Finals

Question 1

What is the criteria for infective endocarditis?

Answer 1

Major criteria

Positive blood cultures

two positive blood cultures showing typical organisms consistent with infective endocarditis, such as Streptococcus viridans and the HACEK group, or

persistent bacteraemia from two blood cultures taken > 12 hours apart or three or more positive blood cultures where the pathogen is less specific such as Staph aureus and Staph epidermidis, or

positive serology for Coxiella burnetii, Bartonella species or Chlamydia psittaci, or

positive molecular assays for specific gene targets

Evidence of endocardial involvement

positive echocardiogram (oscillating structures, abscess formation, new valvular regurgitation or dehiscence of prosthetic valves), or

new valvular regurgitation

Minor criteria

predisposing heart condition or intravenous drug use

microbiological evidence does not meet major criteria

fever > 38ºC

vascular phenomena: major emboli, splenomegaly, clubbing, splinter haemorrhages, Janeway lesions, petechiae or purpura

immunological phenomena: glomerulonephritis, Osler’s nodes, Roth spots

Question 2

What is the minor criteria for IE?

Answer 2

vascula phenomena

immunological phenorma

microbe evidence

tempature above 38 degrees celcius

other - drug user

drink

Question 3

What is the major criteria for Duke’s?

Answer 3

Two +ve cultures over twelve hours or three to four over 1 hour

Echocardiogram

Altered valve

Question 4

What is the single most important evidence for pneumothorax?

Answer 4

Smoking cessation

Avoid flying for 6 weeks

Question 5

What is conservative management of most respiratory diseases?

Answer 5

Smoking cessation

Avoid triggers

Weight loss

Question 6

Which blood prpduct poses greatesrisk of infection?

Answer 6

Platelets

Question 7

What is treatment for stroke in 4.5 hour period?

Answer 7

A combination of thrombolysis AND thrombectomy is recommend for patients with an acute ischaemic stroke who present within 4.5 hours

Important for meLess important

This patient has presented with an acute ischaemic stroke of the anterior cerebral circulation, as manifested by a unilateral hemiparesis and homonymous hemianopia.

Question 8

What is the criteria for managing a stroke?

Answer 8

The Royal College of Physicians (RCP) published guidelines on the diagnosis and management of patients following a stroke in 2004. NICE updated their stroke guidelines in 2019.

Selected points relating to the management of acute stroke include:

blood glucose, hydration, oxygen saturation and temperature should be maintained within normal limits

blood pressure should not be lowered in the acute phase unless there are complications e.g. Hypertensive encephalopathy*

aspirin 300mg orally or rectally should be given as soon as possible if a haemorrhagic stroke has been excluded

with regards to atrial fibrillation, the RCP state: ‘anticoagulants should not be started until brain imaging has excluded haemorrhage, and usually not until 14 days have passed from the onset of an ischaemic stroke’

if the cholesterol is > 3.5 mmol/l patients should be commenced on a statin. Many physicians will delay treatment until after at least 48 hours due to the risk of haemorrhagic transformation

Question 9

What are the three tests for syphillis?

Answer 9

Enzyme immunoassay test (EIA)Positive

Treponema pallidum particle agglutination assay (TPPA)Positive

Rapid plasma reagin (RPR)1 in 2

Question 10

Treatment for CAP?

Answer 10

Amoxiccilin and clarithryomycin

Question 11

When should all cases of pneunomia be tested with a CXR?

Answer 11

All cases of pneumonia should have a repeat chest X-ray at 6 weeks after symptoms have resolved. A repeat chest X-ray is indicated to rule out any underlying malignancies which may be hidden by the original pneumonia consolidation.

Question 12

What is hepatorenal syndrome (HRS)?

Answer 12

Type of AKI and high creatinine.

Vasoconstriction of renal arteries preventing filtration and are common in patients with cirrhosis and high albumin.

The most accepted theory regarding the pathophysiology of HRS is that vasoactive mediators cause splanchnic vasodilation which in turn reduces the systemic vascular resistance. This results in ‘underfilling’ of the kidneys. This is sensed by the juxtaglomerular apparatus which then activates the renin-angiotensin-aldosterone system, causing renal vasoconstriction which is not enough to counterbalance the effects of the splanchnic vasodilation.

Question 13

How is phaeochromocytoma diagnosed and treated?

Answer 13

PHaeochromocytoma - give PHenoxybenzamine before beta-blockers

metanePHrines

Question 14

What are gliptins?

Answer 14

Gliptins (DPP-4 inhibitors) reduce the peripheral breakdown of incretins such as GLP-1

Question 15

What are some investigations for meningitis?

Answer 15

nvestigations suggested by NICE

full blood count

CRP

coagulation screen

blood culture

whole-blood PCR

blood glucose

blood gas

Question 16

What is the hallmark finding for myasthesia gravis?

Answer 16

The hallmark finding of myasthenia gravis is fatiguable, painless muscle weakness that improved with rest

Question 17

How do you treat cellulitis in a pregnant woman with a penicicllin allergy?

Answer 17

Eerythromycin

Question 18

What are the features of DKA?

Answer 18

Answer: diabetic ketoacidosis. In this case scenario, a young man is presenting with diabetic ketoacidosis (DKA). The signs suggestive of this include the presenting complaint of abdominal pain, significant dehydration, the pattern of breathing consistently with Kussmaul respiration and the significantly raised capillary glucose. Patients presenting with DKA are depleted around 5-8 litres which need to be corrected as a matter of urgency.

The diagnostic criteria for diagnosing DKA are:

pH <7.3 and/or bicarbonate <15mmol/L.

Blood glucose >11mmol/L or known diabetes mellitus.

Ketonaemia >3mmol/L or significant ketonuria ++ on urine dipstick

Question 19

In Hep B, what features point to a chronic Hep B infection?

Answer 19

The appearance of ground-glass hepatocytes on light microscopy can point towards a diagnosis of chronic hepatitis B infection

Question 20

How does the Resucitation council suggest reading an ABG?

Answer 20

The Resuscitation Council (UK) advocate a 5 step approach to arterial blood gas interpretation.

1. How is the patient?
2. Is the patient hypoxaemic?

the Pa02 on air should be >10 kPa

3. Is the patient acidaemic (pH <7.35) or alkalaemic (pH >7.45)
4. Respiratory component: What has happened to the PaCO2?

PaCO2 > 6.0 kPa suggests a respiratory acidosis (or respiratory compensation for a metabolic alkalosis)

PaCO2 < 4.7 kPa suggests a respiratory alkalosis (or respiratory compensation for a metabolic acidosis)

5. Metabolic component: What is the bicarbonate level/base excess?

bicarbonate < 22 mmol/l (or a base excess < - 2mmol/l) suggests a metabolic acidosis (or renal compensation for a respiratory alkalosis)

bicarbonate > 26 mmol/l (or a base excess > + 2mmol/l) suggests a metabolic alkalosis (or renal compensation for a respiratory acidosis)

Question 21

What is a feature of giving too much NaCl?

Answer 21

risk of hyperchloraemic metabolic acidosis

Question 22

What are some features of COPD on a chest X ray?

Answer 22

Chronic obstructive pulmonary disease requires spirometry to confirm the diagnosis but this chest x-ray is highly suggestive.

Features include:

hyperinflation

flattened hemidiaphragms

hyperlucent lung fields

Question 24

What are the features of primary, secondary and tertiary syphillis?

Answer 24

Primary features

chancre - painless ulcer at the site of sexual contact

local non-tender lymphadenopathy

often not seen in women (the lesion may be on the cervix)

Secondary features - occurs 6-10 weeks after primary infection

systemic symptoms: fevers, lymphadenopathy

rash on trunk, palms and soles

buccal ‘snail track’ ulcers (30%)

condylomata lata (painless, warty lesions on the genitalia )

Tertiary features

gummas (granulomatous lesions of the skin and bones)

ascending aortic aneurysms

general paralysis of the insane

tabes dorsalis

Argyll-Robertson pupil

Features of congenital syphilis

blunted upper incisor teeth (Hutchinson’s teeth), ‘mulberry’ molars

rhagades (linear scars at the angle of the mouth)

keratitis

saber shins

saddle nose

deafness

Question 25

When should warfarin be stopped before a surgery?

Answer 25

5 days