no short pr or delta waves like WPW MORE COMMON THAN AVRT

Question 95

Arrhythmia - AVRT

Answer 95

AVRT - AV re-entry tachycardia (not nodal) - accessory ciruit is not within AV node - narrow qrs a form of paroxysmal supraventricular tachycardia that occurs in patients with accessory pathways, usually due to formation of a re-entry circuit between the AV node and accessory pathway Can be = Orthodromic AVRT: Anterograde conduction through AV node = Antidromic AVRT: Retrograde conduction through AV node In both forms, the features of pre-excitation are lost

Question 96

Orthodromic AVRT

Answer 96

Orthodromic AVRT: anterograde ECG features of AVRT with orthodromic conduction: = Rate usually 200-300 bpm = Retrograde P waves are usually visible, with a long RP interval = QRS < 120ms unless pre-existing bundle branch block, or rate-related aberrant conduction = QRS alternans: phasic variation in QRS amplitude associated with AVNT and AVRT, distinguished from electrical alternans by a normal QRS amplitude = Rate-related ischaemia is common Orthodromic AVRT, or just AVNRT? This rhythm can appear very similar to AVNRT, but the RP interval can assist us to differentiate: In typical AVNRT, retrograde P waves occur early, so we either don’t see them (buried in QRS) or partially see them (pseudo R’ wave at terminal portion of QRS complex) In AVRT, retrograde P waves occur later, with a long RP interval > 70 msec Treatment of orthodromic AVRT As always, patients that are unstable due to this rhythm require urgent DC cardioversion The anterograde portion of conduction is typically the “weak link” of the re-entry circuit. Management options in the stable patient therefore target slowing conduction through the AV node A stepwise approach similar to AVNRT can be employed, beginning with vagal manoeuvres followed by adenosine and/or verapamil Note that with administration of any AV nodal blocking drug, there is a very small but significant risk of inducing AF. If verapamil is used, patients should be observed for at least 4 hours to ensure AF does not develop as a consequence of AV nodal blockade

Question 97

Antidromic AVRT - resembles VTach

Answer 97

Antidromic AVRT Antidromic AVRT is rare, and makes up only 5% of tachyarrhythmias in patients with WPW. As the name suggests, it involves anterograde conduction via the AP. Retrograde conduction is usually via the AV node, but can also be via another AP. The abnormal direction of ventricular depolarisation results in a broad complex tachycardia, which can be easily mistaken for VT. ECG features of AVRT with antidromic conduction: Rate usually 200-300 bpm Wide QRS complexes due to abnormal ventricular depolarisation via AP Treatment of antidromic AVRT This rhythm can be difficult to distinguish from VT, and if there is any doubt, we should presume a diagnosis of VT and treat accordingly In stable patients, drug therapy should be targeted at the AP Procainamide (class I) would be our first line antiarrhythmic. Ibutilide (class III) and amiodarone are second-line options, but their effectiveness is less established DC cardioversion may still be required if drug therapy fails

Question 98

The re-entry circuit involves the AV node — why can’t we use AV nodal blocking agents?

Answer 98

The re-entry circuit involves the AV node — why can’t we use AV nodal blocking agents? Antidromic AVRT is often associated with a rapidly conducting anterograde AP AV blockade through adenosine may interrupt this re-entry circuit, but as stated above, with administration of any AV nodal blocking agent there is a small risk of inducing AF If this occurs it will likely precipitate cardiac arrest due to rapid conduction via the AP As such, in a stable patient drug therapy should be targeted at the AP

Question 99

WPW Syndrome

Answer 99

WPW Syndrome refers to the presence of a congenital accessory pathway (AP) and episodes of tachyarrhythmias. The term is often used interchangeablely with pre-excitation syndrome. First described in 1930 by Louis Wolff, John Parkinson and Paul Dudley White Incidence is 0.1 – 3.0 per 1000 Associated with a small risk of sudden cardiac death. ---------------------------------- ECG features: - PR interval < 120ms - Delta wave: slurring slow rise of initial portion of the QRS - QRS prolongation > 110ms - Discordant ST-segment and T-wave changes (i.e. in the opposite direction to the major component of the QRS complex) - Pseudo-infarction pattern in up to 70% of patients — due to negatively deflected delta waves in inferior/anterior leads (“pseudo-Q waves”), or prominent R waves in V1-3 (mimicking posterior infarction) APs can be left-sided or right-sided, and ECG features will vary depending on this: Left-sided AP: produces a positive delta wave in all precordial leads, with R/S > 1 in V1. Sometimes referred to as a type A WPW pattern Right-sided AP: produces a negative delta wave in leads V1 and V2. Sometimes referred to as a type B WPW pattern

Question 100

Lown–Ganong–Levine syndrome

Answer 100

Lown–Ganong–Levine syndrome - short PR with pre-excitation due to AV accessory pathway - normal QRS that is no delta wave

Question 101

Sick Sinus syndrome

Answer 101

Sick Sinus Syndrome - also called as Tachy-brady syndrome: due to ischemia, fibrosis or degeneration of SA node. = Sinus pauses of> 2 seconds or sinus arrest. = Junctional or other escape rhythms like AFib might occure causing tachy needs pacemaker

Question 102

Second Degree Heart Block

Answer 102

Second Degree Heart Block: Mobitz Type I(wenkebach) = progressive prolongation of PR interval in ECG followed by a dropped beat Mobitz Type II = no progressive prolongation but dropped beat suddenly, more dangerous, - 2:1, 3:1 or irregular pattern - needs pacemaker

Question 103

Brugada syndrome

Answer 103

Brugada syndrome - = autosomal dominant condition with mutations in SCN5A gene (cardiac sodium channel gene). = 80% developd VT or VF ----------------------------------------- #Type 1 = Coved ST segment elevation >2mm in >1 of V1-V3 followed by a negative T wave. This is the only ECG abnormality that is potentially diagnostic. It is often referred to as Brugada sign. = This ECG abnormality must be associated with one of the following clinical criteria to make the diagnosis: = Documented ventricular fibrillation (VF) or polymorphic ventricular tachycardia (VT). = Family history of sudden cardiac = death at <45 years old . = Coved-type ECGs in family members. = Inducibility of VT with programmed electrical stimulation . = Syncope. = Nocturnal agonal respiration. ------------------------------ #Type 2 = Brugada Type 2 has >2mm of saddleback shaped ST elevation. --------------------------------- # Type 3 = Brugada type 3: can be the morphology of either type 1 or type 2, but with <2mm of ST segment elevation. The only proven therapy is an implantable cardioverter – defibrillator (ICD).

Question 104

Wellens Syndrome

Answer 104

Wellens Syndrome is a clinical syndrome characterised by biphasic or deeply inverted T waves in V2-3, plus a history of recent chest pain now resolved. It is highly specific for critical stenosis of the left anterior descending artery (LAD). The pattern is usually present in the pain free state — it may be obscured during episodes of ischaemic chest pain, when there is “pseudonormalisation” of T waves in V2-3 Wellens syndrome is a key example of why all patients presenting with chest pain must have serial ECGs Type A – Biphasic, with initial positivity and terminal negativity (25% of cases) Type B – Deeply and symmetrically inverted (75% of cases)

Question 105

Transient Loss of consciousness

Answer 105

TrLOC has 3 main causes: 1. Syncope 2. Epilepsy 3. Psychogenic -------------------------- Syncope causes: = Neurogenic reflex mediated - Vasovagal - Carotid Sinus - Situational - cough, micturition = Orthostatic Hypotension - Autonomic = Cardiac causes - Arrhythmias, AS, HOCM, Cardiomyopathy ---------------------------- Also see - Sugar, UPT, HCT%, Postural BP, drug list, Injuries

Question 106

Orthostatic Hypotension

Answer 106

# Primary Autonomic Failure: = Parkinson's disease = Levy body dementia = Multi system Atrophy = Pure autonomic failure # Secondary Autonomic failure: = Diabetes mellitus, long standing = Amyloidosis of chronic diseases = Uremia = Spinal cord injury # Drugs: Ethanol, Diuretics, Anti-HTN, # Dehydration - vomiting, diarrhea, bleeding,

Question 107

ECG Red flags for LOC

Answer 107

ECG red flags in LOC: - Conduction: RBBB, LBBB, blocks - QTc > 450 ms or < 350 ms - Inappropriate persistent Bradycardia - Ventricular arrhythmia, VPC's - Brugada syn. - V1V2V3 concave STE - Pre-excitation-WPW/LGL - short PR, delta waves - RVH OR LVH - Abnormal T wave inversions - Pathololgical q waves - Atrial arrhythmia, sustained - Paced rhythm in ECG

Question 108

Risk scoring-Red flags in LOC

Answer 108

Risks-Red flags in LOC: = ECG abnormalities = Heart failure: History or with signs = LOC during exertion/running/exercise = Family H/o sudden deaths < 40 yrs = No or unexplained SOB = A Heart Murmur = 65 yrs of older without prodromes

Question 109

San Franscisco-CHESS Rule-Syncope

Answer 109

San-Franscisco rule for LOC (CHESS) = Congestive heart failure history = Hematocrit <30% = EKG abnormal (EKG changed, or any non-sinus rhythm on EKG or monitoring) = Shortness of breath symptoms = Systolic BP <90 mmHg at triage

Question 110

Sudden Cardiac Death

Answer 110

Sudden Cardiac Death is within 1 hour of symptoms. It might be due to 1. Structural Heart Diseases or 2. Arrhythmia syndromes 1. Structural Heart Diseases: = IHD associated, reperfusion = DCM: Postpartum, Infection, Autoimmune, Alcohol, Thyrotoxicosis, Idiopathic = HOCM: Genetic, AS, = Valvular Heart disease - Aortic stenosis = Congenital HD: TOF, TOGV, AS, Fontan operation, Marfan syndrome, MVP, Hypoplastic heart syndrome, Eisenmenger syndrome, Ebstein anomaly

Question 111

Sudden Cardiac Death: Arrhythmias

Answer 111

Arrhythmic causes of SCD Long QT syndromes = Inherited: Romano-ward and Jervill-Lange-Nelson syndromes -------------------------------- Acquired Long QT = Drug induced (Quinidine, Amiodarone, Sotalol), TCA, Loratadine, Erythromycin, Phenytoin = Hypo - kalemia/calcemia/magnesemia = Hypothyroidism = Hypothermia = Intracranial haemorrhage: SAH ------------------------------- Short QTc< 0.33 + peaked T waves, K channelopathy ---------------------------- Brugada Syndrome: V1V2V3 ST coving elevation with downsloping ST + inverted T or RBBB without terminal S waves in lateral leads -------------------------------- WPW syndrome - short PR with delta or no delta waves

Question 112

Hypertensive Emergency, Diastolic Blood pressure > 140mmHg, Mean BP = 2x DBP +SBP/all divide by 3

Answer 112

Hypertensive Emergency: = Look for: - Urine blood, proteins - ECG changes of ACS, MI - Fundus for changes, papilloedema - Altered Sensorium, Convulsions, GCS - CXR - congestion, mediastinum - Blood - Hemolysis, RFT, Troponins - CT head for Encephalopathy, ICH ------------------------------------ Treat by - Reduce MAP by 25% in first Hour - Nitroprusside titrate, cover with foil - Labetolol, alfa, beta blocker (good in HTN-stroke) - Nitrate infusion Monitor: ECG, BP, Urine output, GCS,

Question 113

Hypertensive Emergency, Diastolic Blood pressure > 140mmHg, Mean BP = 2x DBP +SBP/all divide by 3

Answer 113

HTN Emergency Effects = Encephalopathy, altered sensorium = MI, STEMI, Non-STEMI etc = Renal injury, rising creatinine = Acute LVF = Aortic dissection = Intracranial Hemorrhage = Eclampsia

Question 114

Causes of Hypertension

Answer 114

Causes of Hypertension: = Essential, idiopathic, primary = Renal: RA Stenosis( High renin levels) = Renal: Parenchymal, Polycystic = Arterial: Coarctation of Aorta, stiffening with loss of elasticity = Phaemochromocytoma, catecholamines = Conn's (Primary Aldosteronism) = Cushing's syndrome - Glucocorticoids = Cocaine, Steroids, OC Pills, Amphetamines, NSAID's,

Question 115

Infective Endocarditis - Duke's

Answer 115

Infective Endocarditis Duke's Diagnostic Criteria Major Criteria: = 1. Blood cultures positive = 2. Blood C/s persistently + for atypical = 3. Evidence of endocardial involvement such as 2D-ECHO findings, Abscess, vegetations, new murmur, valve dehiscence Minor Criteria: 1.Predisposition - IVDU, Heart issues 2. Fever present > 90% cases 3. Vascular: Embolic stroke, Septic PE, Mycotic aneurysms, ICH, conjunctival bleed, Janway Lesions 4. Immunological: Osler nodes, Roth spots, RAF +, Glomerulonephritis 5. Microbiological - + Blood cultures but not major

Question 116

Infect. Endocarditis - Causative Organisms

Answer 116

IE Causative Organisms: - Strep viridian most common - Staph aureus - Enterococci - Strep Bovis --------------------- HACEK group if initial blood cultures negative --------------------------- Brucella, Fungal, Coxiella Burnetti, Bartonella, Chlamydia (all initial blood c/s negative)

Question 117

Infective Endocarditis - Clinical

Answer 117

IE Clinical Presentation = Fever with new murmur = Arthropathy - multiple joint pains = Poor appetite and weight loss = Immunological: Osler nodes, Roth spots, GN evidence = Vascular: Janeway lesions, Splinter haemorrhages = Embolic events: Stroke, PE, Digital infarcts, peripheral skin necrosis, Spleenomegaly

Question 118

Infective Endocarditis- Initial Rx

Answer 118

IE - Empiric Antibiotic regimens Native Valve: = Augmentin + Gentamicin iv 4-6 weeks = Vanco + Genta + Cipro for 4-6 wks if penicillin allergic ----------------------------- Prosthetic Valve: = Vanco iv + Genta iv + Rifampicin PO for 6 weeks

Question 119

Pericarditis: Triad & Causes

Answer 119

Pericarditis Triad: 1. Pleuritis chest pain, more with inspiration & eased by bending forward + 2. Pericardial pleural rub + 3. ECG concave STE --------------------------------------------------- = Viral infections as EBV, CMV = Bacterial - TB, Pneumococci = Uremic pericarditis = Post MI early near infarct zone = Dressler syn, 2-14 wks, autoimmune = Rheumatic Fever = Malignancy - paraneoplastic = CTD - SLE, RA, PAN = Post Cardiac surgery or radiotherapy = Chest Trauma - Blunt or penetrating = Drugs: INH, Ciclosporin, Warfarin, Hydralazine = Idiopathic ------------------------------ Rx = Admit + Brufen 2 wks + Colchicine may be - some times Steroids for autoimmune, Uremia etc

Question 120

Beck's Triad of Tamponade

Answer 120

Beck's triage in cardiac tamponade 1. Low Blood pressure 2. Distended neck veins, specially during inspiration known as Kussmaul sign 3. muffled heart sounds ----------------------------------------------------- Other features: - Pulsus paradoxus, SBP drops >10mmHg on inspiration - Tachycardia, Tachypnea - clear lung fields usually ECG - Alterans in effusion, low voltage tachycardia, non specific changes CXR - Globular heart, clear Lungs

Question 121

Respiratory Failure

Answer 121

Type 1 Resp Failure: = Hypoxemic, PaO2 < 8 kPa = failure of oxygenation = usually due V/Q mismatch = Pneumonia, ARDS, Asthma, PE, LVF ARDS ---------------------------------- Type 2 Resp Failure: = Ventilatory failure with Pco2 >6.5 kPa = due to Hypoventilation = COPD, osa, Chest wall deformity, Neuromuscular disorders, Sedatives, Head injury -------------------------------

Question 122

Kilopascal, Pascal, PSi

Answer 122

kPa = kilopascal (kPa), one thousand times the unit of pressure and stress in the metre-kilogram-second system (the International System of Units [SI]). It was named in honour of the French mathematician-physicist Blaise Pascal (1623–62). 1 kilopascal equals 1,000 pascals. 1 atm is equal to 101.325 kPa or 14.7 psi, which corresponds to atmospheric pressure at mean sea level. The SI unit of pressure is pascal (represented as Pa) which is equal to one newton per square metre (N/m2 or kg m-1s-2). Interestingly, this name was given in 1971. Pounds per square inch (PSI) is the pressure that results when a 1-pound force is applied to a unit area of 1 square inch. It is the measurement of pressure used in the imperial unit system of measurement. Oxygen Values at sea level: Partial pressure of oxygen (PaO2): 75 to 100 millimeters of mercury (mm Hg), or 10.5 to 13.5 kilopascal (kPa). The partial pressure of carbon dioxide (PCO2) is the measure of carbon dioxide within arterial or venous blood. It often serves as a marker of sufficient alveolar ventilation within the lungs. Generally, under normal physiologic conditions, the value of PCO2 ranges between 35 to 45 mmHg, or 4.7 to 6.0 kPa.

Question 123

Hypoxemia Mechanisms

Answer 123

1. Alveolar Hypoventilation 2. Ventilation/Perfusion mismatch 3. Pulmonary diffusion defects 4. Reduced Oxygen concentration air

Question 124

Alveolar Hypoventilation

Answer 124

1. Alveolar Hypoventilation - Oxygen not reaching alveoli due to: = Airway obstruction as in asthma = Respiratory depression, poor drive = impaired ventilation- hemopneumoTx alveolar partial pressure of Oxygen drops and that of CO2 increases from body.

Question 125

Ventilation-Perfusion Mismatch

Answer 125

2. Ventilation/Perfusion mismatch V/Q > 1 - ventilation exceeds perfusion so some defect in perfusion as PE, collapsed alveoli, V/Q < 1 - Perfusion exceeds ventilation so there is some issue in some area as obstruction/ FB/ Mucus plug etc IF more than 30% pulmonary blood goes through regions with V/Q<1 ie no oxygen there - ultimate hypoxemia will result even if other areas get 100% Oxygen.

Question 126

Pulmonary Diffusion defects

Answer 126

conditions causing thickening of alveolar membranes such as fibrosing alveolitis. This impairs O2 transfer into the blood. More oxygen administration can correct this.

Question 127

High Anion Gap

Answer 127

Anion Gap = (NA+K) = (HCO3-Cl) --------------------------------------- High AG Metabolic Acidosis > 18 (MUD PILES) M= Methanol poisoning U= Uremia D= DKA P = Paraldehyde Poisoning I= Iron/INH L= Lactic Acid E= Ethanol/ Ethylene Glycol S= Salicylates Other Causes of High AG: (CAP MARC) C= CO poisoning A= Amphetamines P= Paracetamol Toxicity M= Metformin A= Rhabdomyolysis R = Alcoholic Acidosis C= Cocaine

Question 128

Normal Anion Gap Metabolic Acidosis

Answer 128

Normal AG Metabolic Acidosis FUSED CARS Fistula, Uretero-enteric conduit, Saline load, Endocrine (HyperPTH), Diarrhea, Carbonic unhydrase, Ammonium Cl, RTA, Spironolactone GI Tract Losses of HCO3 : = Diarrhoea = Pancreatic fistula = Small bowel fistula Renal Loss of HCO3 - RTA type 2 Renal failure Hypoaldeosteronism (RTA Type 4) Carbonic anhydrase inhibitor (Diamox) Extra Chloride intake (NH4Cl, MgCl)

Question 129

Osmolor Gap (High)

Answer 129

Osmolality = 2(Na+K) + Urea +Glucose Osmolar Gap - Measured - Calculated Normal OG < 10 mosmol/kg --------------------------- Caused of High OG: = Ethanol = Ethylene glycol = Methanol = Mannitol = Lactic acid = Acetone = Formaldehyde = End Stage Renal Failure = Paraldehyde

Question 130

High Omolol Gap - ME DIE

Answer 130

ME DIE = Methanol, = Ethanol, = Diuretics (such as mannitol and isosorbide), = Isopropanol, and = Ethylene glycol can reach millimolar concentrations in plasma, resulting in significant elevations in the osmolar gap.

Question 131

GOLD-MARK

Answer 131

High Anion Gap Metabolic Acidosis G - Glycols O - Oxoproline L - L Lactate D - D Lactate M - Methanol A - Aspirin R - Renal Failure K - Ketoacidosis

Question 132

Metabolic Alkalosis

Answer 132

Causes of Metabolic Alkalosis 1. Loss of Acid: = GI tract loss: diarrhea, vomiting, NGT = Renal losses: Excess Aldosterone in Conn's syndrome - NA-H exchange rises -------------------------------- 2. Shift of H-ion into cell: Hypokalemia --------------------------------- 3. Alkali Administration: = HCO3 infusion = Excess Antacid consumption = Citrate in massive blood transfusions is converted to HCO3 ---------------------------------------- 4. Contraction Alkalosis: loss of HCO3 rich, Cl rich ECF due to diuretics - Thiazides, Loop Compensation - by Hypoventilation

Question 133

Respiratory Acidosis, CO2 retention

Answer 133

Causes of Respiratory acidosis = CO2 retention as in COPD = Hypoventilation = CNS depression with Hypoventilation = Acute airway obstruction = Neuro-muscular disease

Question 134

Respiratory Alkalosis, CO2 washout

Answer 134

Causes of Respiratory alkalosis as = Hyperventilation in normal Lungs = Stroke, SAH, Meningitis = Altitude Hyperventilation = Fever, Pregnancy = Meds: Salicylates, Aminophylline = Sepsis = CO Poisonins = Hyperthyroidism = Liver Failure = Oral HCO3 therapy

Question 135

Alveolar-Arterial Gradient of O2

Answer 135

A-a Gradient = PAO2(alveolar) - PaO2(arterial) --------------------- PAO2 = FiO2 X (Pb-Psvp) - PaCO2 / RQ where PAO2 = Alveolar Oxygen partialpressure FiO2 = Fraction of inspire O2, 0.21@ air Pb = atmospheric pressure, 101.3 kpa@ sea level Psvp = Saturated vapour pressure of O2 (6.3 kpa) RQ = Respiratory Quotient, 0.8 --------------------- so PAO2 = FiO2 X 95 - (Paco2/0.8) ------------------------------ Normal A-a gradient: < 2 kPa in young adults 2-5 kPa in elderly

Question 136

ABCDE approach to Trauma

Answer 136

A - Airway assessment with Cspine protection: assess phonation, note any stridor, correct if any doubt B - Breathing ie ventilation assessment, spontaneous or not, ventilate if problem C - circulation ie any major bleeding, stop or tournique if found, fluids to give D - Disability: GCS assessment, document E - Expose completely and examine not to miss anything but prevent Hypothermia

Question 137

Heat Exhaustion

Answer 137

Body temperature usually < 39 degrees (102.2F) Intact mental status Non specific symptoms like: Malaise, Myalgia, Nausea, emesis, Headaches, Lightheadedness Dehydration signs Loss of electrolytes

Question 138

Mallampatti classification

Answer 138

I - soft palate, fauces and pillar visible II - soft palate, uvula, fauces visible but not pillars III - soft palate, base of uvula visible IV - Hard palate only visible, (uvula not seen)

Question 139

3-3-2 Rule in LEMON assessment

Answer 139

3 = FINGER distance between upper and lower incisor teeth, if less means difficult mouth opening for intubation so be ready 3 = finger distance between HYOID bone and CHIN, if less means intubation might be difficult 2 = fingers distance between thyroid notch and floor of mouth, if less means difficult intubation Any less distance in 3-3-2 rule indicates difficult intubation and be ready with difficult intubation tray, Tracheostomy tray and fiberoptic scopy

Question 140

LEMON assessment

Answer 140

Look: externally for thick neck, small mouth, any scars Evaluate: 3-3-2 rule for various anatomical distances ( 3 fingers between incisors, 3 fingers between hyoid+chin, 2 fingers from thyroid to floor of mouth) Mallampatti score: 1-4 score Obstruction features: Epiglottitis, tonsils, abscess, traumatic damage Neck movement assessment, dont do it if Hard collar in situ due to suspected neck trauma

Question 141

Cold Injury types

Answer 141

Frost Nip: mildest form, Pain, pallor & numbness of affected part, Reversible with rewarming Frost Bite: Freezing of tissues 1st degree: Hyperemia, edema without skin necrosis 2nd degree: blisters, skin necrosis, hyperemia, edema 3rd degree: Full thickness skin necrosis, Haemorrhagic blisters 4th Degree: Gangrene Non-Freezing Injury: due to microvascular endothelial damage stasis and vascular occlusion Ex - Trench foot

Question 142

Odontoid Process Fracture Types

Answer 142

Type I: involves tip of odontoid process Type II: through base of dens, most common Type III: at base of dens process and extends laterally into the body of axis

Question 143

Depth of Burn assessment

Answer 143

First Degree Burns: superficial with erythema, blisters and intense pain. Epidermis remains intact, no need IV fluids Partial Thickness, 2nd Degree Burns: Painful even with air currents, Red, shiny with blistering, wet appearance, need 14 days to heel, may scar Full Thickness Burns, 3rd Degree: Dark, leathery or white, painless as nerves destroyed generally dry without blanching doesnot heel, needs skin replacement

Question 144

Myotomes

Answer 144

C5 = Deltoid muscle, arm abduction C6 = forearm flexion, Biceps C7 = forearm extension, Triceps C8 = Flexion of wrist and fingers T1 = small finger abductors (digiti minimi), abduction and adduction of fingers L2 = Hip flexors, Iliopsoas L3L4 = Knee extensors Quadriceps, Patellar reflex L4L5S1 = Knee flexion: Hamstrings L5 = Ankle, Big Toe dorsiflexion, tibialis anterior & extensor hallucis longus S1 = ankle plantar flexors, Soleus, Gastrocnemius

Question 145

Heat Stroke

Answer 145

Life threatening condition Two forms: Classic and Exertional Hot flushed dry skin High core temperature > 40 degree (104F) Dehydration severe CNS dysfunction ie altered sensorium Delirium, convulsions, coma Multiple Oran Dysfuction, DIC sets in

Question 146

Pediatric Trauma Score

Answer 146

Weight - >20kg, 10-20 kg, < 10 kg Airway - Normal, Oral or nasal reqd, Intubation Systolic BP - > 90 mmHg, 50-90, < 50 Perfusion - Good, Carotids felt, weak centrals Alertness - Awake, Obtunded, Comatose Fracture - no #, Single closed, Open multiple Cutaneous - Non visible, contusion, Tissue loss injury - Abrasion, Gunshot, Cuts < 7 cm. Stab deep 2 point - 1 point - minus 1 point

Question 147

Pregnancy: Lab Values (Normal)

Answer 147

Haematocrit: 32-42% WBC count: 5-12 k Arterial PH: 7.40-7.45 Bicarbonate serum - 17-22 PaCO2 - 25-30mmHg, due to raised tidal volume Fibrinogen: 3.79 gms/Lit in third trimester

Question 148

Haemorrhage Classification: Severity

Answer 148

Class I Haemorrhage: - blood loss upto 750 ml, 15% - Pulse rate < 100 - Systolic blood pressure - normal - Pulse pressure - normal or raised - Respiratory Rate - 14-20 - Urine output > 30 ml per Hour - Mental Status - slightly anxious - Initial Fluids to give - Crystalloids Class II Haemorrhage: - blood loss: upto 750-1500 ml, 15-30% - Pulse rate < 100-120/min - Systolic blood pressure - normal - Pulse pressure - decreased - Respiratory Rate - 20-30/min - Urine output: 20-30 ml per Hour - Mental Status - anxious but not confused - Initial Fluids to give - Crystalloids Class III Haemorrhage: - blood loss: 1500-2000 ml - Pulse rate: 120-140 - Systolic blood pressure - below 90 - Pulse pressure - decreased - Respiratory Rate - 30-40 - Urine output: 5-15ml per Hour - Mental Status - anxious, confused - Initial Fluids to give - Crystalloids, Blood Class IV Haemorrhage: - blood loss > 2000 ml, 40% - Pulse rate: > 140 - Systolic blood pressure - < 90 - Pulse pressure - decreased - Respiratory Rate - > 35/min - Urine output = negligible - Mental Status - confused - Initial Fluids to give - Crystalloids, blood

Question 149

Shoulder Dislocation: Atraumatic: AMBRI

Answer 149

A - Atraumatic born loose shoulder M - Multidirectional B - Bilateral usually R - Rehabiliation of muscle strengthening I - Inferior capsular shift: surgery if rahab fails

Question 150

Shoulder Dislocation: Trauma: TUBS

Answer 150

T - Traumatic U - Unilateral B - Bankard Lesion: Capsule of shoulder is attached to neck of scapula but dettached from glenoid labrum S - Surgical treatment

Question 151

Rotator Cuff Muscles: SITS

Answer 151

SITS: Supra-spinatus = abduction of shoulder Infra-spinatus = External rotation@ shoulder Teres minor = External rotation + Extension Subscapularis = Internal Rotation

Question 152

Anaphylaxis Management Tips

Answer 152

Oxygen, Epinephrine - 0.5 ml IM 1:1000, repeat @ 5 min Epipen - 300 mcg if used instead of IM dose Chlorpheniramine - 10 - 20 mg slow iv Hydrocortisone - 100-500 mg iv Salbutamol 5 mg nebulization IV Fluids: 1000-2000 ml iv prn Give 50% dose of Salbutamol or Epinephrine if patient is on TCA's or MAO inhibitors. INFORM - Committee on Safety of Medicines Provide - Medical Alert Bracelet Arrange - possible Desensitisation

Question 153

Septic Arthritis Pearls

Answer 153

The case fatality rate of septic arthritis is reported as 11%. More than one joint is affected in approximately 15% of cases of septic arthritis. [4] [5] Septic polyarthritis is more frequent among patients with rheumatoid arthritis Apart from septic arthritis, common differential diagnoses of a hot swollen joint to consider include : - Gout - Inflammatory arthritis - Haemarthrosis - Trauma - Bursitis / cellulitis. The Gram stain is positive in only 50% of episodes of septic arthritis. here is no evidence to support direct inoculation of joint aspirates into blood culture bottles. The specimen is sent fresh to the laboratory for direct agar and broth enrichment culture. Anticoagulation with warfarin is not an absolute contraindication to needle aspiration if septic arthritis is suspected. Antibiotics are given intravenously for up to two weeks or until signs improve. They are then changed to oral antibiotics for about four weeks during which time the patient is often discharged with outpatient follow up. Flucloxacillin has a poor profile in terms of joint space penetration. In practice treatment needs to be given for at least six weeks.

Question 154

Organisms causing Septic arthritis

Answer 154

Which organisms cause septic arthritis? The most common organisms causing septic arthritis are Gram positive cocci: Staphylococcus aureus is the most common type, and streptococci, particularly the beta haemolytic streptococci (for example group A streptococci) are also frequently found. Over recent years there has been an increasing incidence of MRSA as a cause of septic arthritis, particularly where the patient has acquired the infection in a hospital or nursing home. Community acquired MRSA is increasing in incidence as a cause of septic arthritis, and PVL positive S. aureus has also been isolated. Gram negative bacteria account for between 10 to 20% of cases of septic arthritis and are more common in older patients and patients who are immunocompromised. Neisseria gonorrhoea is more commonly found in the US than the UK and western Europe, although overall the proportion of cases is low compared to S. aureus. Neisseria meningitidis has also been isolated. Haemophilus influenzae type b is a rare cause of septic arthritis, and in children it has declined as a cause of septic arthritis due to immunisation. Intravenous drug abusers are especially susceptible to mixed bacterial infections, fungal infections, and unusual organisms.

Question 155

Aortic dissection clues

Answer 155

- Wide mediastinum in CXR - Double knuckle aorta - aortic wall breadth > 5mm gaping - Left pleural effusion - tracheal deviation to right - difficult to control chest pain - new AR murmur - absent or unequal radial pulses - neurological signs due to carotid or spinal artery involvement

Question 156

Contraindications for Air Travel

Answer 156

Contraindications for air travel: - unstable angina - severe, decompensated chronic heart failure or symptomatic valvular heart disease - uncontrolled hypertension or arrhythmia - CABG or CVA within the last 14 days - Eisenmenger syndrome Following acute coronary syndrome: low risk: within 3 days of event medium risk: within 10 days of event high risk or awaiting intervention or treatment: defer air travel until stable Respiratory Contraindications for air travel: - recent hospitalization for acute respiratory illness - severe, labile asthma - bullous lung disease - spontaneous pneumothorax within 7 days or - traumatic pneumothorax within 14 days - pleural effusion within 14 days - need for high levels of supplemental oxygen - major chest surgery within 10 days - severe anemia (Hb < 8.4 g/dl) - cerebral edema due to tumor - < 7 weeks since cranial surgery - cardiovascular, gastrointestinal, or pulmonary complications - uncomplicated appendectomy or laparoscopic surgery within 5 days - major surgery within 14 days - colonoscopy or gastrointestinal bleed within 24 hours - partial bowl obstruction - liver failure, especially if due to cirrhosis or heavy alcohol use

Question 157

Empty Can Test (Rotator Cuff)

Answer 157

Tests Supraspinatus tendon function Abduct shoulder to side, point thumb down as if emptying a can and push up against resistance. Pain at shoulder indicates probable supraspinatus tendon tear or strain

Question 158

External Rotation Test @ shoulder

Answer 158

for infra-spinatus and Teres minor function With elbows at sides and flexed to 90 degrees ie shoulders to side at 90 degrees and elbows at right angle anteriorly - externally rotate at shoulder against resistance - pain indicates infra-spinatus or Teres minor tear.

Question 159

Liff off Test for subscapularis

Answer 159

Patient places dorsum of hand on lumbar back and tries to lift it off the back. Cannot do this if subscapularis injured.

Question 160

Hawkin's impingement, Subacromial

Answer 160

Pain at shoulder with internal rotation when the arm is flexed to 90 degrees with the elbow bent to 90 degrees - indicates sub-acromial impingement at shoulder.

Question 161

Drop Arm rotator Cuff test

Answer 161

Patient is unable to lower his arm from raised position - indicates large rotator cuff tear

Question 162

Anterior drawer Test: Ankle

Answer 162

Examiner pull forward on patient's heel by pushing from back to front in a relaxed position while stabilizing lower leg with other hand. Excessive ankle movement indicates anterior Talo-fibular ligament injury (ATFL).

Question 163

Inversion Stress Test: Ankle

Answer 163

Examiner inverts ankle with one hand while stabilizing lower leg with the other hand. Excessive translation or palpable clunk of talus on tibia suggests Calcaneo-fibular Ligament tear (CFL)

Question 164

Squeeze test: Mid Leg

Answer 164

Examiner compresses tibia/ fibula at mif calf - pain at anterior ankle joint below where examiner is squeezing indicates syndesmotic injury.

Question 165

Lachman Test: Knee

Answer 165

indicated ACL injury if positive, with knee in 20 degree of flexion pull tibia against femur bu encircling hand around knee - excessive translation of knee anteriorly suggests ACL tear

Question 166

Anterior Drawer Test: Knee

Answer 166

with foot fixed on bed, and knee bent at 90 degrees, pull knee forward against femur - excessive anterior movement of knee forward indicates ACL tear.

Question 167

Vulgus Stress: Knee

Answer 167

Knee in 30 degree flexion and again at full extension, medially directed force at knee and laterally directed force at ankle - excessive translation of knee to medial side indicates MCL tear.

Question 168

Varus Stress: Knee

Answer 168

Knee in 30 degrees and again in full extension push knee laterally and pull ankle medially -excessive translation of knee indicates Lateral collateral ligament injury.

Question 169

Drug choices for Status Epilepticus

Answer 169

1. Magnesium sulfate: Eclampsia, Malnutrition, Alcoholics 2. Lorazepam 5-10 mg or 3. Diazepalm 5-10 mg 4. Fosphenytoin 15 mg/kg at 150 mg/min or 5. Phenytoin 15 mg/kg at 50 mg/min 6. Pabrinex A+B, in 50 ml NS over 30-60min 7. General anaesthesia, Intubation

Question 170

Causes of Hypoglycemia

Answer 170

- Insulin use or OHA use - Alcohol causes direct Hypoglycemia - Insulinoma - Addison's disease - Pituitary insufficiency - Post Gastrectomy - Liver failure - Malaria - Extra pancreatic tumors - Suicide attempts using large OHA/Insulin doses

Question 171

Rx of Hypoglycemia

Answer 171

If sugar < 3 mmols, take a venous sample Give Oral Leucozade, Dextrosol or Sugar lumps Give Biscuit with milk ---------------- Glucagon 1 mg sc/im/iv Dextrose 50 ml 50% iv then flush with saline IV Dextrose 10% infusion, keep sugar 7-11 mmol Octreotide for SFU toxicity Mannitol or Dexamethasone if cerebral edema suspected due to hypoglycemia but get CT also

Question 172

Foot nerve supply

Answer 172

Question 173

Kussmaul’s sign

Answer 173

Question 174

Pulsus paradoxus

Answer 174

Question 175

4 AT scoring for delirium

Answer 175

Question 176

Tumor markers

Answer 176

Question 177

Head injury signs

Answer 177

Question 178

Capnographic waveform

Answer 178

Question 179

Spine trauma & MethylPred

Answer 179

Question 180

Choice of anti emetics

Answer 180

The most appropriate first-line antiemetic in this patient with severe hypercalcaemia would be haloperidol. It is a dopamine D2 antagonist and useful in opioid-induced nausea and vomiting too. Haloperidol is usually given orally, once or twice a day, to treat chemically or metabolically induced vomiting. This is an off-label indication for haloperidol tablets and an oral solution. Metoclopramide is useful where there is gastric stasis, cyclizine is useful in raised intracranial pressure or motion sickness and ondansetron in the treatment of chemotherapy-induced emesis.

Question 181

Tumor Lysis Syndrome

Answer 181

The condition is classified using the Cairo-Bishop (2004) definition. This consists of two categories Laboratory Tumour Lysis syndrome (LTS) and Clinical Tumour Lysis Syndrome (CTLS). Laboratory Tumour Lysis syndrome (LTS) is when any two or more of the following occur within 3 days of receiving chemotherapy: Serum uric acid level increases by 25% or more Serum potassium level increases by 25% or more Serum phosphate level increases by 25% or more Serum calcium level decreases by 25% or more This electrolyte imbalance occurs because the cytotoxic agents kill (lyse) the tumour cells, as they die they release cellular contents into the bloodstream which results in raised serum phosphate, potassium and urate and reduced calcium. The serum calcium is lower as a consequence of the raised serum phosphate, calcium binds with phosphate thus leading to a lowering of the serum calcium. Clinical Tumour Lysis Syndrome (CTLS) develops when there is a significant rise in serum creatinine, cardiac arrhythmia, seizure and death. Reflection: It is important to consider that each establishment may interpret its results differently and this needs to be considered when analysing the blood values of patients.

Question 182

Biliary presentations

Answer 182

Please read the difference between 1. Biliary colic (only RUQ pain with no fever or jaundice) 2. Cholecystitis (RUQ pain with fever but no jaundice), and 3. Cholangitis (RUQ pain with fever and jaundice).

Question 183

Duke's Criteria for IE

Answer 183

Major criteria for Infective endocarditis (IE) encompass: - Two positive blood cultures yielding a characteristic microbe - Persistent bacteraemia - Serological positivity for Coxiella - Positive echocardiography demonstrating vegetation, abscess, new regurgitation, and dehiscence of prosthetic valves. The minor criteria for Infective endocarditis (IE) include: - Predisposing cardiovascular disease - Pyrexia >38oC - Immunological events - Vascular events such as major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial haemorrhage, conjunctival haemorrhages, and Janeway lesions. - Echocardiographic findings compatible with IE but failing to fulfil a major criterion and microbiological events (positive blood culture but not fulfilling a major criterion) are also considered as minor criteria. Blood culture-negative IE refers to infectious endocarditis in which no causative microbe can be isolated using conventional blood culture methods.

Question 184

King's college criteria for Acute Liver injury

Answer 184

King’s College Hospital criteria for transplantation in acute liver failure: Paracetamol + pH <7.30 (irrespective of grade of encephalopathy) + Prothrombin time >100 seconds and serum creatinine >300 µmol/L if in grade III or IV coma Non-paracetamol + Prothrombin time >100 seconds (irrespective of the grade of encephalopathy) or + Any three of the following (irrespective of the grade of encephalopathy): aetiology: non-A, non-B (indeterminate) hepatitis, halothane hepatitis, idiosyncratic drug reactions age <10 or >40 years jaundice to encephalopathy interval >7 days prothrombin time >50 seconds serum bilirubin >300 µmol/L

Question 185

Vaccine induced Thrombocytopenia thrombocytopenia

Answer 185

thrombocytopaenia associated with headache 2 weeks after receiving the ChAdOx1 nCoV-19 (AstraZeneca) SARS-CoV-2 vaccine, hence a diagnosis of cerebral venous sinus thrombosis due to vaccine-induced thrombocytopaenic thrombosis should be considered and assessed with CT. The diagnosis of VITT can be supported by measuring antibodies to PF-4. Treatment with IV immunoglobulin plus high-dose glucocorticoids can improve the outcome together with anticoagulation with non-heparin-based anticoagulation, such as argatroban or fondaparinux. The occurrence of VITT is rare and estimated to be 1 in 100,000 exposures and recent studies reveal that this is much lower than the thrombotic risk associated with COVID-19 infection. However, most authorities now avoid the use of the ChAdOx1 nCoV-19 (AstraZeneca) SARS-CoV-2 vaccine in individuals under 50 years.

Question 186

Conditions presenting with HTN Emergency, bP >200/120

Answer 186

- Essential HTN - Co-arctation of Aorta - Renovascular disease: Atheroma, fibromuscular dysplasoa, acute renal disease - Renal Parenchymal disease: Acute GN, Vasculitis, Scleroderma - Endocrine: Phaechromocytoma, Cushing's syndrome, Primary Hyperaldosteronism, Thyrotoxicosis, hyperPTH, Acromegaly, Adrenal cancer - Eclampsia, Pre-Eclampsia - Vasculitis - Autonomic hyperactivity - Drugs: Cocaine, MAO inhibitors, Amphetamines, Ciclosporine, Withdrawal of BB or Clonidine

Question 187

Conditions associated with Aortic dissection

Answer 187

Question 188

Myasthenia gravis management

Answer 188

Management of Myasthenia Gravis: Mild disease: - Pyridostigmine (1st line) - Corticosteroids - Other immunosuppressants as steroid sparing Moderate disease: - Pyridostigmine, Steroids, Azathioprine, MMF, Ciclosporin, Tacrolimus as combinations - Thymectomy - plasma exchange - IV immunoglobulin Severe MG crisis: Unable to swallow Respiratory insufficiency, CO2 retention, dropping FVC, Hypoxic - ventilation if FVC<15ml/kg (normal>60) negative Inspiratory force 20 cmH2O or less (normal >70) - IV IG or plasma exchange - High dose steroids, DVT prophylaxis, ICU care

Question 189

NIV indications in acute hypercapneic respiratory failure

Answer 189

In COPD, after trial of bronchodilators and controlled oxygen therapy: start NIV if - Ph < 7.35 - Pco2 > 6.5 - RR > 23

Question 190

Intraosseus access sites

Answer 190

1. Humerus - lateral surface of proximal humerus, 1 cm above surgical neck, at greater tubercle 2. Proximal tibia: 2-3 cm below tibial tuberocity 3. Distal tibia - 3 cm above medial malleolus medial surface 4. Distal femur - anterolateral surface of distal femur, 3 cm above lateral condyle

Question 191

Allis technique for reduction of posterior Hip dislocation

Answer 191

Stand on trolley, sedate the patient Assistant needs to press down on ASIS of patients pelvis same side of dislocation Flow the hip & knee both 90 degrees Grasp patients knee with both hands Lean back and pull the knee up, pulling the patients hip up - clunk confirms relocation - confirm with X-rays

Question 192

Hip fracture types

Answer 192

See picture

Question 193

Ketamine contraindications

Answer 193

All are relative - airway instability/ tracheal pathology - predisposition to laryngospasm - predisposition to apnea - severe CAD/IHD - CSF obstructive states - previous psychosis - Hyperthyroidism - Globe injury or glaucoma

Question 194

Croup severity score, Westley

Answer 194

See picture

Question 195

Risk of asystole in bradycardia

Answer 195

Recent asystole: Mobitz type II block - regular PR with sudden drop beat Complete heart block with broad QRS Ventricular pause > 3 seconds

Question 196

Medications for Bradycardia Rx

Answer 196

Atropine 500 mcg Second line drugs: - Glucagon if BB/CCB overdose suspected - Digoxin FAB if toxicity features - IV Aminophylline for bradycardia in inferior STEMI, spinal cord injury, post cardiac transplant - Infusion of isoprenaline, adrenaline, dopamine Cardiac pacing - transcutaneous or transvenous

Question 197

Kawasaki disease (vasculitis)

Answer 197

Acute febrile illness > 5 days Conjuntival suffusion, bilateral Erythematous rash over body Strawberry tongue Cervical lymphadenopathy Oral hyperemia Lips - fissuring, cracking, swelling, redness Uncommon: - neck stiffness due to aseptic meningitis - anterior uveitis - facial palsy - pleural effusion - pulmonary infiltration - pericardial effusion, CHF

Question 198

Malignant Hyperthermia

Answer 198

Autosomal dominant, 1:30,000 births Drugs - can trigger it - Halothane - Suxamethonium - Isoflurane - Desflurane - Sevoflurane Master spasm, High fever (late) Rhabdomyolysis Unexplained - tachycardia, rising Pco2, tachypnea, rising need for O2 in patients under anaesthesia Dantrolene 2.5 mg/kg Cooling, Hydration, avoid CCB for arrhythmias Forced diuresis, NaHCO3, Lasix

Question 199

Neuroleptic malignant syndrome

Answer 199

Tetrad of: 1. Altered sensorium 2. muscle rigidity 3. Autonomic instability 4. Hyperthermia Caused by Dopamine antagonist antipsychotics or their sudden withdrawal HTN, Tachycardia, Tachypnea, Fever, Diphoresis, Hypersalivation, Stupor, lead-pipe rigidity, normal pupils, rising CK, Rx - dantrolene, Bromocriptine, Amantadine

Question 200

Serotonin syndrome

Answer 200

Due to serotonin agonist agents Fever, HTN, Tachycardia, Tachypnea, Diphoresis, Hypersalivation, Agitation, Delirium, Hyper-, reflexia, Rigidity with clonus, Dilated pupils, Hyperperistasis, Rx - Valium, Cyproheptadine, Stop offending agent, supportive

Question 201

Doses of local anaesthetics

Answer 201

Lignocaine: 3 mg /kg without adrenaline 7 mg/kg without adrenaline Action lasts 1-2 hrs & 2-4 with adrenaline Prilocaine: 6 mg/kg without adrenaline 9 mg/kg with adrenaline Action lasts 1-2 & 2-4 hrs Used in Bier’s block Bupivacaine: 2 mg/kg Action lasts 3-12 hrs Used in fascia iliaca block

Question 202

Hexavalent vaccine (6 in 1)

Answer 202

vaccine shot contains - 1. diphtheria, 2. tetanus, 3. whole-cell pertussis [DTwP], 4. hepatitis B and 5. Haemophilus influenzae type b) with 6. inactivated polio vaccine (IPV).

Question 203

Anterior uveitis: signs

Answer 203

Ciliary flush Small fixed irregular pupils (adhesions) Eye tender to palpation Talbot sign - pain on convergence(reading) Slit Lamp- synechiae, Flare, Hypopyon, keratic precipitates Symptoms- painful red eye, more on reading, blurred vision, watering, photophobia

Question 204

Important pediatric calculations

Answer 204

Weight: Upto 12 months - (0.5 x age) + 4 1-5 yrs - (2 x age) + 8 6-12 years - (3 x age) + 7 ————- ET tube size, internal diameter : size = age /4 + 4 uncuffed Size = age/4 + 3.5 cuffed Infant 6 months = size 4 Infant at 12 months = size 4.5 Neonate < 3 kg = size 3 or 3.5 ——- ET tube length Age /2 + 12 for oral tube Age/2 + 15 for nasal tube

Question 205

Radioactivity

Answer 205

Amount of ionizing radiation released by a material, US unit - Curie(Ci) International Unit - Becquere(Bq) 1 Bq = 2.7 x 10 rest to -11 C

Question 206

2D Echo signs of tamponade

Answer 206

The core echocardiographic findings of pericardial tamponade consist of: a pericardial effusion, diastolic right ventricular collapse (high specificity), systolic right atrial collapse (earliest sign), a plethoric inferior vena cava with minimal respiratory variation (high sensitivity), and exaggerated respiratory cycle changes in mitral and tricuspid valve in-flow velocities as a surrogate for pulsus paradoxus.

Question 207

Indications to Sync Shocks

Answer 207

Unstable SVT Unstable AFib Unstable A flutter Unstable regular monomorphic tachycardia with pulse