exam cram MD2 2014 answers Flashcards
Features of melanoma
1) Asymmetrical
2) Pushing, irregular border
3) Non- homogenous
4) Greater than 6mm
5) Any changing lesion/ new lesion
Features of SCC
1) Grows rapidly (weeks- months)
2) Occur commonly on chronically sun exposed skin
3) Think, red/ pink nodule
4) tender on palpation
5) Bleeds easily/ ulcerates
RF for developing SCC
1) Smoking
2) Sun exposure
Features of BCC
1) Pearly nodule
2) Telangiectasia
3) Commonly found on head and neck, inner canthus of eye
4) Central depression
5) Raised edges/ margins
6) Central necrosis
7) Bleeding/ ulceration (nodular BCC)
8) Red plaque not responding to topical Rx (superficial BCC)
Metastatic potential of SCC and BCC
- SCC more likely to mets
- BCC less likely to mets, locally invasive
Features on Hx for peptic ulcer disease
1) Epigastric pain especially after meals
2) NSAID use
3) Previous incidences of PUD
4) N & V
5) Dyspepsia
Features on Hx for oesophageal variceal rupture
1) Painless bleeding
2) Sudden onset, without warning (i.e. no symptoms beforehand)
3) Previous Dx of CLD
4) Hx of EtOH abuse, current EtOH intake
Features on Hx for MW tear
1) Epigastric pain
2) Episodes of vomiting preceding haematemesis- e.g. a/w heavy EtOH intake
3) preceded by straining e.g. heavy coughing, defacation
Features on Hx of acute gastritis
1) ‘Gnawing’ epigastric pain
2) Previous mucosal injury -e.g. gastritis, PUD
3) Exposure to noxious/ toxic compounds (NSAIDs, EtOH)
Features on Hx of oesophagitis
Reflux oesophagitis: 1) heartburn, dyspepsia 2) water brash 3) regurgitation Infective oesophagitis: 1) Dysphagia, odonophagia 2) Heart burn 3) N & V 4) Fever, anorexia, fatigue etc
Features on Hx of neoplasm (oesophagus or stomach)
Oesophageal: 1) Positive smoking Hx (SCC) 2) GORD (adenocarcinoma) 3) Dysphagia 4) Weight loss, anorexia, fatigue Stomach: 1) Indigestion, post- prandial fullness 2) N & V 3) Dysphagia 4) Weight loss, anorexia, fatigue
3 predisposing factors for MW tears
1) Hiatus hernia
2) EtOH (especially when a/w vomiting)
3) Any other condition that causes repeated retching/ vomiting (e.g. morning sickness)
How can MW tears be repaired endoscopically?
1) Contact thermal therapy
2) Epinephrine injection
3) Sclerotherapy
4) Band ligation
5) Haemoclip
2 classes of drugs which may prevent re-exacerbation of MW tears and potential SE
1) PPI: headache, N + V + D, abdo pain, constipation
2) Anti-emetics:
a) 5-HT3 R antagonist: constipation, headache, dizziness
b) corticosteroids (dexamethasone): adrenal suppression, immunosuppresion, Na+ and water retention, HTN, hypokalaemia, hyperglycaemia/ DM, dyslipidaemia, OsteoP, increased appetite, delayed wound healing, skin atrophy, bruising, acne, facial flushing, hirsuitism, myopathy, fat distribution, weight gain, amorrhoea, cataracts, pysch effects (disturbances of mood, cognition, sleep and behaviour)
c) DA antagonist: drowsiness/ sedation, dry mouth
Causes of SBO
1) Adhesions
2) hernia
3) Malignancy
4) Stricture
5) Foreign body
6) Volvulus
7) Intussusception
8) Gallstone ileus
Causes of LBO
1) Malignancy
2) Diverticulitis
3) Sigmoid volvulus
4) Faecal impaction
5) Stricture
6) Intussusception
What complications of an SBO might a pt display?
1) Bowel ischaemia
2) TachyC
3) Febrile
4) Leucocytosis
5) Tenderness
6) Guarding
Causes of post-op confusion
1) Hypoxia: atelectasis, chest infection, over-sedation, CCF, MI, PE
2) Sepsis/ infection: chest, urine, wound, abdo
3) Medication: opiates, sedatives
4) Metabolic: ureamia, hyponatraemia, hypoglycaemia, hyperglycaemia
Name some factors that could contribute to a pt developing post- op confusion
1) Stroke
2) Pain
3) Anaemia
4) Hypotension
5) Dementia
What are some Ix you would order for a pt with post op confusion?
1) ABGs
2) U&Es
3) Random BSLs
4) FBE
5) Blood culture
6) MSU
7) CXR
8) ECG
DDx of palpitations, feature on Hx and feature on Ix
1) SVT (e.g. AFlut, WPW, atrial tachy). On Hx: abrupt onset, sweats, dizziness. ECG: normal QRS, abnormal or absent P waves, >140bpm
2) Sinus tachy (caffeine, anxiety, febrile illness, hypovolaemia, exercise). On Hx: gradual onset over minutes of regular palpitations, clear precipitant. ECG: normal ECG, resolution with stopping precipitating factors
3) AF. Hx: irregularly irregular pulse. ECG: no p waves, irregularly irregular, normal QRS complexes
4) Ventricular ectopics. Hx: palpitations noted over hrs-days, a/w anxiety. ECG: Premature, wide QRS complexes
Features of hypothyroidism
1) Weight gain
2) Cold intolerance
3) Fatigue, depression, difficulty concentrating, poor memory
4) BradyC
5) Dry, coarse, itchy skin. Loss of outer 3rd of eyebrow
6) No tremor
7) Slow relaxing reflexes
8) Heavy, irregular periods
9) Brittle nails
Features of hyperthyroidism
1) Weight loss
2) Heat intolerance
3) Nervousness, anxiety, irritability, restlessness, panic, insomnia
4) TachyC
5) Thin skin, warm moist palms
6) Tremor
7) Brisk reflexes
8) Scant, less frequent periods
9) Soft nails
An eye sign unique to Grave’s
Exopthalmos
An eye sign found in thyrotoxicosis
Lid lag
Other than TFTs, what other blood tests would you consider to make a Dx of Grave’s?
Anti-TSH ABs- present in Grave’s
4 causes of hyperthyroidism
1) Graves
2) Multinodular (toxic) goitre
3) Thyroiditis (early Hashimoto’s)
4) Iatrogenic (amioderone, radiocontrast)
Indications for thyroidectomy
1) Cosmetic
2) Risk of malignancy
3) Obstruction of other structures (trachea)
Name 1 structure at risk in thyroidectomy. What symptoms would this cause?
Recurrent laryngeal nerve. Hoarse voice and difficulty breathing
When do you re-check TFTs after finding abnormality and starting Rx?
6 weeks
What non-medical options are there for treating hyperthyroidism
1) Radioactive iodine
2) Thyroidectomy
What are 2 anti-thyroid drugs? SE?
1) Carbimazole (1st line). SE: rash, pruritis (co-Rx antihistamines), neutropenia and agranulocytosis (bone marrow suppression)
2) Propylthiouracil. SE: neutropaenia and agranulocytosis, rash.
Both are teratogenic
Other Rx for hyperthyroidism? SE?
BBs (propanolol, atenolol etc). SE: reflex tachyC, bronchospasm, orthostatic hypotension, dizziness
What are 3 non- modifiable RFs for IHD?
1) Age
2) Male sex
3) FHx of heart disease in relative
What are some modifiable RFs for IHD
1) Smoking
2) HTN
3) DM
4) Hyperlipidaemia
5) Sedentary lifestyle
6) Obesity
What are some DDx for chest pain?
1) ACS
2) Oesophageal reflux/ spasm
3) PE
4) Angina
5) Pericarditis
What are some features on Hx suggestive of ACS?
1) CCP radiating to jaw and L arm
2) >20m
3) A/w N, diaphoresis, palpitations and maybe syncope
4) PHx of angina or decreased exercise tolerance
What are some features on Hx suggestive of oesophageal reflux/ spasm
1) PHx of GORD
2) Worse with meals (especially fatty or spicy)
3) Nocturnal cough
4) Hoarse voice
5) Waterbrash
6) Relief by anti-acids
NB: spasms may be relieved by GTN
What are some features on Hx suggestive of PE?
1) Pleuritic quality (sharp)
2) Worse on inspiration
3) PHx of DVT or previous PE, recent surgery, prolonged stasis (surgery, travel), known malignancy, OCP use)
4) haemoptysis
What are some features on Hx suggestive of Angina
1) CCP lasting
What are some features on Hx suggestive of pericarditis
Pain relieved by leaning forward
ECG features of STEMI
+ cardiac enzymes
1) ST elevation> 1mm in 2 or more contiguous leads
2) Peaked T waves
3) New LBBB
Raised trops
ECG features of NSTEMI
+ cardiac enzymes
1) ST depression
2) T wave inversion or no change
Raised trops
ECG features of unstable angina + cardiac enzymes
1) No ECG changes
2) No raised enzymes
How to confirm AMI at tertiary hospital
1) Coronary angiogram to confirm occlusion
2) Percutaneous coronary intervention (PCI) with stent placement (indicated if pt presents within 90m)
Long term Mx of AMI
1) Dual antiplatelet Rx for 1 year (aspirin, clopidogrel)
2) ACEI (prevents ventricular remodeling)
3) BB (indefinitely)
4) Statin (indefinitely)
DDx for urinary retention
1) BPH
2) Prostate Ca
3) Neurological- spinal injury, stroke, DM, PD
4) Stricture
5) Prostatitis
What are some features on Hx suggestive of BPH?
1) Age>50
2) Absence of other symptoms other than urinary retention
What are some features on Hx suggestive of prostate Ca
1) bone pain
2) Weight loss
3) FHx of prostate Ca
What are some features on Hx suggestive of Neuro related urinary retention?
1) Changes in strength or sensation
2) Trauma to spine
3) Tremor
4) Hx of DM, MS, PD
What are some features on Hx suggestive of urethral strictures?
1) History of IDC
2) Hx of surgery to urethra
3) Trauma
4) Hx of STIs
What are some features on Hx suggestive of prostatitis?
1) Fever
2) Suprapubic or lower back pain
What are some issues with PSA testing?
1) If found to be elevated, not always clear what best course of action is
2) Can be falsely elevated or decreased for many reasons
3) Biopsy of prostate that may be indicated after an elevated PSA can have further serious complications
4 causes of elevated PSH
1) Prostate Ca
2) BPH
3) Prostatitis
4) Instrumentation
Non- medical treatment for BPH
1) Transurethral resection of prostate (TURP)
2) Open prostatectomy
3) Long term IDC
4) Intermittent self-catherisation
DDx of chest pain + SOB
1) AMI/ ACS
2) PE
3) Pneumothorax
4) Aortic dissection
What are some features on Hx suggestive of pneumothorax
1) Pleuritic chest pain
2) Recent chest pain
What are some features on Hx suggestive of aortic dissection
1) Tearing or ripping pain
2) Syncope
3) Predisposing factors: Marfan’s, hypotension, previous aortic surgery, coarctation of aorta
What are some features O/E suggestive of AMI/ ACS
1) Hypertension or hypotension
2) Diaphoretic
3) Pallor
4) APO
What are some features O/E suggestive of PE
1) Tachypnoea
2) TachyC
3) Fever
4) Crepitations
5) loud P2
What are some features O/E suggestive of pneumothorax
1) Decreased or absent breath sounds
2) Resonant percussion note
What are some features O/E suggestive of aortic dissection
1) Hypertension
2) Radio-radial delay or R-F delay
3) Diastolic murmur- AR
Immediate Mx of AMI and SEs
1) Morphine. SE: respiratory depression, constipation, addiction
2) Aspirin. SE: GI haemorrhage
3) Clopidogrel. SE: GI haemorrhage
4) LMWH. SE: GI haemorrhage and thrombocytopaenia
5) Statin. SE: myalgia, myopathy, rhabdomyolysis
6) Cardiac selective BB (metoprolol, nebivolol). SE: reflex tachyC, hypotension
Common DDx for fatigue
1) Anaemia
2) Poor sleep hygiene
3) OSA
4) Hypothyroidism
5) Depression
Features on Hx for poor sleep hygiene
- Late to bed
- Caffeine before bed
- Naps during the day
- Doing things immediately before bed
Features on Hx for OSA
- Snoring
- Partner reports stops of breath
- Morning headaches
- Decreased libido
Features on Hx for depression
- low mood, low motivation, low appetite
Features on Hx for anaemia being the cause of fatigue
any 2 of:
1) Palpitations
2) SOB
3) Ischaemic pain (angina, intermittent claudication)
Features o/e for anaemia being the cause of fatigue
any 2 of:
1) Pallor
2) TachyC
3) Systolic flow murmur
4) HF signs
What is Hct in a FBE?
The volume of RBCs in blood
What is MCV in an FBE?
Average volume of RBCs
What kind of anaemia is iron deficiency anaemia?
Microcytic
What are 3 acquired causes of haemolytic anaemia?
1) AI/ immune mediated anaemia
2) Mechanical (artifical valave, small vessel disease, DIC)
3) Infection (malaria)
What further Ix would help in confirming haemolytic anaemia?
1) Blood film (raised reticulocyte count)
2) Elevated LDH
3) Elevated unconjugated BR
4) urine haemosidirin
Give 4 reasons why DM may increase risk of falls?
1) Hypoglycaemia related to medications
2) Peripheral neuropathy
3) Autonomic neuropathy leading to orthostatic hypotension
4) DM retinopathy compromising VA
RFs for fall other than DM
1) Age
2) OsteoP
3) Poor VA
4) Anti- hypertensive meds
5) AF–> stroke–> neuro impairment
In fractured NOF, why is leg externally rotated and shortened?
Iliopsoas pulling on lesser trochanter
Why is intra-capsular fractured NOF more dangerous than extra-capsular?
1) Bc blood supply to femoral head begins distally, then goes proximally towards head
2) So fracture interrupts blood supply and poses risk of AVN of femoral head
What are the complications following any fracture?
1) Delayed union, mal-union, non-union
2) Nerve damage
3) Vascular compromise
4) Tendon damage
5) Fat embolis
6) Haemorrhage
7) Haemarthrosis
8) Compartment syndrome
9) OsteoM
10) OsteoP
11) OA
2 surgical treatment options for fractures of NOF?
1) ORIF (open reduction internal fixation)
2) Arthroplasty
Complications that may occur peri-operatively in DM
1) Increased risk of DKA (due to catabolic state induced by surgical stress response)
2) Increased risk of hyperglycaemia–> osmotic diuresis–> dehydration
3) Increased risk of hypos
4) Autonomic neuropathy–> haemodynamic instability
5) Stiff joints–> due to glycosylation of tissues–> difficult to intubate
6) Reduced wound healing
7) Increased risk of infection
2 ways to reduce peri-op complications in DM?
1) Aim for early morning surgery to minimise starvation time
2) Monitor BSLs regularly
Nail changes in psoriasis
1) Onycholysis
2) Pitting
3) Subungal hyperkeratosis
4) Salmon pink or oily discolouration of nail bed
2 common RFs for development of skin ca
1) Sun exposure
2) Immunosuppresion
Examination findings you would expect to find in DKA
1) Fruity smelling breath/ acetone
2) Abdo tenderness
3) Kussmaul’s breathing/ air hunger: deep laboured breathing
4) TachyC
5) Dehydration: decreased tissue turgor, dry mucous membranes, decreased JVP
6) Decreased GCS
7) Orthostatic hypotension
Common causes of DKA
1) 1st presentation of T1DM
2) Non- compliance with T1DM Rx
3) EtOH abuse
4) Increased stress- surgery, infection etc
What Ix would be Dx for DKA and what are your expected findings?
1) Serum glucose- elevated
2) ABGs- pH
4 DDx for blurred vision
1) DM retinopathy
2) Cataract
3) Glaucoma
4) Extra-occular muscle palsy
How many grades of DM retinopathy are there?
5
What are the 5 grades of DM retinopathy?
1) B/g
2) Pre-proliferative
3) Proliferative
4) Maculopathy
5) Advanced disease
3 features of background retinopathy
1) Microaneurysms
2) Dot and blot haemorrhages
3) Exudates
2 features of preproliferative retinopathy
1) Cotton wool spots
2) Venous bleeding, loops and doubling
2 features of proliferative retinopathy
1) New vessels at the disc
2) New vessels everywhere
4 features of maculopathy retinopathy
1) Microaneurysms
2) Haemorrhages
3) Exudates
4) Oedema at macula
Advanced disease
1) Iris rubeosis
2) Persistent vitreous haemorrhage
3) Retinal haemorrhage
List 4 RFs a/w development of DM retinopathy and measures of Mx for each
1) Systemic HTN: lifestyle changes, ACEI or ARB
2) Poor diabetic control: regular check up, lifestyle modification, compliance to medication, metformin, SUR
3) Smoking: cessation, nicotine patch
4) Dyslipidaemia: diet and exercise, statins
How do you investigate DM nephropathy?
Albumin/ Cr ratio
What are 3 macrovascular complications of DM?
1) CVD
2) Peripheral vascular disease
3) Cerebrovascular disease
Features of BPH
1) Urinary hesitancy
2) Dribbling stream
3) Difficulty initiating stream
Features of prostate Ca
1) Hesitancy
2) Dribbling
3) Hard to initiate
4) Dysuria
5) Advanced disease may p/w systemic signs of Ca–> bone pains
Features of prostatis
1) Fever
2) Suprapubic/ low back pain
Features of carcinoma of bladder
1) haematuria (can be frank or occult)
2) Dysuria
3) Suprapubic pain
4) Hx of tobacco use
features of UTI
1) Dysuria
2) Fever
3) Lower back, suprapubic pain
Features of neurogenic bladder
1) Hx of Parkinson’s disease
2) Hx of vascular disease
3) Hx of MS
4) Hx of DM with neuropathy
Features of overactive bladder
1) Incontinence
Features of urethral stricture
1) Hx of trauma to the region (e.g. straddle injury)
2) Hx of prior urological surgery
2 initial Ix that could distinguish between BPH and prostate Ca and what are the findings
1) DRE
- firm, indurated, irregular mass (may be nodular). Prostate may feel asymmetrical
2) Biopsy
- Enlarged atypical epithelial cells (enlarged nucleoli, reduced cytoplasm)
- Infiltration of these epithelial cells between benign glands
- Malignant glands lack basal layer
