Kings 2018 (Jan) Flashcards
1)78 year old man presents to ED. Collapsed at home is confused and drowsy. Before collapsing had headache and nausea. Has copd, still smoked 20 a day. Temperature is 35.2, heart rate is high, blood pressure is low. Oxygen is 98% and carboxy is 35% (<1.5) what is the most appropriate form of oxygen therapy
A. 2L/min nasal canala
B. 15L/min non- rebreathable mask
C. 28% venturi mask
D. 35% venturi mask
E. 60% Venturi mask
15L/min non- rebreathable mask
18 month old boy drinks paracetamol suspension 100ml at 120mg/5L. Mum beings him to A&E. 7 hours after his paracetamol plasma levels were 42mg.
On graph the treatment line showed around 57mg.
What’s the most appropriate management?
A discharge to community
B IV acetylcysteine
C admit for observation
D activated charcoal
E gastric lavage
admit for observation
100/5*120=2400mg …anything over 150mg/kg is probably toxic so should be treated
Single acute overdose is defined as an ingestion of >4 g (or >75 mg/kg) in a period of <1 hour.
->acetylcystein
Management of paracetamol overdoes
activated charcoal if ingested < 1 hour ago
N-acetylcysteine (NAC)
liver transplantation
Acetylcysteine should be given if:
there is a staggered overdose* or there is doubt over the time of paracetamol ingestion, regardless of the plasma paracetamol concentration; or
the plasma paracetamol concentration is on or above a single treatment line joining points of 100 mg/L at 4 hours and 15 mg/L at 15 hours, regardless of risk factors of hepatotoxicity
Acetylcysteine is now infused over 1 hour (rather than the previous 15 minutes) to reduce the number of adverse effects.
King’s College Hospital criteria for liver transplantation (paracetamol liver failure)
Arterial pH < 7.3, 24 hours after ingestion
or all of the following:
prothrombin time > 100 seconds
creatinine > 300 µmol/l
grade III or IV encephalopathy
3)50 year old female 6 months Hx of malaise and pruritis. Also jaundiced. No recent travel, use of injections, alcohol use or blood transfusion.
Albumin is low
Alanine aminotransferase high
Bilirubin high
Alkaline phosphatase high
PBC
Primary biliary cholangitis (previously referred to as primary biliary cirrhosis) is a chronic liver disorder typically seen in middle-aged females (female:male ratio of 9:1). The aetiology is not fully understood although it is thought to be an autoimmune condition. Interlobular bile ducts become damaged by a chronic inflammatory process causing progressive cholestasis which may eventually progress to cirrhosis. The classic presentation is itching in a middle-aged woman
Associations
- Sjogren’s syndrome (seen in up to 80% of patients)
- rheumatoid arthritis
- systemic sclerosis
- thyroid disease
Diagnosis
anti-mitochondrial antibodies (AMA) M2 subtype are present in 98% of patients and are highly specific
smooth muscle antibodies in 30% of patients
raised serum IgM
Management
- pruritus: cholestyramine
- fat-soluble vitamin supplementation
- ursodeoxycholic acid
- liver transplantation e.g. if bilirubin > 100 (PBC is a major indication) - recurrence in graft can occur but is not usually a proble
20 year old female with severe acne has tried retinoids to no effect. She would like to try hormonal treatment but has previous history of DVT from a long haul flight. What can you prescribe her?
- Desogestrel
- Co-cyprindiol
- Flucoxacillin
- Lymecycline
Lymecycline
Antibiotic options: tetracycline, minocycline, doxycycline
- Mild acne: no inflammation:
- topical retinoid or salicyclic acid
- Mild acne: with inflammationtopical retinoid + topical antibiotic
- +topical benzoyld peroxide
- +topical azelaic acid
- Moderate acne: No inflammation
- topical retinoid
- Moderate acne with inflammation: topical retinoid + Oral antibiotic
- +topical benzoul peroxide
- +topical azaleic acid
- Severe/resistant acne:
- Oral retinoid
- Oral corticosteroid
week old baby with vomiting after feeding for past few weeks getting worse in last 5 days. Vomits a large amount after breastfeeds. Has lost weight and remains hungry after feeds. What is the diagnosis?
- Pyloric stenosis
- Gastroenteritis
- Overfeeding
- Intussusception
Pyloric stenosis
Features
- ‘projectile’ vomiting, typically 30 minutes after a feed
- constipation and dehydration may also be present
- a palpable mass may be present in the upper abdomen
- hypochloraemic, hypokalaemic alkalosis due to persistent vomiting
30 year old woman with 3 months of diarrhoea which is sometimes bloody. She has pain in the right iliac fossa. Temperature is 37. What is the diagnosis?
- Appendix abscess
- Diverticulitis
- Ileo-caecal intussusception
- Crohn’s disease
Crohn’s disease
- Diarrhoea usually non-bloody
- Weight loss more prominent
- Upper gastrointestinal symptoms, mouth ulcers, perianal disease
- Abdominal mass palpable in the right iliac fossa
Man had STEMI 2 days ago. Presents with central chest pain worse on inspiration and moving forward. He has a normal HR and BP. ECG shows widespread ST Elevation and T inversion. Diagnosis?
- Pericarditis
- Aortic dissection
- Myocardial infarction
Pericarditis
Women presents with lump on neck. Moves with swallowing and lifting the tongue. Diagnosis?
- Thyroglossal cyst
- Branchial cleft cyst
- Multi modular goitres
- Leiomya
Thyroglossal cyst
Man had 100m claudication with ABPI 0.84. Treatment?
- Above knee bypass graft
- Below knee bypass graft
- Exercise therapy
- Long saphenous something
Exercise therapy
A 69 y/o man has a four-day history of breathlessness, fever and rigors. He has a previous 40-pack year history. Temp 37.7, BP normal, RR 30 breaths per minute.
Blood culture taken, IV fluids and antibiotics have been given. CXR shows left sided opacity in the lower left sternal edge.
Blood results show slightly raised urea, normal levels of sodium and potassium.
What’s the next most appropriate investigation?
A. CT pulmonary angiogram
B. Echocardiography
D. Spirometry
E. Urinary legionella and pneumococcal antigen
Urinary legionella and pneumococcal antigen
A 36 y/o woman has a four-day history of weakness from her wrist to the index and middle finger. She is 35 weeks pregnant. She recently developed numbness and tingling. Tinel’s test is negative.
What is the most possible diagnosis?
A. Carpal tunnel syndrome
B. Multiple sclerosis
C. Lateral epicondylitis
D. Ulnar nerve entrapment
E. Thoracic outlet syndrome
Carpal tunnel syndrome
- Sensitivity and specificity of Phalen’s test was found to be respectively 67.2% and 92.9%, and for the percussion test (Hoffmann-Tinel), 53.4 and 95.6%.*
- 98 of 436 patients with carpal tunnel syndrome showed negative results for both tests.*
- The false positive and negative rates of Phalen’s test were 7% and 32.7 respectively.*
- On the other hand the false positive and negative rates of Tinel’s sign were 4.3% and 46.5% respectively.*
History
- pain/pins and needles in thumb, index, middle finger
- unusually the symptoms may ‘ascend’ proximally
- patient shakes his hand to obtain relief, classically at night
Examination
- weakness of thumb abduction (abductor pollicis brevis)
- wasting of thenar eminence (NOT hypothenar)
- Tinel’s sign: tapping causes paraesthesia
- Phalen’s sign: flexion of wrist causes symptoms
Causes
- idiopathic
- pregnancy
- oedema e.g. heart failure
- lunate fracture
- rheumatoid arthritis
Electrophysiology: motor + sensory: prolongation of the action potential
Treatment
- corticosteroid injection
- wrist splints at night
- surgical decompression (flexor retinaculum division)
A baby boy has been crying at night, and tugging at his ear. This is followed by yellow discharge.
Which organism causes this?
- Staph aureus
- Strep pneumoniae
- E.coli
- Pseudomonas aureginosa
Strep pneumoniae
Organisms
- Viral
- Pneumococcus
- Haemophilus
- Moraxella
A woman who is 11 weeks pregnant presents with a macular erythematous rash on her trunk. Her nephew has a similar rash 2 weeks ago and he has had no vaccinations.
Which infection has caused this?
- Chicken pox
- Measles
- Mumps
- Rubella
Chickenpox
…is caused by primary infection with varicella zoster virus. Shingles is reactivation of dormant virus in dorsal root ganglion
- Chickenpox is highly infectious
- spread via the respiratory route
- can be caught from someone with shingles
- infectivity = 4 days before rash, until 5 days after the rash first appeared*
- incubation period = 10-21 days
Clinical features (tend to be more severe in older children/adults)
- fever initially
- itchy, rash starting on head/trunk before spreading. Initially macular then papular then vesicular
- systemic upset is usually mild
A common complication is secondary bacterial infection of the lesions. Rare complications include
- pneumonia
- encephalitis (cerebellar involvement may be seen)
- disseminated haemorrhagic chickenpox
- arthritis, nephritis and pancreatitis may very rarely be seen
A lady in her 60s presents to her GP after experiencing episodes of visible haematuria. Urine dip shows blood 3+. What should the GP do?
- Repeat urine dip after 2 weeks
- Give antibiotics
- Request CT of kidneys, ureters and bladder
- Ultrasound of kidneys
- Urgent referral to urology
Urgent Referal to urology
refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for bladder cancer if they are:
- aged 45 and over and have:
- unexplained visible haematuria without urinary tract infection or
- visible haematuria that persists or recurs after successful treatment of urinary tract infection, or
- aged 60 and over and have unexplained non-visible haematuria and either dysuria or a raised white cell count on a blood test
- consider non-urgent referral for bladder cancer in people aged 60 and over with recurrent or persistent unexplained urinary tract infection
A 24 year old man presents to A+E after coughing up green sputum and experiencing some breathlessness. Sputum microscopy shows gram positive cocci in pairs. What antibiotics should be given to him?
- Amoxicillin
- Metronidazole
- Gentamicin
- Trimethoprim
- Vancomycin
Amoxicillin
