EUMS AMK teach Flashcards
What does a positive Rinnes test show?
Air conduction>bone
How would you conduct a Rinne’s test?
- Place tuning fork on mastoid process
- Ask patient if they can hear it and to let you know when it stops (assesses bone conduction)
- Then move tuning fork in front of ear canal and ask if patient can hear it again (assesses air conduction)
How would you conduct a Weber’s test?
- Place tuning fork in centre of patient’s forehead
2. Ask patient if they can hear it, if so, ask if they hear it louder on either side
What do the results of a Weber’s test show eg side of lateralisation?
Lateralises towards the side of conductive hearing loss
Lateralises away from the side of sensorineural hearing loss
What is the lower volume threshold for normal hearing?
20 DB
What type of hearing loss can otosclerosis and glue ear cause?
Conductive
What type of hearing loss can presbycusis, meniere’s disease and acoustic neuroma cause?
Sensorineural
How is a nose bleed managed in the first 15 minutes?
0-15 mins:
Sit patient upright and leaning forward, pinching soft part of their nose
Cold packs and topical vasoconstrictors eg phenylephrine
How is a nose bleed managed after 15 minutes?
Nasal cautery using silver nitrate:
- Pre: topical anaesthetic spray and vasoconstrictor (lidocaine with phenylephrine)
- Post: Topical antiseptic (naseptin)
Anterior packing:
- Avoid packing in hyper-bleed states such as HHT or post surgery
Posterior packing using foley catheters
What is the final step of management of a nose bleed, after cautery with silver nitrate, anterior packing and posterior packing using foley catheters?
Surgical intervention: ligation or immobilisation
What is the scoring system used for management of tonsilitis?
CENTOR
How is CENTOR used to guide management of tonsillitis?
Used to assess patient’s indication for antibiotic treatment.
If you score 3+ then patient started on abx.
One point for each of the following:
- Tonsillar exudate
- Tender cervical lymphadenopathy
- Fever
- Lack of cough
What is the treatment for tonsillitis if a patient scores 3+ on CENTOR?
IV phenoxymethylpenicillin, then oral penicillin V
When would a tonsillectomy be considered in a patient?
7+ cases in the past year 5+ cases per year for the past 2 years 3+ cases per year for the past 3 years Malignancy is expected More than one episode of quinsy or airway obstruction
A 4 year old boy is seen in a GP clinic with his mum. He had a cough followed by a temperature of 38.5 and a sore throat. The pain has stopped him eating or drinking for 3 days. O/E he has bilaterally inflammed tonsils with exudate, tender anterior cervical lymphadenopathy and his tongue is dry.
What is the best initial step?
a. Send home with reassurance
b. Send to hospital
c. Phenoxymethylpenicillin
d. Amoxicillin
b. Send to hospital.
Child is dehydrated so will require admission
A 20 y/o presents with difficulties in hearing. She says her family has issues with their hearing too.
Rinnes test is negative in both ears and Webers does not lateralise. Everything else is normal, what is the most likely diagnosis?
a. Vestibular schwanoma
b. Presbycusis
c. Otosclerosis
d. Wax impaction
c. Otosclerosis
A 21 year old female presents to ED with a 20 minute Hx of epistaxis. She has been leant forward with her nose pinched for this time. Upon insertion of a thudicum, there is too much blood to identify a single vessel. What is the next most appropriate step in her management?
a. Anterior packing
b. Cauterisation with silver nitrate
c. Adrenalin soaked gauze
d. Embolisation of the anterior ethmoidal a.
c. Adrenalin soaked gauze
A 4 year old presents to his GP with severe unilateral throat pain with extreme difficulty swallowing and difficulty moving his jaw. O/E his uvula is deviated. What is the most likely diagnosis?
a. Peritonsillar abscess
b. Epiglottitis
c. Tonsillitis
d. Retropharyngeal abscess
a. Peritonsillar abscess
Features of quinsy:
Trismus (inability to fully open the mouth) + dysphagia
“hot potato” voice - may appear to be muffled
Deviated uvula medially and inferiorly ( to the unaffected side )
Sore throat, fever, drooling + fetid breath
Referred otalgia
Unilateral Peritonsillar swelling/bulge + exudate
A 70-year-old man was referred to the gastroenterology clinic by his GP after he noticed that his eyes appear yellow and his skin always feels itchy. He denies any pain, but mentions that his appetite has reduced and he feels tired all the time. He has been a smoker since the age of 20 years old and smokes 20 cigarettes a day. Blood tests revealed the following results:
Bilirubin: 51 ALP: 240 ALT: 40 GammaGT: 97 Albumin: 39
What is the most likely diagnosis?
a. Gallstones
b. Ascending cholangitis
c. Pancreatic cancer
d. Acute Pancreatitis
c. Pancreatic cancer
What are the symptoms for gallstones?
Obstructive picture accompanied with RUQ pain
80% are asymptomatic
RF: FFF
What is used first line for gallstone diagnosis?
Abdominal ultrasound
What is the treatment protocol for gallstones?
If asymptomatic:
Observation
If symptomatic:
cholecystectomy
If stones found in the common bile duct, with or without symptoms:
ERCP first line, with stone extraction
What are the symptoms for acute pancreatitis?
Epigastric pain, nausea, vomiting, signs of hypovolemia.
Alcohol and gallstones = the most common causes
How is acute pancreatitis diagnosed?
Serum amylase ot lipase.
Clinical dx usually based on amylase/ lipase that is elevated by 3x.
What is the first line treatment for a patient with acute pancreatitis?
Fluid resuscitation and analgesia.
Consider O2, antiemetic and antibiotics if infection confirmed or suspected.
Other mx depends on cause.
What are the symptoms of ascending cholangitis?
Charcot’s triad:
Abdominal pain, fever and jaundice
What is used to diagnose ascending cholangitis?
FBC, CRP, U+E, ABG, clotting, LFT, blood cultures.
Abdo USS if patient presents with RUQ pain
What is the treatment protocol for ascending cholangitis?
IV antibiotics, ERCR first line. (Allows biliary decompression and stone removal)
55-year-old man presents to the GP with heartburn. He describes epigastric pain that goes away when he eats but then returns two or three hours afterwards, this has been going on for the last 2 months. The pain is 8/10 when it’s at its worst and he has found that over the counter antacids help his pain.
Given his presentation, what is the most likely diagnosis?
a. Gastric ulcer
b. Gastro-oesophageal reflux disease
c. Duodenal ulcer
d. Zollinger Ellison syndrome
e. Myocardial infarction
c. Duodenal ulcer
What are the symptoms of a gastric ulcer?
Epigastric pain mad worse when hungry, nausea
How is a gastric or duodenal ulcer diagnosed?
Helicobacter pylori urea breath test
Upper GI endoscopy (diagnostic)
FBC
What are the symptoms of a duodenal ulcer?
Epigastric pain, relieved by eating, but comes a few hours later. Nausea.
What are the symptoms of Gastro-oesophageal reflux disease (GORD)?
Heartburn and acid regurgitation are typical. Extra oesophageal symptoms include cough, laryngitis and dental erosions.
How is Gastro-oesophageal reflux disease (GORD) diagnosed?
Investigate with a trial of PPIs. Further investigations may be warranted if no response within 8 weeks.
How is Gastro-oesophageal reflux disease (GORD) managed?
Standard dose PPI, plus lifestyle changes. If incomplete response to PPIs- started on a higher dose with H2 antagonist pending further investigations
What are the symptoms of Zollinger- Ellison syndrome?
Gastrin secreting tumour that causes acid overexcretion. Risk factor for ulcers.
How is Zollinger-Ellison syndrome diagnosed?
Fasting serum gastrin
Acid output if serum gastrin raised
Secretin provocation test to confirm diagnosis
How is Zollinger-Ellison syndrome managed?
In localised disease – PPI first line with surgery as an adjunct
What are the symptoms of a STEMI?
Normally classic central crushing chest pain but can present non specifically – often important to rule out before sending a patient home
How is a STEMI diagnosed?
ECG, cardiac troponins, glucose, serum lipids, U&E’s, eGFR, CRP, FBC
How is a STEMI treated?
Aspirin, clopidogrel/ticagrelor, analgesia, anti emetic and prepare for PCI if within 120 mins of dx. Fibrinolysis if indicated and sx onset 2-3hrs ago
A 22-year-old man presents with a three week history of diarrhoea. He says his bowels have not been right for the past few months and he frequently has to run to the toilet. These symptoms had seemed to be improving up until three weeks ago. For the past week he has also been passing some blood in the stool and reports the feeling of incomplete evacuation after going. He has lost no weight and has a good appetite.
Examination of his abdomen demonstrates mild tenderness in the left lower quadrant but no guarding.
What is the most likely diagnosis?
a. Diverticulitis
b. Colorectal cancer
c. Crohn’s Disease
d. Ulcerative colitis
e. Infective diarrhoea
d. Ulcerative colitis
What are the symptoms of ulcerative colitis?
Rectal bleeding, diarrhoea, bloody stools, abdominal pain
How is ulcerative colitis diagnosed?
FBC: Inflam markers* B12, folate, vit D Stool studies Coeliac serology Faecal calprotectin* Abdo X ray Colonoscopy/ flexible* sigmoidoscopy
What is the management for ulcerative colitis?
First line is topical/oral mesalazine
If really severe and passing >10 stools per day, may require admission for IV corticosteroids and fluids
Surgery in last instance
What are the symptoms for chron’s disease?
Diarrhoea but not usually bloody or mucousy
More likely to get weight loss
Mouth ulcers, perianal etc
Abdo pain (often right lower quadrant)
How is Chron’s disease diagnosed?
Iron studies, FBC, B12, folate, CRP and ESR
Colonoscopy
MRI/CT to localise disease
How is chron’s disease managed?
Glucocorticoids to induce remission ie budoneside
drugs ie mesalazine are second line but not as effective
Methotrexate/azathioprine could also be added
80% will go on to have surgery eventually
What are the symptoms of diverticulitis?
Abdo pain, usually left lower quadrant, low grade fever. Risks include inc age and diet
How is diverticulitis diagnosed?
FBC
Hx of diverticulosis
How is diverticulitis managed?
If uncomplicated- analgesia, oral abx and diet modifications
What are the symptoms of colorectal cancer?
Unexplained weight loss, abdominal pain, rectal bleeding
Change in bowel habit
Unexplained Fe anaemia
How is colorectal cancer dianosed?
FBC, Colonoscopy
Biopsy for histological confirmation
How is colorectal cancer managed?
Tx dependent on the stage ie surgical resection, chemo/radiotherapy
A 65-year-old man presents with difficulty swallowing which has been present for 6 months and has been getting worse over the past few weeks. The dysphagia occurs to both solids and fluids equally. He has also noticed some chest pains recently, especially after eating. A barium swallow shows a dilated oesophagus that tapers at the lower oesophageal sphincter.
What is the most likely diagnosis?
a. Achalasia
b. Pharyngeal pouch
c. Oesophageal cancer
d. GORD
e. Ruptured Oesophageal varices
a. Achalasia
What are the symptoms of achalasia?
Dysphagia to both SOLIDS AND LIQUIDS from the beginning
Motility disorder – loss of peristalsis and lower sphinchter dysfunction
Regurgitation
Gradual weight loss
Posturing to aid swallowing
How is achalasia diagnosed?
Oesophageal manometry considered the most important diagnostic investigation
Upper GI endoscopy is however essential to exclude a malignancy
Barium swallow – shows a “birds beak” appearance
How is achalasia managed?
Cardiomyotomy
Pneumatic dilation
What are the symptoms of a pharyngeal pouch?
Dysphagia
Regurgitation
Halitosis
How is a pharyngeal pouch diagnosed?
Endoscopy
Barium swallow
How is a pharyngeal pouch treated?
Surgical
What are the symptoms of oesophageal varices?
Features of alcohol misuse. Varices are a complication of portal hypertension. Ruptured: haematemesis
How are oesophageal varices diagnosed?
OGD considered the best method to identify varices
How are oesophageal varices treated?
Mx of haemorrhage: resuscitation, correct clotting, terlipressin, abx, endoscopy and banding
What is first line tx for c.diff?
Oral metronidazole
What is second line tx for c.diff?
oral vancomycin
What antiemetic drug is contraindicated in parkinsons?
Metaclopromide
How is a paracetamol overdose treated?
N-acetL-cysteine
What is the antidote for organophosphates?
Atrophine
What is the antedote to beta blockers?
Glucagon
What is the antedote to opioids?
Naloxone
A 47-yo lady presents to A/E with sudden onset of severe shortness of breath and chest tightness. She recently returned home from holiday on a 10hr flight journey. A diagnosis of pulmonary embolism was made.
Which of the following ECG changes is most likely to be found in this patient?
a. Atrial fibrillation
b. Ventricular tachycardia
c. ‘S1Q3T3’ sign
d. Sinus rhythm
e. Sinus tachycardia
e. Sinus tachycardia
How would you manage a PE if the wells score was < or = 4?
Do a D-dimer test (high sensitivity, low specificity)
If D-dimer is +ve –> CTPA
How would you manage a PE if the wells score was > 4?
Immediate CTPA
If there is a delay in getting the scan, give LMWH
If allergic to contrast, has hx of renal impairment or is pregnant, do a V/Q scan
A 27-yo man is brought into A/E following a road traffic accident.
O/E, his BP – 106/72, HR – 113, RR – 22 and a GCS of 14.
Assuming the man weighs 70kg, approximately how much blood has he lost?
a. < 735 ml
b. 735-1470 ml
c. 1470-1960 ml
d. 1960-2200 ml
e. >2200 ml
b. 735-1470 ml
Estimated circulating volume = SV (about 70 ml) X weight in kg.
A 56-yo lady presents to AMU complaining of a 1-week history of worsening wheezy cough and SoB. She had a chest infection 6 weeks, which was treated with antibiotics. PMHx, she was diagnosed with asthma 39 years ago and is currently being treated for hypertension. She takes a ‘blue inhaler’ as and when needed, along with a Montelukast.
On examination, she looks quite tired and exhausted, HR -76, RR – 22, BP – 110/70, SpO2 – 97% on air. Her peak flow is 50% her usual best. On auscultation, an expiratory wheeze could be heard.
Given her presentation, which would be the most appropriate first-line treatment?
a. A puff of GTN
b. Antibiotics
c. Nebulised salbutamol + oral prednisolone
d. Nebulised salbutamol + oral prednisolone + O2
e. Adrenaline
c. Nebulised salbutamol + oral prednisolone
A 22-year-old university student presents to A&E with a temp of 38C, severe headache, and photophobia.
On examination, she has severe neck stiffness and trouble extending her leg at the knee joint whilst performing the Kernig’s test. She also has non-blanching purpuric rash all throughout her body and a BP of 90/62.
A diagnosis of meningococcal disease was made.
Which of the following is the most appropriate first-line management?
a. IV cefotaxime/ ceftriaxone stat.
b. Bloods (cultures/VBG/etc).
c. IM benzylpenicillin stat.
d. LP
e. Fluids
a. IV cefotaxime/ ceftriaxone stat.
A 22-year-old university student presents to A&E with a temp of 38C, severe headache, and photophobia.
On examination, she has severe neck stiffness and trouble extending her leg at the knee joint whilst performing the Kernig’s test. She also has non-blanching purpuric rash all throughout her body and a BP of 90/62.
A diagnosis of meningococcal disease was made.
Which of the following is the most appropriate first-line management?
a. IV cefotaxime/ ceftriaxone stat.
b. Bloods (cultures/VBG/etc).
c. IM benzylpenicillin stat.
d. LP
e. Fluids
a. IV cefotaxime/ ceftriaxone stat.
While working in an emergency department you are called to resus to see a 7-year-old who has come in with an allergic reaction. Her teacher is present. She had been on a school trip when another pupil gave her a peanut and she started to become short of breath, pale, sweaty and experienced tingly and swollen lips and tongue. It is clear she requires emergency treatment.
Based on the most likely diagnosis, what is the first thing you will do to manage this patient?
a. IM Adrenaline 300 micrograms
b. IV Adrenaline 1 mg, 1 in 10,000 solution
c. Oxygen
d. Call for senior help
e. IM Chlorphenamine 5 mg
a. IM Adrenaline 300 micrograms
A 9-year-old boy is brought to the emergency department by ambulance. For approximately 24 hours he has had nausea and vomiting. However, he has now developed acute abdominal pain and when he arrives in the emergency department his breathing is noted to deep and laboured. He is usually fit and well and is not prescribed any medication. Blood results show the following:
Na -> 130, K -> 4.5, 𝐻𝐶𝑂3-> 14, Blood Glucose -> unrecordable, tender abdomen.
What is the most likely diagnosis for this patient?
a. Diabetic ketoacidosis (DKA)
b. Hyperosmolar hyperglycaemic state
c. Meningitis
d. Intestinal obstruction
e. Sepsis
a. Diabetic ketoacidosis (DKA)
A 52-year-old woman has developed sepsis as a complication of her treatment for COVID-19. Unfortunately, she has now developed acute kidney failure 2° to sepsis. You are the doctor on-call and you have just reviewed her latest VBG.
Her potassium was found to be 7.2 mmol/litre and she was severely acidotic (lactate > 4 mmol/litre). Seeing the results, you are rightfully panicking.
What is the first thing you will do to manage this patient?
a. NaHCO3 for her acidosis
b. ECG
c. IV insulin + dextrose
d. IV Ca gluconate
e. Dialysis
d. IV Ca gluconate
