General Flashcards
Fever, diarrhoea (non bloody, yellow green) , abdo pain, constipation, rose spots (small pink spots on abdomen) - organism
Salmonella typhi - typhoid
2 types systemic sclerosis, symptoms and Abs associated with each
Limited cutaneous = raynauds, scleroderma affects face + distal limbs first. Anti-centrometer abs. CREST Syndrome
Diffuse cutaneous systemic sclerosis = scleroderma affects trunk and proximal limbs. Anti-scl-70 Abs. Most common cause death is respiratory involvement
In the context of tachyarrhythmia and SBP<90 what is the immediate management
DC cardio version
Acute HF not responding to treatment - what might be useful to use when severe dyspnea
CPAP
Flashes and floaters with no redness or pain - dx
Vitreous/retinal detachment
Acute vs prophylaxis migraines
acute: triptan + NSAID or triptan + paracetamol
prophylaxis: topiramate or propranolol
Inguinal hernia in infants vs umbilical hernia mx
Inguinl hernia in infants = urgent surgery
Umbilical - can be left up to a year as can resolve
Mx of symptomatic bradycardia if atropine fails
External pacing
Raised ICP causing third nerve palsy - how?
Trans-tentorial herniation
The combination of a fixed and dilated pupil with an eye deviated inferiorly and laterally (‘down and out’) is indicative of a third nerve palsy. In the context of a decreasing conscious level and an intracranial mass (the haematoma) this is indicative of a trans-tentorial, or uncal, herniation.
What is cerebellar tonsillar herniation
Cerebellar tonsillar herniation affects the medulla oblongata and is often a terminal event in an unconscious patient resulting in asystolic cardio-respiratory arrest. Although a classical cause of a third nerve palsy, a posterior communicating artery aneurysm is not the most likely cause here given the history of trauma and an intracranial mass. Frontal eye field injury would cause a functional ocular paralysis and the eye would tend to the neutral position in a state of reduced consciousness. Optic nerve compression would not cause deviation of the eye.
Scoring system for acute pancreatitis
There are several scoring systems used to identify cases of severe pancreatitis which may require intensive care management. These include the Ranson score, Glasgow score and APACHE II.
The specifics of each scoring system will not be repeated here. However, some common factors indicating severe pancreatitis include:
age > 55 years
hypocalcaemia
hyperglycaemia
hypoxia
neutrophilia
elevated LDH and AST
Note that the actual amylase level is not of prognostic value.
IgA nephropathy vs Post-strep glomerulonephritis
IgA nephropathy - visible haematuria after recent URTI
Post strep glomerulonephritis 1-2 weeks after URTI and ass with proteinuria. From bacteria (strep)
Rapidly enlarging aneurysm or over 5.5cm needs surgery - which type surgery (not blown)
Elective end-vascular aneurysm repair
I blown (unstable) need urgent and that has to be open
What type of stoma is used to defunciton colon to protect anastomosis
Loop ileostomy
Episcleritis vs scleritis
Scleritis is painful
Caput Succedaneum vs cephalhaematoma
Caput succedaneum is a puffy swelling that usually occurs over the presenting part and crosses suture lines
(Starts with s so spreads)
Cephalhaematoma - haemorrhage between skull and peritoneum and limited by boundaries of cranial bones.
(starts with h so halts at suture lines)
At what age do you refer women with unexplained breast lump for cancer referral
Refer women aged >30 with an unexplained breast lump using a suspected cancer pathway referral
First line treatment delirium tremens
Chlordiazepoxide
Acute reactive arthritis (eg with urination prob, itchy eyes etc after stomach bug) management
nsaid- ibUPROFEN IF NO ci
(can’t see can’t see can’t climb a tree with reactive arthritis)
Miscarriage mx
NICE guidelines recommend expectant management as first line in the treatment of miscarriage, unless one of the following factors is present: there is an increased risk of bleeding, there are previous adverse experiences associated with pregnancy, there is increased risk from the effects of haemorrhage or there is evidence of infection. The most appropriate option in the above case, which represents an infected miscarriage with the patient progressing to septic shock, is to evacuate the pregnancy as soon as possible through surgical management.
Symptoms hypomania in primary care - mx
Routine referral to CHMT
If neoplastic spinal cord compression is suspected, what is Mx
High dose oral dexamethasone
Hypercalcaemia vs hyperkalaemia on ecg
Hypercalcaemia = shortening QT interval but
Hyperkalaemia is tall tented t waves
In step down treatment asthma what to do with ICS
In the step-down treatment of asthma, aim for a reduction of 25-50% in the dose of inhaled corticosteroids
ie, half ICS dose and review in 6m
Confirmed miscarriage vs threatened
A transvaginal ultrasound demonstrating a crown-rump length greater than 7mm with no cardiac activity is diagnostic of a confirmed miscarriage
Threatened = get pains etc but stilll have signs life
Sinusitis prophylaxis if recurrent episodes is…
Intransala corticosteroids
Myxoedemic coma treatment
Thryoxine and hydrocortisone
Thyrotoxic storm tx
Beta blockers,
Propylthiourical
Hydrocortisone
Ectopic pre first surgery
Salpingectomy is first line for women with no other RFs for infertility
Intrahepatic cholestasis mx
Increases risk still birth so elective induction of el from 37 weeks
Tx of the condition is ursodeoxycholic acid
Common drugs for causes of urinary retention
Opioid analgesia (tramadol) and anticholinergic drugs
DKA - what insulin do you have and continue vs stop
In the acute management of DKA, insulin should be fixed rate whilst continuing regular injected long-acting insulin but stopping short actin injected insulin
what is the status
Positive anti-HBc IgG, negative anti-HBc IgM and negative anti-HBc in the presence of HBsAg implies chronic HBV infection
Initial bloods/tests for screening when erectile dysfunction
HbA1C
Lipids
Testosterone
When to add a second drug in T2DM
A second drug should be added in type 2 diabetes mellitus if the HbA1c is > 58 mmol/mol
Anterior uveitis treatment
Steroid eye drops with mydriatic eye drops
Vestibular neuronitis vs viral labyrinthitis
VN + layrinthtis = Dizziness, off balance, sickness, tinnitus
But unaffected hearing points more to vestibular neuritis and in viral labyrinthitis you would expect a preceding viral infection
Correcting sodium levels rapidly - the complications (hypo correction vs hyper correction)
Correcting sodium levels rapidly is dangerous:
Hyponatraemia correction - osmotic demyelination syndrome
Low to high- brain will die
Hypernatreamia correction - cerebral oedema
High to low brain will blow
Because if you have high sodium then u must be dehydrated so if you correct you pump loads of water and it swells
Acute dystonia secondary to antipsychotics - management
Procyclidine
Psoriasis - which medication can worsen it???
A. Lithium
B. Amoxicillin
C. Clindamycin
D. Methotrexate
E. Amlodipine
Lithium
Also BBlockers
Resus fluids for paeds
10ml/kg over <10
What Ix to do before starting biologics fro RA
CXR- to check for TB as biological can cause reactivation
If metformin is not tolerated due to GI side effects, what do you do
If metformin is not tolerated due to GI side-effects, try a modified-release formulation before switching to a second-line agent
Most common secondary cause of hypertension and the Ix
Primary hyperaldosteronism (Conns syndrome)
Renin aldosterone ratio
Whilst a patient is receiving PCA opioids then what drugs to stop in normal meds
Stop all other opioid to avoid toxicity
When babies are suspected cows milk protein intolerance, what might you prescribe for mum when she is cutting out cows milk from diet
Calcium and vitamin D
Investigating a PE: If the CTPA is negative then what Ix is next steps
Proximal leg vein doppler US
Bonocular vision post facial trauma - what type of fracture and which bone does this suggest
Bonocular vision post facial trauma is suggestive of depressed fracture of zygoma
Interpretation of pupillary findings in head injuries
where should IV amiodarone be given and why?
Into central vein as it is a common cause of thrombophlebitis
Confidentiality regarding HIV diagnoses to partner
You may disclose information to a known sexual contact with a patient with a sexually transmitted serious communicable disease if you have reason to think that they are at risk of infection and that the patient has not informed them and cannot be persuaded to do so.
(Give pt opportunity to tell them and inform them that if they don’t you will have to)
Pt presents with bones, stones, abdomen groans and psychic moans. Their bloods show raised calcium, low phosphate and PTH may be raised (or inappropriately normal due to raised calcium)
Pepperpot skull
Diagnosis
Primary hyperparathyroidism
Features of heparin induced thrombocytopeniaa and what Abs are presents
- Abs form against completes of platelet factor 4 and heparin
- These abs binds and indie platelet activation
- Usually doesn’t develop until after 5-10 days of treatment
- Despite low platelets association it is prothombrotic
Sudden painless loss vision, severe retinal haemorrhages on fundoscopy - diagnosis
Central retinal vein occlusion
A 49-year-old man is brought into ED after he was found on the side of the road unconscious. The paramedics give a history of alcohol abuse. You ask the nurse to perform a set of basic observations, capillary blood glucose (CBG) and an ECG.
His basic observations are: a temperature of 35.9ºC, blood pressure 190/110 mmHg, heart rate 51 beats/min, respiratory rate is 24 breaths/min (Cheyne-Stokes breathing), oxygen saturations 95% on air. His Glasgow coma scale is 4/15 (E1V1M2).
Capillary blood glucose comes back as 10.1.
The ECG shows T wave inversion in all leads and QT prolongation.
What is the most likely diagnosis?
Head injury
(Global T wave inversion - think non cardiac cause of abnormal egg)
T2DM initial therapy - if metformin is contraindicated and patient has a risk of CVD, established CVD or chronic HF then what medication to start
SGLT-2 mono therapy
A 57-year-old man presents to the emergency department with a 2-day history of right upper quadrant abdominal pain. His past medical history is remarkable for type 2 diabetes mellitus and alcohol excess.
There are no clinical signs of jaundice, and the patient denies pale stools or dark urine.
An ultrasound of the biliary tree shows no gallstones, demonstrating some regional lymphadenopathy. Further imaging is suggestive of extramural compression of a branch of the biliary tree.
Given this information, where is the most likely location of the lesion?
Ampulla Vater, common bile duct, common hepatic duct, cystic duct, sphincter odd
Cystic duct - blockage of cystic duct or gallbladder doesn’tcause jaundice
Pt presents with petechia, pupa, bleeding and isolated thrombocytopenia - what is dx and mx
ITP
Orla prednisolone
In compartment syndrome - what biochemical abnormality is most likely seen and why
Alkalosis, hypercalcaemia, hypocalcaemia, hyperkalaemi, hyponatraemia
Hyperkalaemia - muscle death causes release potassium and probably degree of renal impairment
Headaches, amenorrhoea, visual field defects- dx
Prolactinoma
What is useful for helping prevent attacks of Menderes disease vs acute attacks
Betahistine and vestibular rehab for prevention
Acute - buck or IM prochlorperazine
What Abs has a side effect of rash with infectious mononucleosis
Amoxicillin
What Abs have side effect cholestasis
Co-amox
Flucloxiicllin
Side effects trimethoprim
Rashes - photosensitivity
Prutitis
oppression haeamtopeisis
Most common organism causing cholangitis
E.COLI
Question 44 of 50
An 83-year-old male is referred to the ophthalmology clinic by his general practitioner with a new-onset inability to see objects near to him, especially at night. On fundoscopy, the doctor notices well-demarcated red patches. He has a past medical history of hypertension and he is a life-long smoker.
Given the most likely diagnosis, which one of the following is the most appropriate treatment?
AMD - Anti VEGF
This patient has the characteristic signs and symptoms: a reduction in visual acuity, particularly for near field objects, worse at night and red patches representing intra-retinal or sub-retinal fluid leakage or haemorrhage visible on fundoscopy.
What monitoring is needed on methotrexate
FBC U&E LFT
Monitoring needed on levetiracetam
No routine monitoring needed
monitoring needed on amiodarone
TFT LFT
Pacenta accrete, increta, percreta
Accrete = chorionic villi attach to myometrium, rather than being restricted within decide basalts
Increate = chorionic villi invade into myometrium
Percreta = chorionic villi invade through perimetruym
A 48-year-old man presents to his GP with a number of symptoms that have come on over the past few days. His vision is blurred and his right eye is painful, as well as having a generalised headache.
On examination, the right eye has deviated inferiorly and laterally. There is visible ptosis of the upper right lid, and the pupil is dilated. It does not respond to light. This eye does not follow movements well, but the left eye appears unaffected and is normal upon testing.
Where is the most likely location of the lesion?
Posterior communication artery (aneurysm) - painful third nerve palsy
Loss of vibration sense, ataxia and absent ankle reflexes with recent gastrectomy - dx
Subacute degeneration of cord
2nd most common ass cancer in HNPCC after CRC
Endometrial cancer
Mechanism of controlled hyperventilation as a management in raised ICP
Hyperventilation -> reduce co2 -> vaoconstrict cerebral arteries -> reduce ICP
Hypokalaemia EGC findings
small or absent T waves (occasionally inversion)
prolong PR interval
ST depression
long QT
A baby is noted to have micrognathia (post displacement of tongue) and a cleft palate. He is placed prone due to upper airway obstruction. There is no family history of similar problems
Diagnosis
Pierre robin syndrome
If a mild-mod flare of UC doesn’t respond to topical OR oral aminosalicylates then what to add
Oral corticosteroids
Acriomioclavicular joint injury - grades and mx
Injury to the AC joint is relatively common and typically occurs during collision sports such as rugby following a fall on to the shoulder or a FOOSH (falls on outstretched hand).
AC joint injuries are graded I to VI depending on the degree of separation.
Grade I and II injuries are very common and are typically managed conservatively including resting the joint using a sling.
Grade IV, V and VI are rare and require surgical intervention.
The management of grade III injuries is a matter of debate and often depends on individual circumstances.
Young females with suspected appendicitisis - next step in iX
US abdomen - helps rule out ovarian pathology and/or increase suspicion of appendicitis
Young females with suspected appendicitisis - next step in iX
US abdomen - helps rule out ovarian pathology and/or increase suspicion of appendicitis
Young females with suspected appendicitisis - next step in iX
US abdomen - helps rule out ovarian pathology and/or increase suspicion of appendicitis
MRCG grading for muscle weakness
In tx anaphylaxis - how often can you repeat adrenaline and salbutamol inhalers?
Every 5 mins
In people with achalasia and the dysphagia has worsened with a mass on oesophagus - what type of cancer
Squamous cell carcinoma - this is increased risk in achalasia
NYHA Classification of CHF
NYHA Class I
no symptoms
no limitation: ordinary physical exercise does not cause undue fatigue, dyspnoea or palpitations
NYHA Class II
mild symptoms
slight limitation of physical activity: comfortable at rest but ordinary activity results in fatigue, palpitations or dyspnoea
NYHA Class III
moderate symptoms
marked limitation of physical activity: comfortable at rest but less than ordinary activity results in symptoms
NYHA Class IV
severe symptoms
unable to carry out any physical activity without discomfort: symptoms of heart failure are present even at rest with increased discomfort with any physical activity
Contact lens wearers with red painful eye - mx
refer to eye casualty to exclude microbial keratitis
Confusion, pink mucosa - dx
CO poisoning
A 42-year-old male presents to her general practitioner with a 2-week history of asymmetrical oligoarthritis predominantly affecting his lower extremities, associated with dysuria and conjunctivitis. He is usually well apart from suffering from a diarrhoeal illness 1 month ago.
What is the most appropriate first-line management of this patient?
NSAIDs - acute reactive arthritis
Scleritis vs episcleritis
Scleritis = Red eye, classically painful, watering and photophobia are common, gradual decrease in vision
Episcleritis is classically not painful
Hypertensive retinopathy on fundosocpy - grading system
I - arteriolar narroing and tortuosity, increased light reflex (silver wiring)
II - AV nipping
III - cotton wool exudates, flame and blot haemorrhages
IV - Papilloedema
Cholangiocarcinoma vs pancreatic cancer
Cholangio - may present with persist symptoms of biliary colic and very rare ass with IBD
Pancreatic - lost weight, onset fatigue, Rfs liek DM, jaundice, enlarged gallbladder (may feel mass). No pain
Tx diabetic maculopathy (if proliferative retinopathy also)
Panretinal photocoagulation and intravitreal VEGF.
VEGF - maculopathy
Panretinal photocoagulation for proliferative retinoopathy
rules for weight bearing after hip fracture surgery
immediate unrestricted weight bearing in all
Mx HUS
supportive - fluids + dialysis as example
Mx ACS when o2 >94% and hypotensive and going PCI
Aspirin + ticagrelor + fondaparinux
no nitrates as hypotensive
clubfoot - position of foot
Inverted + plantar flexed foot which is not passively correctable
Women with suspected PCOS should have which Ix….
Pelvic US, FSH, LH, Prolactin, TSH, Testosterone, sex hormone binding globulin
Factors fvaoruign rhythm control in AF
Age <65
First presentation
Symptomatic
BMI >50 first line mx
Bariatric surgery
When is a missed pOP - desogestrel vs traditional
Traditional <3hrs
Desogstrol <12hrs
Wells score and cut off for CTPA
PE likely = >4 points - CTPA
PE unlikely = <4 points - D dimer (if neg then stop anticoagulant)
Treatment for salicylate overdose
Urinary alkalisation with iV bicarb, haemodialysis
Opioid overdose Tx
Naloxone
Benzodiazepine overdose tx
Flumazenil
Tricyclic antidepressant overdose tx?
No specific antidote but IV bicarb can help educe risk seizures etc
Might need dialysis to help remove
Heparin overdose mx
Protamine sulphate
Ethylene glycol and methanol poisoning antidote
Ethanol (now fomepizole mosltyly)
Organophosphate insecticide overdose mx
Atropin
Digoxin overdose mx
Digoxin specific antibody fragments
Mx PPH order
RCOG guidelines then suggest to initially use Syntocinon 5 Units by slow IV injection.
This should then be followed by ergometrine (contraindicated in hypertension) and
then a Syntocinon infusion.
Carboprost (contraindicated in asthma) and then misoprostol 1000 micrograms rectally are then recommended. If pharmacological management fails then surgical haemostasis should be initiated.
High uric acid and renal impairment following chemo - what s the diagnosis and how to prevent
tumour lysis syndrome
If high risk then IV Allopurinolc or IV rasburicase prior and during first days of she,o
(high potassium and high phosphate in presence low calcium_
Bets induction agent for haemodynamically unstable patients in anaesthesia
Ketamine
Downs syndrome on combined screening test
Increased HCG, Decreased PAPP-A, thickened nuchal translucency
Pt develops acute heart failure 5 days after MI. New pan-systolic murmur is noted on exam -dx
VSD
Carpal tunne syndrome - what happens in nerve conduction evlauation (to action potential in sensory and motor axons)
Prolongs
Renal failure, sensorineural hearing loss and ocular abnormalities in a child - dx
Alport syndrome
Suspected DVT and raised D dimer but scan negative - what to do (already on anticoagulant)
Stop anticoagulant and repeat scan in 1 week
Pain on radial side wrist/ tenderness over radial styled process - dx
De Quervains tenosynovitis
Trnsvers myelitis vs GBS on reflexes
GBS = hyporflexia
Transverse myelitis= hyperreflexia
What score is useful to assess hypemrobility
Beighton score - positive if at least 5/9 in adults or least 6/9 in children
S/E Isoniazid
Peripheral neuropathy, hepatitis, agranulocytosis
S/E pyrazinamide
Hyperuricaemia causing gout
Arthralgia, myalgia, hepatitis
S/E ethambutol
Optic neuritis - check visual acuity before and during
S/E Rifampicin
Hepatitis, orange secretions, flu-like symptoms
Signs digoxin toxicity
Generally unwell - lethargy, N&V, anorexia, confusion, yellow-green vision, arrhythmias (av BLOCK), GYNAECOMASTIA
Inferior mI and aortic regurgitation murmur with taring chest pain - dx
proximal aortic dissection
A 78-year-old man presents to emergency department with sudden onset, severe, diffuse abdominal pain at 7:30pm after finishing his evening meal. It is intermittent and severe in nature. However the abdomen is soft on examination. While in hospital he suffers from 1 episode of non-bloody emesis. Initial imaging does not yield any diagnosis. He has a history of GORD, hernia repair, hypertension, myocardial infarction and atrial fibrillation. What is the most likely diagnosis?
ischaemia colitis - pain after meal, with predisposing factors
What might be one of the earliest symptoms in aspirin overdose
Tinnitus
Reversal agent for dabigatran/ bleeding on dabigatran
Idarucizumab
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?
Achalasia
What ECG abnormality ub Subarachnoid space
Polymorphic ventricular tachycardia
Which gene translation is bursitis lymphoma ass with
C-Myc gene translocation
What is the risk of SSRI + NSAID and how to treat this
Increased risk gI bleeding when aspirin/ NSAIDs are combine with SSRIs so offer PPI like lansoprazole (as in IHD you can’t just stop aspirin)
Red facial rash which looks greasy and fine scale over affecting cheeks, nasolabial folds, eye brows, nasal bridge and scalp
Dx
Seborrheic dermatitis
if the Bishop score is </= 6 then management
vaginal PGE2 or oral misoprool for induction labour
score 5 or less suggests labour unlikely o start without induction
If Angie is not controlled with a Beta blocker - what do we use
Longer acting dihydropyridine CCB like amlodipine
lentigo maligna
Addisons with intercurrent illness - does glucocorticoids and fludrocortisone dose stay same
No
Double hydrocortisone, same fludrocortisone
Small bowel obstruction
Bone pain, tenderness, proximal myopathy (waddling gait) and low calcium, low phosphate, high ALP, low Vit D, high PTH
osteomalacia
Prolactinoma Tx
Mostly treated with dopamine agonist (bromocriptine) which inhibit release prolactin from pituitary gland.
Surgery si for those who can’t tolerate or fail to respond to medical therapy (transphenoidal)
A 65-year-old lady has recently had a colonoscopy and been found to have a malignant tumour in the most distal portion of the rectum, involving the anal sphincter.
which surgical procedure
Abdominoperineal (AP) resection
Rectal cancer on anal verge - abdomino-perineal excision of rectum
Blood stained nipple discharge
Duct papilloma
Grene brown discharge of the nipple + red, swollen
Duct ectasia
Upper rurinary tract obstruction causing hydronehrosis - primary mx
nephrostomy
A 35-year-old woman presents with a one week history of progressive leg swelling. Her past medical history includes type 2 diabetes which is diet-controlled. On examination, there is bilateral pitting oedema up to her knees and periorbital oedema. Her observations are heart rate 88/min, blood pressure 151/91mmHg, oxygen saturations 97%, temperature 37.1ºC, and respiratory rate 14/min. Urine dipstick shows protein +++. Two days later, she complains of left-sided flank pain and haematuria.
What complication has occurred?
A. Haemorrhage into renal cyst B. Splenic infarction C. Renal vein thrombosis D. Haemolytic crisis E. Ureteric stone
Nephrotic syndrome Is ass with hyper coagulable state due to loss of antithrombin III via kidneys and therefore here - renal vein thr0ombpsis has occurred
Stooping of vol movement or staying still in unusual position with schizophrenia
= Catalonia
A 21-year-old male presents to the emergency department with a cough, fever and dyspnoea. On examination he is hypoxic. Pulmonary infiltrates are seen on chest x-ray. He has suffered with anaemia, jaundice and general weakness since the age of 3 months, as well as severe pain when exposed to cold conditions.
sickle cell disease
Acute chest syndrome is a complication of sickle-cell disease and presents with dyspnoea, chest pain, cough, hypoxia and new pulmonary infiltrates seen on chest x-ray
What would you see on synovial fluid for reactive arthritis
Cloudy yellow colour, Culture negative, No crystals, White cell count: 20,000/mm
What is the threshold for platelet transfusion
Platelet transfusion is appropriate for patients with a platelet count < 30 x 109 and clinically significant bleeding
Which cancer can CLL transofrm into and what is this called
Richeters transformation - high grade lymphoma (non Hodgkins)
Bilious vom in kids
All breech babies at, or after 36 weeks gestation - what do they need
DDH screening at 6 weeks regardless mode del
What is the main benefit of prescribing albumin when treating large volume ascites’?
A. Reduce postparacentesis circulatory dysfunction
Patients who have had an episode of SBP require antibiotic prophylaxis
which one
ciprofloxacin
Primary hgyperaldosteronism (conn syndrome) treatment
Spironolactone
Acut edelirium tx when Parkinson’s disease
lorazepam
A 55-year-old woman presents to the emergency department with a sudden onset of central chest pain while she was at rest. The pain was not relieved by her glyceryl trinitrate spray. She has a past history of angina and hypertension. ECG and cardiac biomarkers were positive for an ST-elevation myocardial infarction (STEMI).
A few minutes later, she complained of worsening shortness of breath. On examination, her pulse was weak and thready. Her jugular venous pressure is increased. On chest auscultation, there was a new systolic murmur. Her pulse rate was 130 beats per minute and blood pressure was 80/55 mmHg. There were no new acute changes to the ECG.
mitral regurgitation
Next course of action after WLE with sentinel LN biopsy Neg
radiotherapy
first line for stroke
non contrast ct head
How do BB work in open angle glaucoma
Reduced aqueous section by ciliary body
PANCREAS severity scoring system for pancreatitis
P - PaO2 <8kPa
A - Age >55-years-old
N - Neutrophilia: WCC >15x10(9)/L
C - Calcium <2 mmol/L
R - Renal function: Urea >16 mmol/L
E - Enzymes: LDH >600iu/L; AST >200iu/L
A - Albumin <32g/L (serum)
S - Sugar: blood glucose >10 mmol/L
preferred anti platelet for secondary prevention after stroke
clopidogrel
otitis externa mx
Topical gentamicin + hydrocortisone drops
A 55-year-old woman presents to the emergency department with progressive weakness of the arms and legs bilaterally that started today. She has also been getting progressively more tired, with some episodes of sweating. Her past medical history includes hypertension, diabetes and a transient ischaemic attack (TIA) 6 months ago. She is taking clopidogrel, metformin, gliclazide and ramipril. On examination, she appears confused and drowsy. She has 4/5 power on both arms and legs.
most appropriate next ix in this patient
capillary blood glucose
Widened QRS or arrhythmia in tricyclic overdose mx
iv bicarb
acute flare mx ra
methylprednisolone iM
in palliative patients - what is the pain relief choice when renal impairment
Oxycodone
when is clinical jaundice on bilirubin level
when it hits 50
props in household contacts meningitis
ciprofloxacin
In a patient with suspected anaemia of chronic disease secondary to CKD, what should be checked before commencing EPO
Iron status
A 72-year-old patient presents to her general practitioner complaining of a 6-month history of unexplained weight loss. She reports that she has also noted yellowing of her eyes and skin over the same time period, but denies any abdominal pain or fever. Her past medical history is significant for ulcerative colitis (UC) and primary sclerosing cholangitis (PSC), both of which presented in her 30’s.
On examination, the woman is cachectic and jaundice. Her abdomen is soft and non-tender, with palpable peri-umbilical lymph nodes. The gallbladder is non-palpable.
dx
cholangiocarcinoma
> = 75 years following a fragility fracture
mx
Start alendronate in patients >= 75 years following a fragility fracture, without waiting for a DEXA scan
dose adrenaline in ALS
Recommend Adult Life Support (ALS) adrenaline doses
anaphylaxis: 0.5mg - 0.5ml 1:1,000 IM
cardiac arrest: 1mg - 10ml 1:10,000 IV or 1ml of 1:1000 IV
Which is a depolarising muscle relaxant
Suxamethonium
MOA flumenazil
GABA antagonist
Sudden onset vertigo and vomiting, dysphagia, ipsilateral facial pain + temp loss, contralateral limb pain and temp loss and ataxia
Which artery is the stroke in
Posterior inferior cerebellar artery
Mx status epilepticus
- ABC
- IV benzos or in pre hospital rectal (diazepam/lorazepam).
- In hospital IV lorazepam mostly used and can be repeated once after 10-20mins
- If ongoing then phenytoin/phenobarbitl infusion
- If no response in 45mins from onset then induction general anaesthesia
What can GBS be triggered by
surgery involving GI or respiratory tract, infection
Symptoms GBS
Weakness ascending
Reflexes reduced or absent
Sensory symptoms tend to be mild
Hx gastroenteritis poss
May have Resp muscle weakness, CN involvement, autonomic involvement…
Ix in GBS
Lumbar puncture - rise in protein, normal WBC
Nerve conduction studies - decreased motor nerve conduction velocity, prolonged distal motor latency, increased F wave latency
Defintion malnutrition
unintentional weight loss greater than 10% in last 3-6months
Breast cancer referral - urgent vs non urgent
Cance pathway =
30 + with UE lump or without pain OR
50+ with any: changes in one nipple (discharge/retraction/othe changes of concern)
Non urgent if <30 with UE breaks lump with or without pain
Initial mx od open fractures
IV ABS, photography of wound, application of sterile soaked gauze and impermeable film
Women aged >30 with dysmenorrhoea, menorrhagia, enlarged boggy uterus = dx
Adenomyosis - endometrial tissue grows in myometrium. More common in older females approaching menopause
normal as all above green line
Horners syndrome - how does anihydrosis determine lesion
Horner’s syndrome - anhydrosis determines site of lesion:
head, arm, trunk = central lesion: stroke, syringomyelia
just face = pre-ganglionic lesion: Pancoast’s, cervical rib
absent = post-ganglionic lesion: carotid artery
When ACEi aren’t tolerated - which medication next
ARB
- A 28-year-old man is playing tennis when he suddenly collapses and has a GCS of 4 when examined.
which type haemorrhage
Subarachnoid - sudden collapse and loss consciousness
A 78-year-old man is brought to the emergency department by the police. He is found wandering around the town centre and is confused. His family report that he is usually well apart from a simple mechanical fall 3 weeks previously from which he sustained no obvious injuries.
which type haemorrhage and acute vs chronic
Chronic sub dural haematoma
Hepatic encephalopathy mx
Lactulose
Diagnosis:
Younger females, Asian
Systemic features - malaise, headache
Unequal bloo depressor ein upper limbs
CAROTI BRUIT + TENDERNESS
absent or weak peripheral pulses
Upper and lower limb claudication one exertion
Aortic regurgitation in some
Takayasus arteritis -
Ix - MRA/CTA
mx is steroids
Flush to the skin stoma - which type
Colostomy
What is the most common cause primary headache in children
Migraine - unilateral, pulsating, 4-72hrs, exacerbation by routine activity
Cluster headache mx
Acute = 100% o2, submit triptan
Trophy = verapamil
Mx of abdominal wound dehiscence
Coverage of wound with saline impregnated gauze + iV broad-spectrum Abxs
Which type pneumonia is as with eryisipelas
Streptococcus pyogenes
dysentery, liver abscesses, colonic abscesses, or inflammatory masses in the colon
which organism
Entamoeba histolytica
cause of recurrent watery or sticky eye in neonates and usually, self-resolves by 1 year of age
Congenital tear (lacrimal) duct obstruction
Primary VS Secondary vs Tertiary Hyperparathyroidism
Primary = hypercalcaemia with raised o inappropriately normal PTH. PTH levels are generally elevated. Renal impairment commonly seen in it as a consequence of dehydration
Secondary hyperparathyroidism is incorrect. This occurs as the physiological response to hypocalcemia. Kidney failure and vitamin D deficiency are the most common causes of secondary hyperparathyroidism. The key biochemical features are hypocalcemia and a raised PTH. A raised ALP also occurs due to excessive bone resorption. Phosphate levels will vary with aetiology e.g. raised in kidney failure and decreased in vitamin D deficiency.
Tertiary hyperparathyroidism is incorrect. This occurs when an excess of PTH is secreted by the parathyroid glands, usually after longstanding secondary hyperparathyroidism results in hyperplasia of the parathyroid glands. It biochemically presents the same as primary hyperparathyroidism with raised calcium and elevated PTH. Although this remains a possibility, the patient only has mild renal impairment making this a less likely diagnosis. Furthermore, the phosphate level would generally be high in tertiary hyperparathyroidism (due to reduced renal clearance).
For moderate/severe OCD + SSRI is contraindicated - what is the drug to use
Clomipramine
Clustered erythematous papule around the mouth (perioral) but also perinatal and pericoular. Skin immediately adjacent to vermillion border of lip is often spared. What is the dx and mx
Perioral dermatitis
Topical and oral antibiotics
Steroids can worsen symptoms
Obese T2 diabetic is on metformin but HbA1C is 64. What second line meds may be helpful
DPP-4 inhibitors
What are the grades of hepatic encephalopathy
Grade I - irritability
Grade II - confusion, inappropriate behaviour
Grade III - incoherence, restless
Grade IV - coma
In SIADH what happens to Sodium
Low
Ulcerative colitis and cholestasis - diagnosis
PSC
Brigade syndrome vs arrhythmogenic right ventricular cardiomyopathy (ARVC)
ARVC = T wave inversion V1-3
Brigade - ST elevation V1-3
Patient with AF and acute stroke - when to start anticoagulant therapy after event
2 weeks
Which class is liraglutide and how it is given
GLP-1 receptor - protons weight loss - injections
Class of meds that empagliflozin is and s.e
SGLT-2 inhibitor - weight loss.
Less severe vs more severe depression on the pHQ-9 score
Score <16 = less severe
More severe s >/16
What level do you need a platelet transfusion
90 x 10^9/L
ECG changes in hyperkalaemia
Tall tented t waves
Small p waves
Widened QRS - sinusoidal pattern and asystole
Plummer vinson syndrome
Dysphagia, glossiis, IDA
First line treatment for lichen plants
Topical steroids
Greek boy develops pallor and jaundice after having a lower respiratory tract infection. He has a history of neonatal jaundice. The blood film shows Heinz bodies
G6PD Def
Tx of choice for Toxic multi nodular goitre
Radioactive iodine
Tx uveitis
Steroid and cycloplegia (mydratic) drops
,Mx pts with acute ischaemic stroke presenting in 4.5hrs
Thrombolysis AND thrombectomy
Acute dystonia - what is this
Sustained muscle contraction like torticollis or uculogyric crisis
Which type of stoma is spouted
Ileostomy - prevent skin coming into contact with enzymes in small intestine
Aspirin overdose mx
Activated charcoal if <1hr ingestion
IV bicarb - can be used later down the lie
Pruritis (worst after taking showers or hot baths).
Tingling, burning, and numbness in arms, hands, and feet.
Headaches and lethargy.
Splenomegaly.
Elevated haemoglobin on full blood
dx and mx.
Polycythaemia vera
Venesection first line
How to decide which surgery needed for ectopic
Sapingectomy first line for women with no other RFs for infertility
Dyspepsia (indigestion) and nausea and elevated platelet count - next step mx
Urget upper gastro endoscopy
Thrombocytosis can occur in context malignancy as reaction to inflammation
cAPUT SUCCEDANEUM VS Cephalohaematoma
Succedanum = cross suture lines
Haematoma - H for halt os doesn’t cross suture lines
Which Abx for brain abscess
Ceftriaxone and metronidazole
Reverse agent rivaroxaban
Andexanet alfa
Cerebellar signs, contralteral sensory loss and ipsilateral Horners
Lateral medullary syndrome - Posterior inferior cerebellar artery
(App side artery to the leg/arm problems)
Crown rump length greater than 7mm with no cardiac activity - what is this
Diagnostic of miscarriage
High reticulocyte count - what can this suggest
Increased destruction (eg haemolytic) or increased los (bleeding) of red cells
A/E of aromatase inhibitors (anastrozole)
Osteoporosis, hot flushes, arthralgia, myalgia, insomnia
First and second line meds for GAD
- SSRI
- SSRI or SNRI
Communicating hydrocele mx in newborn males
Uuslaly resolv
Reassurance, surgical repair if doesn’t resolve in 1-2 years
Lights criteria for transudative vs exudative
Exudates - protein >30g/l
Transudates <30
If 25-35 then lights criteria…
Exudative likely if at leats one met…
- Pleural fluid protein divided by serum protein >0.5
Pleural fluid LDH divided by serum LDH >0.6
Pleural fluid LDH more than 2/3 the upper limits of normal serum LDH
A 25-year-old man attends with a 3-month history of numbness in his right hand. On examination, you note the loss of sensation to the palmar and dorsal aspect of the 5th digit. Sensation of the forearm is preserved.
What is the most likely diagnosis?
Cubital tunnel syndrome
Ulnar nerve supplies sensory to palmar and dorsal aspects 1 and 1/2 fingers medially
A 17-year-old girl presents with a sore throat. On examination she has inflamed tonsils covered in white patches. Tender cervical lymphadenopathy and a low grade pyrexia are also present. Which one of the following organisms is most likely to be responsible?
Streptococcus viridans
Streptococcus agalactiae
Streptococcus pneumoniae
Staphylococcus aureus
Streptococcus pyogenes
Streptococcus pyogenes
Typical distribution eczema in 10month old child
Face and trunk
Which medication ahs been overdosed on and mx…
GIT: nausea, vomiting, anorexia, diarrhoea
Visual: blurred vision, yellow/green discolouration, haloes
CVS: palpitations, syncope, dyspnoea
CNS: confusion, dizziness, delirium, fatigue
Digoxin (toxicity) - yellow/green discolouration
Administer digoxin specific antibody fab fragments (digibind iV)
Absestosis vs pleural plaques on CXR
Pleural plaques = all over (image) - benign, do not go malignant
Asbestosis is more lower lung fibrosis
What medications can treat orthostatic hypotension
Fludrocortisone and midodrine
Medication to treat bowl colic in palliation
Hyoscine hydromromide
Most common S/E isotretinoin
Dry skin
chronic infection with hep b
hbsag if >6m can be chronic!!
mx pre menstrual syndrome
mild symptoms can be managed with lifestyle advice
apart from the usual advice on sleep, exercise, smoking and alcohol, specific advice includes regular, frequent (2–3 hourly), small, balanced meals rich in complex carbohydrates
moderate symptoms may benefit from a new-generation combined oral contraceptive pill (COCP)
examples include Yasmin® (drospirenone 3 mg and ethinylestradiol 0.030 mg)
severe symptoms may benefit from a selective serotonin reuptake inhibitor (SSRI)
this may be taken continuously or just during the luteal phase (for example days 15–28 of the menstrual cycle, depending on its length)
Which medication for glaucoma causes increased eyelash length
Prostaglandin analogues alongside iris pigmentation an dperiocular pigmentation
WHta is best for motion sickness
Hyoscine then cyclizine/cinnarizine if not good
High serum PTH with moderately raised serum calcium and CKD - type hypoparathyroidism
Tertiary hyperparathryoidism
Chlamydia in pregnancy - mx
Azithromycin, erythromycin, or amoxicillin may be used
Most common cause PPH
Uterine atony
First line test acromegaly
Serum IGF-1 levels
Recurrent episodes natal cleft pain with discharge - mx
pilonoidal cystectomy
GCS
Antifreeze antidote
Fomepizole
A 45-year-old man presents to the emergency department with pain in his lower back, buttocks, and legs over the last 5 days that persists at rest. Today he has noticed weakness and pins and needles. He has a history of ischaemic heart disease, type 2 diabetes, and an episode of gastroenteritis 2 weeks ago. He has a family history of ankylosing spondylitis. The patient works as a builder.
He is afebrile, his pulse is 85 bpm, and his blood pressure is 135/75 mmHg. Despite having paraesthesia, lower limb sensation is intact. There is bilateral lower limb weakness and hyporeflexia.
What is the most likely diagnosis?
Gullain barre syndrome - back/ leg pain is seen in majority pts with GBS
Blue vision - which drug is this a S/E of
Sildenafil
Yellow - green vision = which is this a S/E of
Digoxin
What positioning can help in Acute respiratory distress syndrome
Prone position - improves oxygenation and decreases mortality rates
Hernias that are superior and medial to pubic tubercle
Inguinal hernias
Baby blues mx
Reassurance and follow up
Speech non fluent, comprehension normal, repetition impaired
Brocas dysphasia, frontal lobe
which type fracture
A 14-year-old boy jumps off a 10 foot wall and lands on both feet. An x-ray shows a bimalleolar fracture of the right ankle.
Potts
which type fracture
A 14-year-old boy jumps off a 10 foot wall and lands on both feet. An x-ray shows a bimalleolar fracture of the right ankle.
Potts
which type fracture
A 14-year-old boy jumps off a 10 foot wall and lands on both feet. An x-ray shows a bimalleolar fracture of the right ankle.
Potts
Which type fracture
A 22-year-old drunk man is involved in a fight. He hurts his thumb when he punches his opponent.
Bennetts
- A 73-year-old woman presents with pain in her wrist after falling on to an outstretched hand. On examination there is dorsal displacement and angulation. An x-ray shows a transverse fracture of the radius around 2 cm proximal to the radio-carpal joint.
Colles fracture
Visual field defect in glaucoma
Common in peripheries
Low grade MALT lymphoma management
Eradicate H.Pylori
A 45-year-old woman attends the ear, nose and throat clinic with a 3-month history of left-sided hearing loss. She describes an occasional ringing in her left ear and feels off-balance. Her past medical history includes type 1 diabetes which is well-controlled and she denies any recent infective symptoms.
On examination, Rinne’s test is positive in both ears with Weber’s test lateralising to her right ear. There is no evidence of nystagmus and her coordination remains intact. Aside from an absent left-sided corneal reflex, the remainder of her cranial nerve examination is unremarkable.
What is the most likely diagnosis?
acoustic neuroma - always think of this with loss of corneal reflex
If 2 level PE wells score is 4 or less and D dimer is negative then what to do
Stop anticoagulant and consider alternative dx
First line treatment of heart failure
ACE inhibitor and B Blocker
(2nd line is aldosterone antagonist like spironolactone and third line is things like ivabradine by specialist)
Furosemide - MOA and location
Inhibits Na-K-Cl co transporte rin thick ascending limb of loop of hence
HTN in diabetes - which is the first line medication
ACEP/ARB (regardless age)
S/E of calrithromycin which can cause ECG changes
Torsades de Pointes
Diastolic murmur + AF -> which murmur
mitral stenosis
How to differentiate cardiac tamponade and constrictive pericarditis
Kussmauls sign (raised JVP that doesn’t fall in insporation) with constrictive pericarditis
Mx symptomatic bradycardia
Atropine 500mcg IV first line
If not good enough then atropine up to 3mg. Transcutaneous pacing. Isporenaline/adrenaline infusion titrated to response
Pericarditis vs myocarditis
Myocarditis = <50, recent viral illness, inflammatory markers and torpnonin raised, ECG shows non specific ST segment and T wave changes. Can manifest as new onset CHF
Pericarditis = similar but doesn’t cause symptoms left ventricular dysfunction and troponin less likely to be raised with more global ST elevation rather than focal
Type murmur for aortic regurgitation
Early diastolic murmur
When are you advised to take statins
Last thing in an evening
New onset haemoptysis and mid late diastolic murmur = cause
Mitral stenosis
MOA Fondaparinux
Activates antithrombin III
Recent sore throat, rash, arthritis, murmur (systolic) - dx
Rheumatic fever
What medication can cause torsades de pointes
Macrolides like clarithromycin
Which murmur is turners syndrome ass with
Bicuspid aortic valve - systolic, loudest over aortic alve. Also prone to aortic valve stenosis and coarctation
What 2 meds should be given with peripheral arterial disease
Antiplatelet and statin
What do Q waves suggest on ECG
Prev MI
Neutropenic sepsis Abx choice
IV Piperacillin with tazobactam (Tazocin)
Large U waves - what can this suggest
Hypokalaemia
Hydrogen breath test - what is it used for
Small bowel overgrowth syndrome, lactose eintolerance etc
H.Pylori test
Urea breath test
When to use anterior resection vs abdominoperineal resection
Anterior resection = rectal tumours (high ones)
APR = distal 8cm of rectum (low) and into sphincters
Any unstable tacky needs
Synchronised cardio version
What Ix in Kawasaki to screen cx
ECHO
Mastoiditis in ear infeciton can lead to….
meningitis
in preterm prelabour rupture of membranes what need to be given to reduce rsik resp distress syndrome
Dexamethasone
In a miscarriage with missed or incomplete with closed os - what medicaiton to given
Vaginal misoprostol
Which type of stoma is faeculant matter in bag with flush to skin
Colostomy
(ileosotmy is spouted)
Symptoms of mania - what to do referral wise
urgently to community mental health team
Bilious vomiting on first day life - what is it mostly likely to be
Duodenal atreesa (or intestinal atresia)
n haemothoax when >1.5L blood initially lost or losses >200ml per hour for >2hrs then what is the mx
thoracotomy
dx postural hypotension
drop systolic >20 or diastole >10
in paeds BLS what is the ratio CPR to breaths
15:2
serum amylase in pancreatitis
> 900 ish as normal is 300 so x3
Stages of COPD
osteoporosis bone labs
NORMAL all
How often mammography for breast screening
every 3 years
salicylate poisoning - what abg
resp alkalosis
mx asymptomatic bacteriuria in pregnant women
Abx therapy asap
what can recipitste digoxin toxicity
thiazides
is statin allowed in pregnancy
NO
what drugs can trigger G6PD def
Sulph containing drugs - sulphonamides, sulphasalazine, sulfonylureas - can trigger haemolytic
if a pt is on anti-coag or bleeding disorder and they are suspected tIA what is immed mx
Exclude haemorrhage - CT!!!!! then maybe aspirin
metabolic abnormality in bushings
hypokalaemic met alkalosis
first line ix for preterm prelabour rupture of membranes
careful speculum exam
Anaphylactoid reaction to IV NAC - mx (urticaria and facial flushing)
Anaphylactoid reactions to IV N-Acetylcysteine are generally treated by stopping the infusion, then restarting at a slower rate
pts with cellulitis and penicillin allergy
erythromycin
A 73-year-old man attends the emergency department with sudden-onset visual loss in the left eye. He reports no pain or headache, and there was no history of preceding trauma. There are no neurological symptoms.
He has a past medical history of poorly-controlled type 2 diabetes, and hypertension.
On examination, he his just about able to distinguish light from dark with the left eye. His red reflex is absent. You are unable to gain any view of the retina with fundoscopy. His neurological examination is otherwise normal.
vitreous haemorrhage
what medication is lined to new fasciitis of genitalial or peirneum (fourniers gangrene)
dapagliflozin
When Is the time out stage of Who checklist
before ski incision
tx acute pancreatitis (even with bruising in flank- grey turnerss)
fluids and analgesia
first-line for patients mild papules and/or pustules and rosacea
ivermectin
pts with acute, severe, symptomatic hyponatraemia - mx
hypertonic saline
if CBT or EDMR therapy ineffective in PTSD then what is first line drug tx
venlafaxine or ssri
A 72-year-old man has been an inpatient on the elderly care ward for the last 2 weeks. He has a new diagnosis of metastatic lung cancer. On the morning ward round, he complains that his pain is not being adequately controlled. He currently takes oral morphine sulphate 20mg four times a day along with codeine 30mg four times a day and regular ibuprofen.
Breakthrough dose = 1/6th of daily morphine dose
Oral codeine to morphine (divide by 10). Therefore, oral codeine 10mg = oral morphine 1mg.
30mg x 4 = 120mg codeine. This equals 12mg morphine.
20mg x 4 = 80mg morphine.
Total morphine = 80mg + 12mg = 92mg.
The breakthrough dose of morphine is 1/6th of the total dose of morphine in 24 hours. This main takes 92mg of morphine in 24 hours. 1/6th of this is 15mg.
Symptom control in non-CF bronchiectasi
inspiratory muscle training + postural drainage
A 70-year-old man comes to the GP surgery with his wife because she is growing increasingly concerned about his health. Five years ago he began to suffer from periods of confusion and sleepiness that seemed to come and go at random. More recently he has also developed a unilateral tremor in his right hand.
Upon questioning, his wife tells you that she has slept in a separate bed for the last 30 years because her husband suffers from bad nightmares.
Lewy body
Otitis externa in diabetics
treat with ciprofloxacin to cover Pseudomonas
tx trichomonads vaginalis - trophozoites
mETRONIDAZOLE
HOW to take hydrocortisone in Addisons
hydrocortisone split with majority given in first half day 9try mimic natural)
IN statu sepilepticus, the stepwise mx
- Buccal midazolam/ IV lorazepam
- IV Lorazepam
- IV phenytoin
Rapid sequence induction anaesthesia with thiopental sodium
Neurogenic thoracic outlet syndrome
typical presents with muscle wasting of hands, numbness, and tingling and possiblyy autonomic symptoms
aBS IN see
ANA positive - sensitive (good to rule ou)
some RF +
Anti-dsDNA highly specific
Anti smith specific…
