Friday [17/09/2021] Flashcards

Question

When to refer to secondary care for burns?

Answer 1

all deep dermal and full-thickness burns. superficial dermal burns of more than 3% TBSA in adults, or more than 2% TBSA in children superficial dermal burns involving the face, hands, feet, perineum, genitalia, or any flexure, or circumferential burns of the limbs, torso, or neck any inhalation injury any electrical or chemical burn injury suspicion of non-accidental injury

Answer 2

Following the burn, there is a local response with progressive tissue loss and release of inflammatory cytokines. Systemically, there are cardiovascular effects resulting from fluid loss and sequestration of fluid into the third space. There is a marked catabolic response. Immunosupression is common with large burns and bacterial translocation from the gut lumen is a recognised event. Sepsis is a common cause of death following major burns.

Answer 3

The initial aim is to stop the burning process and resuscitate the patient. Intravenous fluids will be required for children with burns greater than 10% of total body surface area. Adults with burns greater than 15% of total body surface area will also require IV fluids. The fluids are calculated using the Parkland formula which is; volume of fluid= total body surface area of the burn % x weight (Kg) x4. Half of the fluid is administered in the first 8 hours. A urinary catheter should be inserted. Analgesia should be given. Complex burns, burns involving the hand perineum and face and burns \>10% in adults and \>5% in children should be transferred to a burns unit. Circumferential burns affecting a limb or severe torso burns impeding respiration may require escharotomy to divide the burnt tissue. Conservative management is appropriate for superficial burns and mixed superficial burns that will heal in 2 weeks. More complex burns may require excision and skin grafting. Excision and primary closure is not generally practised as there is a high risk of infection. There is no evidence to support the use of anti microbial prophylaxis or topical antibiotics in burn patients.

Answer 4

Indicated in circumferential full thickness burns to the torso or limbs. Careful division of the encasing band of burn tissue will potentially improve ventilation (if the burn involves the torso), or relieve compartment syndrome and oedema (where a limb is involved)

Answer 5

As a general rule it is safer to assume that growth plate tenderness is indicative of an underlying fracture even if the x-ray appears normal. Injuries of Types III, IV and V will usually require surgery. Type V injuries are often associated with disruption to growth.

Answer 6

Non accidental injury Delayed presentation Delay in attaining milestones Lack of concordance between proposed and actual mechanism of injury Multiple injuries Injuries at sites not commonly exposed to trauma Children on the at risk register

Answer 7

Genetic conditions, such as osteogenesis imperfecta, may cause pathological fractures.

Answer 8

Defective osteoid formation due to congenital inability to produce adequate intercellular substances like osteoid, collagen and dentine. Failure of maturation of collagen in all the connective tissues. Radiology may show translucent bones, multiple fractures, particularly of the long bones, wormian bones (irregular patches of ossification) and a trefoil pelvis.

Answer 9

Type I - The collagen is normal quality but insufficient quantity. Type II - Poor collagen quantity and quality. Type III - Collagen poorly formed. Normal quantity. Type IV - Sufficient collagen quantity but poor quality.

Answer 10

Bones become harder and more dense. Autosomal recessive condition. It is commonest in young adults. Radiology reveals a lack of differentiation between the cortex and the medulla described as marble bone.

Answer 11

Arterial pH is the single most important factor in paracetamol OD 'Arterial pH' is the correct answer. Paracetamol overdose produces metabolic acidosis and arterial pH is the most important prognostic factor. This patient has a pH of 7.2 and needs a liver transplant as the King's college criteria for liver transplantation in paracetamol overdose only requires a patient to have an arterial pH \< 7.3 more than 24 hours after ingestion for liver transplantation to be indicated.

Answer 12

While these are all poor prognostic factors, arterial pH is the single most important one. The King's college criteria for liver transplantation in paracetamol overdose requires a patient to have 'an arterial pH \< 7.3 more than 24 hours after ingestion' OR for a patient to HAVE ALL 3 OF: 'grade III/IV hepatic encephalopathy', 'creatinine \> 300 µmol/L' and 'prothrombin time \> 100 seconds' to require a liver transplant. This demonstrates how arterial pH is the most important prognostic factor

Answer 13

The minority of patients who present within 1 hour may benefit from activated charcoal to reduce absorption of the drug.

Answer 14

Acetylcysteine should be given if: there is a staggered overdose\* or there is doubt over the time of paracetamol ingestion, regardless of the plasma paracetamol concentration; or the plasma paracetamol concentration is on or above a single treatment line joining points of 100 mg/L at 4 hours and 15 mg/L at 15 hours, regardless of risk factors of hepatotoxicity

Answer 15

Acetylcysteine is now infused over 1 hour (rather than the previous 15 minutes) to reduce the number of adverse effects. Acetylcysteine commonly causes an anaphylactoid reaction (non-IgE mediated mast cell release). Anaphylactoid reactions to IV acetylcysteine are generally treated by stopping the infusion, then restarting at a slower rate.

Answer 16

Cocaine abuse The scenario described in this question is consistent with that of placental abruption. Cocaine abuse, pre-eclampsia and HELLP syndrome are known causes of placental abruption, which typically presents with hyperreflexia. HELLP syndrome can be ruled out since the full blood count shows no indication of anaemia or low platelets as would be expected in this condition. Dilated pupils + hyperreflexia seen on physical examination point towards cocaine abuse. Heroin abuse would often present with pinpointed pupils and has not been associated with an increased risk of placental abruption. Although pre-eclampsia in pregnancy is associated with an increased risk of placental abruption, the findings on physical exam are more consistent with that of cocaine abuse. Disseminated intravascular coagulopathy is a complication placental abruption, not an underlying cause. Additionally, the normal partial thromboplastin time (PTT) and activated partial thromboplastintime (APTT) decrease the likelihood of underlying DIC.

Answer 17

Maternal risks hypertension in pregnancy including pre-eclampsia placental abruption Fetal risk prematurity neonatal abstinence syndrome

Answer 18

Monitor - no immedate action is required Decompression haematuria doe snot require further management if the patient is haemodynamically stable

Answer 19

This patient has decompression haematuria. Decompression haematuria occurs commonly after catheterisation for chronic urinary retention due to the rapid decrease in the pressure in the bladder. It usually does not require further treatment and resolves spontaneously over a few days. Patients should be monitored to ensure the bleeding does not become severe.

Answer 20

Bladder washouts are indicated for moderate or severe haematuria, but are not needed in this case as the bleeding from decompression haematuria is likely to settle on its own. [bladder irrigation helpful to control haematuria also]

Answer 21

Tranexamic acid is generally contra-indicated in haematuria as it causes clots to form in the bladder, leading to bladder outflow obstruction. Therefore, this is an incorrect answer.

Answer 22

Painless and insidious

Answer 23

Chronic urinary retention is characterised by being painless and insidious. High pressure retention impaired renal function and bilateral hydronephrosis typically due to bladder outflow obstruction Low pressure retention normal renal function and no hydronephrosis

Answer 24

Duration of hearing aid use -Adults are generally required to have had a failed trial of hearing aids before having a cochlear implant The feature of the history that most suggests that a cochlear implant is an appropriate management strategy is the duration of his hearing aid use. A cochlear implant is appropriate in the management of a patient who has failed a trial of hearing aids for at least 3 months.

Answer 25

A cochlear implant is an electronic device that may be offered to patients with severe-to-profound hearing loss. The device has both internal and external components. Externally, the microphone recognises the environmental sound and sends it to the sound processor. This, in turn, transforms the impulses received into a digital signal that which is then transferred to the transmitter coil. The transmitter coil conveys the signal to the internal components. Internally, a receiver, which magnetically connected to, and sits directly above the transmitter coil, and receives the impulses from the external apparatus which are then processed by a set of electrodes. The electrodes do the work that would be performed by the inner ear hair cells in a 'normal' ear. The brain can then process these signals to comprehend sound. Rechargeable batteries can be used to power the apparatus and life span depends upon usage and the individual device. Hearing link describes cochlear implants as '...the world’s most successful medical prostheses in that less than 0.2% of recipients reject it or do not use it and the failure rate needing reimplantation is around 0.5%.'

Answer 26

In children, audiological assessment and/or difficulty developing basic auditory skills. In adults, patients should have completed a trial of appropriate hearing aids for at least 3 months which they have been objectively demonstrated to receive limited or no benefit from.

Answer 27

Genetic (accounts for up to 50% of cases). Congenital e.g. following maternal cytomegalovirus, rubella or varicella infection. idiopathic (accounts for up to 30% of childhood deafness). Infectious e.g. post meningitis.

Answer 28

Viral-induced sudden hearing loss. Ototoxicity e.g. following administration of aminoglycoside antibiotics or loop diuretics. Otosclerosis Ménière disease Trauma

Answer 29

Aminoglycoside antibiotics, or loop diuretics

Answer 30

Prior to an assessment for the cochlear implant, patients should have exhausted all medical therapies aimed at targeting any underlying pathological process contributing to the loss of hearing. In addition, they should have explored 'conventional' amplification strategies i.e. hearing aids and found the devices insufficient to allow functioning within daily life and/or support language development/maintenance.

Answer 31

Whilst implants are necessitated by the destruction or degeneration of the organ of Corti, it is essential that there are surviving spiral ganglion neurons to ensure the success of the implant. An assessment of the patient anatomy should be undertaken by an experienced otolaryngologist/skull base surgeon.

Answer 32

Surgical implantation may be complicated by infection, facial paralysis due to nerve injury intra-operatively, cerebrospinal fluid (CSF) leakage, and meningitis. To reduce the risk of meningitis as far as possible, it is recommended that all patients should have up-to-date vaccinations against Streptococcus and Haemophilus.

Answer 33

Contraindications to consideration for cochlear implant: Lesions of cranial nerve VIII or in the brain stem causing deafness Chronic infective otitis media, mastoid cavity or tympanic membrane perforation Cochlear aplasia Relative contraindications: Chronic infective otitis media or mastoid cavity infections Tympanic membrane perforation Patients that may be seen to demonstrate a lack of interest in using the implant to develop enhanced oral communication skills.

Answer 34

Optic neuritis - can be a feature of MS

Answer 35

Significant lethargy

Answer 36

Diagnosis can be made on the basis of two or more relapses and either objective clinical evidence of two or more lesions or objective clinical evidence of one lesion together with reasonable historical evidence of a previous relapse.

Answer 37

Visual optic neuritis: common presenting feature optic atrophy Uhthoff's phenomenon: worsening of vision following rise in body temperature internuclear ophthalmoplegia Sensory pins/needles numbness trigeminal neuralgia Lhermitte's syndrome: paraesthesiae in limbs on neck flexion Motor spastic weakness: most commonly seen in the legs Cerebellar ataxia: more often seen during an acute relapse than as a presenting symptom tremor

Answer 38

Others urinary incontinence sexual dysfunction intellectual deterioration

Answer 39

Hydroxychloroquine - first-line Tx for SLE

Answer 40

This vignette describes a patient with systemic lupus erythematosus (SLE). SLE is a systemic inflammatory autoimmune connective tissue disease that takes a relapsing-remitting course and results in chronic inflammation. 'Erythematosus' in the name refers to the red malar 'butterfly' rash that typically forms across the cheeks and bridge of the nose. SLE presents with non-specific symptoms such as fatigue, weight loss, arthralgia and myalgia along with the characteristic photosensitive 'butterfly' rash.

Answer 41

Basics NSAIDs sun-block Hydroxychloroquine the treatment of choice for SLE If internal organ involvement e.g. renal, neuro, eye then consider prednisolone, cyclophosphamide

Answer 42

Inhibits ovulation 88% The questions asks for the primary mode of action. The Faculty for Sexual and Reproductive Health (FSRH) state Combined Hormonal Contraception (CHC) works primarily by inhibiting ovulation via action on the hypothalamo-pituitary-ovarian axis to reduce luteinising hormone and follicle-stimulating hormone. Alterations to cervical mucus and the endometrium may also contribute to the efficacy of CHC.

Answer 43

. Implantable contraceptive (etonogestrel) Thickens cervical mucus only The correct answer is: Inhibits ovulation 54% The Faculty for Sexual and Reproductive Health (FSRH) state The progestogen-only implant is a long-acting reversible method of contraception (LARC). The primary mode of action is to prevent ovulation. Implants also prevent sperm penetration by altering the cervical mucus and possibly prevent implantation by thinning the endometrium.

Answer 44

. Copper intrauterine contraceptive device (used as a standard contraceptive) Inhibits implantation of the conceptus The correct answer is: Decreases sperm motility and survival 67%

Answer 45

Gastroenteritis The correct answer is: Pancreatitis 65% Epigastric pain that worsens on lying down and radiates into the back is typical of a pancreatitis picture. Acute gastritis is also a possible differential, particularly following a potentially heavy meal. However, the nature of the pain makes pancreatitis more likely. Gastroenteritis following a takeaway is another possible differential, however, the overarching symptoms tend to be vomiting and diarrhoea with generalised abdominal pain, rather than focal epigastric pain. Appendicitis typically starts with pain in the umbilical region which then localises to the right iliac fossa. It is usually associated with a fever. In this case, pancreatitis is the single most likely cause.

Answer 46

Inflammatory bowel disease (IBD) The correct answer is: Irritable bowel syndrome (IBS) 64% In a busy city worker, stress is likely the trigger of this patient's abdominal symptoms, which are most likely caused by IBS. In patients with IBS, their symptoms can comprise abdominal pain, bloating, diarrhoea or constipation. IBS is normally a diagnosis of exclusion in patients who have experienced symptoms for at least 6 months, as in this case. IBD would also be a differential that needs to be ruled out, however, IBD tends to occur in acute flares rather than daily symptoms over a three-month period. In addition, IBD is more commonly associated with rectal bleeding and weight loss. Bowel cancer should also be ruled out with a faecal immunochemical test however, it is less likely given the intermittent nature of the symptoms and lack of systemic symptoms such as weight loss.

Answer 47

Appendicitis The correct answer is: Constipation 70% In this scenario, the young child is complaining of localised pain and so several differentials must be excluded. His abdomen is soft with only mild tenderness and no guarding. This, coupled with the absence of a fever, vomiting and normal observations make appendicitis less likely. Furthermore, appendicitis pain occurs most commonly in the right iliac fossa. He has not been recently unwell and therefore mesenteric adenitis is also unlikely. He last opened his bowels three days ago. The most likely option, therefore, is constipation and his recent lack of eating may be

Answer 48

acute coronary syndrome diabetic ketoacidosis pneumonia acute intermittent porphyria lead poisoning

Answer 49

Vitamin C defiency: - bleeding gums, think scurvy This question is asking about a woman presenting with lethargy, arthralgia, easy bruising and bleeding gums. While there are many differentials for this presentation it is quite classic of a vitamin C deficiency (also known as scurvy). Scurvy is more common in people from low-income backgrounds, the elderly, alcoholics or those with a poor diet (as indicated in this case with the patient recently moving away from home). Bleeding gums is a characteristic symptom.

Answer 50

Vitamin C (ascorbic acid) is found in citrus fruits, tomatoes, potatoes, Brussel sprouts, cauliflower, broccoli, cabbage and spinach.

Answer 51

Deficiency (commonly called scurvy) leads to impaired collagen synthesis and disordered connective tissue as ascorbic acid is a cofactor for enzymes used in the production of proline and lysine.

Answer 52

It is associated with severe malnutrition as well as drug and alcohol abuse, and those living in poverty with limited access to fruits and vegetables.

Answer 53

Symptoms and signs include: Follicular hyperkeratosis and perifollicular haemorrhage Ecchymosis, easy bruising Poor wound healing Gingivitis with bleeding and receding gums Sjogren's syndrome Arthralgia Oedema Impaired wound healing Generalised symptoms such as weakness, malaise, anorexia and depression

Answer 54

Reduced total serum copper. Wilson's disease is a problem with copper, in which excess copper is deposited in tissues, causing a low serum copper. It has many unusual manifestations, the most common of which are behavioural or speech changes.

Answer 55

Some tell-tale signs that you might see in exam questions include brown rings in the eyes (Kayser-Fleischer rings), blue nails, and a reduced serum copper and reduced caeruloplasmin.

Answer 56

Wilson's disease is an autosomal recessive disorder characterised by excessive copper deposition in the tissues. Metabolic abnormalities include increased copper absorption from the small intestine and decreased hepatic copper excretion. Wilson's disease is caused by a defect in the ATP7B gene located on chromosome 13.

Answer 57

The onset of symptoms is usually between 10 - 25 years. Children usually present with liver disease whereas the first sign of disease in young adults is often neurological disease

Answer 58

Features result from excessive copper deposition in the tissues, especially the brain, liver and cornea: liver: hepatitis, cirrhosis neurological: basal ganglia degeneration: in the brain, most copper is deposited in the basal ganglia, particularly in the putamen and globus pallidus speech, behavioural and psychiatric problems are often the first manifestations also: asterixis, chorea, dementia, parkinsonism Kayser-Fleischer rings green-brown rings in the periphery of the iris due to copper accumulation in Descemet membrane present in around 50% of patients with isolated hepatic Wilson's disease and 90% who have neurological involvement renal tubular acidosis (esp. Fanconi syndrome) haemolysis blue nails

Answer 59

slit lamp examination for Kayser-Fleischer rings reduced serum caeruloplasmin reduced total serum copper (counter-intuitive, but 95% of plasma copper is carried by ceruloplasmin) free (non-ceruloplasmin-bound) serum copper is increased increased 24hr urinary copper excretion

Answer 60

penicillamine (chelates copper) has been the traditional first-line treatment trientine hydrochloride is an alternative chelating agent which may become first-line treatment in the future tetrathiomolybdate is a newer agent that is currently under investigation

Answer 61

Amniotic fluid embolism: -A history of sudden collapse occurring soon after a rupture of membranes is suggestive of amniotic fluid embolism. The patient is clearly too unwell for this to be a simple vasovagal event. Amniotic fluid emboli can indirectly lead to myocardial infarcts, but It is hard to arrive at a primary diagnosis of myocardial infarction without mention of preceding chest pain. Occult bleeding and hypovolaemic shock would also typically evolve at a slower pace. Postural orthostatic tachycardia syndrome is more common in women of a reproductive age but would not be associated with marked hypotension as present here.

Answer 62

This is when fetal cells/ amniotic fluid enters the mothers bloodstream and stimulates a reaction which results in the signs and symptoms described below.

Answer 63

Epidemiology: Rare complication of pregnancy associated with a high mortality rate.Incidence 2/ 100,000 in the U.K . Aetiology: Many risk factors have been associated with amniotic fluid embolism but a clear cause has not been proven. A consistent link has been demonstrated with maternal age and induction of labour. It is widely accepted that maternal circulation must be exposed to fetal cells/ amniotic fluid in order for an amniotic fluid embolism to occur. However the precise underlying pathology of this process which leads to the embolism is not well understood, though suggestions have been made about an immune mediated process.

Answer 64

Clinical presentation: The majority of cases occur in labour , though they can also occur during caesarean section and after delivery in the immediate postpartum. Symptoms include: chills, shivering, sweating, anxiety and coughing. Signs include: cyanosis, hypotension, bronchospasms, tachycardia. arrhythmia and myocardial infarction. Diagnosis: Clinical diagnosis of exclusion, as there are not definitive diagnostic tests. Management: Critical care unit by a multidisciplinary team, management is predominantly supportive

Answer 65

Systemic sclerosis