General Medicine Block Flashcards
MFE - what does the term “deconditioning” mean?
When a patient loses the strength in their muscles
Wasting of the muscle bulk
How can you test if a patient has deconditioning in their legs (quads)?
Stand up from chair with arms folded
Define sarcopenia
Loss of muscle mass and muscle function with ageing (pathological, more than the normal amount of mass and function lost)
With age, the following normal changes happen:
Muscle mass - increase/decrease ?
Body fat - increase/decrease ?
Cerebral blood flow - increase/decrease ?
Cardiac output - increase/decrease?
Muscle mass - decreases
Body fat - increases
cerebral blood flow - decreases
Cardiac output - decreases
Postural hypotension is defined in a drop in ___ mmHg or more in the systolic OR a drop in ___ mmHg or more in the diastolic?
20mmHg or more systolic
10mmHg or more diastolic
What is the largest weight bearing joint and therefore the joint most likely to be affected by OA ?
Knee
Name features suggestive of metabolic syndrome?
Overweight
High blood glucose
Lipid profile off (Lots of LDL, low HDL)
Sedentary lifestyle
Constipation increases/decreases with age?
Increases
Older patients with constipation should always get a laxitive?
True
Patient admitted to hospital and at night he/she asks for a sleeping tablet. Should you prescribe and justify your answer?
No!! Try to avoid as much as possible
- highly addictive
- can increase likelihood of falls
Which type of medications are sleeping tablets?
Benzodiazepines
- diazepam etc
What should you do for patients instead of giving them sleeping tablets?
Sleep hygine
Define frailty
When normal ageing has become pathological.
Loss of biological reserves (ie homeostasis is not as good as it should be) across multiple body systems resulting in increased vulnerability to relatively minor events and leading to adverse outcomes
What is dyspepsia?
Indigestion
Epigastric pain
Associated with eating
Differential diagnoses of dyspepsia?
GORD
Peptic ulcer disease (gastritis, gastric erosions)
Malignancy
Angina
Upper GI red flag symptoms
Weight loss
Dysphagia
Recurrent vomiting
2 main causes of peptic ulcer disease?
H. Pylori (most common)
NSAIDs
Investigations for H. Pylori include
Urease breath test
Stool antigen test
H. Pylori antibody serology
Urease breath test and stool antigen test for H. Pylori - are often done. What do you need to remember medication wise before carrying out these investigations?
Off antibiotics for previous month
Not on PPI for 2 weeks beforehand
Patients getting tested for H. Pylori should stop their PPI medication for __ weeks before the investigation?
2 weeks
Management of H. Pylori infection
PPI + amoxicillin + metronidazole (total 7 days)
use clarithromycin in penicillin allergic pt
If patient has had treatment of H. Pylori but experiences recurring symptoms, what should you do?
Re-check H. Pylori test
Patient presents with symptoms of GORD. What should you do?
No need for investigations.
Trial of PPI and if symptoms settle, continue PPI
Curative Tx for oesophageal cancer
Oesophagectomy Radical radiotherapy (Squamous cell carcinoma)
Palliative treatment for oesophageal cancer?
Stent
Ablation (lasers)
Name some causes of dysphagia
Stricture - benign (GORD) - malignant (cancer) Motility disorder - achalasia
Which is a helpful investigation to visualise achalasia and what does it show
Barrium swallow
- shows bird beak appearance
- widened oesophagus. muscles above the LOS don’t work and the LOS doesn’t relax
- floppy oesophagus
What is the diagnostic investigation for achalasia?
Oesophageal manometry
Name the 2 types of oesophageal cancer
Adenocarcinoma
Squamous cell carcinoma
What is the first line MEDICATION treatment in delirium?
Halloperidol
If a patient with parkinsons disease has delirium and needs pharmacological treatment, which drug is commonly used?
Lorazepam
In which condition is halloperidol use contraindicated?
Parkinsons disease
- halloperidol blocks dopamine receptors
What is the best anti-emetic to use in parkinsons patient?
Odansetron
- don’t use metochlopromide since this blocks dopamine receptors
Which dose of halloperidol should be used to treat delirium in an old patient?
500 micrograms
In terms of endocrine imaging, which imaging modality is best for assessing the adrenals?
CT scan
In terms of endocrine imaging, which imaging modality is best to see the pituitary gland?
MRI scan
What is the only organ in the body which likes iodine?
Thyroid gland
What is the role of osteoclasts (with bone)
Bone resorption - ie they break down bone
Which hormone is important in the regulation of calcium
PTH (parathyroid hormone)
What does a raised calcium suggest?
Problem in the parathyroid gland or elsewhere
If a patient has raised calcium level, what should you test for?
PTH level
If patient has a raised calcium and a raised PTH, what is the likely diagnosis
Primary hyperparathyroidism
If a patient has a raised calcium but a normal PTH, what does this suggest?
The raised calcium is coming from somewhere else (ie not the parathyroid gland). It could be an indicator of malignancy
Name 3 things which could make calcium levels raised/
Hyperparathyroidism
Malignancy
Granulomatous disease (TB, sarcoidosis)
What is a pack year (smoking)
20 cigarettes in a pack
How many packs per year?
Which condition (asthma or COPD) responds better to bronchodilators?
Asthma
If a patient presents with obstructive spirometry results but you can’t tell whether they are asthmatic or have COPD, what do you do?
Post bronchodilator spirometry test
- If asthmatic, patient will respond better to bronchodilators
Peak flow curve in obstructive airway disease.
Angle is shallower/steeper and why is this?
Angle is shallower, air can’t get out quickly
Spirometry results in obstructive disease:
FEV1 - normal/high/reduced
FVC - normal/high/reduced
FEV1/FVC - normal/high/reduced
FEV1 - reduced
FVC - normal
FEV1/FVC - reduced
Spirometry results in restrictive disease:
FEV1 - normal/high/reduced
FVC - normal/high/reduced
FEV1/FVC - normal/high/reduced
FEV1 - reduced
FVC - reduced
FEV1/FVC - normal
Which 3 disease processes cause obstructive spirometry results?
Asthma
COPD
Bronchiectasis
How do you confirm a diagnosis of COPD?
Spirometry
How do you confirm the severity of COPD?
Combination of breathlessness and number of exacerbations
Why might the FVC be disproportionately high in COPD?
If the patient has hyperinflated lungs
Emphysema is most common at the top/bottom of the lungs?
Top of the lungs
What is the best imaging modality for emphysema?
CT scan
Patient wakes up in the middle of the night gasping for breath. What is this?
PND
- paroxysmal nocturnal dyspnoea
If a patient is quite well in himself but nurse notices an irregular pulse and orders an ECG. ECG shows AF, what should you counsel the patient about?
Consider stroke risk
Starting tablets
Stroke due to AF is worse/better prognosis than a stroke minus AF?
Worse prognosis if patient has AF, clot is affecting a bigger part of the brain.
What is the main risk factor for developing AF
Hypertension
How do you tell when a patient in AF gets complete heart block?
No P waves
Slow rate
regular rhythm
What do electrical spikes on an ECG suggest?
Pacemaker
If patient has AF where in the heart to clots tend to form?
Left atrial appendage
For AF what is the first line rate control drug?
Beta blocker
Patient with AF who is also asthmatic. What is the first line rate control drug in THIS patient?
CCB
For AF, what is the second line rate control drug?
CCB
For AF, what is the third line rate control drug?
Digoxin
What does digoxin block?
AV node
What is the treatment of pre-excited AF?
DO NOT give AV node blocking drugs (eg digoxin, CCB) as this will make the patient go fast.
Cardiovert the patient early.
Why should you be wary of AF with fast ventricular rate (over 220bpm) ?
May not be conducting through the AV node. May be an accessory pathway.
It is common to have a raised troponin in patients with AF. True or false?
True
You should check troponin levels in AF patients?
NO
Default treatment for AF is rate or rhythm control?
Rate control
What is the definition of a haemarthrosis? and what is the most common cause?
Bleeding into the joint (usually knee)
common cause - traumatic injury
If a patient has poor renal function but is in severe pain, which medication should be used?
Use oxycodone instead of morphine
What adverse effect can tramadol have?
Causes delirium
Co-trimoxazole causes hyper/hypo -kalaemia?
Hyperkalaemia
What is the treatment of pemphigus vulgaris?
Steroids
Which is most common to affect mucosal surfaces: Pemphigoid or pemphigus?
Pemphigus
If a patient has a pinpoint pupil in one eye and a normal pupil in the other eye, what does this make you think is going on?
CN lesion (CN 3)
Pemphigus is more fragile/tense than pemphigoid?
Pemphigus - fragile, superficial
Furosemide can cause hyper/hypo -kalaemia?
Hypokalaemia
Normal volume of resuscitation fluids is 500ml. If a patient has severe heart failure, which volume of resuscitation fluids should be given and why?
Give 250ml resuscitation fluids instead.
Concern is fluid overload
What are the 3 R’s of fluid replacement
Resuscitation
Replacement
Routine maintenance
When should you do daily weights on a patient?
If on IV furosemide
Patient with increased calcium levels and also increased parathyroid hormone. Where is the problem likely to be?
Parathyroid gland
Patient with increased calcium levels and normal parathyroid hormone levels. Where is the problem likely to be?
Not in the parathyroid gland, elsewhere
bones (malignancy
Sardoid
TB
Prolonged QT interval is associated with which condition?
Ventricular Tachycardia
If patient has a PE, acutely what is the risk in the first 7 days?
Death
If a patient has a PE, what is the long term risk?
pulmonary hypertension
5% dextrose = ??mg/ml ?
50mg/ml
1% lidocane = ??mg/ml
10mg/ml
What is xanthochromia?
Yellow appearance of CSF which occurs hours after a bleed into the subarachnoid space
Where is xanthochromia measured?
LP
What is the maximum score on a 4AT
12
What does a pacemaker ECG look like?
no P waves
line on ECG
What would you expect to see on an echo if a patient has had an MI
Regional wall motion abnormality
For murmur classification, how many grades are there?
6 grades 1 - experienced cardiologist 2 - experienced cardiologist 3 - student 4 - student + thrill 5 - student + thrill + hear without stethescope 6 - very very loud (never get this)
When looking at the JVP, what are you actually looking at?
Right atrium
JVP in tricuspid regurgitation?
CV wave
If you measure the LH and FSH of a post-menopausal woman, what would you expect to find? and why?
LH and FSH should be very high.
The ovaries have decided to pack in, the pituitary doesnt know that and the pituitary gland is therefore trying to drive the ovaries harder.
What is the most common cause of pituitary hormone excess?
pituitary adenoma
What is the commonest cause of cortisol excess (cushing’s syndrome) ?
Exogenous steroids
Ectopic ACTH from which cancer can give a cushing’s syndrome picture?
Small cell lung cancer
From simple blood tests, how can you tell if cortisol excess is due to a pituitary tumour or an adrenal tumour?
Pituitary tumour - high cortisol, high ACTH
Adrenal tumour - high cortisol, low ACTH (pituitary is still working, sees a high cortisol and wants to correct it by lowering the ACTH)
How does ACTH arise?
Pro-hormone (POMC) is chopped up by enzymes into ACTH and melanocyte stimulating hormone (MSH)
Why does excess ACTH and hyper pigmented skin go hand in hand?
ACTH and Melanocyte stimulating hormone (MSH) arise together in the anterior pituitary gland
Any disease that results in ACTH excess will result in a pigmented patient. True or false?
True
High ACTH + High Cortisol - where is the problem (2)
Pituitary gland Ectopic ACTH (SCLC)
Low ACTH + High Cortisol - where is the problem (1)
Adrenal gland
What is the normal function of prolactin?
Initiation and maintenance of lactation
What is the most common pituitary tumour?
Prolactinoma
If someone has galactorrhoea and amenorrhoea, what is the best investigation?
Measure prolactin
- if raised and the patient is not pregnant or breast feeding, request MRI pituitary (thinking prolactinoma)
What is the most effective treatment of a prolactinoma?
Dopamine agonist (cabergoline)
What is the gold standard investigation for acromegaly?
Glucose tolerance test
Why do we do a glucose tolerance test to look for excess GH (acromegaly) ?
GH is an insulin antagonist
What is the function of oxytocin?
For lactating woman
- prolactin makes the milk
- oxytocin squeezes the milk out of the milk ducts
What is the function of ADH ?
Stops the body from losing too much water
Conserves water
Diabetes insipidus - main clinical feature
Pee out lots of dilute urine
Diabetes insipidus
urine osmolality - low/normal/high
plasma osmolality - low/normal/high
urine osmolality - low
plasma osmolality - high
When you think a patient may have diabetes insipidus, what should you check?
If hypokalaemia
If hypercalcaemia
If taking lithium
these can all cause people to pee out lots of dilute urine
What is the best diagnostic test for diabetes insipidus?
water deprivation test
Which hormone abnormalities can cause a picture which looks like SIADH?
Hypothyroidism
Low cortisol
If elderly patient has fallen and has been lying on the floor for a while, what enzyme will go up?
Creatinine Kinase
What does romberg’s test test for?
Proprioception
Active vitamin D increases absorption of which two things?
Increased calcium absorption
Increased phosphate absorption
increased PTH results in
- increased/normal/decreased calcium
- increased/normal/decreased phosphate
Increased calcium Decreased phosphate (but increased urinary phosphate)
If a patient has ?coeliac disease, what initial investigation should you do and what is the definitive diagnostic investigation
Do anti-TTG test. If this is positive then do a duodenal biopsy
What is a very important side effect you MUST counsel patients on when starting bisphosphonate therapy?
Osteonecrosis of the jaw
Why should patients get dental work before starting bisphosphonates
To reduce the likelihood of developing bisphosphonate-related osteonecrosis of the jaw
What is the only way of differentiating between ischaemic and haemorrhagic stroke?
Imaging - usually CT scan
Which type of stroke is most common: ischaemic or haemorrhagic stroke?
Ischaemic (around 80%)
What do the vertebral arteries arise from?
The first branch of the subclavian artery
What does the external carotid artery supply?
Face and scalp
The circle of willis is able to save strokes. True or false?
True
How is the PR interval measured? and what is a normal PR interval?
From the start of the P wave to the start of the QRS complex
Normal PR interval = 3-5 small squares (0.12-0.2s)
What does a prolonged PR interval suggest?
Some form of AV node block (heart block)
How would you identify a Q wave on an ECG?
If the first deflection after the P wave is negative, this is a q wave
As soon as you hear ‘irregularly irregular’ think
AF
The magic number 150bpm suggests which arrhythmia?
Atrial flutter
ECG with retrograde P wave, around 150bpm, narrow QRS complex makes you think of?
AVNRT
How do you work out a persons maximum heart rate?
220 - age
What are we trying to achieve by doing vagal manouvres?
CNX carries parasympathetics to the heart. It sends a supply to the SA and AV node to SLOW CONDUCTION.
therefore, CNX slows the heart rate
Name 2 vagal manouvres
carotid sinus massage
valsalva
Vagal manouvres can cure atrial flutter. True or false?
False
- they are not curative
Why are vagal manouvres helpful in atrial flutter?
They unmask the saw tooth baseline and get rid of the QRS complex
- diagnostic tool which can be used
- not curative
What is the mainstay of treatment in AVNRT?
Vagal manourves
Why is adenosine given in some arrhythmias?
adenosine stops conduction through the AV node
- must be given in very small doses
SE of adenosine?
Sense of impending doom
Half way through a bedside teaching session, a student collapses. What is the most likely cause of this?
Vasovagal collapse
How do you treat a vasovagal collapse?
Leave them lying there for a while
Sit on a chair with feet up
When do benign palpitations tend to happen? At rest or during activity ?
At rest
- when you are more hyperaware of own heartbeat
When would you do an exercise ECG?
For people who have experienced syncope during exercise
What does an ECHO investigation look at?
Structure of the heart
Looks at heart valve
Looks at function of the heart
What is worse: getting vasovagal syncope standing up or sitting down?
Sitting down is worse
If a patient gets vasovagal syncope whilst sitting down, what should happen in terms of driving?
No driving for at least 1 month and must notify the DVLA
In haematology, why is vitamin B 12 important?
It is required to allow the red cells to develop normally
Why is doing a reticulocyte count useful
lots of reticulocytes - think spurious anaemia -> think haemolysis
lack of reticulocytes - think bone marrow is not able to produce red cells, marrow struggling to keep up
Main cause of iron deficiency anaemia in young people
Menorrhagia
What is the INR
A measure of how long it takes for blood to clot
Why do you not tend to give young women warfarin?
Terratogenic
Which drugs can commonly interfere with warfarin
Antibiotics
Aspirin
St Johns wart
If patient is on warfarin and is bleeding excessively, how do you reverse the effects of the warfarin?
Vitamin K injection
For a young patient who is on warfarin but they wwant to have a baby, what is the alternative treatment?
Fragmin injections
When would you do an exercise ECG?
If the patient has exertional symptoms
What does the left bundle branch divide into?
Fascicles
What would you be more worried about - narrow or wide QRS complex?
Wide
= worrying, wentricles
What is the most common heart rhythm disturbance?
Ectopy
“my heart skips a beat and this is followed by a hard/forceful beat” - what does this Hx make you automatically think of?
Ectopy
Features of ventricular ectopy
Wide QRS complex
for the ectopic (extra) beat, there is less time of the ventricles to fill as the extra beat comes prematurely…therefore this is the sensation of heart skipping a heat
the next beat will be normal but will seem like a thud because the previous beat was so weak
AVNRT - findings on an ECG
QRS - wide or narrow?
Rate?
Narrow QRS
Rate: around 150 bpm
Which arrhythmia is commonly associated with a retrograde P wave?
AVNRT
In most patients, what is the treatment of AVNRT?
Vagal manouvres
CNX carries the sympathetics/parasympathetics to the heart and tells the heart speed to increase/decrease?
Parasympathetics
Decrease heart rate
Atrial flutter: what is the atrial rate and what is the ventricular rate (commonly)
Atrial rate: 300 bpm
Ventricular rate: 150 bpm
(2:1 conduction)
Vagal manouvres are the curative treatment for atrial flutter. True or flse?
False
- they are not curative
In what sense are vagal manouvres useful in atrial flutter?
Vagal manouvres are diagnostic of atrial flutter as it will unmask the saw tooth base line
Name 2 instances where radiofrequency ablation is used commonly to treat
SVT
Atrial flutter
Define syncope
Transient loss of consciousness caused by a sudden drop in blood pressure
Vasovagal syncope - what are the 3 P’s
Posture - prolonged period of standing
Prodromal symptoms - vision closing in, nauseous, dizzy, tinnitus
Provoking factor - procedure/pain
Describe situational syncope
clearly and consistently provoked by a trigger
- straining during micturation
- coughing
What are the top 3 differentials for sudden chest pain
MI (ACS)
PE
Aortic dissection
Why would you die having an MI?
And why should the patient with suspected MI come into the hospital via ambulance?
Incase the patient goes into Ventricular Fibrillation
Describe stable angina
STABLE narrowing of the coronary arteries caused by plaque build up
Predictable symptoms
Describe NSTEMI
UNSTABLE symptoms
the plaques from the stable angina rupture and the artery becomes unstable
Artery is still open but there is severe/critical narrowing
Describe STEMI
UNSTABLE symptoms
plaques rupture and completely occlude (block) the artery so there is no flow
If you have a patient with AF, what are they at increased risk of?
Stroke
Why should you be very wary of AF with a ventricular rate above 220bpm?
May not be conducting through the AV node, may be an accessory pathway. If you use rate control drugs on these patients, it will make the AF worse and the patient will go into VF
Which is most common: ischaemic or haemorrhagic stroke?
Ischaemic
What are the first arteries to come off of the aorta?
Coronary arteries
Where is a clot most likely to lodge out of the 3 branches of the aorta?
- brachiocephalic trunk
- left common carotid
- left subclavian
Left common carotid
What do we use to help determine whether a patient should get anticoagulation or not?
CHA2DS2VASc score
What are the components of the CHA2DS2VASc score?
Congestive heart failure Hypertension Age (1 pt if between 65-74, 2 pt if over 75) Diabetes Stroke/tia Vascular disease Sexual category (female)
CHA2DS2VASc score of X or more means you must anticoagulate the patient?
2 or more
What is the main side effect to be aware of with amiodarone?
Extravasation
- it is deposited in the skin
What is the pro-arrhythmic affect of beta blockers
Bradycardia
In which type of AF should digoxin NOT be used
- paroxysmal
- permanent
Paroxysmal
Why must rate control drugs NOT be used in the treatment of pre-excited AF
They act by blocking the AV node, so will make the patient’s heart go faster (through the accessory pathway) and can trigger ventricular fibrillation
What is pre-excited AF
Accessory pathway AF - not going through the AV node - ventricular rate can get very high
Where medications are necessary, what is the first line pharmacological intervention for delerium?
Haloperidol
Where medications are necessary, what is the first line pharmacological intervention for a patient with parkinsons who has delirium?
Lorazepam
Name 2 cortical signs of the dominant hemisphere of the brain
Dysphasia - receptive - expressive Agnosia - failure to recognise objects
Name 1 cortical signs of the non-dominant hemisphere of the brain
Neglect
What is the only way to differentiate between embolic vs thrombotic strokes?
Presence or absence of cortical signs
- presence = embolic, large vessel occlusion
- absence = thrombotic, small vessel occlusion
Lacunar strokes are thrombotic or embolic infarcts?
Thrombotic infarcts
- deep in the brain
What is the difference between intracerebral and intracranial haemorrhage ?
Intracerebral haemorrhage - haemorrhagic stroke, brain damage
intracranial haemorrhage - any type of bleeding within the skull
Causes of haemorrhagic strokes
Due to blood
- ie being on anti-platelet or anti-coagulant (increases bleeding risk)
Due to vessel walls
- Hypertension
- Vasculitis
- Vessel wall abnormalities (aneurysm, AVM)
Overall, waht is the most common causative factor of stroke?
Hypertension
What layer of the artery does atherosclerosis affect?
Inner layer (endothelium)
What layer of the artery does arteriosclerosis affect?
Middle layer of the artery
- hardening of the arteries, loss of elasticity
When would a carotid endartectomy be carried out?
If a patient has had a TIA or minor stroke
If there is over 70% stenosis noted on the carotid US scan
If the patient is within 14 days of TIA/minor stroke
What are the 3 arms of virchow’s triad
Hypercoagulability (too much clotting)
Endothelial injury (damage to the vessel wall)
Haemostasis
Venous clots are treated with antiplatelets/anticoagulants?
Anti-coagulants
- venous clots are formed by coagulation factors
Arterial clots are treated with antiplatelets/anticoagulants?
Anti-platelets
- arterial clots are platelet rich
AF related strokes cause arterial/venous clots?
Venous
What are the 3 components of secondary prevention for a stroke?
Anti-coagulant / Anti-platelet
Anti-hypertensive
Statin
Anti-platelets to be used post ischeamic stroke
- for first 2 weeks
- thereafter
300mg Aspirin for first 2 weeks
Switch to 75mg clopidogrel
It is important to give a combination of aspirin + clopidigrel in the management of stroke. True or false?
False
- don’t use them both together as it increases the bleeding risk
When would you give aspirin and clopidogrel at the same time?
MI
What is the target range for INR?
2-3
- takes 2-3 times longer to clot
Which imaging modality (CT/MRI) is best for visualising acute haemorrhage?
CT scan
Which imaging modality (CT/MRI) is best for visualising acute infarct?
MRI scan
Increased ALT / AST LFT makes you think?
Pathology is in the liver
- ?hepatitis
Increase in which LFT makes you think of excess alcohol useage?
- ALT
- AST
- GGT
- Alk phos
GGT
Increased Alk phos LFT makes you think of what clinical picture?
Obstruction
- gallstones?
What do you give to reverse the effects of opioids and benzodiazepines?
Naloxone
Cauda equina compression causes flaccid/spastic paralysis with loss of/brisk reflexes.
Spinal cord compression usually causes flaccid/spastic paralysis with loss of/brisk reflexes.
Cauda equina compression
- flaccid paralysis
- loss of reflexes
Cord compression
- spastic compression
- brisk reflexes
Which 3 medications are used for prophylaxis of migraine?
- propranolol
- diclofenac
- amitryptiline
- topiramate
- rizatriptan
Propranolol
Amitryptiline
Topiramate
Why should amoxicillin be avoided in the treatment of glandular fever?
Cause a rash in glandular fever
What is the treatment of choice for scarlet fever?
Penicillin V
IVOST - when can you consider discharge after you switch to oral therapy for treatment of severe pneumonia
After 24 hours
If someone is an inpatient for treatment of pneumonia, upon discharge who should get a follow up CXR at 6/52 ?
Patients that are at risk of lung cancer
- smokers
- over 50 years old
Empyema is one of the most common complications of pneumonia. True or false?
True
Patient with persisting/swinging pyrexia, new chest pain. Patient had previously been treated for pneumonia but despite adequate treatment with antibiotics, symptoms are persisting and the CRP is climbing. What is the likely problem and what investigations should be done?
Likely that this is empyema
CXR initially - if fluid present then do US
Which imaging investigation is best for clarifying the presence of pleural fluid?
US scan
How do you diagnose an empyema?
Pleural tap
Check the pH. if <7.2 then infection is present
What is the treatment (including dosage) for an infective exacerbation of COPD
Ipratropium bromide nebuliser (500mcg QDS) Salbutamol nebuliser (2.5mg QDS) Oxygen (if required) Amoxicillin Prednisolone (30mg OD)
What are the target O2 sats in patients with COPD?
88-92% usually
- CO2 retainers
Which pattern of ABG’s would make you think type 2 respiratory failure?
Decreased PO2
Increased PCO2
What is the treatment of decompensated type 2 respiratory failure secondary to a COPD exacerbation?
ISOAP (as for normal exacerbation of COPD)
+ BIPAP
Call for help
Do hourly ABGs
Name a situation (other than PE) when D-dimers might be raised?
Post surgery
- open wound -> degradation of fibrin
What is the treatment of moderate asthma attack
Oxygen
Salbutamol nebuliser (5mg QDS)
Steroid (hydrocortisone or prednisolone)
Why do surgeons not like to give patient’s steroids?
It decreases wound healing
What is the treatment of life threatening asthma attack
Oxygen Salbutamol nebuliser Steroid: oral prednisolone or IV hydrocortisone Ipratropium bromide nebuliser Magnesium sulphate Theophyline/aminophyline
How do you diagnose pneumonia ?
Must have CXR showing new changes
How do you know if a patient is rotated on a CXR?
Look at the spinous processes and the distance of this from the clavicles
In radiology, “sail sign” is associated with
Left lower lobe collapse - will be found in the region where the heart normally is
Trachea is displaced to the right on a CXR suggests that there is overall reduced volume on the right/left hand side?
Reduced volume on the right side
Which is most common in the elderly:
subdural haemorrhage
extradural haemorrhage
Subdural haemorrhage
What is a contrecoup (contra-coo) brain injury typically associated with?
High speed injury (deceleration injury)
Palliative care - when an individual’s pain is not being managed effectively with paracetamol, the WHO analgesic ladder suggests what?
Moving to an opioid
What is a modified release opioid good for?
Controlling background pain over 24 hours
What are the signs of opioid toxicity
Pin point pupils
Respiratory depression
unconsciousness
cold peripheries, cyanosis
How do you convert oral morphine sulphate dose -> subcutaneous morphine sulpate dose?
Divide oral dose by 2 to get subcutaneous dose
Patient getting 30mg subcutaneous morphine / 24hours through syringe driver. What is the breakthrough dose the patient will get?
1/6th of the total dose
therefore, 1/6th of 30 –> 5mg
In ABG interpretation, if the BE is low (minus figures) then its more likely to be an acidosis or an alkalosis?
An acidosis
Comparison of DKA and HHS:
- age:
- diabetes type (1 or 2)
DKA age: younger
HHS Age: older
DKA diabetes: mainly type 1
HHS diabetes: mainly type 2
Mainstay of treatment for DKA
Insulin
Fluids
What is IV pabrinex
High dose vitamins
What is the triad of Kartaganers syndrome?
Dextrocardia + sinus invertus
Chronic sinusitis
Bronchiectasis
2 potential causes of air under the diaphragm
perforated bowel
post op
What is surgical emphysema
air/gas under the skin
- can be caused by pneumothorax
What can cause a complete white-out of lung?
Pleural effusion (trachea and mediastinum push away) Complete lung collapse (trachea and mediastinum pull toward)
Acute asthma attack, what treatment should everyone get?
What treatment is only for the deteriorating patient if normal treatment fails?
Everyone should get: Oxygen - if required Salbutamol (nebs) Prednisolone Oral (IV hydrocortisone if patient can't swallow) Ipatropium bromide (neb)
Deteriorating patients should get:
IV magnesium sulphate
IV aminophyline / theophyline (oral)
What is the treatment for acute on chronic type 2 respiratory failure?
Non invasive ventilation
What is the best volume expander - colloid or crystalloid fluids?
Colloids
Do they struggle with fine finger movements.
Do they drop things.
Do they ever fall over when their eyes are shut.
Do their legs twitch at night.
These four questions are important to consider when thinking about which diagnosis?
Cervical Myelopathy
Blow to the head -> initial loss of consciousness -> lucid interval -> deterioration
this describes extradural / subdural haematoma?
Extradural haematoma
Blow to the head -> immediately symptomatic -> continued decreasing consciousness
this describes extradural/subdural haematoma ?
Subdural haematoma
Which medication may be used in patients with stress incontinence who don’t respond to pelvic floor muscle exercises and decline surgical intervention?
- oxybutynin
- duloxetine
- mirabegron
- tolterodine
Duloxetine
A chest x-ray which shows widening of the mediastinum suggests ?
Lymphoma
Which thyroid cancer is most common in young females
- follicular carcinoma
- papillary carcinoma
- anaplastic carcinoma
- medullary carcinoma
Papillary carcinoma
A lady has thyrotoxicosis (low TSH) and a hot solitary nodule. What does this indicate?
Toxic adenoma
Hypertension + hypokalaemia makes you think
Primary hyperaldosteronism
What is the first line investigation for suspected primary hyperaldosteronism
plasma aldosterone/renin ratio
- should show high aldosterone levels alongside low renin levels (negative feedback due to sodium retention from aldosterone)
The combination of frontal headache with tenderness/pain on palpation/brushing over the temporal regions, combined with jaw claudication on eating is highly suggestive of which condition?
Giant Cell Arteritis
how to best distinguish between giant cell arteritis and trigeminal neuralgia?
Trigeminal neuralgia is severe and episodic, giant cell arteritis is constant.
First line management of acute pericarditis involves combination which 2 medications
NSAID
Colchicine
Woman with hypothyroidism is pregnant. What changes should be made to her levothyroxine medication>
Increase the dose of levothyroxine
what is the preferred antiplatelet for secondary prevention following stroke
Clopidogrel
What is the key drug to use in anaphylaxis?
Adrenaline
Wilson’s disease symptom onset is in early life or later life?
Early life - the onset of symptoms is usually between 10 - 25 years
change in bowel habit, rectal bleeding and abdominal pain but malignancy is excluded. What is therefore most likely and where is this most likely to be found?
Diverticular disease
Sigmoid colon
Which drug is used in pregnancy induced pregnancy?
- Doxazosin
- Methyldopa
- Amlodipine
- Ramipril
Methyldopa
raised transferrin saturation and ferritin, but a low total iron binding capacity…what condition does this suggest?
Haemachromatosis
combination of vertigo, hearing loss, tinnitus and an absent corneal reflex. What does this suggest?
Acoustic neuroma (vestibular schwannoma)
Howel jolly bodies in which condition?
Hereditory spherocytosis
Bones, moans, stones, groans makes you think
Hypercalcaemia
Patient with increased serum calcium.
Subsequent tests: PTH (high) Phosphate (low) Urine calcium excretion (high) Alk phos (normal)
Primary hyperparathyroidism
Patient with increased serum calcium.
Subsequent tests: PTH (normal) Phosphate (high) Urine calcium excretion (normal) Alk phos (high)
Bony metastasis
What is the management of malignant hypercalcaemia
Lots of fluid intake (4L 0.9% NaCl over 24 hours) IV bisphosphonates (zolendronic acid) Furosemide
Thiazide / loop diuretics cause hypercalcaemia?
Thiazide diuretics cause hypercalcaemia
Main cause of secondary hypoparathyroidism
CKD
Vit D deficiency
Patient presents with transient visual disturbance in right eye, describes it as a curtain coming down.
What is this condition called?
What internal carotid artery is affected (R or L) ?
Amaurosis Fugax Right side (symptoms on ipsilateral side as carotid artery stenosis)
Patient has 6 hour Hx right sided arm weakness. ?TIA
What internal carotid artery is affected (R or L)?
Left internal carotid artery affected (contralateral to symptoms)
First line investigation in carotid artery disease?
carotid artery duplex US
Which patients with carotid artery disease are considered for surgery and what is the surgery called?
Patients with large stenosis in carotid artery
Procedure called: carotid endarectomy
Immediate medical management of a patient with carotid artery disease
Discuss risk factors
Dual antiplatelet therapy aspirin and clopidogrel
Statin
Manage hypertension
When should carotid endarectomy be carried out?
WITHIN 2 WEEKS of carotid artery disease event
Why is a carotid endarectomy done?
To reduce the risk of further stroke/TIA
Rusty coloured sputum is common in which type of pneumonia?
Strep pneumonia
IVDU pneumonia
Staph aureus - due to the introduction of bacteria into the bloodstream from dirty needles
Which pneumonia affects young people living in close proximity?
Mycoplasma pneumonia
First line treatment for SVT
what to do if this fails
Carotid sinus massage or valsalva manouvre
Adenosine if this fails
NICE recommend that all heart failure patients should take which 2 medications since they both reduce mortality in heart failure?
Beta blocker
ACE inhibitor
The most common organism causing infective exacerbations of COPD is
haemophilus influenzae
DVLA advice post MI
Can’t drive for 4 weeks
Patient on warfarin but has major intracerebral bleed. What should be done?
Stop warfarin
Administer IV vit K 5mg
Administer IV prothrombin complex concentrate
A patient develops acute heart failure 5 days after a myocardial infarction. A new pan-systolic murmur is noted on examination. Whats the diagnosis
Ventriculr septal defect
What is the management if patient has fast AF but is haemodynamically unstable
DC cardioversion
What is the management if patient has fast AF but is haemodynamically stable
B-blocker
Patients with a suspected pulmonary embolism should be initially managed with
DOAC (rivaroxaban)
Patients with COPD exacerbations which are not responsive to optimal medical management should be started on BiPAP CPAP Nebulised adrenaline Intubation and manual ventilation
BiPAP
If blood pressure target is not reached within 3 months, a second antihypertensive drug from a different pharmacological class at a low-moderate dose should be initiated OR increase the dose of the first drug?
Add a second drug
Which medication is used first line to prevent angina attacks?
Beta blocker
CCB
Hypertension + hypernatraemia + hypokalaemia
Conns syndrome
What is the treatment of choice for ventricular tachycardia?
emergency DCCV
Elevated serum ACTH, supressed by high dose dexamethasone. Where is pathology?
Pituitary gland
Elevated serum ACTH, not suppressed by high dose dexamethasone. Where is the pathology?
Ectopic ACTH
- small cell lung cancer
Low serum ACTH where is the pathology?
Adrenals
What is the commonest cause of viral encephalitis in adults?
HSV
Cushing’s triad is a set of three clinical signs. What are they?
irregular respirations, bradycardia and systolic hypertension resulting from raised intracranial pressure.
pituitary tumour secreting ACTH producing adrenal hyperplasia
is this cushings disease or cushings syndrome?
Disease
In gestational diabetes, if blood glucose targets are not met with diet/metformin, what should be added?
Insulin
What are some symptoms of hyponatraemia?
headache
dehydration
confusion
What is paroxetine licensed for?
Major depressive episode
Woman presents with acute confusion, hypothermia. On examination, she is overweight, there is non-pitting oedema affecting the eyes and legs, and she has dry skin and coarse hair. What is the likely diagnosis?
Myxeodema coma
- potentially fatal complication of longstanding undertreated hypothyroidism
In the context of an acute illness, a normal TSH and low T3 and T4 levels are diagnostic of
sick euthyroid syndrome
Conn’s syndrome is associated with hypo/hyper kaleamia?
Hypokalaemia
Low/high urine osmolality is seen in diabetes insipidus
Low
What is NOW the first line test for acromegaly?
IGF1 levels
- these have now overtaken the OGTT
suspected primary hyperaldosteronism - what is first line investigation?
aldosterone/renin ratio
Secondary hyperparathyroidism
- PTH (low/normal/high)
- calcium (low/normal/high)
PTH - high
Calcium - normal or low
What would a blood gas look like in a cushing’s patient?
Metabolic aLKalosis
What is an important complication of fluid resuscitation in DKA, especially in young patients
cerebral oedema
In graves disease, can the goitre be tender?
nO
- this would be subacute thyroiditis
How to differentiate between cranial and nephrogenic diabetes insipidus?
Cranial
- urine osmolality LOW
- plasma osmolality HIGH
Nephrogenic
- urine osmolality LOW
- plasma osmolality LOW
A 57 year old man presents with fluctuating symptoms of intense anxiety, sweating, palpitations and headache. These can last half and hour and happen several times a day. They have been getting worse over the last 2 months. What is likely diagnosis and first line management?
Phaeochromocytoma
24 hr urinary cateholamines or serum metanephrines
Tx: alpha blocker -> beta blocker -> surgery
You suspect cushings syndrome in a patient and arrange a dexamethasone suppression test. The patient has no suppression of cortisol with 1mg of dexamethasone, and 8mg of dexamethasone is unable to suppress his cortisol but does suppress ACTH levels.
adrenal adenoma
How to treat SIADH
Fluid restriction then vaptans (tolvaptan)
Sick day rules for addison’s disease
double dose of steroids
Hypoglycaemia, hyponatraemia, hyperkaemia - makes you think
Addison’s disease
What is the most appropriate first line medication to start for trigeminal neuralgia
Carbemazapine
Which diabetic medication causes weight gain and hypoglycaemia?
Sulphonylurea
What is gliclazide?
Sulphonylurea
Which medication is used to stimulate ovulation in women conceiving by IVF?
Clomifene
Which type of thyroid cancer carries the poorest prognosis?
Anaplastic carcinoma
What is the treatment of phaeochromocytoma
Alpha blocker
Beta blocker
Surgery
What is the treatment of conn’s syndrome
Spironolactone
Spironolactone causes hypo/hyper-kalaemia
Hyperkalaemia
Secondary hyperparathyroidism occurs due to
RENAL DISEASE
Secondary hyperparathyroidism
- PTH level
- calcium level
PTH level increased
Calcium level decreased
When does tertiary hyperparathyroidism occur
After prolonged secondary hyperparathyroidism
Patient with spontaneous episodes of hypoglycaemia which are relieved by administering glucose. What is the likely diagnosis?
Insulinoma
What is the treatment of cranial diabetes insipidus?
Desmopressin
In acromegaly, there is increased/decreased glucose?
Increased
In addison’s disease there is increased/decreased glucose?
Decreased
Adrenalectomy is a cause of addison’s disease. True or false ?
True
What is first line analgesia (in a hospital setting) for renal colic
IM diclofenac
If anal fissures don’t respond to conservative measures, what do you do?
Sphincterotomy
Reduced chest expansion
Dulness to percussion
Increased tactile vocal ressonance
Suggests
Consolidation - most common cause being pneumonia
Atypical pneumonias should be treated with
macrolides (eg clarithromycin)
Which type of pneumonia has an association with autoimmune haemolytic anaemia (cold agglutinins)
Mycoplasma pneumonia
Granulomatosis with polyangitis typically presents with
Nasal symptoms
chest pathology
Pulmonary oedema is associated with
- left ventricular failure
- right ventricular failure
Left ventricular failure
Patient with COPD, severe exacerbaton. Has been treated with oxygen, nebulised bronchodilators and oral prednisolone. An hour later his ABG reveals T2 resp failure. What is the best treatment?
Non-invasive positive pressure ventilation (BiPap)
Frank haematuria lasts for 3-4 days after recent URTI. What is likely diagnosis
- Goodpastures syndrome
- Alports syndrome
- IgA nephropathy
IgA nephropathy
18 year old patient, has reflux symptoms, tried antacids but they’re not working. Otherwise well and no other findings. What is next best step?
- refer for endoscopy
- PPI
- test for helicobacter pylori
- prescribe mucosal protective agent
Prescribe PPI
25, female, fatigue. 3 months ago she developed a sore throat with cervical lymphadenopathy. What investigation will be most diagnostic?
- HIV serology
- EBV serology
- throat swab
- endoscopy
EBV serology
Man with pulse 72bpm, BP 210/110. Radiofemoral delay, notching on CXR. What does this suggest?
Coarctation of the aorta
Man 2/52 Hx coughing up blood, fatiuge, joint pains (ankles and wrists swollen and tender) . Mid zone crepitations in chest, purpuric rash on lower legs. Urinalysis: Protein 3+, blood 2+.
Which antibodies are likely to be found in high titres?
- anti-endomesial antibodies
- ANCA
- ANA
- AMA
- anti glomerular basement membrane antibodies
ANCA
- this is GPA
Patient with breathlessness 3 days after STEMI. Pan systolic murmur with radiation to the axilla. Bibasal inspiratory creps. What is the likely diagnosis?
- ventricular septal rupture
- papillary muscle rupture
- chordae tendinae rupture
- pericarditis
- PE
Papillary muscle rupture
Man had a stroke. Unable to understand how to put on his shirt, often attempting to put it on backwards and doesn’t know how to work the buttons. Which brain lobe was the stroke in?
- cerebellum
- frontal lobe
- parietal lobe
- temporal lobe
Parietal lobe
- dressing apraxia is a feature of parietal lobe lesion
COPD patient with evidence of hypercapnia and respirateoy acidosis with hypoxia despite controlled oxygen therapy. What is next line management?
NIV (BiPAP)
Male, visible haematuria, R loin pain. Masses are palpable in both flanks. What is likely diagnosis? what is initial imaging investigation?
PKD
US renal tract
middle aged woman, fatigue, itch. AST 60 (10-50) ALP 920 ( 25-115) What is likely diagnosis? Which autoantibodies will be raised?
PBC
Raised AMA
A 48-year-old man who chronically abuses alcohol has presented with abdominal pain. He has not eaten for the week prior to admission to hospital.
While in hospital he resumes eating normal meals. He initially complains of dysphagia and weakness. Following this he becomes increasingly confused.
What does this suggest?
What abnormalities on bloods?
Refeeding syndrome
Hypophosphataemia
Hypomagnesiuma
Hypokalaemia
Post thyroidectomy you may have which abnormal finding?
Hypocalcaemia
This young woman has a normal thyroxine (T4) yet elevated thyroid-stimulating hormone (TSH) and has been taking medication for approximately one year. The most likely explanation for this result is….
Non compliance with treatment
