Emergency medicine Flashcards
1
Q
Name 2 symptoms that describe a SAH
A
first and worst
thunderclap
2
Q
Which 2 diagnoses give unilateral headache and eye pain?
A
Acute glaucoma
Cluster headache
3
Q
What disease gives a headache initiated with a cough? Give 2 other times when this is made worse.
A
Raised ICP
Sx:
Worse in morning
Worse on bending forward
4
Q
What potassium level counts as an emergency? Why are you worried?
What potassium level counts as hyper/hypokalaemia?
A
> 6.5mmol/L
Cardiac excitability leading to VF and cardiac arrest
- Hyper-5.3mmol/L
- Hypo-3.5mmol/L
5
Q
Name 3 signs/sx of hyperkalaemia.
A
Irregular pulse, chest pain, weakness, palpatations, lightheadedness
6
Q
What would you see on an ECG with someone who has hyperkalaemia? Name 3.
A
Flattened P
Widened QRS
Tall tented T
VF
7
Q
Name 3 artefactual causes of hyperkalaemia.
A
Difficult venepuncture
Pts with thrombocythaemia (K+ leaks out of cells during clotting)
Prolonged fist clenching in venepuncture
8
Q
Name 3 causes of hyperkalaemia.
A
K+ sparing diuretics Excess K+ therapy Addisons disease Burns ACE-i
9
Q
How does addisons lead to hyperkalaemia?
A
Adrenal insufficieny=low aldosterone=unable to remove potassium
10
Q
How do you manage hyperkalaemia? Name 3 things
A
Treat cause
- calcium chloride/gluconate (IV)-stabilise cardiac myocyte if ECG changes present (10ml of 10% by slow IV injection over 3-5mins)
- Insulin (actrapid 10U with 50ml 50% glucose given as IV injection over 5-15mins)
- Oral resin to bind K+ in gut
11
Q
What are the 2 leading causes of death in those with learning disabilities?
A
Pneumonia (from aspiration, reflux, swallowing) and congenital heart disease
12
Q
What is the immediate next step after a suspicious death occurs?
A
inform the police who will directly liaise with the coroner
13
Q
Name 4 things that must be done after all deaths.
A
1) Notify next of kin, if not already there
2) Notify coroner
3) Notify GP
4) Cancel any future OP appointments
14
Q
Which situations must you inform a coroner of the death?
A
RTA Sudden deaths cause of death unknown Violent/unnatural deaths Death occurred during operation Death caused by job (industrially)
15
Q
In a RTA situation, what information is required of the doctor, to disclose to the police? What 3 other situations may it be suitable to disclose info to the police?
A
Name and address but not clinical info
- terrorist
- gunshot wounds
- Disclosure to public (e.g. murder, rape, robbery)-however clinician is under no legal duty to do so
16
Q
What health professional can take alcohol specimens from patients? Name of specific doctor role. Are they able to take a blood specimen from the unconscious patient?
A
police surgeon
-Yes, if they are suspected to have been driving under the influence-retained for later testing
17
Q
When assessing febrile patients for serious infectious disease, what does FTOCC stand for?
A
Febrile->38 Travel hx Occupation Clustering cases Contact hx
18
Q
How do you treat herediatry angioedema, as compared to a similar condition, anaphylaxis? What symptom don’t you get with hereditary angioedema?
A
C1 esterase inhibitor (inhibits complement activation and prevents spontaneous activation)
-Urticaria
19
Q
Name 4 symptoms from 4 different systems, experienced in anaphylaxis.
A
- Resp- swelling on lips tongue, pharynx, dyspnoea, wheeze, chest tightness
- Skin-pruritis, erythema, urticaria, angioedema
- CVS- hypotension, shock, arrhythmia, ischaemic chest pain
- GI-nausea, vomiting, diarrhoea, abdo pain
20
Q
In anaphylaxis, you should give 50% of the usual dose of adrenaline in patients taking which 3 medications?
A
- TCA’s
- MAOI
- B blockers
21
Q
If IV adrenaline does not work in anaphylaxis, what medication should you give and what dose?
A
IV/IM glucagon 1-2mg
22
Q
In anaphylaxis, what would you do for:
1) airway compromise
2) Shock, resp difficulty
3) Hypotension
4) Allergy+inflammation
5) How long to observe for after sx have settled?
A
1) 100% O2+ intubation/surgical airway (cricothyroidotomy), B2 agonist (salbutamol 5mg)+/- ipratropium bromide (Muscarinic antagonist=inhibits bronchoconstriction and mucous production)
2) IM adrenaline (0.5mg 1:1000), if doesn’t work then IV (1:10,000) (Epipen 300mcg usually sufficient but further doses recommended if needed)
3) IV fluids as needed
4) Antihistamine-chlorphenamine+ranitidine+hydrocortisone
5) 4-6 hours
23
Q
What medication do you give in a severe benzodiazepene overdose and why isn’t it licensed in the UK?
A
Flumazenil
-Can cause convulsion and cardiac arrhythmia
24
Q
Measuring CO2 levels in cardiac arrest can show which 2 things? Explain if possible.
A
- Correct ET tube placement-if in one bronchus, CO2 levels will rise due to lack of perfusion of other lung
- Measure of cardiac output-no exchange of CO2 and O2 if low CO
25
What happens to venous return to right ventricle during inspiration?
- Increases due to neg intrathoracic pressure which dec LV ability to fill
- Therefore preload decreases, CO decreases so HR increases
26
A low diastolic BP and thus a. vasodilation occurs in which 2 circulatory compromises?
- Sepsis
| - Anaphylaxis
27
A narrow pulse pressure and thus a. vasoconstriction occurs in which 2 circulatory compromises?
- Hypovolaemia
| - Cardiogenic shock
28
At what % should you start giving O2 for ACS?
94% and below
29
How often should you give adrenaline in cardiac arrest?
every 3-5mins
30
What dose of amiodarone do you give in cardiac arrest?
300mg first
| A further 150mg if needed
31
What manouver can you do in a situation where there is a bardyarrhythmia but pacing equipment is not yet available?
External cardiac percussion
32
Define severe sepsis and septic shock.
Severe sepsis-sepsis with organ dysfunction/hypoperfusion
| Septic shock-sepsis with hypotension unresponsive to fluids
33
What 4 components make up SIRS?
Temp
RR
HR
WCC
34
Name the 5 things that contribute to shock.
```
Hypotension
Oliguria
Altered consciousness
Tachypnoea
Peripheral poor perfusion
```
35
Give 3 causes of haemorrhagic hypovolemia?
GI bleed
Ruptured ectopic
Ruptured AAA
Trauma
36
Give 3 causes of third space loss hypovolemia?
Burn
GI loss (vomiting, diarrhoea)
Sepsis
Pancreatitis
37
Name 3 causes of primary and 3 causes of secondary cardiogenic shock.
Primary-MI, arrhythmia, valve dysfunction, myocarditis (usually viral cause)
Secondary- cardiac tamponade, tension pneumothorax, massive PE
38
Name 3 common offending organisms and 3 offending organisms in the immunocompromised that lead to septic shock.
Common-S Aureus, Strep pneumoniae, N. meningitidis
| Immunocomp-pseudomonas, viruses, fungi
39
Name 10 differentials of chest pain
- MI
- aortic dissection
- PE
- Angina
- costochondritis
- GORD/oesophagitis
- pleurisy
- pneumothorax
- Pneumonia
- cholecystitis
- oesophageal rupture
- pancreatitis
- vertebral collapse
- tabes dorsalis
40
What sign is shown when there is bradycardia in acute cholecystitis? Due to GB inflammation what cardiac blood test change can be seen?
Copes sign
| Elevated troponin due to reduced flow to myocardium
41
what is tabes dorsalis?
demylenation of DCML fibres caused by syphilis after exposure to spirochete bacteria
42
Name 3 RF for MI
smoking
hypertension
FH of IHD
43
Name 4 general management steps of angina/NSTEMI. Name 5 drugs used to treat.
oxygen
nitrites
antiplatelets
revascularisation
- aspirin
- clopidogrel/ticagrelor/prasugrel (stops platelet activation)
- LMWH-heparin/fondaparinux
- glycoprotein IIa/IIIb inhibitors (stops platelet activation by preventing activation of fibrin and VWF)
- atenolol (b blocker to prevent O2 demand of heart)-if contraindicated, give verapamil/diltiazem for LV dysfunction
44
What scoring system is used to determine mortality in pts who have angina/NSTEMI?
TIMI score (thrombolysis in MI score)
45
What is the condition called where chest pain is associated with coronary artery vasospasm and sometimes also ST elevation? It resolves rapidly with GTN spray
prinzmetal/variant angina
46
Name 5 RF for MI
```
Smoking
hypertension
hyperlipidaemia
Diabetes
male sex
FH
age
```
47
What 3 environmental factors can worsen angina?
Cold
stress
exercise
48
2/3 of which features are required for a dx of MI?
- clinical hx
- ECG changes
- elevated cardiac markers
49
Describe the classic presentation of MI. Name 3 associated symptoms.
Central, crushing chest pain which radiates to arms neck and jaw
- N+V
- sweating
- breathlessness
50
Name 3 patient groups that may present with atypical MI symptoms.
- older age
- female
- diabetic
- HF
51
Name some atypical sx of MI.
- new onset dyspepsia
- collapse
- confusion
- stroke
- LVF
52
Describe the physiological process that causes a splitting S2 heart sound during inspiration.
1) chest expands causing inc in neg pressure
2) vacuum causes venous return to increase
3) vacuum causes pulm return to LV to decrease
4) RV systole lasts longer than left
5) pulm valve shuts slightly later than aortic valve
53
When examining for MI doing a CVS exam, what are you trying to rule out/what might you find in the following:
1) Pulse, BP and trace
2) Heart ausculation
3) Lung fields
4) peripheral pulse
5) DVT
6) Palpate for abdo tenderness/mass
1) Arrhythmia, cardiogenic shock (MI, HF, valve disease)
2) Murmur, 3rd heart sound (HF)
3) LVF, pneumonia, pneumothorax
4) aortic dissection
5) PE
6) ruptured AA, cholecystitis, pancreatitis, perforated peptic ulcer
54
If you are suspicious of MI but ECG initially appears normal, how often should you re-do ECG?
every 15mins
55
If you are suspicious of LVF or aortic dissection, what imaging should you request?
CXR
56
After how many hours, is troponin an accurate marker of MI?
Which troponins are specific to cardiac myocytes?
Which other conditions, apart from MI, do you get raised troponin due to damaged myocytes? Name 3
12 hours
trop I and T
- PE (back pressure causes RV dilation and damage)
- Pericarditis
- sepsis
- renal failure (reduces trop excretion)
57
In MI, when is ST elevation significant? Name the 2.
1) 1mm in 2 limb leads
| 2) 2mm in 2 adjacent chest leads
58
A short PR interval on ECG suggests which condition and why?
WPW due to accessory pathway causing quick connection between atria and ventricle
59
An increase in QRS amplitude indicates which condition?
Left ventricular hypertrophy
60
Name 3 conditions that cause ST elevation.
MI
Prinzmetal angina
Brugada syndrome
HCOM
61
What ECG changes do you get in torsades de pointes?
```
Polymorphic VT (varying widths of QRS+ tachy)
AND prolonged QT
```
62
What happens to T waves on ECG in hyper/hypokalaemia?
hyper-tall tented
| hypo-flattened
63
Name 3 acute changes in MI.
ST elevation
Pathological Q waves
T wave inversion
LBBB
64
What are the 3 criteria needed, to diagnose MI in a pt with LBBB?
- ST elevation >1mm in leads with +ve QRS
- ST elevation >5mm in leads with -ve QRS
- ST depression in V1,2,3
65
Treatment for MI is similar to NSTEMI/angina apart from which crucial extra step?
When is atenolol, i.e. b blockers, contraindicated? Give 3
PCI
- bradyarrhythmia
- HF
- hypotension
66
Name 5 contraindications of thrombolysis.
```
Recent head injury/bleed
Stroke
GI bleed
Pregancy
Severe hypertension
Aortic dissection
Ruptured AA
Major surgery within past few weeks
```
67
What is the main choice of agent for thrombolysis and how does it occur, briefly? Name a common one
tPA (tissue plasminogen activator)
- Converts plasminogen into plasmin, which then breaks down fibrin (a clotting agent)
- Alteplase
68
Name 3 complications of MI.
cardiogenic shock
arrhythmia (watch out for VF/VT)
hypokalaemia
pulm oedema
69
Name 3 signs/symptoms of pericarditis.
- chest pain
- low grade fever
- pericardial rub
70
Describe the chest pain seen in pericarditis.
sharp central retrosternal, worse on inspiration, movement, exercise and dysphagia (if pericardial effusion compresses oesophagus)
71
Name 3 broad causes of pericarditis
- MI
- Bacteria
- Viruses
- TB
- local invasive carcinoma
- Drug
72
How do you treat:
1) Idiopathic/viral pericarditis
2) Dresslers syndrome
1) NSAIDS+PPI
2) Aspirin+steroids
3)
73
What is dresslers syndrome?
an AI antigen response to damaged myocytes 2-3 weeks post MI in around 3% of MI's. Usually resolved by aspirin+steroids and doesn't progress to tamponade
74
When protecting cardiac myocytes in hyperkalaemia, how should administration of calcium gluconate change, in a patient on digoxin and why?
- digoxin toxicity may occur
| - dilute with 100ml of 5% glucose and give over 20mins
75
Which drug that causes hypokalaemia, can be used in patients with hyperkalaemia? Which patient groups should you be wary of-name 1
salbutamol
| -IHD patients
76
If hyperkalaemia persists despite all treatment, what is the final last ditch management step?
dialysis
77
What oral medication can you use to reduce potassium levels? What should you prescribe with it and why?
```
calcium resonium (oral resin that binds K+ and promotes excretion)
laxative as causes constipation
```
78
Below what number, counts as hypoglycaemia?
4mmol/L
79
If a a patient with low glucose levels (but above 4mmol/L) is symptomatic but with full consciousness, what is the treatment?
A carbohydrate snack such as banana, bread
| Check glucose after 15mins to see if has resolved
80
If a a patient with low glucose levels (below 4mmol/L) is symptomatic but with full consciousness, what is the treatment?
15-20g quick acting carbohydrate
Gluco/dextro tablets
Glucojuice
Fruit juice
4 heaped tsp of sugar dissolved in water
Recheck glucose 15mins later
If still below, repeat quick acting carbs up to 3 times
If still below after 3 cycles, consider IM glucagon 1mg or 10% glucose infusion IV 150-200ml over 15mins
Then ensure a small long acting carb (20g) taken (slice of bread etc) BUT if glucagon given, have large carb snack (40g) to replenish glycogen stores
81
If a a patient with low glucose levels (below 4mmol/L) is symptomatic and with normal consciousness BUT confused/agressive, what is the treatment?
Glucogel or dextrogel
OR
IM glucagon ONCE
If still below 4, repeat gluco/dextrogel 3 more times
If still below, IV 10% glucose 150-200ml over 20mins
Then short/long acting carb snack depending on if glucagon was taken
82
If a a patient with low glucose levels (below 4mmol/L) is symptomatic and with reduced/loss of consciousness what is the treatment?
if IV access avail:
-glucose 75-100ml 20% over 15mins
OR glucose 150-200ml 10% over 15
If still below, repeat administration
If no IV access:
-IM glucagon 1mg
83
In each scenario, explain whether blood insulin, c peptide and b hydroxybutyrate levels are high or low:
1) insulinoma
2) Insulin overdose
3) Alcohol ketosis
1) High, high, low
2) High, low, low
3) Low, low, high
84
When does a:
1) Lorry driver
2) Normal car driver
have to inform DVLA of their diabetes diagnosis?
1) When on oral antidiabetic meds and insulin
| 2) When on insulin
85
What situations should a pt inform DVLA of diabetes? Name 3.
1) had more than 1 ep of hypoglycaemia within last 12months
2) Imparied awareness of hypo
3) Had ep whilst driving
86
What are the 3 characteristic features of DKA? Name the values too
1) Hyperglycaemia >11mmol/l
2) Metabolic acidosis with HCO3- <15mmol/l and/or PH<7.3
3) Ketonaemia >3 in blood, or ketonuria >2 in urine
87
What is the immediate first step in management of DKA? And how much?
FLUID replacement! (Due to glycosuria)
-NaCl 500ml in 15mins then
NaCL 500ml in 45mins
88
When giving insulin in DKA, what kind of infusion is it? Also, how many units/kg/hr? After how many hours should insulin be started?
How much insulin in total?
Fixed rate infusion of 0.1units/kg/hr
After 1 hour
50units of actrapid diluted into 50ml of NaCl
89
What are dehydrated DKA patients at high risk of and how would you treat it?
VTE
| Treat with prophylactic LMWH
90
What treatment would you give if the insulin infusion prescription was delayed in DKA?
An IM bolus of insulin 0.1u/kg
91
When giving insulin for DKA, K+ drops. How do you manage this? Give treatment for each of the 3 ranges.
- Over 5.5mmol/l=none
- Between 3.5-5.5mmol/l=give 40mmol/l bag
- Less than 3.5mmol/l=senior involvement
92
DKA mostly occurs in type 1 diabetics. Which medication group taken by those with type 2 can cause euglycaemic DKA?
SGLT2 inhibitors (cana/dapagliflozin)
93
Name 3 features of HHS (hyperosmolar hyperglycaemic state)
- hypovolaemia (due to inc removal of glucose to combat hyper)
- marked hyperglycaemia
- inc osmolarity
94
What is the main aim in treatment for HHS?
| Is insulin given and why?
Normalise osmolarity (main contributors are glucose and Na+)
Give 0.9% saline or 0.45% if osmolarity not resolving
No insulin given as glucose normalises through rehydration
95
Why are patients who are treated for HHS at risk of cerebral oedema? Explain pathophys
-rapid correction of glucose can cause brain cells to trap active osmolar substances=cells swell in brain causing oedema
96
When should you use amiodarone in treatment of AF? What can you use instead?
When pt is haemodynamically compromised
| Digoxin
97
Name 3 non drug causes of sinus bradycardia.
```
Hypothyroidism
Cholestatic jaundice
Hypothermia
Raised ICP
Chronic degeneration of SA node
```
98
Name 3 drug causes of sinus bradycardia.
Amiodarone
B blockers
Most antiarrhythmics
99
What drug is used to manage symptomatic bradycardia and what dose?
Atropine 500micrograms-can be given up to 3mg
100
Name 2 causes of a sinus pause (transient absence of p waves on ECG). Name 3 symptoms and the definitive treatment.
Stroke
MI
Digoxin toxicity
Fibrosis of SA node
Sx: dizziness, lethargy, breathlessness, collapse
Pacemaker
101
What is sick sinus syndrome and name the 2 treatments.
Periods of brady and tachyarrhythmia
Presents with palpatations and dizziness
Rx: pacemaker+rate limiting drugs
102
What are the indications of a permanent pacemaker? Name 3
VT with pauses
Carotid sinus hypersensitivity
Symptomatic SA node dysfunction
symptomatic bradyarrhythmia
Pauses lasting >3 secs
Bifasicular block (2/3 branches of fasicular bundles) with intermittent 3rd degree
Trifasicular block with 2nd/3rd degree block
103
Name 3 conditions that may lead to AF.
```
Thyroid dysfunction
Diabetes
Symptomatic heart failure
Cardiomyopathy
Chronic renal failure
Valvular disease
```
104
Which valvular disease is most likely to lead to AF?
Mitral stenosis/regurge
105
What are the 4H's and 4T's of cardiac arrest?
- Hypovolaemia, hypoxia, Hypo/hyperkalaemia, Hypothermia
| - Tension pneumothorax, tamponade (cardiac), toxins, thrombus (pulm or coronary)
106
In severe HTN, what is the diastolic BP above? Name 3 features of hypertensive encephalopathy.
```
125
N+V
Confusion
Fits/seizure
Headache
Retinopathy (haemorrhage, exudate)
Reduced consciousness
```
107
Describe the chest pain in aortic dissection.
Sharp tearing ant/post pain-can invlove back
108
Name 3 clues for a diagnosis of aortic dissection.
Hypertension
Absent/asymmetric pulses
Neurological weakness (if carotid/spinal a. involved)
Aortic regurg murmur
109
Name 3 findings on CXR in aortic dissection.
Double knuckle aorta
Widened mediastinum
Left pleural effusion
calcified aorta
110
What is the definitive Ix for aortic dissection for a) haemodynamically stable and b) haemodynamically unstable patients?
a) CT angiography
| b) trans-oesophageal echo
111
Give 3 management steps in aortic dissection.
Which type of dissection is managed surgically and which medically?
O2 by face mask
Crossmatch 6U
IV morphine titrated according to response (+/- anti emetic)
Arterial line +BP medication
```
Type A (proximal+closest to heart)-surgically
Type B (distal)-medically
```
112
Name some causes of haemoptysis:
- Cardio (3)
- Resp (3)
- Other (2)
- Cardio-, ruptured aortic aneurysm, PE, pul oedema
- Resp-pneumonia, carcinoma, TB, abscess, bronchiectasis
- Other- goodpastures, wegeners granulomatosis
113
Name the 3 management techniques in ABC for haemoptysis.
A-suction of contents, intubate (wearing face shield), tilt trolley head down
B- Oxygen
C- 2X 14G cannulae with fluids/blood/clotting
114
What does yellow colour in a bruise imply?
wound is >18hours old
115
What is the most important Ix when assessing skin wounds?
Assessment/exploration under anasthesia
116
Name 3 types of wounds you would not explore.
Stab to neck, chest, abdo, perineum
Clear neurovascular/tendon damage
Septic joints
117
What 2 drugs are useful when exploring profusely bleeding scalp wounds?
lidocaine with adrenaline
118
Name 5 causes of pericarditis.
```
idiopathic
Viral infection (e.g. cocksakie)
Dresslers syndrome
Uraemic pericarditis
AI diseases (SLE, scleroderma, RA)
Cancer
Medication (penicillin, anticonvulsants)
```
119
Name 2 signs of pericarditis.
Fever
| Sharp, central, retrosternal pain that is worse on deep inspiration
120
What is the most specific finding on auscultation in pericarditis?
pericardial rub
121
What ECG change do you see in pericardial effusion?
decreased QRS amplitude
122
Name 6 ix for pericarditis.
ECG CXR
FBC, U&E, trop, ESR, CRP
Blood cultures (if evidence of infectious cause)
ECHO
123
What sign do you see on CXR in pericarditis?
water bottle sign/jam fois humidifier shape
124
How do you treat pericarditis?
- NSAIDS+PPI in viral/idiopathic
- Specialist input for dresslers
- Pericardiocentesis for tamponade
125
What neurological manifestation can severe hypertension lead to?
hypertensive encephalopathy
126
if diastolic BP>125 or hypertensive encephalopathy is present, name 2 drugs that may treat.
b blocker-labetelol/atenolol
Calcium channel blocker-nifedipine
Sodium nitroprusside( short vasodilator)
127
Name 3 resp and 3 cardio causes of dyspnoea.
Resp: pneumothorax, pleural effusion, pneumonia, asthma, exacerbation COPD
Cardio: pulm oedema, MI, PE, arrhythmia
128
Name 2 severe signs of pulm oedema.
cyanosis
| coughing up pink frothy sputum
129
What position should you put a patient in pulm oedema?
sit them upright!
130
Name 4 generic treatments of pulm oedema.
| What o2 device can help if not improving?
O2
GTN spray
IV furosemide
IV opioid
NIV-BiPAP/CPAP
131
Name 4 cardiogenic and 4 non cardiogenic causes of pulm oedema.
cardiogenic: MI, valvular disease, LHF, arrhythmia, cardiomyopathy, b blockers
Non cardiogenic: sepsis, reduced oncotic pressure, drugs, near drowning, fluid overload
132
Name 3 exudative and 2 transudative causes of pleural effusion.
exudate-infection (leaky capillaries allowing largre proteins to leave), trauma, malignancy, inflammatory conditions
transudate-nephrotic syndrome, cirrhosis
133
Name 2 symptoms of large pleural effusion (small ones may go unnoticed!).
pleurisy (chest pain on inspiration)
SOB
Dyspnoea
134
Name 3 examination findings in pleural effusion.
decreased breath sounds
dullness to percussion
decreased tactile fremitus
IF LARGE: tracheal deviation may be seen
135
Name the criteria used to distinguish between transudative and exudative fluid and name the 2 substances measured.
light criteria
proteins fluid:serum
LDH fluid:serum
136
Simply, name the management for each pleural effusion:
a) small effusion from heart failure
b) large effusion from cancer
c) empyema from pneumonia or TB
a) diuretics/sodium restriction
b) draining with tube
c) surgery (too thick to drain)
137
What are the PEF % in:
a) moderate asthma
b) acute severe
c) life threatening
a) 50-75%
b) 33-50%
c) <33%
138
Name the 4 criteria of acute severe asthma.
When do you obtain an ABG?
inability to complete full sentences
PEF 33-50%
RR>25
HR>110
When SpO2<92%
139
Name 4 criteria of life threatening asthma.
What sign means a person is in near fatal asthma?
When do you obtain an ABG?
cyanosis
confusion/coma/exhaustion
silent chest
oxygen<92%
hypercapnia!
When SpO2<92%
140
Name 7 treatments, in order, of acute asthma management.
oxygen!
5mg salbutamol nebs back to back if needed
Corticosteroid-pred 40-50mg or hydrocortisone 100mg IV
Anticholinergic- nebs ipratroprium bromide 500micrograms
IV mag sulphate
IV aminophylline
IV salbutamol
141
Name 3 symptoms that suggest advanced COPD.
cyanosis
cor pulmonale
plethora (Excessive body fluid)
142
The treatment of COPD is the same as asthma except which one thing?
don't give magnesium in COPD, but give antibiotics if suspicious of pneumonia
143
Which situation is CPAP used?
obstructive sleep apnea
144
Name 5 causes of secondary spont pneumothorax
```
COPD
TB
Bronchial carcinoma
Asthma
marfans syndrome
CF
infection
oesophageal rupture
```
145
What looks like pneumothorax on an xray, seen in COPD patients?
emphasematous bullae
146
How should you treat:
a) primary spont pneumo
b) secondary spont pneumo
a) needle aspiration and if unsuccessful, insert seldinger chest drain
b) chest drain
147
If a patient has a WELLS score>3 and d-dimer +ve what ix should be done? What is this ruling out?
USS of WHOLE leg
(femoral, popliteal and calf veins)
DVT
148
What is the rx for DVT?
| What 2 services should they see after?
LMWH and home supply for 1 week
| Anticoagulation service and medical OP
149
Where else can you get DVT apart from the leg? What do you call the condition where you have a clot in a superficial vein and what is the treatment?
upper limb!! mainly in pts with central lines having chemo
superficial thrombophlebitis
Rx: NSAIDS
150
Name 6 RF of DVT.
```
Sepsis
pregnancy
coagulation disorder
malignancy
bed bound
Recent travel/immobilisation
Recent surgery
Previous VTE event
FH of VTE
```
151
Name 3 symptoms of massive PE.
Name 2 other symptoms of PE.
```
syncope
cardiac arrest
cyanosis
angina
(increased RR&HR, decreased BP)
```
dyspnoea
haemoptysis
pleurisy
152
What scoring system is used for PE?
| When is CTPA required?
modified wells
score>2 OR elevated d dimer
153
In PE, what imaging technique is used in pregnant and young patients and why?
V/Q scanning
| lower dose radiation
154
How do you treat:
a) PE
b) massive PE
a) LMWH then warfarin therapy
| b) IV alteplase
155
Name 5 causes of upper GI bleeding.
```
Gastric ca
mallory weiss tear
Oesophageal varices
peptic ulcer
Mucosal inflammation (gastritis, duodenitis, oesophagitis)
Co-ag disorder
```
156
Name 2 symptoms of upper GI bleed.
haematemesis
| malena (fresh PR blood if massive bleed)
157
What is the ix of choice in upper GI bleeding?
endoscopy
158
What scoring system is used in upper GI bleeding and what does it indicate?
What 4 parameters are used?
rockall score
mortality
Age
HR
BP
Co-morbidities
159
Name 5 steps to treat oesophageal varices GI bleeding.
```
IV fluids
terlipressin
If high INR, vit K
abx
balloon tamponade
```
160
What is a rare cause of upper/lower GI bleeding?
aorto-enteric fistula
161
Name 3 drug classes that may cause GI bleeding.
NSAIDS!!
Aspirin (salicilate/NSAID)
steroids
anticoags
162
What 2 examinations must be done in lower gi bleeding?
abdo exam+PR!
163
Name 3 features that make a headache worrying.
altered mental status
focal neurology
fever
164
If a CT is -ve for SAH, what ix should be done and what are you looking for?
LP
| RBC and xanthochromia (yellow colour occuring after bleeding into CSF)
165
Name 3 other symptoms of SAH apart from worst headache, thunderclap.
Vomiting
neck pain
photophobia
Unilateral eye pain
166
What cranial nerve is usually involved in a SAH caused by a berry aneurysm?
occulomotor nerve due to post communicating a. involvement
167
Which is worse and thus scores less on the GCS scale? Decerebrate or decorticate posture?
Decererate is worse ('cere' severe')
| scores 2 whereas other one scores 3
168
Name 5 management options of SAH.
analgesia+antiemetic
tracheal intubation/IPPV if GCS<8
Nimodipine to treat ischeamic neurological defects (vasodilator)
Mannitol if raised ICP
169
Name 3 treatments of migraine.
paracetemol
NSAIDS
sumatriptan
170
Name 5 symptoms/signs of cluster headache.
Name 3 treatments.
alcohol can bring it on
severe unilateral headache lasting 18-180mins
May vomit, miosis, ptosis, lacrimation, rhinorrhoea, sweating
O2 for 15mins (12L non rebreathe)
Paracetemol/NSAIDS
sumatriptan
171
Name a symptom of trigeminal neuralgia and 3 situations that make it worse.
What is the single treatment and what can be used if it doesn't work?
severe shooting pain in distribution of trigeminal nerve
worse on chewing, hair brushing, touching
carbamezepine
paracetemol/NSAIDS
172
What headache appears band like in nature and is treated with analgesia and GP follow up?
tension headache
173
Name 3 symptoms of patients with temporal arteritis/GCA.
What marker is usually raised in this condition?
How would you confirm dx?
How would you treat. Name the one thing.
```
weight loss
night sweats
fever
jaw claudication
reduced vision
shoulder stiffness
myalgia
```
ESR
Confirm by doing temporal artery biopsy
Treat with corticosteroids
174
Name 2 symptoms of space occupying lesion.
Dull and achey pain
| worse on lying down
175
What sudden onset headache causing nausea and vomiting is common in sinus infections, pregnancy and post partum? Clue is increased ICP
cerebral venous thrombosis
176
What is another word for acute confusional state?
| Give examples of how a patient might behave in this state
delirium
Conscious level and mood-excitation, aggression, drowsiness
Cognition-memory disturbance, motor weakness, speech, orientation, attention
Hallucinations (mainly visual)
177
Name 2 causes of delirium in each category:
a) Prescribed drugs
b) Abused drugs
c) Drug withdrawal
d) Metabolites
e) Neurology
f) Endocrine
g) Infections
a) digoxin, analgesia, anticholinergic, antiparkinsonian, steroids, diuretics
b) opioids, ecstasy (MDMA), amphetamines (stimulant), benzodiazepines, hallucinogens
c) alcohol, opioid, steroid, anxiolytic
d) hypoxia, hypercapnia, hypoglycaemia, hypercalcaemia, hyponatraemia, acidosis
e) Head trauma, chronic subdural, meningitis, post ictal state
f) diabetes, addisons, thyrotoxicosis
g) UTI, pneumonia, meningitis, encephalitis, septicaemia
178
What is the role of a MMSE?
- Test of cognitive impairment
| - most commonly in dementia
179
Name 6 mandatory basic ix needed in assessing acute confusion.
```
BMG (finger prick glucose)
FBC, U&E, blood glucose
ABG
urinalysis
CXR
ECG
O2 sats
```
Have a low threshold for: LP, blood cultures, toxic drug screens, CT brain
180
Name the 4 commonest causes of dementia.
alzheimers
vascular
Lewy body
181
Name 3 causes of syncope on exertion.
valvular disease
cardiomyopathy
pulm HTN
coronary artery disease
182
Name 5 causes of syncope.
```
ruptured ectopic pregnancy
GI bleed
SAH
dissection
PE
```
183
After what event do you get GBS (guilliane barre)? Explain some symptoms seen.
resp/GI VIRAL infection
Distal to proximal muscle weakness+parasthesia and numbness
May see autonomic features (hyper/hypotension, tachy/bradycardia, bladder atony)
184
What kind of disease is MS?
| Name some symptoms associated with is.
demyelinating disease of CNS-aged 20-50
Sx: relapsing and remitting. Sensory loss, muscle weakness, ataxia, bladder dysfunction. Also present with optic neuritis (pain in eye and blurred vision)
185
Name 3 symptoms of polymyositis.
Name 3 difficult movements
What marker is raised?
Inflammatory myopathy
PROXIMAL muscle weakness+ arthritis and muscle tenderness
Climbing stairs, rising from a low chair, brushing hair
Creatine kinase
186
Name 3 common symptoms found in myasthenia gravis?
AI disease resulting in painless muscle weakness (affects AP's at NMJ's)-reflexes and pupil responses normal
ptosis, diplopia, blurry vision
187
When are you worried in myasthenia gravis? Name 1 situation.
Resp muscles affected, compromising ventilation-intubate and assist with ventilation
188
Name 4 causes of generalised weakness.
```
tetanus
stroke/TIA
alcoholic myopathy
spinal cord compression
lead poisoning
Diptheria
```
189
What is non forehead sparing facial nerve palsy called? Which situation would you get a forehead sparing one?
bells palsy
| stroke
190
What is todds paresis.
focal or generalised paresis AFTER a seizure
191
What score is used to recognise stroke?
Rosier score
192
IF a patient is unable to take oral aspirin PO in ischaemic stroke, due to swallowing deficit, how should you give it? What if they are allergic?
rectally
| Give other anti platelet such as clopidogrel
193
What 1 criteria allows you to diagnose TIA?
resolved symptoms within 24hours
194
What scoring system is used for TIA?
ABCD2
195
Explain the pathopys of brain herniation in stroke.
Lack of glucose in cells, allows Na+ and Ca2+ to build up
This leads to cell swelling and apoptosis, leading to cell leakage of contents
This compromises BBB and so fluid seeps into space between brain and skull
Causes brain shift due to hard skull:
-cingulate herniation
-uncal
-cerebellar tonsil herniation
196
What is particularly dangerous about cerebellar tonsil herniation?
can compress brainstem and cause LOC/stop breathing
197
Name 4 causes of ischaemic stroke.
| Name 3 treatments of stroke
thrombus
hypoperfusion
embolus
atherosclerosis
thrombolysis if within 4.5hours
carotid endarterectomy (remove clot surgically)
stent placement
198
How do you treat seizures in pre eclampsia?
IV magnesium sulphate
199
If IV lorazepam, buccal midazolam 10mg or rectal diazepam 10mg do not work in status epilepticus, what are the 2 next mx steps?
```
IV phenytoin (18mg/kg)
Rapid sequence induction and intubation
```
200
Name 3 causes of hypernatraemia.
diabetes insipidus (cerebral/nephrogenic)
Too much IV fluid
Dehydration
Kidney injury
201
How do you treat ACUTE hypernatraemia in patients?
5% glucose 5ml/kg/hr until Na+ back to 145
| Then, 1ml/kg/hr until down to 140
202
How do you treat CHRONIC hypernatraemia in stable patients with and without diabetes insipidus?
Without-pure water through NG tube
With-desmopressin
203
Which 2 situations may cause a reading of low sodium even when it is not?
Inc lipid and protein situations
multiple myeloma
Hyperlipidaemia
204
Name 3 sx of hyponatreamia.
Nausea
Vomiting
Muscle cramps
cerebral oedema
205
What are 3 complications of cerebral oedema?
```
confusion
coma
death
inc ICP
herniation=resp problem
```
206
How do you treat hyponatraemia:
a) SIADH
b) hypovolaemia
c) severe hypo
a) fluid restrict
b) fluid
c) Hypertonic saline
207
What must you beware of when giving hypertonic saline for severe hyponatraemia?
cerebral pontine myelinosis
loss of myelin in pons
208
Which 3 events can cause addisons disease to become apparent? (i.e. heightened adrenal response) What is this called?
injury
surgery
infection
Addisonian crisis
209
Why does adrenal insufficiency affect women's sex drive and pubic hair but not men?
most of male sex hormones derived from testes and not adrenals
210
Name 3 symptoms of addisonian crisis.
Pain in back abdo legs
Vomiting and diarrhoea>dehydration
Low blood pressure (lack of aldosterone)>LOC
DEATH
211
What unique disease can also cause addisonian crisis and how?
What organism causes it commonly?
waterhouse-friderichsen syndrome whereby you get adrenal gland failure due to high BP leading to bleeding into the adrenal glands.
Neisseria meningitidis
212
How do you diagnose adrenal insufficiency? How do you treat?
ACTH test to determine cortisol and aldosterone levels
Lifelong steroid treatment
213
How do you treat addisonian crisis?
ADMIT
hydrocortisone
glucose for hypo
fluid replacement if needed
214
Name 4 triggers of thyrotoxic crisis/thyroid storm.
stressors-surgery, trauma, infection
taking too much thyroid
abruptly stopping carbimazole
215
Name 4 symptoms of of hyperthyroidism and how they can transform into symptoms of thyrotoxic crisis/thyroid storm.
weight loss
heat intolerance (FEVER)
tachycardia (ARRHYTHMIA/CARDIAC FAILURE), sweating, anxiety (AGITATION), insomnia
MAY MIMIC ACUTE ABDO
216
Name 5 treatments of thyroid storm. What is last resort if treatment is unsuccessful?
```
b blockers for tachycardia
carbimazole and iodine
dexamethasone/hydrocortisone
sedation with benzo
abx if infective cause
```
plasmapharesis
217
Which bacteria most commonly causes UTI?
E coli
218
Which organisms cause atypical pneumonia? Name 2.
Mycoplasma (Low Hb and IgM)
| Legionella (causes low Na+, deranged LFT&U&E)
219
Commonest organism causing pneumonia in <15 yr olds.
H. Influenza
220
Which organism is likely to cause pneumonia in patients with HF and COPD?
pseudomonas aurigenosa
221
Commonest organism causing pneumonia in 15-65yr olds.
Strep.pneumoniae
222
Commonest organism causing pneumonia in +75yr olds.
moraxella caterrhalis
223
What needs to be given with dextrose to prevent hypo?
give K+ to prevent hypokalaemia as bag does not contain much K+
224
How do you know if a pt has developed parkinsons dementia after parkinsons disease?
it develops after 5 years
225
Name 4 stages of pneumonia.
Consolidation
grey hepatization
red hepatization
Resolution
226
```
What kind of hallucinations are seen in:
-lewy body
-PD
-alcohol induced
dementia?
```
- monkeys in trees
- children playing
- spiders crawling (tactile)
227
Name 5 symptoms of:
a) lower UTI
b) pyelonephritis
a) dysuria, frequency, haematuria, burning/stinging, suprapubic tenderness, cloudy urine with offensive smell
b) fever, malaise, loin/back pain, vomiting, rigors
228
If the elderly have bacteria in their urine with no symptoms, should they be commenced on abx?
NO
229
When should asymptomatic bacteriuria be treated with abx?
pregnancy
230
Name 3 groups of patients who should be referred for ix and rx with UTI.
```
pregnant
immunosuppressed
renal transplant
men
women with recurrent UTI
```
231
Name the first line treatment of pyelonephritis+2 alternatives.
PO ciprofloxacin
co-amoxiclav
cefalexin
232
Name 3 complications of UTI.
| Name 3 in pregnancy.
pyelonephritis
perirenal abscess
AKI
sepsis
pyelonephritis
preterm delivery
anaemia
233
Name 2 other bacterial causes of UTI apart from E coli.
staph saprophyticus
| Klebsiella pneumoniae
234
Name 3 emergency presentations of haemodialysis patients.
pulm oedema
pre dialysis hyperkalaemia
comp of vascular access
235
Name 2 complications of peritoneal dialysis.
```
hernias
bact peritonitis (cloudy fluid)
```
236
Name 2 comps of renal transplant.
acute rejection
Infections
Poor wound healing/avascular necrosis/pathological fractures
237
If there is severe acidosis in hyperkalaemia, what treatment can you give?
8.4% sodium carbonate
238
What is a porphyria? What inheritance pattern does it show?
hereditary abnormality in haem biosynthesis-causes urine to become dark
autosomal dominant
239
Name 4 symptoms of porphyria. What is the 4P's mnemonic?
- abdominal pain with severe N+V
- peripheral motor neuropathy
- tachycardia, HTN
- psychiatric-depression, hallucinations, psychosis
Polyneuropathy
Painful abdomen
Psychological disturbance
Port-wine coloured urine
240
What does the mnemonic C BRAVADO stand for?
Contractions
```
Baseline RAte
Variability
Accelerations
Decelerations
Overall impression
```
241
What is a normal baseline rate (e.g. heart rate)?
110-160
242
What counts as foetal tachycardia and name 3 causes.
```
>160
Fetal hypoxia
Chorioamnionitis
hyperthyroidism
Foetal or maternal anaemia
```
243
What counts as foetal bradycardia and name 2 causes.
<100
cord prolapse
cord compression
244
What is variability on a CTG and how is it significant?
variation in heart rate of between 5-25bpm is normal
abnormal:
<5 over 50mins
>25 over 25mins
245
What happens with the urine in porphyria?
goes dark red/brown on exposure to light
246
What are normal accelerations and decelerations?
15bpm over 15 seconds in line with uterine contractions
247
What is the significance of decelerations?
foetus reduces heart rate during hypoxia to reduce demand on heart and preserve oxygenation and perfusion of heart
248
Are early decelerations normal and why?
yes, inc in vagal tone when mother contracts uterus
249
What do late decelerations indicate?
reduced perfusion to uterus and placenta causing fetal hypoxia
250
Prolonged deceleration after how many mins is abnormal?
3 minutes
251
What deceleration pattern indicates high foetal mortality?
sinusoidal pattern
252
Prolonged deceleration after how many mins is abnormal?
3 minutes
253
What deceleration pattern indicates high foetal mortality?
sinusoidal pattern
254
What places do you get bleeding in:
a) platelet deficiency
b) clotting factor deficiency?
a) epistaxis, heavy menstruation, purpura, bruising, GI/GU
| b) big spaces-peritoneal, joints
255
What situation can aggravate a bleeding tendancy?
hypOthermia
256
What 3 lab findings occur with DIC?
Low PT
Low PTT
Elevated D dimer
257
What is the treatment of acute intermittent porphyria? Name the 2.
Glucose and haem
258
What 3 lab findings occur with DIC?
Low PT
Low PTT
Elevated D dimer
259
What is the treatment of acute intermittent porphyria? Name the 2.
Glucose and haem
260
What drug is used to treat menniers disease?
buccal or IM prochlorperazine
