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Final year > Emergency medicine > Flashcards

Emergency medicine Flashcards

1
Q

Name 2 symptoms that describe a SAH

A

first and worst

thunderclap

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2
Q

Which 2 diagnoses give unilateral headache and eye pain?

A

Acute glaucoma

Cluster headache

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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

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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
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5
Q

Name 3 signs/sx of hyperkalaemia.

A

Irregular pulse, chest pain, weakness, palpatations, lightheadedness

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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

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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

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8
Q

Name 3 causes of hyperkalaemia.

A 
K+ sparing diuretics
Excess K+ therapy
Addisons disease 
Burns
ACE-i
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9
Q

How does addisons lead to hyperkalaemia?

A

Adrenal insufficieny=low aldosterone=unable to remove potassium

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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
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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

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12
Q

What is the immediate next step after a suspicious death occurs?

A

inform the police who will directly liaise with the coroner

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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

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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)
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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
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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

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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
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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

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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
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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
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21
Q

If IV adrenaline does not work in anaphylaxis, what medication should you give and what dose?

A

IV/IM glucagon 1-2mg

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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

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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

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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
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25
Q

What happens to venous return to right ventricle during inspiration?

A
  • Increases due to neg intrathoracic pressure which dec LV ability to fill
  • Therefore preload decreases, CO decreases so HR increases
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26
Q

A low diastolic BP and thus a. vasodilation occurs in which 2 circulatory compromises?

A
  • Sepsis

- Anaphylaxis

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27
Q

A narrow pulse pressure and thus a. vasoconstriction occurs in which 2 circulatory compromises?

A
  • Hypovolaemia

- Cardiogenic shock

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28
Q

At what % should you start giving O2 for ACS?

A

94% and below

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29
Q

How often should you give adrenaline in cardiac arrest?

A

every 3-5mins

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30
Q

What dose of amiodarone do you give in cardiac arrest?

A

300mg first

A further 150mg if needed

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31
Q

What manouver can you do in a situation where there is a bardyarrhythmia but pacing equipment is not yet available?

A

External cardiac percussion

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32
Q

Define severe sepsis and septic shock.

A

Severe sepsis-sepsis with organ dysfunction/hypoperfusion

Septic shock-sepsis with hypotension unresponsive to fluids

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33
Q

What 4 components make up SIRS?

A

Temp
RR
HR
WCC

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34
Q

Name the 5 things that contribute to shock.

A 
Hypotension
Oliguria
Altered consciousness 
Tachypnoea
Peripheral poor perfusion
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35
Q

Give 3 causes of haemorrhagic hypovolemia?

A

GI bleed
Ruptured ectopic
Ruptured AAA
Trauma

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36
Q

Give 3 causes of third space loss hypovolemia?

A

Burn
GI loss (vomiting, diarrhoea)
Sepsis
Pancreatitis

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37
Q

Name 3 causes of primary and 3 causes of secondary cardiogenic shock.

A

Primary-MI, arrhythmia, valve dysfunction, myocarditis (usually viral cause)
Secondary- cardiac tamponade, tension pneumothorax, massive PE

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38
Q

Name 3 common offending organisms and 3 offending organisms in the immunocompromised that lead to septic shock.

A

Common-S Aureus, Strep pneumoniae, N. meningitidis

Immunocomp-pseudomonas, viruses, fungi

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39
Q

Name 10 differentials of chest pain

A
  • MI
  • aortic dissection
  • PE
  • Angina
  • costochondritis
  • GORD/oesophagitis
  • pleurisy
  • pneumothorax
  • Pneumonia
  • cholecystitis
  • oesophageal rupture
  • pancreatitis
  • vertebral collapse
  • tabes dorsalis
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40
Q

What sign is shown when there is bradycardia in acute cholecystitis? Due to GB inflammation what cardiac blood test change can be seen?

A

Copes sign

Elevated troponin due to reduced flow to myocardium

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41
Q

what is tabes dorsalis?

A

demylenation of DCML fibres caused by syphilis after exposure to spirochete bacteria

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42
Q

Name 3 RF for MI

A

smoking
hypertension
FH of IHD

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43
Q

Name 4 general management steps of angina/NSTEMI. Name 5 drugs used to treat.

A

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
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44
Q

What scoring system is used to determine mortality in pts who have angina/NSTEMI?

A

TIMI score (thrombolysis in MI score)

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45
Q

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

A

prinzmetal/variant angina

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46
Q

Name 5 RF for MI

A 
Smoking
hypertension
hyperlipidaemia
Diabetes
male sex
FH
age
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47
Q

What 3 environmental factors can worsen angina?

A

Cold
stress
exercise

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48
Q

2/3 of which features are required for a dx of MI?

A
  • clinical hx
  • ECG changes
  • elevated cardiac markers
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49
Q

Describe the classic presentation of MI. Name 3 associated symptoms.

A

Central, crushing chest pain which radiates to arms neck and jaw

  • N+V
  • sweating
  • breathlessness
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50
Q

Name 3 patient groups that may present with atypical MI symptoms.

A
  • older age
  • female
  • diabetic
  • HF
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51
Q

Name some atypical sx of MI.

A
  • new onset dyspepsia
  • collapse
  • confusion
  • stroke
  • LVF
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52
Q

Describe the physiological process that causes a splitting S2 heart sound during inspiration.

A

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

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53
Q

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

A

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

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54
Q

If you are suspicious of MI but ECG initially appears normal, how often should you re-do ECG?

A

every 15mins

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55
Q

If you are suspicious of LVF or aortic dissection, what imaging should you request?

A

CXR

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56
Q

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

A

12 hours
trop I and T

  • PE (back pressure causes RV dilation and damage)
  • Pericarditis
  • sepsis
  • renal failure (reduces trop excretion)
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57
Q

In MI, when is ST elevation significant? Name the 2.

A

1) 1mm in 2 limb leads

2) 2mm in 2 adjacent chest leads

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58
Q

A short PR interval on ECG suggests which condition and why?

A

WPW due to accessory pathway causing quick connection between atria and ventricle

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59
Q

An increase in QRS amplitude indicates which condition?

A

Left ventricular hypertrophy

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60
Q

Name 3 conditions that cause ST elevation.

A

MI
Prinzmetal angina
Brugada syndrome
HCOM

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61
Q

What ECG changes do you get in torsades de pointes?

A 
Polymorphic VT (varying widths of QRS+ tachy)
AND prolonged QT
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62
Q

What happens to T waves on ECG in hyper/hypokalaemia?

A

hyper-tall tented

hypo-flattened

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63
Q

Name 3 acute changes in MI.

A

ST elevation
Pathological Q waves
T wave inversion
LBBB

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64
Q

What are the 3 criteria needed, to diagnose MI in a pt with LBBB?

A
  • ST elevation >1mm in leads with +ve QRS
  • ST elevation >5mm in leads with -ve QRS
  • ST depression in V1,2,3
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65
Q

Treatment for MI is similar to NSTEMI/angina apart from which crucial extra step?
When is atenolol, i.e. b blockers, contraindicated? Give 3

A

PCI

  • bradyarrhythmia
  • HF
  • hypotension
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66
Q

Name 5 contraindications of thrombolysis.

A 
Recent head injury/bleed
Stroke
GI bleed
Pregancy
Severe hypertension
Aortic dissection
Ruptured AA
Major surgery within past few weeks
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67
Q

What is the main choice of agent for thrombolysis and how does it occur, briefly? Name a common one

A

tPA (tissue plasminogen activator)

  • Converts plasminogen into plasmin, which then breaks down fibrin (a clotting agent)
  • Alteplase
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68
Q

Name 3 complications of MI.

A

cardiogenic shock
arrhythmia (watch out for VF/VT)
hypokalaemia
pulm oedema

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69
Q

Name 3 signs/symptoms of pericarditis.

A
  • chest pain
  • low grade fever
  • pericardial rub
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70
Q

Describe the chest pain seen in pericarditis.

A

sharp central retrosternal, worse on inspiration, movement, exercise and dysphagia (if pericardial effusion compresses oesophagus)

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71
Q

Name 3 broad causes of pericarditis

A
  • MI
  • Bacteria
  • Viruses
  • TB
  • local invasive carcinoma
  • Drug
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72
Q

How do you treat:

1) Idiopathic/viral pericarditis
2) Dresslers syndrome

A

1) NSAIDS+PPI
2) Aspirin+steroids
3)

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73
Q

What is dresslers syndrome?

A

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

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74
Q

When protecting cardiac myocytes in hyperkalaemia, how should administration of calcium gluconate change, in a patient on digoxin and why?

A
  • digoxin toxicity may occur

- dilute with 100ml of 5% glucose and give over 20mins

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75
Q

Which drug that causes hypokalaemia, can be used in patients with hyperkalaemia? Which patient groups should you be wary of-name 1

A

salbutamol

-IHD patients

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76
Q

If hyperkalaemia persists despite all treatment, what is the final last ditch management step?

A

dialysis

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77
Q

What oral medication can you use to reduce potassium levels? What should you prescribe with it and why?

A 
calcium resonium (oral resin that binds K+ and promotes excretion)
laxative as causes constipation
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78
Q

Below what number, counts as hypoglycaemia?

A

4mmol/L

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79
Q

If a a patient with low glucose levels (but above 4mmol/L) is symptomatic but with full consciousness, what is the treatment?

A

A carbohydrate snack such as banana, bread

Check glucose after 15mins to see if has resolved

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80
Q

If a a patient with low glucose levels (below 4mmol/L) is symptomatic but with full consciousness, what is the treatment?

A

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

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81
Q

If a a patient with low glucose levels (below 4mmol/L) is symptomatic and with normal consciousness BUT confused/agressive, what is the treatment?

A

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

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82
Q

If a a patient with low glucose levels (below 4mmol/L) is symptomatic and with reduced/loss of consciousness what is the treatment?

A

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

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83
Q

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

A

1) High, high, low
2) High, low, low
3) Low, low, high

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84
Q

When does a:
1) Lorry driver
2) Normal car driver
have to inform DVLA of their diabetes diagnosis?

A

1) When on oral antidiabetic meds and insulin

2) When on insulin

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85
Q

What situations should a pt inform DVLA of diabetes? Name 3.

A

1) had more than 1 ep of hypoglycaemia within last 12months
2) Imparied awareness of hypo
3) Had ep whilst driving

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86
Q

What are the 3 characteristic features of DKA? Name the values too

A

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

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87
Q

What is the immediate first step in management of DKA? And how much?

A

FLUID replacement! (Due to glycosuria)
-NaCl 500ml in 15mins then
NaCL 500ml in 45mins

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88
Q

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?

A

Fixed rate infusion of 0.1units/kg/hr
After 1 hour

50units of actrapid diluted into 50ml of NaCl

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89
Q

What are dehydrated DKA patients at high risk of and how would you treat it?

A

VTE

Treat with prophylactic LMWH

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90
Q

What treatment would you give if the insulin infusion prescription was delayed in DKA?

A

An IM bolus of insulin 0.1u/kg

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91
Q

When giving insulin for DKA, K+ drops. How do you manage this? Give treatment for each of the 3 ranges.

A
  • Over 5.5mmol/l=none
  • Between 3.5-5.5mmol/l=give 40mmol/l bag
  • Less than 3.5mmol/l=senior involvement
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92
Q

DKA mostly occurs in type 1 diabetics. Which medication group taken by those with type 2 can cause euglycaemic DKA?

A

SGLT2 inhibitors (cana/dapagliflozin)

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93
Q

Name 3 features of HHS (hyperosmolar hyperglycaemic state)

A
  • hypovolaemia (due to inc removal of glucose to combat hyper)
  • marked hyperglycaemia
  • inc osmolarity
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94
Q

What is the main aim in treatment for HHS?

Is insulin given and why?

A

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

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95
Q

Why are patients who are treated for HHS at risk of cerebral oedema? Explain pathophys

A

-rapid correction of glucose can cause brain cells to trap active osmolar substances=cells swell in brain causing oedema

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96
Q

When should you use amiodarone in treatment of AF? What can you use instead?

A

When pt is haemodynamically compromised

Digoxin

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97
Q

Name 3 non drug causes of sinus bradycardia.

A 
Hypothyroidism
Cholestatic jaundice
Hypothermia
Raised ICP
Chronic degeneration of SA node
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98
Q

Name 3 drug causes of sinus bradycardia.

A

Amiodarone
B blockers
Most antiarrhythmics

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99
Q

What drug is used to manage symptomatic bradycardia and what dose?

A

Atropine 500micrograms-can be given up to 3mg

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100
Q

Name 2 causes of a sinus pause (transient absence of p waves on ECG). Name 3 symptoms and the definitive treatment.

A

Stroke
MI
Digoxin toxicity
Fibrosis of SA node

Sx: dizziness, lethargy, breathlessness, collapse
Pacemaker

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101
Q

What is sick sinus syndrome and name the 2 treatments.

A

Periods of brady and tachyarrhythmia
Presents with palpatations and dizziness
Rx: pacemaker+rate limiting drugs

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102
Q

What are the indications of a permanent pacemaker? Name 3

A

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

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103
Q

Name 3 conditions that may lead to AF.

A 
Thyroid dysfunction
Diabetes
Symptomatic heart failure
Cardiomyopathy
Chronic renal failure 
Valvular disease
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104
Q

Which valvular disease is most likely to lead to AF?

A

Mitral stenosis/regurge

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105
Q

What are the 4H’s and 4T’s of cardiac arrest?

A
  • Hypovolaemia, hypoxia, Hypo/hyperkalaemia, Hypothermia

- Tension pneumothorax, tamponade (cardiac), toxins, thrombus (pulm or coronary)

106
Q

In severe HTN, what is the diastolic BP above? Name 3 features of hypertensive encephalopathy.

A 
125
N+V
Confusion
Fits/seizure
Headache
Retinopathy (haemorrhage, exudate)
Reduced consciousness
107
Q

Describe the chest pain in aortic dissection.

A

Sharp tearing ant/post pain-can invlove back

108
Q

Name 3 clues for a diagnosis of aortic dissection.

A

Hypertension
Absent/asymmetric pulses
Neurological weakness (if carotid/spinal a. involved)
Aortic regurg murmur

109
Q

Name 3 findings on CXR in aortic dissection.

A

Double knuckle aorta
Widened mediastinum
Left pleural effusion
calcified aorta

110
Q

What is the definitive Ix for aortic dissection for a) haemodynamically stable and b) haemodynamically unstable patients?

A

a) CT angiography

b) trans-oesophageal echo

111
Q

Give 3 management steps in aortic dissection.

Which type of dissection is managed surgically and which medically?

A

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
Q

Name some causes of haemoptysis:

  • Cardio (3)
  • Resp (3)
  • Other (2)
A
  • Cardio-, ruptured aortic aneurysm, PE, pul oedema
  • Resp-pneumonia, carcinoma, TB, abscess, bronchiectasis
  • Other- goodpastures, wegeners granulomatosis
113
Q

Name the 3 management techniques in ABC for haemoptysis.

A

A-suction of contents, intubate (wearing face shield), tilt trolley head down
B- Oxygen
C- 2X 14G cannulae with fluids/blood/clotting

114
Q

What does yellow colour in a bruise imply?

A

wound is >18hours old

115
Q

What is the most important Ix when assessing skin wounds?

A

Assessment/exploration under anasthesia

116
Q

Name 3 types of wounds you would not explore.

A

Stab to neck, chest, abdo, perineum
Clear neurovascular/tendon damage
Septic joints

117
Q

What 2 drugs are useful when exploring profusely bleeding scalp wounds?

A

lidocaine with adrenaline

118
Q

Name 5 causes of pericarditis.

A 
idiopathic
Viral infection (e.g. cocksakie)
Dresslers syndrome
Uraemic pericarditis
AI diseases (SLE, scleroderma, RA)
Cancer
Medication (penicillin, anticonvulsants)
119
Q

Name 2 signs of pericarditis.

A

Fever

Sharp, central, retrosternal pain that is worse on deep inspiration

120
Q

What is the most specific finding on auscultation in pericarditis?

A

pericardial rub

121
Q

What ECG change do you see in pericardial effusion?

A

decreased QRS amplitude

122
Q

Name 6 ix for pericarditis.

A

ECG CXR
FBC, U&E, trop, ESR, CRP
Blood cultures (if evidence of infectious cause)
ECHO

123
Q

What sign do you see on CXR in pericarditis?

A

water bottle sign/jam fois humidifier shape

124
Q

How do you treat pericarditis?

A
  • NSAIDS+PPI in viral/idiopathic
  • Specialist input for dresslers
  • Pericardiocentesis for tamponade
125
Q

What neurological manifestation can severe hypertension lead to?

A

hypertensive encephalopathy

126
Q

if diastolic BP>125 or hypertensive encephalopathy is present, name 2 drugs that may treat.

A

b blocker-labetelol/atenolol
Calcium channel blocker-nifedipine

Sodium nitroprusside( short vasodilator)

127
Q

Name 3 resp and 3 cardio causes of dyspnoea.

A

Resp: pneumothorax, pleural effusion, pneumonia, asthma, exacerbation COPD
Cardio: pulm oedema, MI, PE, arrhythmia

128
Q

Name 2 severe signs of pulm oedema.

A

cyanosis

coughing up pink frothy sputum

129
Q

What position should you put a patient in pulm oedema?

A

sit them upright!

130
Q

Name 4 generic treatments of pulm oedema.

What o2 device can help if not improving?

A

O2
GTN spray
IV furosemide
IV opioid

NIV-BiPAP/CPAP

131
Q

Name 4 cardiogenic and 4 non cardiogenic causes of pulm oedema.

A

cardiogenic: MI, valvular disease, LHF, arrhythmia, cardiomyopathy, b blockers

Non cardiogenic: sepsis, reduced oncotic pressure, drugs, near drowning, fluid overload

132
Q

Name 3 exudative and 2 transudative causes of pleural effusion.

A

exudate-infection (leaky capillaries allowing largre proteins to leave), trauma, malignancy, inflammatory conditions
transudate-nephrotic syndrome, cirrhosis

133
Q

Name 2 symptoms of large pleural effusion (small ones may go unnoticed!).

A

pleurisy (chest pain on inspiration)
SOB
Dyspnoea

134
Q

Name 3 examination findings in pleural effusion.

A

decreased breath sounds
dullness to percussion
decreased tactile fremitus

IF LARGE: tracheal deviation may be seen

135
Q

Name the criteria used to distinguish between transudative and exudative fluid and name the 2 substances measured.

A

light criteria
proteins fluid:serum
LDH fluid:serum

136
Q

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

a) diuretics/sodium restriction
b) draining with tube
c) surgery (too thick to drain)

137
Q

What are the PEF % in:

a) moderate asthma
b) acute severe
c) life threatening

A

a) 50-75%
b) 33-50%
c) <33%

138
Q

Name the 4 criteria of acute severe asthma.

When do you obtain an ABG?

A

inability to complete full sentences
PEF 33-50%
RR>25
HR>110

When SpO2<92%

139
Q

Name 4 criteria of life threatening asthma.

What sign means a person is in near fatal asthma?

When do you obtain an ABG?

A

cyanosis
confusion/coma/exhaustion
silent chest
oxygen<92%

hypercapnia!

When SpO2<92%

140
Q

Name 7 treatments, in order, of acute asthma management.

A

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
Q

Name 3 symptoms that suggest advanced COPD.

A

cyanosis
cor pulmonale
plethora (Excessive body fluid)

142
Q

The treatment of COPD is the same as asthma except which one thing?

A

don’t give magnesium in COPD, but give antibiotics if suspicious of pneumonia

143
Q

Which situation is CPAP used?

A

obstructive sleep apnea

144
Q

Name 5 causes of secondary spont pneumothorax

A 
COPD
TB
Bronchial carcinoma
Asthma
marfans syndrome
CF
infection 
oesophageal rupture
145
Q

What looks like pneumothorax on an xray, seen in COPD patients?

A

emphasematous bullae

146
Q

How should you treat:

a) primary spont pneumo
b) secondary spont pneumo

A

a) needle aspiration and if unsuccessful, insert seldinger chest drain
b) chest drain

147
Q

If a patient has a WELLS score>3 and d-dimer +ve what ix should be done? What is this ruling out?

A

USS of WHOLE leg
(femoral, popliteal and calf veins)
DVT

148
Q

What is the rx for DVT?

What 2 services should they see after?

A

LMWH and home supply for 1 week

Anticoagulation service and medical OP

149
Q

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?

A

upper limb!! mainly in pts with central lines having chemo

superficial thrombophlebitis
Rx: NSAIDS

150
Q

Name 6 RF of DVT.

A 
Sepsis
pregnancy
coagulation disorder
malignancy
bed bound
Recent travel/immobilisation 
Recent surgery
Previous VTE event
FH of VTE
151
Q

Name 3 symptoms of massive PE.

Name 2 other symptoms of PE.

A 
syncope
cardiac arrest
cyanosis
angina
(increased RR&amp;HR, decreased BP)

dyspnoea
haemoptysis
pleurisy

152
Q

What scoring system is used for PE?

When is CTPA required?

A

modified wells

score>2 OR elevated d dimer

153
Q

In PE, what imaging technique is used in pregnant and young patients and why?

A

V/Q scanning

lower dose radiation

154
Q

How do you treat:

a) PE
b) massive PE

A

a) LMWH then warfarin therapy

b) IV alteplase

155
Q

Name 5 causes of upper GI bleeding.

A 
Gastric ca
mallory weiss tear
Oesophageal varices
peptic ulcer
Mucosal inflammation (gastritis, duodenitis, oesophagitis)
Co-ag disorder
156
Q

Name 2 symptoms of upper GI bleed.

A

haematemesis

malena (fresh PR blood if massive bleed)

157
Q

What is the ix of choice in upper GI bleeding?

A

endoscopy

158
Q

What scoring system is used in upper GI bleeding and what does it indicate?
What 4 parameters are used?

A

rockall score
mortality

Age
HR
BP
Co-morbidities

159
Q

Name 5 steps to treat oesophageal varices GI bleeding.

A 
IV fluids
terlipressin
If high INR, vit K
abx
balloon tamponade
160
Q

What is a rare cause of upper/lower GI bleeding?

A

aorto-enteric fistula

161
Q

Name 3 drug classes that may cause GI bleeding.

A

NSAIDS!!
Aspirin (salicilate/NSAID)
steroids
anticoags

162
Q

What 2 examinations must be done in lower gi bleeding?

A

abdo exam+PR!

163
Q

Name 3 features that make a headache worrying.

A

altered mental status
focal neurology
fever

164
Q

If a CT is -ve for SAH, what ix should be done and what are you looking for?

A

LP

RBC and xanthochromia (yellow colour occuring after bleeding into CSF)

165
Q

Name 3 other symptoms of SAH apart from worst headache, thunderclap.

A

Vomiting
neck pain
photophobia
Unilateral eye pain

166
Q

What cranial nerve is usually involved in a SAH caused by a berry aneurysm?

A

occulomotor nerve due to post communicating a. involvement

167
Q

Which is worse and thus scores less on the GCS scale? Decerebrate or decorticate posture?

A

Decererate is worse (‘cere’ severe’)

scores 2 whereas other one scores 3

168
Q

Name 5 management options of SAH.

A

analgesia+antiemetic
tracheal intubation/IPPV if GCS<8
Nimodipine to treat ischeamic neurological defects (vasodilator)
Mannitol if raised ICP

169
Q

Name 3 treatments of migraine.

A

paracetemol
NSAIDS
sumatriptan

170
Q

Name 5 symptoms/signs of cluster headache.

Name 3 treatments.

A

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
Q

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?

A

severe shooting pain in distribution of trigeminal nerve
worse on chewing, hair brushing, touching

carbamezepine
paracetemol/NSAIDS

172
Q

What headache appears band like in nature and is treated with analgesia and GP follow up?

A

tension headache

173
Q

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.

A 
weight loss
night sweats
fever
jaw claudication
reduced vision
shoulder stiffness
myalgia

ESR

Confirm by doing temporal artery biopsy
Treat with corticosteroids

174
Q

Name 2 symptoms of space occupying lesion.

A

Dull and achey pain

worse on lying down

175
Q

What sudden onset headache causing nausea and vomiting is common in sinus infections, pregnancy and post partum? Clue is increased ICP

A

cerebral venous thrombosis

176
Q

What is another word for acute confusional state?

Give examples of how a patient might behave in this state

A

delirium
Conscious level and mood-excitation, aggression, drowsiness
Cognition-memory disturbance, motor weakness, speech, orientation, attention
Hallucinations (mainly visual)

177
Q

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

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
Q

What is the role of a MMSE?

A
  • Test of cognitive impairment

- most commonly in dementia

179
Q

Name 6 mandatory basic ix needed in assessing acute confusion.

A 
BMG (finger prick glucose)
FBC, U&amp;E, blood glucose
ABG
urinalysis
CXR
ECG
O2 sats

Have a low threshold for: LP, blood cultures, toxic drug screens, CT brain

180
Q

Name the 4 commonest causes of dementia.

A

alzheimers
vascular
Lewy body

181
Q

Name 3 causes of syncope on exertion.

A

valvular disease
cardiomyopathy
pulm HTN
coronary artery disease

182
Q

Name 5 causes of syncope.

A 
ruptured ectopic pregnancy
GI bleed
SAH
dissection
PE
183
Q

After what event do you get GBS (guilliane barre)? Explain some symptoms seen.

A

resp/GI VIRAL infection
Distal to proximal muscle weakness+parasthesia and numbness
May see autonomic features (hyper/hypotension, tachy/bradycardia, bladder atony)

184
Q

What kind of disease is MS?

Name some symptoms associated with is.

A

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
Q

Name 3 symptoms of polymyositis.
Name 3 difficult movements
What marker is raised?

A

Inflammatory myopathy
PROXIMAL muscle weakness+ arthritis and muscle tenderness

Climbing stairs, rising from a low chair, brushing hair

Creatine kinase

186
Q

Name 3 common symptoms found in myasthenia gravis?

A

AI disease resulting in painless muscle weakness (affects AP’s at NMJ’s)-reflexes and pupil responses normal

ptosis, diplopia, blurry vision

187
Q

When are you worried in myasthenia gravis? Name 1 situation.

A

Resp muscles affected, compromising ventilation-intubate and assist with ventilation

188
Q

Name 4 causes of generalised weakness.

A 
tetanus
stroke/TIA
alcoholic myopathy
spinal cord compression
lead poisoning
Diptheria
189
Q

What is non forehead sparing facial nerve palsy called? Which situation would you get a forehead sparing one?

A

bells palsy

stroke

190
Q

What is todds paresis.

A

focal or generalised paresis AFTER a seizure

191
Q

What score is used to recognise stroke?

A

Rosier score

192
Q

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?

A

rectally

Give other anti platelet such as clopidogrel

193
Q

What 1 criteria allows you to diagnose TIA?

A

resolved symptoms within 24hours

194
Q

What scoring system is used for TIA?

A

ABCD2

195
Q

Explain the pathopys of brain herniation in stroke.

A

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
Q

What is particularly dangerous about cerebellar tonsil herniation?

A

can compress brainstem and cause LOC/stop breathing

197
Q

Name 4 causes of ischaemic stroke.

Name 3 treatments of stroke

A

thrombus
hypoperfusion
embolus
atherosclerosis

thrombolysis if within 4.5hours
carotid endarterectomy (remove clot surgically)
stent placement

198
Q

How do you treat seizures in pre eclampsia?

A

IV magnesium sulphate

199
Q

If IV lorazepam, buccal midazolam 10mg or rectal diazepam 10mg do not work in status epilepticus, what are the 2 next mx steps?

A 
IV phenytoin (18mg/kg)
Rapid sequence induction and intubation
200
Q

Name 3 causes of hypernatraemia.

A

diabetes insipidus (cerebral/nephrogenic)
Too much IV fluid
Dehydration
Kidney injury

201
Q

How do you treat ACUTE hypernatraemia in patients?

A

5% glucose 5ml/kg/hr until Na+ back to 145

Then, 1ml/kg/hr until down to 140

202
Q

How do you treat CHRONIC hypernatraemia in stable patients with and without diabetes insipidus?

A

Without-pure water through NG tube

With-desmopressin

203
Q

Which 2 situations may cause a reading of low sodium even when it is not?

A

Inc lipid and protein situations
multiple myeloma
Hyperlipidaemia

204
Q

Name 3 sx of hyponatreamia.

A

Nausea
Vomiting
Muscle cramps
cerebral oedema

205
Q

What are 3 complications of cerebral oedema?

A 
confusion 
coma
death
inc ICP
herniation=resp problem
206
Q

How do you treat hyponatraemia:

a) SIADH
b) hypovolaemia
c) severe hypo

A

a) fluid restrict
b) fluid
c) Hypertonic saline

207
Q

What must you beware of when giving hypertonic saline for severe hyponatraemia?

A

cerebral pontine myelinosis

loss of myelin in pons

208
Q

Which 3 events can cause addisons disease to become apparent? (i.e. heightened adrenal response) What is this called?

A

injury
surgery
infection

Addisonian crisis

209
Q

Why does adrenal insufficiency affect women’s sex drive and pubic hair but not men?

A

most of male sex hormones derived from testes and not adrenals

210
Q

Name 3 symptoms of addisonian crisis.

A

Pain in back abdo legs
Vomiting and diarrhoea>dehydration
Low blood pressure (lack of aldosterone)>LOC
DEATH

211
Q

What unique disease can also cause addisonian crisis and how?
What organism causes it commonly?

A

waterhouse-friderichsen syndrome whereby you get adrenal gland failure due to high BP leading to bleeding into the adrenal glands.

Neisseria meningitidis

212
Q

How do you diagnose adrenal insufficiency? How do you treat?

A

ACTH test to determine cortisol and aldosterone levels

Lifelong steroid treatment

213
Q

How do you treat addisonian crisis?

A

ADMIT
hydrocortisone
glucose for hypo
fluid replacement if needed

214
Q

Name 4 triggers of thyrotoxic crisis/thyroid storm.

A

stressors-surgery, trauma, infection
taking too much thyroid
abruptly stopping carbimazole

215
Q

Name 4 symptoms of of hyperthyroidism and how they can transform into symptoms of thyrotoxic crisis/thyroid storm.

A

weight loss
heat intolerance (FEVER)
tachycardia (ARRHYTHMIA/CARDIAC FAILURE), sweating, anxiety (AGITATION), insomnia

MAY MIMIC ACUTE ABDO

216
Q

Name 5 treatments of thyroid storm. What is last resort if treatment is unsuccessful?

A 
b blockers for tachycardia
carbimazole and iodine 
dexamethasone/hydrocortisone
sedation with benzo
abx if infective cause

plasmapharesis

217
Q

Which bacteria most commonly causes UTI?

A

E coli

218
Q

Which organisms cause atypical pneumonia? Name 2.

A

Mycoplasma (Low Hb and IgM)

Legionella (causes low Na+, deranged LFT&U&E)

219
Q

Commonest organism causing pneumonia in <15 yr olds.

A

H. Influenza

220
Q

Which organism is likely to cause pneumonia in patients with HF and COPD?

A

pseudomonas aurigenosa

221
Q

Commonest organism causing pneumonia in 15-65yr olds.

A

Strep.pneumoniae

222
Q

Commonest organism causing pneumonia in +75yr olds.

A

moraxella caterrhalis

223
Q

What needs to be given with dextrose to prevent hypo?

A

give K+ to prevent hypokalaemia as bag does not contain much K+

224
Q

How do you know if a pt has developed parkinsons dementia after parkinsons disease?

A

it develops after 5 years

225
Q

Name 4 stages of pneumonia.

A

Consolidation
grey hepatization
red hepatization
Resolution

226
Q 
What kind of hallucinations are seen in:
-lewy body
-PD
-alcohol induced
dementia?
A
  • monkeys in trees
  • children playing
  • spiders crawling (tactile)
227
Q

Name 5 symptoms of:

a) lower UTI
b) pyelonephritis

A

a) dysuria, frequency, haematuria, burning/stinging, suprapubic tenderness, cloudy urine with offensive smell
b) fever, malaise, loin/back pain, vomiting, rigors

228
Q

If the elderly have bacteria in their urine with no symptoms, should they be commenced on abx?

A

NO

229
Q

When should asymptomatic bacteriuria be treated with abx?

A

pregnancy

230
Q

Name 3 groups of patients who should be referred for ix and rx with UTI.

A 
pregnant
immunosuppressed
renal transplant
men
women with recurrent UTI
231
Q

Name the first line treatment of pyelonephritis+2 alternatives.

A

PO ciprofloxacin

co-amoxiclav
cefalexin

232
Q

Name 3 complications of UTI.

Name 3 in pregnancy.

A

pyelonephritis
perirenal abscess
AKI
sepsis

pyelonephritis
preterm delivery
anaemia

233
Q

Name 2 other bacterial causes of UTI apart from E coli.

A

staph saprophyticus

Klebsiella pneumoniae

234
Q

Name 3 emergency presentations of haemodialysis patients.

A

pulm oedema
pre dialysis hyperkalaemia
comp of vascular access

235
Q

Name 2 complications of peritoneal dialysis.

A 
hernias
bact peritonitis (cloudy fluid)
236
Q

Name 2 comps of renal transplant.

A

acute rejection
Infections
Poor wound healing/avascular necrosis/pathological fractures

237
Q

If there is severe acidosis in hyperkalaemia, what treatment can you give?

A

8.4% sodium carbonate

238
Q

What is a porphyria? What inheritance pattern does it show?

A

hereditary abnormality in haem biosynthesis-causes urine to become dark

autosomal dominant

239
Q

Name 4 symptoms of porphyria. What is the 4P’s mnemonic?

A
  • 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
Q

What does the mnemonic C BRAVADO stand for?

A

Contractions

Baseline RAte
Variability
Accelerations
Decelerations
Overall impression
241
Q

What is a normal baseline rate (e.g. heart rate)?

A

110-160

242
Q

What counts as foetal tachycardia and name 3 causes.

A 
>160
Fetal hypoxia
Chorioamnionitis
hyperthyroidism 
Foetal or maternal anaemia
243
Q

What counts as foetal bradycardia and name 2 causes.

A

<100

cord prolapse
cord compression

244
Q

What is variability on a CTG and how is it significant?

A

variation in heart rate of between 5-25bpm is normal

abnormal:
<5 over 50mins
>25 over 25mins

245
Q

What happens with the urine in porphyria?

A

goes dark red/brown on exposure to light

246
Q

What are normal accelerations and decelerations?

A

15bpm over 15 seconds in line with uterine contractions

247
Q

What is the significance of decelerations?

A

foetus reduces heart rate during hypoxia to reduce demand on heart and preserve oxygenation and perfusion of heart

248
Q

Are early decelerations normal and why?

A

yes, inc in vagal tone when mother contracts uterus

249
Q

What do late decelerations indicate?

A

reduced perfusion to uterus and placenta causing fetal hypoxia

250
Q

Prolonged deceleration after how many mins is abnormal?

A

3 minutes

251
Q

What deceleration pattern indicates high foetal mortality?

A

sinusoidal pattern

252
Q

Prolonged deceleration after how many mins is abnormal?

A

3 minutes

253
Q

What deceleration pattern indicates high foetal mortality?

A

sinusoidal pattern

254
Q

What places do you get bleeding in:

a) platelet deficiency
b) clotting factor deficiency?

A

a) epistaxis, heavy menstruation, purpura, bruising, GI/GU

b) big spaces-peritoneal, joints

255
Q

What situation can aggravate a bleeding tendancy?

A

hypOthermia

256
Q

What 3 lab findings occur with DIC?

A

Low PT
Low PTT
Elevated D dimer

257
Q

What is the treatment of acute intermittent porphyria? Name the 2.

A

Glucose and haem

258
Q

What 3 lab findings occur with DIC?

A

Low PT
Low PTT
Elevated D dimer

259
Q

What is the treatment of acute intermittent porphyria? Name the 2.

A

Glucose and haem

260
Q

What drug is used to treat menniers disease?

A

buccal or IM prochlorperazine

Final year (8 decks)

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