MD2 High Yield Flashcards
Which two common factors (one disease and one medication) often reduce pain - leading to typical pain signs not being present? Eg. no chest pain for an MI
Diabetes - neuropathy reduces pain response
Steroids - typically pred, reduce inflammation leading to less pain - eg. no pain for burst diverticulum
Tooth pain is a common presentation for which set of diseases?
Ischemic heart issues - either AMI or angina.
Fine crackles on lung auscultation are indicative of which group of diseases?
Interstitial Lung Disease (pulmonary fibrosis)
Describe the spirometry findings for interstitial Lung disease?
Full vital capacity is reduced.
FEV1/FVC is in normal range or even heightened.
Diffusion capacity (gas exchange) is impaired.
Why is GTN used in heart attacks and how does this relate to use in atypical heart attack presentations.
GTN is primarily used to treat chest pain. This means in cases where chest pain is not present, eg. In some NSTEMIs, it may not be necessary. The vasodilator effects must be considered, what will vasodilation achieve?
Best immediate treatment for an NSTEMI?
Anticoagulation. Clexane/Enoxaparin or Heparin IV. Clot busters are inappropriate because there is no clot unlike a STEMI. However a clot may form following damage to heart, so thinners are the best bet.
Which biochemical test can easily confirm pancreatic pathology, what does the number value relate to?
Lipase.
Number is irrelevant, if it’s heightened, whether it’s 300 or 3 million, it confirms pancreatic involvement and does not relate to severity of disease.
It’s a yes or no test.
How does a PE impact vital signs (/5)?
(3 main, 2 possible)
- oxygen saturation falls
- resp rate increases
- Heart Rate increases
- BP can fall - especially in severe embolism - due to reduced LA filling
- Temp - mild temp increase is common but not always present
IV magnesium is used in the ED as a potential treatment for which presentation?
Asthma that doesn’t respond to first line treatments.
(Would also accept arrhythmias.)
What is a Hartmann’s procedure?
Creation of a stoma after bowel resection
Which vitamins and minerals are in IV Hartmann’s (CSL).
NaCl
- KCl
- CaCl2
- sodium lactate
More physiologically similar to serum.
Order of vessels + nerve in the intercostal space?
VAN - top to bottom
Vein, Artery, Nerve
Opiods commonly cause which side effect and what are the first line treatments for this side effect?
Cause slowing of the bowel/constipation - treat with movicol/coloxyl
Name the 4 main categories of anticoagulants and a common example of each?
ORAL
Warfarin
NOAC - Apixiban
IV
Heparin
LMWH - Enoxaparin
Which types of nosocomial infections are the most common?
Chest, Skin, Urine.
(SUC)
What is amlodipine?
A vessel-selective Calcium Channel Blocker.
What are the 3 symptoms of Horner’s syndrome?
PAM is Horny
P - Ptosis - droopy lids
M- Miosis - constricted pupil
A - Anhydrosis - loss of sweating
How could you differentiate aortic stenosis from aortic sclerosis on examination? (provided a aortic murmur was heard)
Palpation of the carotids - a weak carotid pulse indicates stenosis, as blood is not effectively making it past the aortic valve. Maintained pulse strength indicates sclerosis rather than stenosis.
Heart failure most commonly causes which valvular defect?
Mitral regurgitation
What is the most common congenital valvular defect?
Bicuspid aortic valve
What is a worrisome level of weight loss?
10% of body weight over a less than 3 month period is worrisome.
Name 2 common medications for neuralgia.
Gabapentin, Pregabalin
A big square on the ECG represents how much time?
0.2 seconds
Name the 2 ways to calculate HR from ECG.
Divide 300 by no. of large squares between QRS’ (if regular rate)
If irregular - multiply number of QRS on rhythm strip by 6.
What is a sinus rhythm?
There is a P wave for every QRS and vice versa.
What are some causes of ST depression?
ischemia and digoxin are main ones.
How would you identify an old infarct on an ECG?
Pathological Q waves - 1/4 of the R height in any given area.
Of the 12 heart leads, name those that contribute to each heart region.
Lateral - I, avL, V5 and V6
Inferior - II, III, aVF
Anteroseptal - V1, V2, V3, V4
Name a unique side effect caused by thiazide diuretics not caused by the other diuretics.
Hyponatremia (hypokalemia too but frusemide does that too).
What are the 5 magic cardio risk factors?
HTN, FMHx, Dyslipids, Smoking, T2DM
What are the 4 red flag cardiothoracic pathologies?
AMI, PE, Pneumothorax, Aortic Dissection
What are the history presentations for PE and vital changes?
Sudden onset SOB, can have chest pain, signs of hypoxia in older people.
Reduced BP, tachycardia, RR up, reduced sats, HR up.
Why do oesophageal pathologies cause chest pain?
It is immediately posterior to the heart.
Best way to differentiate MSK chest pain from other systems?
MSK chest pains can be reproduced by firm palpation.
Dermatomal pattern of pain, including chest pain, should cause suspicion for?
Shingles
A raised or invisible JVP indicates what?
Raised = fluid buildup due to pathologies such as SVC obstruction, tricuspid valve stenosis, tricuspid regurgitation etc
Invisible - dehydration or hypovolemia
What are the main diastolic murmurs?
Aortic regurgitation is the main one but mitral stenosis is possible if there is a history of rheumatic fever.
A widened pulse pressure is commonly caused by which valvular defect?
Aortic regurgitation
What is dyspepsia?
Indigestion (can’t digest the pepsi)
What is bronchiectasis?
Permanent widening of the bronchioles, which become plugged with mucus leading to chronic cough and infections.
What is the first investigation to do if a brain bleed is expected?
CT non contrast
What are the 4 broad steps to the neuromotor exams?
Tone
Power
Reflexes
Coordination
What is a laminectomy?
Surgery to remove part of the vertebrae to create space.
Describe the 3 key examinations for acute appendicitis?
McBurney’s Point - slow pressure and release to point between umbilicus and ASIS
Rosving’s sign - palpation of LLQ will elicit pain in RLQ
Psoas sign - activation of psoas muscle causes pain as psoas overlies appendix.
What is Murphy’s sign?
A sign of acute cholecystitis.
Ask patient to take a deep breath, palpate RUQ beneath subcostal area, exhale = Pain in RUQ.
Risk factors for gallstones?
Fat fertile female in forties.
What is Charcot’s Triad?
A triad of symptoms that indicate Cholangitis - an emergency.
- FEVER
- RUQ pain
- Jaundice
How will the bowel appear on X ray during an obstruction?
Dilated proximal to the obstruction, collapsed distal to the block.
How would you refine a presentation of dysphagia into different categories?
Oropharyngeal dysphagia (difficulty breathing and swallowing) vs oesophageal dysphagia (food and drink getting stuck.
Upper GI pathologies tend to be associated with _____ and lower GI pathologies tend to be associated with _____.
- Eating
- Pooing
Why would someone with a Hx of chronic alcohol abuse vomit blood?
Most likely reason: burst oesophageal varicose vein, due to portal hypertension from liver disease.
Loin to groin pain is a description of which pathology?
Renal stones
Name 2 common diseases improved by leaning forward.
- Pericarditis
- Pancreatitis
Name 3 molecules that could cause metabolic flap.
Ammonia (liver), Urea, CO2 (respiratory).
Which organ is responsible for extravascular haemolysis?
Spleen
Name the key endocrine products of the kidney.
EPO and Vit D.
Which electrolyte balance is the most important and what causes this?
Potassium levels. Hyperkalemia can kill you.
Due to crap kidney function /diuretics OR due to acid/base balance as cells will swap H+ in blood for their K+.
Why is serum creatinine a somewhat poor indicator of renal function?
Serum Creatinine doesn’t start to rise until eGFR is around 60% or less.
Differentiate IgA nephropathy from Post-Strep glomerulonephritis on history.
IgA - sore throat AND hematuria concurrently, or within 4 days of each other.
Post-Strep - sore throat THEN hematuria, week or more later.
Is urine output a good measure of kidney function?
No. End stage renal disease kidneys could still make the right amount of urine. The urine balance with other molecules will just be fucked.
What is the relationship between renal failure and calcifications?
Poor renal function leads to poor calcium absorption primarily and kidney and also poor calcitriol release. This causes an increase in PTH and bone breakdown, which can chronically cause hypercalcemia. This can lead to calcifications in other systems such as the heart.
Compare the use of ACE inhibitors in an AKI vs in CKD?
AKI never use ACEi, stop use immediately. Low perfusion with added efferent arteriole dilation puts glomerulus in an awful position.
CKD always use ACEi. Takes pressure off the already damaged/reduced glomeruli - renoprotective.
Main risk factor for end stage renal failure?
diabetes
how does an ideal PaO2 on a blood gas relate to oxygen concentration?
PaO2 should be 4-5x of O2 concentration. On room air, O2 concentration is 21%, so PaO2 should be 84-100%. We want that PaO2 to be as high as possible, definitely above 60.
But if we are giving supplemental O2 at 40% O2 conc, their PaO2 should be 160-200. If it’s still 100, that looks good but is actually still showing a defect in ventilation.
Most common cause of hyperventilation in a clinical setting?
Forced mechanical ventilation - leading to a respiratory alkalosis.
Why might cardiac arrest cause acidosis?
No pump = no O2 delivered = anaerobic respiration = production of lactic acid
What are the three broad mechanisms of cardiothoracic chest pain?
- ischemic chest pain
- pericardial inflam
- pleural inflam
What descriptors are typically used to describe cardiac ischemia?
Tightness, pressure, squeezing, someone sitting on my chest.
What descriptors make cardiac ischemia less likely?
Sharp pain, reproducable, pleuritic, localised (if they can point to pain with one finger, it’s MSK).
What are the two ‘great maskers’ of pain?
Diabetes and Anti-Inflammatories (especially steroids).
What are the surgical and non-surgical treatments for a STEMI?
Clotbuster - thrombolytics
Surgery - PCI (acute) or CABG
What is the goal of GTN and how does it work?
Reduce chest pain.
Causes vasodilation to reduce preload.
Which 3 pharmacological agents are NECESSARY in acute coronary syndrome and which fourth is often added?
Heparin/Clexane, Aspirin, GTN.
The typical fourth is morphine.
Which two leads can be checked to easily assess axis.
If leads 1 and aVF are both + then axis is normal
Which arrythmia is described as sawtooth?
Atrial flutter
Describe the ECG changes for atrial hypertrophy (dilation).
P pulmonale (right atria) - tall P wave
P mitrale (left atria) - ‘M’ shape P wave
What ECG findings occur in pericarditis?
ST elevation with PR depression
How does Guillian Barre impact reflexes?
What are you most concerned about with this illness?
Hyporeflexia/absent reflexes.
Respiratory depression.
What is myasthenia gravis?
Autoimmune destruction of the synaptic terminals of neurons - widening of synapse.
What would a postural BP check reveal on a diabetic with autonomic neuropathy?
BP would fall as is normal, but rebound tachycardia is not present as it would be in healthy people (if they have autonomic dysfunction)
Which biochemical molecule is the best to check if dialysis is working?
Urea. Creatinine no longer useful - the horse has bolted.
What does the CSF look like in Guillian Barre?
CSF is high in protein (Ig) but low in WCC.
Define shock.
Supply and demand mismatch of blood - can happen to any tissue
What are the different causes of Shock?
SHOC N Awe
S - septic
H - hypovolemic
O - obstructive
C - cardiogenic
N - neurogenic
A - anaphylactic
Give 3 examples of obstructive shock.
PE, cardiac tamponnade, pneumothorax.
Describe the ECG findings of a Bundle Branch Block.
Wide QRS.
RBBB - MarroW
LBBB - WillaM
It’s meant to be William but Willam makes more sense to me - six letters, V6.
Pathological difference in cause of Vtach vs Vfib.
Vtach is due to ventricular ectopics that originate in the ventricular wall, cause contraction with inability to fill properly in time - syncope common. Only one site is causing the ectopics.
Vfib - ectopics arising from all over the ventricle.
Basically dead.
How to spot a pacemaker on an ECG?
Vertical lines present in front of the P wave or QRS (depending on if they have atrial or ventricular pacing).
How to spot a pacemaker on an ECG?
Vertical lines present in front of the P wave or QRS (depending on if they have atrial or ventricular pacing).
Name a drug that causes ST depression.
Digoxin
What is the most common ECG finding for a PE?
Sinus tachycardia
Which body landmark can be used to differentiate small gut pain from large gut pain?
Umbilicus. Pain above the umbilicus is more likely to be the small gut, below it is more likely to be the large gut. - Due to dermatomes.
Compare ovarian pain to acute appendicitis pain.
Ovarian pain is way more acute, it is essentially sudden. In comparison to the evolving diffuse pain over time common with appendix issues.
Should you be wary of someone with appendicitis feeling suddenly better?
Yes. Often they feel better when their appendix has popped. Feel good for about an hour until the sepsis sets in.
What colour are body fluids at each stage of the digestive tract?
Stomach - clear
Proximal small bowel - radioactive green
Distal small bowel - like feces (closer to colon).
What are the shockable rhythms?
Vfib and unconscious V tach.
How does Adenosine work?
Slows AV node and conduction. Causes heart rate to slow down. Patients feel like they’re going to die.
How does Adenosine work?
Slows AV node and conduction. Causes heart rate to slow down. Patients feel like they’re going to die.
Which coronary artery controls the inferior region? Which controls the anteroseptal region? Lateral?
Inferior - RCA.
Anteriorseptal - LMDA.
Lateral - LCA
Vital sign consequence of a STEMI in the Right Coronary Artery?
RCA feeds Right Atrium and SA node - damage to SA node will lead to bradycardia.
What are the main symptoms of aortic stenosis?
SAD
S - syncope
A - angina
D - dyspnea
What is the most common cause of aortic stenosis?
Calcifications related to age.
List 2 causes of secondary hypertension.
Renal issues - stenosis, disease
Adrenal disease - leading to hyperaldosteronism etc
Explain isolated systolic hypertension and the common cause.
Just the systolic is high, not the diastolic. This is evidence of a widening pulse pressure. The most common cause is stiff arteries from age/atherosclerosis.
List the ideal progression of medications for control of hypertension.
- ACEi (ideal)/ Calcium blocker
- both of the above
- both of the above + diuretic
- if still poorly controlled, check for compliance/secondary causes
Which program is needed for long term management following an AMI?
Cardiac Rehab
List five categories of post-AMI complications and an example of each.
Further Ischemia - angina, reinfarct
Mechanical - heart failure, valve dysfunction, cardiogenic shock
Arrhythmia - SA or AV issue or other arrhythmia
Embolic - self explanatory
Inflammatory - Pericarditis
Why might an epidural spinal cause an AKI?
Turning off sympathetic system will decrease tone, leading to fall in BP which can cause AKI.
How to differentiate the small and large bowels on CT?
Large bowel has double semi circle shape - two bent lines across colon.
Small bowel lines go all the way across the intestine.
Which colours are common in Raynaud’s?
French Flag
Blue, White, Red
Which types of joints tend to be targeted in RA vs OA? What about fingers?
RA targets synovial joints.
OA targets weightbearing joints.
RA spares the distal interphalangeal joints, OA targets them because they are weight bearing.
What is crepitus?
Creaking/grating of damaged joints. Typical of OA.
Compare the broad action of the jejunum to the ileum/colon.
The jejunum is all about food absorption and will secret fluid to aid in food digestion and absorption.
The ileum and colon are largely about water resorption.
List 2 causes of non-pitting edema.
Lymphedema or parasites
What is a dangerous symptom of hyponatremia?
Encephalopathy
Which coagulation test checks efficacy of Warfarin?
INR
Think WINR
W(arfarin)INR
Best way to remember Apixaban function?
Api ‘Xa’ Ban
It bans factor Xa
- NOAC/DOAC
What is an ileus and how would you know it had resolved?
An ileus is a non-mechanical small bowel obstruction.
You’ll know it’s resolved when they fart. Poo is also used but is a poorer indicator of resolution than gas.
What do stomach parietal cells produce?
HIP
HCl, Intrinsic factor - Parietal cells
‘partial or total separation of previously approximated wound edges, due to a failure of proper wound healing’ Describes which pathology?
Dehiscence
Strawberry milkshake type fluid in a drain is likely to be?
Chyle - white fat drained from lymphatics that is tinged pink from a bit of blood
Which vitamin injection would be administered in suspected pancreatitis?
Vit K - inability of pancreas to function will stop ADEK fat soluble vitamins from being absorbed.
Vitamins ADE are not an acute worry.
Does the size of a gallstone matter for pathology progression?
Yes. Large gallstones tend to lodge at the opening of the gallbladder and cause a solely cholecystitis picture.
Smaller stones can exit the gallbladder and block distal areas of the biliary tree leading to pancreatitis etc.
Which biochemical marker tests for pancreatic dysfunction?
Lipase
Which liver enzymes are reflective of the gallbladder and which of the liver?
GGT and ALP = gall
AST and ALT = liver
Why would we examine the sides of the face in the GIT exam?
Parotidomegaly - sign of alcohol abuse.
What are the two main causes of gynocomastia (aside from natural gyno)?
Chronic liver disease and spironelactone use.
What are the two key signs of peritonitis?
GUARDING - tensing of abdominal muscles on light palpation
REBOUND TENDERNESS - pain felt on release of pressure rather than application of pressure
What are the typical pre-surgical changes to:
Aspirin
NOACS
Warfarin
Metformin
Aspirin - do not cease
NOAC - stop 3 days before
Warfarin - takes 5 days to wash out
Metformin - stop night before surgery
Upper GI pain radiating to the back indicates?
Pancreatitis
Compare a type A and B Aortic Dissection
Type A - dissection arises before the 3 aortic offshoots. Way more dangerous.
Type B - dissection starts after the offshoots.
What is pleurodesis?
permanent joining of the lung to the chest wall (really is a joining of the visceral and parietal pleura) to remove the pleural space.
What is the ideal time to take pain relief before physio?
40 minutes beforehand
What is Naloxone? What is Targin?
Naloxone (Narcan) is a medication to treat the effects of opiods. It can be used in overdoses or just to combat side effects of opiod analgesia.
Targin is a mix of oxycodone and naloxone - an opiod and a side effect medication in one.
What is endone?
Immediate release oxycodone.
What is cholestasis?
Low/no bile flow through biliary tree
What is leg claudication?
Angina of the leg
Is Hb level proof of bleeding?
Not acutely.
If bleeding, concentration of blood does not change, only the volume changes. So the Hb number won’t change but they are bleeding. The Hb will change when you give fluids (unless that fluid is blood) because you have diluted them. It will also change in a chronic bleed as the body tries to fix the volume issue.
What is a definition of cardiac failure and what are the two broad types?
Cardiac output is not sufficient to meet need.
Typically due to cardiac damage but can also be due to increased demand.
The two broad types are HFrEF (systolic) and HFpEF (diastolic).
What is Starling’s Law and how does it relate to heart failure?
Starling’s law states that increased volume will increase cardiac contractility.
For heart failure, this means that in order to meet tissue demands, cardiac output can be raised by increasing contractility by holding onto more fluid (volume).
What are the four broad causes of edema?
Increased venous pressure
Hypoalbuminemia
Blocked lymphatics
Leaky Capillaries (infection)
How does heart failure impact the kidneys?
Inability to meet cardiac output will result in poor perfusion to the kidneys. Nephrons will assume BP is low as the reason and will activate RAAS to hold onto fluid.
Which two radiological Ix would you do for heart failure?
CXR and ECHO
Does a normal ECHO exclude heart failure?
No, it could still be HFpEF
What is the key physiological target when treating cardiac failure?
AFTERLOAD.
The aim is to treat afterload so that the heart is capable meeting the demand with less strain.
What is your first suspicion if you see broad complex tachycardia?
V tach
List 3 causes of extreme axis deviation on an ECG.
- incorrectly placed leads
- hyperkalemia
- V tach
Which two heart block types are more or less benign?
Type 1 and Mobitz I (Wechenbach) (gradual lengthening of PR interval.
Describe the impact of potassium on the ECG.
High potassium - tall T waves
Low potassium - short T waves and potential U wave
What are the numerical cutoffs for type 1 and type 2 respiratory failure?
Type 1 - O2 level below 60
Type 2 - CO2 level above 50
What is acute respiratory distress syndrome?
ARDS is a respiratory emergency that usually follows trauma.
‘Wet lung’ where fluids and proteins leak into the alveoli en masse
What is the mnemonic for Nephrotic Syndrome.
O he’s PALE.
(O for nephrOtic instead of nephritic)
P - proteinuria (massive)
A - albumin (hypo)
L - lipids (hyperlipidemia)
E - edema
Stoney Dullness is synonymous with which condition?
Pleural effusion
What is the gold standard test for a PE?
CTPA. (pulm artery should be thinner than aorta diameter) (pulm artery is Y shaped as it splits in two)
Don’t say D dimer.
Is a Troponin only raised in AMI?
No, anything that strains the heart could cause a rise in troponin. A PE leading to right heart strain could cause it to rise.
What is the main Treatment for a PE?
Anticoagulation. DOACs usually.
Thrombolysis only if severe.
Chronic asthma leads to which changes to the lungs?
Chronic bronchoconstriction, goblet cell hyperplasia, mucosal thickening, smooth muscle thickening, increased inflammation (underpinning the rest).
What is the primary treatment for asthma?
Acute symptoms - B2 agonist bronchodilator
Underpinning inflammation - steroids
Side effects of oral steroids?
Thrush, hoarse voice.
Best test to measure endogenous insulin production?
C peptide
name a factor that could render HbA1c inaccurate.
Red cell turnover - if they are readily needing new RBC then the glycation of those cells will not be representative of the truth. Could be due to anemia etc.
Describe the timeline of pharmacological intervention in type 2 diabetes.
- Lifestyle
- Metformin
- Metformin + 1 other oral
-Metformin + 2 other oral - Insulin + oral
- Insulin alone
Name the major contraindication for Metformin.
Renal failure due to acidosis risk.
Main Metformin side effect?
GI disturbances
Name the two diabetes drug groups that target the incretin system and how these drugs work.
The incretin system is a gut based hormone system that releases the hormones GLP1 and GIS to modulate hunger and insulin release. The incretin hormones are quickly degraded by the DPP4 enzyme naturally.
Two drugs that target this system:
DPP4 inhibitors (Oral) - inhibit DPP4 enzyme, allowing incretin hormones to act for longer
GLP-1 analogues (IV) - an exogenous form GLP1 that is altered to resist DPP4. Extremely effective in both diabetes control and weight loss (ozempic).
Name a diabetes medication that typically causes weight gain.
Sulphonylureas
Aside from its diabetes effects, SGLT-2 inhibitors are beneficial to which other organs?
Renoprotective and great for heart failure
Aside from its diabetes effects, SGLT-2 inhibitors are beneficial to which other organs?
Renoprotective and great for heart failure
Name 2 side effects of SGLT-2 inhibitors.
UTIs, polyuria
At what eGFR would you cease metformin?
30 or less
Is bariatric surgery effective in weight loss?
Yes. Some of the lost weight will be regained but long term it does lead to weight loss.
What are the 5 aspects of metabolic syndrome?
- Central adiposity
- HTN
- High triglycerides
- Low HDL
- Impaired blood glucose
What is the FEV1/FVC for interstitial lung disease?
Interstitial lung disease is restrictive, meaning FVC is significantly reduced.
Depending on the FEV this can lead to an FEV1/FVC that is normal or elevated.
Name a medication that causes pulmonary fibrosis?
Methotrexate (also accept amioderone)
What is the lung interstitium?
The tissue between and lining the alveoli and the vessels.
What are the main two symptoms of chronic interstitial lung disease AKA pulmonary fibrosis
Shortness of Breath and dry cough
Name 3 findings on examination that point toward pulmonary fibrosis.
- FINE CRACKLES !!!!
- evidence of pulmonary hypertension
- clubbing
Does interstitial lung disease have a bronchodilator response?
No, that’s really just asthma
What is the deadliest form of interstitial lung disease?
IPF - idiopathic pulmonary fibrosis - mortality rates just below pancreatic and lung cancer
‘honeycombing’ on CT is typically related to which condition.
Idiopathic Pulmonary Fibrosis
How is the GCS divided score-wise.
Eyes - 4
Voice - 5
Motors - 6
15 points all up.
Aggressive diabetes treatment must be balanced against risk of ____.
Hypoglycemia
90% of small bowel obstructions are due to what?
Adhesions
What is TPN?
Feeding through a tube
Which antibody types are common in Type 1 Diabetes?
Anti GAD and Anti islet cells
Which common drugs could cause incorrectly elevated random/fasting blood glucose levels?
Steroids
Does hypoglycemia affect the heart?
Yes, it can cause arrhythmias
Name 2 diabetes medications that can cause weight loss and 2 that can cause weight gain.
loss - SGLT2 inhibitors and GLP1 analogues.
gain - sulphonylureas and insulin
What is the ‘basal bolus’ approach to insulin administration?
Long term insulin given around bedtime to mimic basal insulin levels and counter nighttime gluconeogenesis.
Short acting insulin given at meals as a bolus to mimic mealtime insulin release.
How can we further refine diabetic neuropathy into two categories and give some examples.
Split into autonomic neuropathy and peripheral neuropathy.
Autonomic - postural BP drop without compensation tachycardia, erectile dysfunction.
Peripheral - loss of sensation or abnormal sensation. Glove and stocking.
Larger people often have raised creatinine levels. How could you check for renal damage in overweight diabetics?
Albumin:creatinine ratio to check if they’re leaking protein
Absent/reduced pulses are evidence of which macrovascular diabetic complication?
Peripheral vascular disease
What is the best anti-HTN medication for diabetics?
ACE inhibitors/ARBs
Why should we treat fat tissue as an endocrine organ?
Because it is. It produces inflammation and impacts HTN and atherosclerosis and thrombosis.
Aside from these inflammatory signals, they also make SCFA.
Why is PCOS related to diabetes?
Increases insulin resistance –> increases risk of diabetes
How do short chain fatty acids released by adipose tissue impact diabetes?
They are used by liver in gluconeogenesis to make more sugar and they also lodge as triglycerides (due to VLDL) in muscle leading to insulin resistance.
The -liptin drugs are which class of medication?
DPP4 inhibitors for diabetes
The -tide drugs are part of which medication class?
GLP1 analogues
The -flozin drugs are in which medication class?
SGLT2 inhibitors
Glipizide is what type of medication?
Sulphonylurea
What is an S3 sound and what does it indicate? What about S4?
Treat S4 as S0.
S3 is just after S2, it is often a response to volume overload.
S4 is just before S1 (think S0) and is indicative of pressure overload. (stiff ventricles)
both occur in diastole
Aortic Stenosis is often described as a _____ murmur.
Crescendo Decrescendo
Mitral regurgitation is often described as a ____ murmur.
Late systolic
Aortic Regurgitation is often described as a ____ murmur.
Early diastolic
Mitral stenosis is often described as a ____ murmur.
Mid/late diastolic
List the abdominal layers in order.
organs
visceral peritoneum
Parietal peritoneum
fat layer
transversalis fascia
transversus abdominus
internal oblique
external oblique
superficial fascia
subcutaneous fat
skin
Think of it as mirrored layers. Fat covers fascia which covers 3 muscles, repeat.
Which dimension of the inguinal canal is formed by the inguinal ligament?
the inguinal ligament forms the floor (inferior) of the inguinal canal
The deep and superficial inguinal rings are the openings of the inguinal canal. Which abdominal layers do they occur in?
Deep ring - transversalis fascia
Superficial ring - external oblique (with internal oblique aponeurosis)
Why are groin hernias more common in males?
Process vaginalis must be longer (stretch farther) to deliver male gonads to scrotum in comparison to delivery of female gonads to pelvis.
Why does the inguinal canal form?
To deliver gonads
Outline the difference between a direct and indirect hernia - which inguinal rings are involved in each?
Indirect - abdominal contents move through an un-obliterated process vaginalis (can end up in scrotum). Contents pass through both superficial and deep rings.
Direct - abdo contents push on a weak area of transversalis fascia (posterior wall of inguinal canal) due to increased abdominal pressure. Then it comes out the superficial inguinal ring. Deep ring NOT involved.
A pansystolic murmur is typical of which murmur?
Mitral regurgitation
What is the immediate treatment of Sepsis?
SEPSIS SIX - 3 in 3 out
In: O2, fluid, antibiotics
Out: Hb/lactate, blood for micro, urinary catheter for monitoring.
Why does albumin effectively increase BP?
Increases the ‘half life’ of given fluid. The increased osmotic pressure stops the fluid from entering the interstitium as quickly - keeps it in the vessels
Which antibiotic classically causes tubular necrosis?
Gentamicin
Which type of murmur tends to radiate to the axilla?
Mitral murmurs
What are the 3 foramina of the pelvis, which structures run through these? Which does the femoral artery use?
The greater and lesser sciatic foramen (split by the sacrospinous ligament) and the obturator foramen.
Greater sciatic - path of most structures including sciatic nerve
Lesser sciatic - for pudendal structures
Obturator - for obturator structures
Femoral artery, nerve and vein don’t pass through any of these - they pass underneath the inguinal ligament - very anterior
What are the nerve roots of the sciatic nerve?
L4 to S3
What are the two main causes of pancreatitis?
Gallstones and alcohol
Which nerve controls shoulder abduction?
Axillary - muscle Is deltoid, axillary controls deltoid.
Which two muscles form the bladder, what are their functions?
Detrusor - controls bladder contraction = urination.
Trigone - triangle shaped one that stops urinary reflux.
Mnemonic for post-MI complications?
PRIME
Pericarditis
Rhythm
Ischemia
Mechanical
Embolus
Which coronary artery gives off the posterior interventricular artery?
The RCA (usually)
Which white blood cell rises particularly in parasitic infection?
Eosinophils
Severe anemia can cause cardiac ischemia due to _____ ischemia.
Demand
Where do MI’s tend to radiate to?
Jaw and left arm
Which types of chest pain are aided by GTN? Which aren’t?
Cardiac ischemia and esophageal chest pain are aided by GTN, the rest, notably pleuritic pain, are not.
Does a PE elevate troponin?
It can, due to right heart strain
What is the difference between stable/unstable angina and an AMI?
The rise of cardiac biomarkers (troponin).
What are the three required categories to diagnose an MI? (need 2/3)
- symptoms
- ECG changes
- Raised biomarkers (troponin)
What is the treatment for an NTSEMI?
Therapeutic anticoagulation
What are the pros and cons of heparin vs clexane?
Heparin - short acting and reversible but huge ballache to monitor
Clexane - no need to monitor as much, way easier but irreversible.
What is the treatment for AF?
Two pronged approach:
- Anticoagulation
- Rate/Rhythm control
Mnemonic for causes of AF?
PIRATES
Pulmonary
Infection/ischemia
Rheumatic heart disease
Alcohol/anemia
Thyroid
Electrolytes
Sepsis
What is Wolff Parkinson White disease?
Person has a 2nd conduction pathway in the heart leading to bouts of tachycardia and Vtach risk
What is the biggest consideration when wondering whether to cardiovert someone to sinus rhythm from Afib?
CLOT RISK - return to sinus is associated with short term increase in clot risk - they may need to be anticoagulated depending on how long the AF has been present.
What is the primary treatment for adult hernias?
Surgery
Why does hypotension cause tachypnea?
hypotension –> poor perfusion –> anaerobic respiration –> lactate production –> acidosis –> tachypnea.
What is rigor?
Shivers + high temp
What amount of urine is typical during an AKI?
Depends on the cause.
Anuria and oliguria are the most common, but can have polyuria if the cause is tubular damage.
What is Piptaz?
Pipercillin - broad antibiotic
Taz = betalactmase inhibitor
Why does an AKI cause hyperkalemia?
- poor excretion of K+ in exchange for Na+
- cells regulating high H+ (as kidneys can’t excrete) by taking it in in exchange for K+.
Compare the pain differences in inflammatory, perforation and colic pain.
Inflammatory - tends to start sudden then build
Perforation - sudden and immediately severe and stays at that level
Colic - come and go pain
If pain radiates to the back, which organs are likely to be involved?
pain in back = involvement of retroperitoneal organs
(Aorta, pancreas, duodenum).
What is the approximate time course for peritonitis?
very acute, pain will occur very shortly after perforation - NOT hours, earlier.
List 4 causes of pancreatitis (2 main ones).
Gallstones and alcohol are the main 2.
Viral illness, autoimmune disease, ERCP and tumours can all also do it.
What is an AXR?
Abdominal X ray
What is loperamide?
Opiod medication used to slow digestion (allow for better absorption or stop diarrhea).
What molecule does octreotide imitate? What does it do?
Mimics somatostatin - broadly, it stops the gut, stops gut motility, exocrine functions and stops release of GH.
How does metoclopramide function, what is it used for?
Anti-emetic/nausea drug - dopamine antagonist - therefore promotes gut motility (dopamine inhibits gut movement).
What is the best history qn to ask to establish rigors vs regular shivers?
Could you hold a cup of water without spilling any?
A splenectomy should raise alarm bowels for what type of disease causing agent?
Encapsulated Bacterial infection
Fever with new onset backpain should always be treated as an ____?
Epidural abscess (note - pancreatitis pain is in the RUQ with radiations to back).
Fever in a traveller is ____ until proven otherwise.
Malaria (would probably accept TB)
Name the 3 broad groups of beta lactams as well as well as key antibiotics in each group.
Penicillins - split into narrow, mid and broad spectrum.
Narrow - penicillin G or V and flucloxacillin.
Mid - amoxicyllin or ampicillin
Broad - PipTaz
Cephalosporins - 1st and 3rd generation.
1st - Cephazolin (IV) and Cephalexin (oral)
3rd - Ceftriaxone
Carbapenems
- Marepenem - nuclear bomb of antibiotics
Which are the two main medications for pseudomonas treatment, which other two are sometimes used with unfortunate side effects? What are these side effects?
PipTaz (Tazosin) and Maropenem are the usual 2.
Gentamicin is also used but it causes tubular necrosis and damage to the 8th cranial nerve, causing renal injury and ototoxicity respectively.
Ciprofloxacin is the other one, but it often leads to C.diff infections.
What is the go to antibiotic for anaerobes?
Metranidazole
What is trimethoprim used for? When is it contraindicated?
UTIs - can’t use in pregnancy
(Try Meth in the Pram)
Rifampicin is used for what disease? What is a side effect?
TB. Turns body fluids red or orange
What is the only oral antibiotic for pseudomonas?
Ciprofloxacin - but many strains are resistant
Which antibiotic class is often responsible for C.diff infections?
Fluoroquinolones - eg. ciprofloxacin
Which antibiotics would be used for cellulitis?
Flucloxacillin is the textbook answer, but it can cause liver injury (jaundice). So many people use Cephalexin instead even though it is more broad.
What are the atypical causes of pneumonia?
What are the hospital acquired pneumonias?
A legion of Mike’s with chlamydia (think Mike Wazowski).
Legionella, Mycoplasma, Chlamydia.
no-socomial is all the regular ones and klebsiella or pseudomonas
Is Staph in the urine a concern?
Yes. A huge concern. Staph in the urine goes beyond simple UTI. You no longer have a UTI you have staph bactermia and must treat it as such.
What is the choice antibiotic for febrile neutropenia and which groups typically experience this diagnosis?
PipTaz or Meropenem - think of need to cover pseudomonas.
Febrile neutropenia is classically in cancer patients and people receiving chemotherapy.
What is the chance of a penicillin allergy also applying to cephalosporins?
About 1%, typically very safe.
Describe a UTI in terms of volume, frequency and post-void feeling.
Frequency - very often
Volume - only small amounts of urine each time
Post-void - feel that bladder is still full
In hypocalcemia, what are the first line treatment options?
eg. following a thyroidectomy with PTH sort of all over the place.
Use caltrate with calcitriol to up blood calcium.
Where are the borders of each of the gut segments and why is this relevant when removing bowel cancers?
Foregut - ends at end of D2 in duodenum.
Midgut - From D2 to 2/3 way through transverse colon.
Hindgut - distal 1/3 of transverse colon to anus.
For cancer removal, you want to remove area supplied by blood supply of cancer to limit potential metasteses.
I.e if a tumour was present halfway through the transverse colon you would do a right EXTENDED hemicolectomy, to remove the colon all the way to the 2/3 mark of the transverse colon where the blood supply switches to the Inferior Mesenteric artery.
Which common biochemical marker is a good indication of nutrition level?
Albumin
What are colloids? Crystalloids?
Colloids - fluids given to raise oncotic pressure eg. gellofusine or albumin
Crystalloids - salts dissolved in water, eg. saline or Hartmann’s
What is the vocal resonance difference between pneumonia and pleural effusion.
Pneumonia - solidity causes increases resonance.
Pleural effusion - the one that doesn’t make sense - resonance is decreased.
How does hyperchloremia cause acidosis? What causes hyperchloremia?
the excess Cl- leads to a reduction in free bicarb (to maintain net negative charge), which lowers the pH. It’s typically due to too much saline. Give Hartmann’s instead.
What are the desired SO2 sats for an adult? what about an adult wit COPD?
95+, 88-92 for COPD.
What can an altered mental/conscious state indicated in someone with dyspnea?
Hypoxia of the brain = severe respiratory distress
Compare stridor vs wheeze.
Wheeze = lower resp system
Stridor = upper resp system
What imaging is typical for suspected pulmonary fibrosis?
HRCT - high resolution CT
How can sleep apnea contribute to heart failure?
Sleep apnea increases pulmonary hypertension leads to Right Heart Strain
Mnemonic for acute treatment of APO?
LMNOP
Lasix
Morphine to vasodilate
Nitrate to vasodilate
Oxygen
Position
How might ascites impact frusemide mode of delivery?
Fluid around gut will impact oral frusemide intake, better to give IV.
How does CKD alter frusemide treatment?
Less frusemide is getting to the Loop of Henle due to nephron damage, so more frusemide is needed to have the same effect.
Mnemonic for long-term heart failure drugs?
BASS
Beta Blockers
ACEi/ARB
Spironolactone
SGLT2 inhibitors
What are the two broad types of pleural effusion? List some causes of each.
Exudative (inflammatory) and Transudative (oncotic - edema).
Exudate - pneumonia, cancer, TB.
Transudative - heart failure, liver failure, kidney failure.
Why does a pleural effusion being bilateral help refine the diagnosis?
A bilateral effusion is more likely to be due to a systemic illness like heart failure as opposed to an infection like pneumonia which will cause pleural effusion on one side.
Amlodipine is what class of drug? Which site does it act on?
A Calcium channel blocker, dihydropiridine (vessel selective).
Think AmloDiVas
Amlodipine, dihydropyridine, vasculature
What is the path of CSF in the brain?
LIT AF
Lateral ventricles
Interventricular foramen
Third ventricle
Cerebral aqueduct
Fourth ventricle
Eventually into subarachnoid space
How is syncope defined?
Transient loss of consciousness due to transient cerebral hypoperfusion that is rapid onset, very brief and leads to a quick and complete recovery.
What is the main alternate DDx for a syncopal episode? How could you tell them apart?
seizure - do not recover quickly - due to post-ictal phase. Often tired and sore after. Event tends to last longer than syncope.
What are the major causes of cardiac syncope?
Anything that reduces CO can do it, but typically the two main culprits are arrythmias and structural issues like valve problems.
Does syncope cause jerks?
It can! Jerks can follow from brain hypoxia, so jerks are not just for seizures.
What is a significant postural BP change and why would you check Heart rate when checking postural BP?
A change of 20 in systolic or 10 in diastolic.
People SHOULD become tachycardic on standing, but people with autonomic dysfunction (like diabetics) may not have this tachycardia.
Comparing BP in both arms is useful to assess for?
Aortic Dissection
What are the two scans used for detection of PE’s?
CTPA and VQ scan
What is the typical non-pharmalogical treatment for 3rd degree heart block?
Pacemaker
At what GCS should you intubate?
If GCS 8, intubate
Pinpoint pupils is typically a sign of what? What about dilated pupils?
Pinpoint - opiod overdose
Dilated - raised ICP
Which cranial nerves control taste?
Anterior 2/3 - facial
Posterior 1/3 - glossopharyngeal
In diabetic nueropathy, which sensation and reflexes are the first to go?
Foot sensation and achilles reflex
Do cranial nerves crossover?
Only cranial nerve 4
Which infection can cause Bells Palsy?
Shingles - Herpes Zoster infection of cranial nerve 7
‘Hip drop’ can be due to a palsy of the ________ nerve or due to weakness of the _______ muscle (ON THE CONTRALATERAL SIDE).
The _______ sign is a test for hip drop.
Superior gluteal.
Gluteus medius.
Trendelenburg.
How does renal artery stenosis impact BP (physiology)?
By narrowing the renal artery, less blood flow reaches each nephron. The Juxtaglomerulosa and Macula densa cells detect these changes (low BP by juxta cells and low NaCl by Macula Densa) and cause the release of renin. Renin causes BP rise (largely through production of ANGII - which causes aldosterone release from adrenals and mass vasoconstriction to raise BP). This has no affect on kidneys themselves as no amount of BP raising will increase flow through the stenotic artery - vicious cycle of massive hypertension.
What are the 5 impacts of ANG2?
systemic vasoconstriction especially the efferent arteriole
upregulates Na/H transport in proximal tube
promotes ADH creation
aldosterone release
SNS activated leading to more vasoconstriction, more renin and more CO.
What is pre-eclampsia?
HTN in pregnancy. Dangerous
What height should BP be measured at?
At the same height as the heart
What are the values for HTN?
140/90 generally
List 6 causes of secondary hypertension (not including pharmalogical agents).
Hyperthyroidism
Hyperaldosteronism
Hyperreninism
Hypercortisolemia
Renal artery stenosis/renal damage
Obstructive sleep apnea
Which investigation will reveal kidney damage the earliest?
Urine test - proteinuria comes before creatinine.
Flash acute pulmonary edema is commonly cause by _____ ______ ______.
Renal artery stenosis
Beta Blockers aren’t really used for hypertension alone, but they are often used for other cardiovascular pathologies. List 3.
AF
Ischemic Heart Disease
Heart Failure
Name two unique side effects of thiazide diuretics (as compared to other diuretics).
- hyponatremia
- gout risk (uric acid increase).
ACEi drugs typically reduce renal function due to dilation of the efferent arteriole, so less blood is filtered. This is clinically acceptable, except when the renal function drop is huge. What condition commonly causes this huge drop in function following ACEi/ARB use?
Renal stenosis
How should you manage hypertension in the context of ischemic stroke?
Don’t try to lower BP - need the BP high to get blood to brain, lowering BP risks new infarct.
What is a give away clinical presentation for Addison’s?
Hyperpigmentation, especially in gums.
Tryptan/tryptase is a test for ______.
Anaphylaxis
Compare the uses of a fine bore vs wide bore tube (NG).
Fine - feeding
Wide - drainage
Why does lactate rise?
Ischemia or Necrosis.
What is the most specific test for Rheumatoid arthritis?
Anti-CCP (cyclic citrullinated peptide). Rheumatoid factor is + in many conditions.
Chronic disease gives what type of anemia?
Normocytic
What is the biggest worry for Guillian Barre syndrome?
Respiratory depression
What are the 5 main causes of hand joint pain? Which is correctable? Which has a rash?
OA, RA, gout, SLE (correctable), psoriatic arthritis (rash).
Tx for syphilis?
IM penicillin
Gentamycin is toxic to which two organ systems?
Ototoxicity and nephrotoxicity
Which class of antibiotics causes tendinopathy?
Fluroquinolones
What is the definitive treatment for Necrotizing fascitis?
Fasciotomy
What are the main 2 organisms implicated in infective endocarditis?
Staph aureus and strep viridans
What is the treatment for APO?
POND mnemonic:
P - position
O - Oxygen
N - nitrates
D - diuretic (furosemide).
In simple terms, how does the vestibulo-ocular reflex occur and which cranial nerves does it involve?
Movement of the head/body is detected by hair cells in the semicircular canals due to movement of the fluid inside. This signal travels down the 8th cranial nerve and is integrated into the brainstem, especially via the nucleus of Cahal in the medial longitudinal fasiculus. This leads. to communication to the cranial nerves controlling the eye movements in both eyes to move eyes according to head movement - normal nystagmus.
Which two muscles muffle the sound from inside a person’s own head and which cranial nerves control these muscles?
Tensor Tympani (trigeminal 5.3)
Stapedius (seventh - facial)
On an ECG what qualifies as an elongated PR interval?
Larger than one big square - FROM THE START OF THE P WAVE, not the end
How do you establish LVH on ECG?
Deepest S wave height in V1 or 2 added to tallest R wave in V5 or 6.
Mobitz type 2 can progress to which dangerous pathologies?
3rd degree heart block or asystole
A really bad PE may show which patterns on an ECG?
S1 Q3 T3 (the numbers are the leads - limb leads)
Tall (S), present (Q), inverted (T) respectively.
What are the typical ECG findings for pericarditis and what is the best treatment?
‘WIDESPREAD’ ST elevation (giveaway word) and PR depression. Treat with NSAIDS, it is all that works.
What does hypokalemia do to an ECG?
Shallow T wave (unlike huge T wave in hyperkalemia) followed by U wave.
Common side effects of asthma SABA’s?
tachycardia, restlessness, shakes. All just adrenergic stuff.
How can asthma cause both an alkalosis and an acidosis?
Initially it can cause an alkalosis as the patient is hyperventilating, but as they begin to tire out and decompensate, the CO2 will build up causing an acidosis.
Aside from Heart Failure, chronic disease of which two other major organs can cause bilateral leg edema?
Liver - albumin loss (can’t make it)
Kidney - albumin loss via proteinuria and RAAS fluid gathering.
How can rheumatic heart disease cause both mitral stenosis and regurgitation?
As a child - REGURG
As an adult - STENOSIS
Which two hand signs indicate infective endocarditis?
Janeway’s lesions and Osler nodes.
What is the typical gross cause of an S4 heart sound?
Pressure raise due to cardiac stiffening.
How is IBD diagnosed?
You must see it, need colonoscopy/gastroscopy.
Mnemonic for multiple myeloma symptoms?
CRAB
C - calcium (hyper)
R - renal damage (due to paraproteins)
A - anemia
B - bone lytic lesions
A stroke in which location could cause a vertical nystagmus?
Brainstem
A stroke in which location could cause a horizontal nystagmus?
Cerebellum
What are Heberden’s nodes?
Osteophytes in OA that can be seen clinically, not just on X ray
What is otorrhea?
Discharge from the ears
Explain Rinne’s and Weber’s tests. What would an eardrum perforation cause in regards to these tests?
Weber - middle of forehead. Lateralises any pathology but cannot specify nature of deficit.
Rinne - bone vs air. If bone > air - conductive. If air > bone, normal or sensory loss if pathology present from Weber.
Perforation can cause conductive hearing loss (due to eroding ossicles).
What is the chordae tympani?
The branch of the facial nerve that passes amongst the ossicles to provide taste to anterior 2/3 of tongue.
MOA of carbimazole?
Thyroid peroxidase inhibitor - stops TPO from iodinating tyrosine residues on thyroglobulin.
How could you localise which ear you are looking at just from the eardrum?
The malleus points upward anteriorly.
The main tracts of the spine I need to know are located where in the spine?
Ventral motor - ventral
dorsal medial sensory - dorsal
anterolateral spinothalamic tract - anterolateral direction, think next to ventral motor
Corticospinal tract - true lateral, above spinothalamic
Collapsing carotid pulse is typical of which murmur?
Aortic regurg - think blood is there i systole to form pulse but pulse rapidly drops due to low diastolic pressure as blood re-enters heart.
What is a murmur ‘grade’?
Loudness - not a measure of severity
Late peaking systolic murmur is typical of which murmur?
Aortic stenosis - mirror of early systolic murmur - doesn’t get going till after it should.
Explain the waves of the JVP and which murmurs could louden each wave type.
a and v wave - atrial wave and ventricular wave.
Atrial wave - right atrium contracts, strengthened by greater volume in atria during atrial contraction - tricuspid stenosis
Ventricular wave - right ventricle contracts, strengthened by greater volume in atria during ventricle contraction - tricuspid regurg.
How does inspiration/expiration impact loudness of mitral regurg?
Expiration makes it louder (heart closer to chest wall), inspiration makes it softer.
Do all pneumothoraxes cause trachael deviation away from impacted side?
No, only tension pneumothorax. Pleural effusion will push trachea away though.
The vast majority of chronic cough cases is caused by which 3 conditions?
COPD, asthma, post-nasal drip
What is the main clinical examination sign to look for in lung cancer?
clubbing
How could you tell if a sputum sample was dodgy?
Similar to urine sample - presence of squamous cells and if it looks too much like saliva and not sputum
When should you conduct spirometry?
when patient is WELL - establishes baseline
If they use steroids, what obstructive airway disease is most likely?
ASTHMA, not COPD
Features of COPD on CXR?
Hyperinflated chest and relatively smaller heart
Can smokers be on O2 supplementation at home?
No - it could blow up
What is the most common iatrogenic cause of venous dilatation?
Anti HTN drugs - cause more venous stasis
What are some causes of edema due to increased tissue permeability?
SEPSIS, burns and trauma as well
hypoalbuminemia can be due to which two broad systems?
Renal - losing albumin
Liver - not making albumin
Name 4 causes of lymphatic based edema.
- cancer
- parasites
- surgical intervention eg. mastectomy
- myxedema due to hypothyroid
How can edema be linked to thyroid disease?
Myxedema due to extreme hypothyroidism
Frothy urine is indicative of what?
Albumin in urine - proteinuria
Easy bruising can be a sign of which system failure?
Liver - not making coagulation factors
What molecule does the body naturally use to breakdown clots?
Plasminogen/Plasmin
Unilateral leg edema suggests what kind of issue in comparison to bilateral?
Unilateral suggests it’s a mechanical/local obstruction rather than a systemic issue.
Name 2 causes of non-pitting edema
- lymphedema
- myxedema
Which heart murmur can be diagnosed without auscultation and why?
Tricuspid Regurg -
can diagnose with prominent v waves, pulsatile liver and leg edema
What is the relationship between BNP and heart failure?
BNP is produced by the left ventricle in response to volume overload and is therefore a great test for heart failure. High BNP suggests HF. In a way BNP works to oppose the effects of RAAS
Which LFT enzymes indicate liver damage and which indicate biliary obstruction? Of the two liver ones, which is specific to the liver? Which is higher in liver disease?
The transaminases (AST and ALT) are for the liver and ALP and GGT are for the biliary tree. ALT is specific to the liver, AST is made in many places. ALT is higher than AST in most liver diseases EXCEPT alcohol damage which causes AST to be greater.
What is the most important Ix finding for haemachromatosis?
Transferrin Saturation is high
Aside from the GIT, where else is ALP made?
Bones
What clinical finding indicates haemachromatosis?
Bronze skin
An isolated raised bilirubin with no other abnormal LFTs is likely to be due to?
Haemolysis - cause of bilirubin release before liver.
Name 3 clinical signs of chronic alcohol abuse.
- Dupuytrens contracture
- parotidomegaly
- peripheral neuropathy
HCC can only be caused by which two things?
Hep B or Cirrhosis
Why might antibiotics be regularly given for ascites?
Spontaneous bacterial peritonitis is a risk with ascites
What is the most serious and red flag complication of chronic liver disease?
Varices - need regular scopes
Name one surgical and one medical prophylactic treatment for esophageal varices?
Banding and non-selective B blocker like propanolol
Explain hepatorenal syndrome.
Patients with liver damage have splanchnic vasodilation due to portal hypertension, causing low perfusion and thus activation of RAAS. The overactivation of RAAS causes an AKI due to renal artery vasoconstriction by ANG2.
Do both deep and superficial veins cause DVTs? Which DVTs are most likely to progress to PEs?
Typically only deep veins cause DVTs.
Proximal DVTs tend to become PEs (those at/above the popliteal region).
What is polycythemia?
Too many RBCs
An elevated JVP, loud P2 over the pulmonary valve and RV heave are consistent with?
PE!!!- Pulm hypertension leading to right heart strain and building preload.
What is the only reason you would use thrombolysis for a PE?
If it was a huge PE causing haemodynamic instability (hypotension)
When are SGLT2s contraindicated?
Low eGFR
Which hormones does somatostatin suppress?
TSH, insulin, GH, CCK
which consumed macromolecules induce CCK release?
Fat and protein
Mallory Bodies are present in which disease?
Liver damage
Which 4 factors will cause a rightward shift in O2:Hb association and what does this mean?
Increased CO2, H+, BPG, Temp will all cause O2 to fall off Hb easier
Run through the physiology of alcohol damage to the liver.
- chronic alcohol
- normal alcohol dehydrogenase pathway saturated
- cytochrome and peroxisomes recruited
- ROS made in excess
- Fat synthesis and oxidative stress occur
- inflammation
- stellate cells cause scarring of space of disse - impede liver function
describe the timeline of optic neuritis
SUDDEN vision loss - often colour goes first
What does a HbeAg positive mean on serology?
Hep B is currently replicating in the host
Distribution of chickenpox rash?
All over except palms and feet soles
What is primary sclerosing cholangitis?
Scarring of the biliary tree due to inflammation secondary to IBD.
How does PTH impact the kidneys?
Decrease phosphate resorption to increase free calcium
What Ix MUST be done if septic arthritis is suspected?
Arthrocentesis
tenderness on palpation of costophrenic angles typically relates to a pathology of which system?
renal
What might a CXR show with a peptic ulcer?
If perforated - pneumoperitoneum pushing up diaphragm
What will an untreated small bowel obstruction progress to?
Perforation
Name 2 causes of low MCV anemia.
iron deficiency and thalassemia
What are the two divisions of macrocytic anemia?
Megaloblastic (B12/folate deficiency - will have hypersegmented neutrophils) or non-megaloblastic.
Name 2 causes of haemolysis
Infection eg. malaria and sickle cell disease
List 3 causes of non-haemolytic normocytic anemia.
- bleeding
- low EPO from CKD
- anemia of chronic disease
What supplement is recommended during treatment with methotrexate?
folate
A pulsatile liver is related to which type of murmur?
Tricuspid
Which anti-HTN can you NOT use during APO?
Beta blocker
Which murmurs are louder on expiration and which on inspiration? (mnemonic)
lEft is louder on Expiration
rIght is louder on inspiration
How would aortic stenosis impact BP?
Lowers it - less blood escaping heart
Sudden cardiac death in young, fit people may be due to which type of cardiomyopathy? Which clinical sign may be heard (provided they’re not dead)
Hypertrophic Obstructive cardiomyopathy
S4 gallop
‘electrical alternans’ is med school codeword for what condition?
Cardiac tamponade
The P mitrale and P pulmonale P wave findings for atrial dilation are relevant to which ECG lead?
usually lead II
If there is an ECG qn on an exam and the vignette is post surgery, what should you be looking for?
PE
S1Q3T3
Name 1 Antibiotic for TB
Rifampicin
Which antibiotic class is gentamycin and name 2 side effects
aminoglycosides
Ototoxicity and nephrotoxicity
What is an easy trick to establish whether something is metabolic or respiratory on ABG?
If the pH and bicarb are going the SAME direction it is METABOLIC.
If they’re going different directions, it’s RESPIRATORY.
Compare BPPV, labyrinthitis and acoustic neuroma in terms of vertigo and accompanying symptoms.
BPPV - brief episodes regularly, no impact on hearing.
Labyrinthitis - prior URTI, really bad vertigo for weeks. Hearing loss. Sudden.
Neuroma - may not even notice vertigo due to slow growing nature. Hearing loss.
Stroke in the posterior circulation can cause which type of nystagmus?
Horizontal (cerebellar)
name the classes that accompany these suffixes:
- flozin
- gliptin
- tide
flozin - SGLT2 inhibitors
gliptin - DPP4 inhibitors
tide - GLP1 analogues
Why is high K+ in DKA misleading?
DKA causes acidosis, so the cells swap their K+ to take in H+ to try and mediate this but it gets to an extreme point where the cells are now potassium deficient - dangerous.
Compare venous and arterial ulcers.
Venous - poorly demarcated and shallow
arterial - well demarcated and deep
Low Hb + high urea should ring alarm bells for what?
Upper GI bleed - loss of Hb due to bleeding but blood is being digested and metabolised into urea
Compare medical vs surgical treatment of esophageal varices?
Medical. -non-selective b blocker like propanolol
surgical - banding
How can gastric vs duodenal ulcers be separated on history?
Worse with food - gastric
better with food - duodenal
List the haemorrhoid stages.
1 - internal
2- prolapse with spontaneous retraction
3 - prolapse with mechanical retraction
4 - prolapse with no retraction possible
Name 2 buzz phrases for ascites?
Shifting dullness, fluid thrill
What is the most common complication of gallstones?
pancreatitis
Which glucose channel does insulin upregulate?
GLUT4
How can liver damage impact platelet and glucose levels?
makes both low
Name 2 mineral based pathologies that can cause liver failure
Wilsons - copper
haemachromatosis - iron
What is the role of prostaglandins in kidney function?
PGE causes dilation (no matter where it is). In this case the dilation is of the afferent arteriole (this is part of the autoregulation). NSAIDS stop PGE production hence afferent vasoconstriction.
Compare urination frequency and volume in diabetes and in UTIs
Frequency AND volume up - diabetes
Frequency up but volume down - UTI
Explain diabetes insipidus and the two sites that can cause it.
Issue with ADH function leading to symptoms of diabetes (peeing a lot and thirsty) without actually having anything to do with sugars. Can be neuro (not enough ADH made) or renal (shit ADH receptors).
Name 3 causes of post-renal obstruction.
- stones
- cancer
- BPH
Which scan is best for renal stones?
CTKUB non contrast
If, on commencement of an anti-HTN drug, a person’s HTN skyrocketed, what would you expect?
Renal artery stenosis
What is sterile pyuria and what does it commonly indicate?
WCC high in urine but no organisms.
Indicates STI - gonnorhea or chlamydia
How does PTH impact phosphate levels?
PTH promotes kidneys to excrete phosphate whilst keeping calcium.
The immediate treatment for hyperkaemia is ______.
CALCIUM (calcium gluconate).
Compare the causes of the following in the urine:
- red cell casts -
- white cell casts -
- brown cell casts -
- fatty casts -
red - nephritic syndrome
white - pyelonephritis
brown - acute tubular necrosis
fat - nephrotic syndrome
What is the typical vignette for minimal change disease?
Nephrotic syndrome in a child, often with allergies
Compare the 3 causes of rapidly progressing glomerulonephritis - how could you differentiate them?
SLE - classic SLE features
Goodpastures (haemoptysis)
Granulomatosis with polyangitis (vasculitis, ANCA +, ENT bleeding)
Name a buzzword for both the histological and CT findings of idiopathic pulmonary fibrosis.
histo: fibroblastic focus
CT: honeycombing
Mnemonics for causes of upper lobe and lower lobe fibrosis:
Lower: RASIM
Rheumatoid arthritis
Asbestosis
Scleroderma
Idiopathic pulmonary fibrosis
Methotrexate (and other drugs)
Upper: SATS
Silicosis
Ank spon
Tb
Sarcoidosis
What is rhinophyma?
big nose due to alcohol abuse
Which anti-htn should you avoid in variant angina?
B blocker
What is shown here?
Bleeding peptic ulcer
What is shown in the following CXR?
Acute Gastric Dilatation
What is shown in the following CXR?
Hiatus Hernia
Which medical intervention is shown here and what is the diagnosis?
Barium swallow - achalasia
What is shown in this CXR?
Pneumothorax - left lung TOO clear - no signs of tissue, just air. Consolidated white area near heart is collapsed lung.
These two CXRs show two different severities of which condition?
Pneumoperitoneum
This scan shows an _____ _____ with _____ ______.
Extradural hematoma with midline shift
This scan shows what?
Apple core sign - bowel cancer growing around and into the lumen of the bowel, constricting the bowel.
What is shown in this scan?
Coffee bean appearance = volvulus.
Pointing toward the sigmoid area so it’s a sigmoid volvulus (as opposed to caecal).
What is shown in this scan?
Haemopneumothorax with subcut emphysema (trauma) as well as a potential pneumomediastinum
What is shown in this scan?
A kidney stone with mild subsequent hydronephrosis
What is shown in this scan?
Diverticulitis - gas filled (black) outpouchings of bowel alongside areas of thickened bowel walls (inflammation)
What does this ECG show?
First degree heart block
What does this ECG show?
Inferior STEMI
What does this ECG show?
LVH
What does this ECG show?
Mobitz 2
What does this ECG show?
Mobitz 1
What does this ECG show?
Ventricular pacing (pacing spikes + widened QRS)
What does this ECG show?
Dual chamber pacing
What does this ECG show?
Hyperkalemia - abnormally peaked T wave
What does this ECG show?
Hyperkalemia - worsening - bizarre peaks
What does this ECG show?
Severe hyperkalemia - sine wave appearance
What does this ECG show?
LBBB - WillaM
What does this ECG show?
Severe PE - S1Q3T3
What does this ECG show?
Pericarditis - widespread ST elevation, PR depression
What does this ECG show?
Hypokalemia - flattened T wave and presence of U wave
What does this ECG show?
Sinus arrhythmia
Which 2 molecules carry triglycerides around the body?
VLDL and Chylomicrons
Tenderness to palpation at the costophrenic angles relates to what organ system?
Renal/urogenital
List 4 causes of normocytic anaemia.
- lack of EPO
- anaemia of chronic disease
- haemolysis
- acute bleeding
P mitrale and P pulmonale ECG signs are located in which lead?
lead II
Salbutamol can cause which electrolyte disturbance?
hypokalemia
What causes a Mallory Weiss tear?
High pressure due to coughing or vomiting, alcohol too
what is the approximate urine cut off level to classify oliguria
0.5ml per kg per hour or less
Which type of dialysis can be done at home?
Peritoneal dialysis can be done at home. Haemodialysis directly involves the blood so really has to be done at hospital.
What are the 3 key cytokines that cause inflammation?
TNF-a, IL-1, IL-6
Best way to remember catalase and coagulase test for gram positive cocci differentiation?
First split is staph vs strep, ‘catalase’ is alphabetically before ‘coagulase’ so it’s the first test.
Coagulase is next up and it differentiates staph aureus (+) from all other staph species.
What are the main 2 regulatory cytokines?
TGF-B and IL-10
How to remember pharmacodynamics from pharmacokinetics?
pharmacoDynamics - all the D words. what DRUG DOES to body.
What are the broad targets of Th1, Th2 and Th17 cells?
1- intracellular
2- parasites
17 - extracellular
Mnemonic for hypersensitivities?
ACID
Allergy
Cytotoxic
Immune
Delayed
What levels do the 3 structures pass through the diaphragm?
8 - IVC
10 - esophagus
12 - aorta
What level is the transverse thoracic plane?
T4/5
Compare transudate to exudate.
Transudate - think transient fluid. Edema type buildup due to system failure like renal, heart or liver.
Exudate - has cells in it. It’s inflammatory. Infection, infarction or cancer.
How does digoxin work?
N/K ATPase blocker - keeps Na in cardiomyocyte for longer, Ca stays with Na. Allows for more Ca to build up.
Where are B1 and B2 adrenergic receptors located?
B1 - heart (and kidneys)
B2 - lungs
How does ezetimibe work?
Stops absorption of gut cholesterol
Mnemonic for lower lobe causes of restrictive lung disease?
RASIM (like raisin sort if :))
Rheuamtoid artheritis
Asbestosis
Scleroderma
Idiopathic pulmonary fibrosis
Methotrexate
What is fetor?
Smell
Which of the big 4 resp pathologies cause absent/reduced breath sounds?
All of them except pneumonia which causes coarse crackles.
The rule ‘more solid = better vocal resonance’ is true for all of the big 4 lung pathologies except for?
Pleural effusion - despite being more solid (liquid) the resonance is reduced, this is because the fluid is sort of acting as a wall stopping the vocal sounds in the lungs.
What WBC is dominant in COPD? What about asthma?
COPD - neutrophils that provide the proteases
Asthma - eosinophils
The Achilles reflex relates to which spinal level?
S1 and S2.
What spinal level does the stomach begin at?
L1
Which two molecules stimulate the pancreas to release digestive enzymes? Which of these causes gallbladder contraction?
CCK and Secretin.
CCK acts on gallbladder.
Name a common complication of central lung tumours and a common complication of peripheral lung tumours
central - obstruction
peripheral - pleural effusion
Where would you find Mallory Denk Bodies?
Liver damage
What does Cushing’s cause hypertension?
Cortisol has a minor mineralocorticoid reaction - leads to ENaC upregulation.
Describe the distribution of T3/4 in different body locations.
T4 is better at circulating so is higher in the blood, it is converted to T3 intracellularly because T3 is better at actually doing the job.
Describe the pathophysiology of CAH - congenitial adrenal hyperplasia
Adrenals have horrible response to ACTH, so low cortisol and aldosterone. The latter leads to salt wasting.
Testosterone production is fine.
List 6 deficiencies vegans are at risk of.
Iron, Zinc, B12, Vitamin D, calcium and selenium.
Which medication can be used to treat symptoms in hyperthyroidism?
Beta Blocker
Name one nerve, one bone and one muscle that could be the cause of hip drop.
Nerve - superior gluteal
Bone - greater trochanter of femur
Muscle - gluteus medius
How will renal osteodystrophy impact phosphate levels?
Damaged kidneys are unable to seperate Calcium from phosphate, get too much phosphate.
Which nerves supply sensation to the foot/toes?
Underside of foot = tibial (follows along from it being a posterior nerve)
Most of foot = superficial fibular
Big toe = deep fibular
Which leg compartment does eversion?
Lateral compartment
Which fungus commonly causes meningitis?
Cryptococcus
Which dermatome is the bottom of the foot?
S1
Mnemonic for the tarpal tunnel? (Flexor retinaculum)
Tom Dick And Very Naughty Harry
Lewy Bodies are associated with which disease?
Parkinsons
Meningitis + rash should raise suspicion of which cause of meningitis?
Neisseria
Of the two major motor paths (lateral corticospinal and ventral path) which controls the limbs?
Lateral corticospinal, the ventral path is more for central things like staying standing etc.
Down and Out eyes is typical of what pathophysiology?
Raised ICP impeding on CN3
Mnemonic for branches of the external carotid.
Seven Loud Femmes Arguing Over PMS
Superior thyroid
Lingual
Facial
Ascending pharyngeal
Occipital
Posterior Auricular
Maxilliary
Superficial temporal
Which cranial nerve controls blinking?
Blinking done by orbicularis oculis, muscles of face done by CN7
Do cranial nerves control contra- or ipsi- lateral areas.
All control ipsilateral areas aside from CN4 which deccusates.
what is celocoxib?
NSAID
alpha synucelin is a protein associated with which disease?
Parkinsons
Which bacterial cause of meningitis does NOT have a vaccine?
Listeria
‘Slapped cheek’ is caused by which virus?
Parvovirus
What is carbidopa?
A medication to treat the side effects of levidopa.
What does the embyronic endoderm become?
Resp + gut system
Compare the growth of BPH vs prostate cancer and what this means for symptoms/DRE.
BPH - grows peri-urethrally, less likely to feel on DRE but more likely to cause obstructive urological symptoms.
Prostate cancer - grows peripherally, more likely to be felt on DRE.
A rash on the palms and soles of the feet should raise a red flag for?
Syphilis
A neck of femur fracture could lacerate which nearby artery?
medial circumflex artery
Neonatal purulent conjunctivae is often caused by:
gonnorhea
Deafness in neonates may be caused by which virus?
CMV
What is the blood supply of the ovaries?
Suspensory ligament of ovary
The IVC is directly behind which anatomical pouch?
epiploic foramen
What is the most serious complication of SGLT2 inhibitors?
euglyceamic ketoacidosis
Pheochromocytoma occurs in which cell type?
Chromaffin cells in the adrenal medulla
What happens to amylase in pancreatitis?
Amylase RISES - think of inflammation squeezing all the amylase out of the pancreas
‘Trouble going down stairs’ related to an eye pathology is alarm bells for what pathology?
Damage to CN4, typically via trauma.
What does the parasympathetic nervous system do to pupil size?
Reduces (constricts) pupils.
Think of sympathetic drugs like MDMA making people’s pupils HUGE.
When do you stop aspirin for surgery?
You don’t.
What is the triad of anaesthesia?
Hypnosis, analgesia and paralysis
Why might a bowel obstruction be of worry to an anaesthetist?
Risk of aspiration of backed up bowel contents.
Which vital sign could show that an endotrachael tube has not been properly inserted?
if O2 sats fall after the tube has been inserted
Which common anaesthetic agent does NOT cause respiratory depression?
Ketamine
Tramadol impacts which 3 targets?
- serotonin
- opioid
- Noradrenaline
Outline the different placement of nicotinic vs muscarinic receptors.
Nicotinic - neuromuscular junction (control skeletal muscle)
Muscarinic - viscera
can think of muscarinic not doing muscles or that you need to move your muscle to get a cigarette (nicotine) to your lips
What is the main way to reverse paralytics?
Anti-acetylcholinesterases.
Paralytics function by impairing Ach at the nicotinic receptors. If you stop the breakdown of Ach you by acetylcholinesterases then it can build up and overwhelm the paralysis.
What level should a spinal anaesthetic be at?
L3-L4 to miss the L1/2 spine end.
What layer is a spinal injected into?
Sub arachnoid space
What are some risks with a spinal?
Infection, nerve damage, hypotension, HEMATOMA that compresses spine
What molecule can enhance the longevity of local anaesthetics?
Adrenaline
Name 3 groups of medications for neuropathic pain.
- tricyclic antidepressants - amytriptyline
- anti convulsants - gabapentin/pregabalin
- SNRIs - duloxetine
What is the antidote to opioids?
Naloxone
What are the 3 causes of ulcers (cause 95%)
- ischemic (arterial)
- neuropathic
- venous
Which ulcer factors are unique to neuropathic ulcers?
Usually painLESS and thus hidden away (eg. on sole of foot) where they worsen because patient cannot feel them.
What question could differentiate between leg claudication and critical ischaemia?
Does it occur at rest/at night.
What is the main cause of arterial occlusion in the legs and how could you localise where the occlusion is on examination?
Main cause: atherosclerosis
Localise by checking pulses. No pulse = no flow.
Sudden leg pain with a white leg probably indicates which condition?
Femoral artery embolic occlusion
Which type of shock is ‘warm’ and which is ‘cold’?
Warm - septic - because temperature
Cold - haemorrhagic because losing blood
Which medication can be used to dilate tubes in the urogenital system ie. dilate ureter for a stone and dilate urethra for a BPH obstruction?
ALPHA BLOCKERS
-osin drugs
Macroscopic haematuria (clots in urine not just pink colour) should ring alarm bells for what?
Urothelial cancer
Mnemonic for causes of heamaturia?
PRINTS
Prostate (cancer)
Renal
Infection
Nephritic
Thinners
Stone
Dullness to percussion indicates which 2 common lung conditions and how could you differentiate them?
Pleural effusion and pneumonia.
Pleural effusion will have absent breath sounds and pneumonia will have crackles.
What are the best ways to investigate pre-renal vs renal vs post-renal.
Pre renal - exam is king
Renal - urine is king
Post renal - imaging is king
What is Resonium?
Medication that binds to K+ in diet and causes us to shit it out to prevent hyperkalemia.
What are the two pillars of medical treatment for BPH?
Alpha blockers - to relax muscular component of prostate
5a reductase inhibitors - to atrophy glandular component of prostate
Compare an incarcerated hernia to a strangled hernia.
Incarcerated - non-reducible hernia
Strangled - ischaemic hernia
Acute onset, severe pain in the scrotum with nausea and vomiting should raise alarm bells for?
Torsion
What are the two examinations to help differentiate torsion from epididymo-orchitis?
Cremasteric reflex - stroke of inner thing should raise testicles - doesn’t happen in torsion.
Lift test - torsion pain is not relieved when testicles are raised
What are the 3 main causes of itchy skin?
Eczema, psoriasis and ringworm.
Which big 3 factors on examination/Hx seperate psoriasis from eczema?
SCALP ITCH
EAR RASH
JOINT PAIN
= psoriasis
Which body areas do eczema and psoriasis target?
FEEP
Flexor Eczema
Extensor Psoriasis
A ‘yellow crusty’ itchy area is likely what condition?
Impetigo - staph aureus skin infection.
‘Punched out erosions’ on the skin are a red flag for what condition?
HSV/VSV infection of the skin
Which factors seperate rosacea from other skin conditions?
IT IS NOT ITCHY, NOT SCALEY and DOES NOT SCAR. It is largely linked to sun exposure.
What is the main Ddx for rosacea?
Lupus - could come with joint pain
A sudden uncontrollable itch, especially on the hands and feet, and spreading to family members is probably which condition?
Scabies
What type of lesion should you never partially/punch biopsy?
Pigmented lesions
Where are BCCs usually located?
The neck and up
Describe a typical BCC under a dermatoscope.
A pearly pink/white lesion with telangiectasia (little red arteries on the lesion).
How could you seperate a Squamous cell carcinoma from a BCC with one question?
SqCC are PAINFUL, BCC are not
What is the most important pathology to rule out for TLOC?
Stroke
Mnemonic for steps in stroke management:
Call BEES
Call code stroke
Bloods x5 (FBE, Coags, LFT, UEC, glucose)
ECG
Examine on the way to scan
Scan - CT non contrast
What are the acute treatment options for ischaemic stroke? What are their positives and negatives?
Thrombolysis
- easy
- all vessel sizes
- within 4.5 hrs only
- bleed risk
Clot retrieval
- 6-24 hrs
- needs specialist team
- only large vessels
Syncope + headache: think ___
SAH
Syncope + chest pain: think ____
ischaemic of heart or arrythmia
syncope + dyspnea: think ____
PE
What is the relationship between AF and atrial dilation?
AF can either be as a result of atrial dilation (stretch of myocardium causing ectopics) or can itself cause atrial dilation (no proper atrial contraction leads to volume build up in atria and eccentric hypertrophy).
What are the CHADS-VASc and HAS-BLED scores?
CHADS VASC - risk of stroke in patient with AF
HAS BLED - risk of bleeding in anticoagulated AF patient
Name one physical and one medical treatment for acute supra-ventricular tachycardia.
Physical - valsalva maneouvre
Medical - adenosine
What is the end result of heart valve dysfunction?
heart Failure
What are the EDV and ESV in a compensating heart?
EDV is greater - more volume to expel
ESV is normal - hence the compensation.
Starling’s forces are raising CO to maintain stroke volume.
Which medication must be commenced with a mechanical heart valve?
Must be warfarin. DOACs unacceptable.
Name two findings on examination unique to aortic regurg.
- collapsing pulse (volume re-entering heart)
- widened pulse pressure (systolic strong by diastolic low due to loss of volume back into heart)
What are the two key diagnostic tests for haematological conditions?
Blood film and bone marrow biopsy.
List 3 features unique to AML/APML.
- Auer rods in faggot cells
- DIC - disseminated intravascular coagulopathy
- PML RAra mutation
Why might leukemia cause elevated LDH and urate?
Tumour lysis syndrome - big for leukemias. Urate will cause AKI.
Smear cells are typical of which cancer?
CLL.
name a unique treatment for ALL.
L-asparaginase - think - B-ALL is the one in kids because kids plays with BALLS. Kids hate asparagus, so that’s their yucky chemo drug.
Which leukemias typically cause organomegaly and which typically cause lymphoma-like symptoms?
CML and AML (with M) cause MEGALY.
CLL and ALL (with L) cause LYMPHOMA.
Why are bisphosphonates used in myeloma?
To counter bone degradation by bone lytic lesions.
What are the 3 ‘B symptoms’?
fever, night sweats, weight loss. NOT FATIGUE.
Compare the lymphadenopathy in infection vs lymphoma.
Infection - painful.
Lymphoma - firm and painless.
On histology, lymphocytes with clear white bubbles inside of them are typical of which cancer?
Burkitt Lymphoma
What is verapamil?
Cardio selective Ca blocker. Think of it as the opposite of amlodipine.
List 4 features of chest pain that would make it LESS likely to be ischaemic.
- sharp
- positional
- pleuritic
- reproducible
When to do a stress test and when to do coronary angiogram?
Low risk patient with ischaemia - can do stress test. If high risk, the stress test will just kill them.
Which parasite can commonly cause biliary obstruction and how would you test for this?
Ascaris. Check stool for eggs.
When do you thrombolyse an NSTEMI?
never.
What are Type1 and Type 2 AMIs?
Type 1 = STEMI or NSTEMI
Type 2 = demand ischaemia
What is the main contraindication for thrombolysis?
Active bleeding/head trauma
Name an endocrine cause for AF
Hyperthyroidism
Why would you do an ECHO and CXR for AF?
AF tightly linked with HF, checking for signs of HF or compensation, eg. dilated atria
Which medications should be avoided in Wolff Parkinson White?
Anything that targets the AV node, primarily adenosine and cardiac calcium channel blockers.
Which is safer in AF, rate or rhythm control?
rate
How can obesity impact resp function?
obesity can cause a restrictive lung disease
What are the two key investigations for Guillian Barre?
Lumbar Puncture and nerve conduction studies
What is myotonic dystrophy and what is a hallmark sign?
Myotonic dystrophy is a type of muscular dystrophy. Hallmark - atrophy of muscles AND inability to relax muscles once contracted. Classic example: can’t release fist when clenched
What is the O2 saturation aim for a COPD patient?
88-92%
What is pulsus parodoxus and what condition typically causes this?
Fall in BP on inhalation - typical of cardiac tamponade
Compare stridor to wheeze.
Stridor - upper resp
Wheeze - lower resp
Mnemonic for findings of HF on CXR?
ABCDE
Alveolar edema
B-lines (kerly)
Cardiomegaly (beware AP films)
Dilated pulmonary vessels
Effusions
Compare the causes of a bilateral vs one-sided pleural effusion.
Bilateral - more likely to be a systemic (transudative) cause.
Unilateral - more likely to be a local issue like infection.
What is the hallmark of myasthenia gravis and what is typically the earliest sign?
Typical: muscle weakness that worsens with use and improves with rest
Earliest sign - typically eye changes like double vision (diplopia) or eyelid sagging (ptosis).
What are the 3 major causes of exudative pleural effusion?
Cancer, pneumonia, TB.
How does estrogen impact bone density?
Estrogen increases OPG, OPD binds to RANK-L to stop its activation of osteoclasts.
What is mupirocin and it’s indications?
Antibiotic used for skin infections, mainly impetigo.
Why does liver damage impact platelet level?
Liver makes thrombopoieton which stimulates platelet growth
Which initial imaging technique would be indicated in a suspected bowel obstruction?
Erect and supine abdominal films
In what ways can the parasympathetic nervous system impact cardiac output?
Only via heart rate not stroke volume
Which broad class of drug is contraindicated in heart failure?
Calcium Channel Blockers
Name a histological finding in an MI that would appear within 24 hrs of the MI.
Contraction band necrosis
‘short, rotated leg’ is med school code for which pathology?
Neck of Femur fracture
‘orphan annie eyes’ + ‘coffee bean cells’ are descriptors of which pathology on histology?
Papillary thyroid carcinoma
If a patient has TOO much calcitonin, which neoplasm may be responsible and which genetic condition could be at play?
Medullary thyroid carcinoma - ALWAYS THINK M.E.N SYNDROME WITH THESE CASES - look for pheochromocytoma
Strengthening which muscles could help to relieve pain from knee osteoarthritis?
Quads, hamstrings and calves.
What is the generic name for the osteoporosis drug Prolia?
Denosumab
Left homonymous hemianopia could be due to a lesion in which 2 locations?
RIGHT optic tract or RIGHT occipital lobe (eg. optic radiations)
A large goiter can impact which nerve?
Recurrent laryngeal
Which neonatal/peadiatric infection can cause pancreatitis?
Mumps
What are purpura?
Bruises essentially, caused by low platelets.
Which medications are involved in a standard induction for anaesthesia? What about maintenance?
Induction - fentanyl for analgesia and propofol for hypnosis.
Maintenance with volatile agents eg. Sevo
Which spinal layer does a spinal anaesthetic go in?
sub-arachnoid space
What is the most common indication for a fascia iliaca nerve block?
HIP FRACTURES
If someone has a gout flare up but also have chronic renal disease, which treatment is best?
Steroids - prednisolone. Can’t give NSAIDS due to renal damage.
Where is a colle’s fracture located?
Wrist fracture
What is the Schober test and what is it used for?
The bend and touch your toes test - used to diagnosed spondoarthropathies. ESPECIALLY ANK SPON.
How could you differentiate neurogenic claudication from vascular claudication?
Neurogenic claudication (due to spinal stenosis) will not have any of the vascular sequalae, eg. pulses will be normal.
Which imaging is best for spinal stenosis?
CT
Sudden ischemia is typically due to what?
An embolus (as opposed to a local thrombus that will cause gradual worsening ischemia).
What is the best scan for an AAA?
CT
Which resuscitation fluid is best for a ruptured AAA?
They are profusely bleeding so blood is needed.
A hypovolemic patient with a pulsatile abdominal mass is typical of which pathology?
Ruptured AAA
What are the 3 skin sequelae of chronic venous insufficiency?
- varicose eczema
- lipodermatosclerosis
- ulcers
A patient presenting with typical renal colic pain with a temperature likely has what pathology? What would be the immediate treatment?
Infected obstructed kidney. Urology need to put in a nephrostomy or a stent in prior to surgery.
Macroscopic haematuria should be treated as what until proven otherwise?
Urothelial cancer
The most common cause of an SAH is trauma. What is the most common non-traumatic cause?
Aneurysm
What is risonium?
Medication that binds to dietary potassium to prevent absorption in hyperkalemics.
What investigation must be done in meningitis before a diagnostic lumbar puncture is performed?
CT head to ensure no raised ICP that may lead to coning following a lumbar puncture.
What are the 4 pillars of meningitis empiric therapy?
Ceftriaxone, Penicillin, Dexamethasone, Vancomycin (+/-)
What is the best imaging for testicular torsion?
Ultrasound with Doppler
What is overflow incontinence?
Incontinence due to a full bladder - could be a neurological or obstructive picture.
What is the Phalen’s test for?
Carpal Tunnel
Which surfaces are usually affected by eczema vs psoriasis?
PEEF
Psoriasis is Extensor
Eczema is Flexor
Compare skin prick testing to patch testing.
Skin prick - immediate reaction testing type 1 hypersensitivities.
Patch test - delayed reaction (48hrs) testing for Type 4 hypersensitivities
What is the most common cause of contact dermatitis?
Nickle
Which 3 body areas are uniquely targeted by psoriasis?
Scalp
Ears
Buttcrack
What are the 2nd and 3rd line treatments for psoriasis?
2nd - phototherapy
3rd - methotrexate
What is permethrin used for?
Topical treatment of Scabies.
What is the ‘post-exposure’ treatment for HepA?
vaccination
Actinic (Solar) keratosis is a precursor to which dermatological condition?
squamous cell carcinoma
Which melanoma factor directly relates to mortality?
depth
What are the 3 broad steps in treatment of melanoma?
- Check the rest of the skin
- Excisional (NOT PUNCH) biopsy
- Wide local excision surgery
Which fungus causes ringworm?
Tinea Corporis
Mnemonic for steps in suspected stroke?
Call BEES
Call code stroke
Bloods x5 - FBE, UEC, LFT, Coags, Glucose
ECG
Examinations to rule out other causes on the way to:
Scan - CT non contrast
What will you see on a CT non contrast for an acute ischemic stroke?
Nothing really. There would be loss of grey matter differentiation about 5 days post stroke.
Which type of syncope classically occurs in a crowded area?
Vasovagal
What are the two main causes of Long QT syndrome? (aside from medications)
Electrolyte imbalance and genetic pre-disposition
Describe the impacts of different murmurs on pressure/volume and heart remodeling.
STENOSIS will cause increased pressure in the prior chamber as the doorway is smaller. - CONCENTRIC HYPERTROPHY
REGURGITATION will cause increased volume as the blood flows back through the door. ECCENTRIC HYPERTROPHY
Longer INR, Longer APTT and low fibrinogen represent which pathology?
DIC - disseminated intravascular coagulopathy. Typical of AML.
On histo, if there were more WBC than RBCs, what would you be thinking?
haem cancer
Smear cells on histo are typical of which pathology?
CLL
Monoclonal antibody for lymphoma?
Rituximab
Which two main pulmonary pathologies can cause full white out of a lung on CXR - how could you tell them apart?
Collapsed lung - trachea moves toward white
Pleural effusion - trachea moves away from white
What shape do the pulmonary arteries form on CT and what pathology should you look for there?
Sideways ‘Y’ shape.
Look here for PEs.
Why does tension pneumothorax actually kill?
It tamponades the IVC.
Pneumothorax CXR findings?
DRMT
Diaphragm flattening
Rib splaying
Mediastinal shift
trachael deviation
Compare the management of Type A vs B aortic dissection.
Type A - must be surgical due to risk of dissecting heart.
Type B - medical management
diplopia and trouble going down the stairs is common for pathology of which cranial nerve?
CN4 Trochlear
Dilated pupil, Drooping eyelid and a laterally leaning eye may be indicate of which cranial nerve pathology?
CN3 oculomotor damage
Retinoic acid and arsenic are common treatments for which disease?
APML Leukemia
What is iloprost?
IV prostacyclin injection to vasodilate fingers in Reynauds
What causes the lap belt sign and what organs are at risk?
Typically a MVA causing tightening of the seatbelt around the tummy. Lumbar spine fractures and a huge risk as well as pancreas, liver, kidneys and spleen.
Which antibody is unique to scleroderma?
SCL-70
Which medication can help maintain the health of bones in myeloma?
Bisphosphonates
What are the top 3 differentials for upper GI Bleed?
Varices, ulcers, malignancy.
List the 3 broad causes of splenomegaly.
- Portal HTN
- infection eg. EBV
- haematological cancers
What are the key imaging techniques for breast cancer?
Mammogram (x-ray) and breast ultrasound
Removal of all of the lymph nodes in an area makes the area at risk of _______.
Lymphedema
What is Tamoxifen?
A SERM - selective estrogen receptor modulators.
Great drug as it stops the activity on estrogen on breast tissue (a cause of cancer) but acts like estrogen on bone, so less chance of osteoporosis.
What is anastrozole?
An Aromatase inhibitor - stops the production of estrogen. Essentially creates early menopause.
What is colchicine?
An acute treatment for gout
What are the key 3 things to report when describing an ECG?
rate, rhythm, broad/narrow.
A broad QRS complex indicates an issue originating where?
The ventricles
What are the top 2 electrolytes to check in abnormal heart function?
Potassium and Magnesium
Aside from the joints, Ank Spon can commonly affect which two other systems?
Eyes and Lungs
What is the span of a normal liver?
12cm
Compare a lupus facial rash to a dermatomyositis facial rash.
Lupus tends to spare the naso-labial folds whereas dermatomyositis does not
How can scleroderma involve the mouth?
Patients often cannot fully open their mouths
Myocarditis secondary to coxsackie B virus is a cause of which cardiomyopathy?
Dilated
What is the most common type of cardiomyopathy and which social factors may contribute to its development?
Dilated cardiomyopathy. Alcohol and cocaine may cause it.
Sudden death/syncope in athletes may be due to which cardiomyopathy?
Hypertrophic cardiomyopathy
Acute pericarditis is often complicated by which pathology?
Pericardial effusion
_____ cardiomyopathy is often due to stiffening of the heart due to sarcoidosis, amyloidosis or post radiation fibrosis.
Restrictive
How can an NG tube impact acid/base balance?
Can cause metabolic alkalosis due to suctioning out acid from stomach
Anaesthetised patients will likely experience which acid/base imbalance?
Respiratory acidosis
What level of base excess is relatively severe?
5/-5 or above is severe
What is the treatment for MS?
Steroids and Mabs
List some complications of chronic steroid use:
insomnia, diabetes, weight gain, immune suppression, osteoporosis.
What is anti-phospholipid syndrome and what is the main complication?
Congenital autoimmune illness - MUCH greater risk of clots.
Neurodegenerative disorders tend to kill patients via which process?
Respiratory Depression
Young stroke patients should be checked for which stroke aetiologies?
Patent foramen ovale and dissected vertebral artery.
Severe OA, swelling and damage in a diabetic foot is most likely due to:
Charcot’s foot - diabetic neurogenic arthropathy)
What is the common diagnostic tool for pericardial effusion/tamponade?
ECHO
What is the emergency treatment for unstable tamponade?
Pericardiocentesis
Scarring of the SA node and bouts of tachycardia/bradycardia are symptoms of which pathology?
Sick sinus syndrome. Pacemaker but be careful.
List 3 broad infection groups typically responsible for reactive Arthritis?
GIT infections, STIs and parvovirus
Which bacteria is typically implicated in Guillian Barre?
Campylobacter
What are the two main common side effects of a radical prostatectomy?
Impotence and incontinence
Which type of therapy is best to deal with palliative bone mets?
Radiotherapy
Why don’t prostate cancer bone mets typically raise calcium levels?
Unlike other bone mets, they are typically sclerotic not lytic
What are the two main markers for testicular cancer and how can these be used to monitor disease after an orchidectomy?
Beta HCG and alpha fetoprotein - should return to normal with removal of the cancer
How may seminomas vs non-seminomas be described on palpation?
Seminoma - slow growing, smooth.
Non-seminoma - fast growing, irregular.
Why can testicular cancer cause back pain?
Migration to para-aortic lymph nodes.
Compare heamaturia in renal cell carcinoma vs transitional cell carcinoma?
RCC bleeding is rare.
TCC bleeding VERY COMMON - macroscopic haematuria
Compare nephrectomy in RCC vs TCC?
RCC often only requires a partial nephrectomy due to local impact.
TCC that spreads up the ureter to the renal pelvis requires a total nephrectomy.
Winging of the scapula can be due to a defect in which nerve?
Long thoracic nerve
Which two conditions cause ‘copious’ amounts of sputum?
BRONCHIECTASIS (main one), and COPD
What is the link between bronchiectasis and infections?
Infections cause mucus secretion, poor clearance leads to mucus plugging and more infections. Vicious cycle.
‘Frothy pink sputum’ is pathognomonic of which condition (in MCQ not real life)?
Heart failure
List cardio, GIT and resp causes of clubbing:
Cardio - endocarditis
GIT - IBD, cirrhosis, celiac
Resp - everything except COPD
List 3 paraneoplastic syndromes caused by small cell lung cancer.
- PTPrp
- SIADH (produces ADH)
- ectopic ACTH
What is Light’s Criteria?
How to determine whether a pleural effusion is transudative or exudative. LDH or protein of aspirate / serum level of over 0.6 means the aspirate is full of LDH and proteins and is therefore an exudate.
Surgical treatment for repeated pleural effusions?
Pleurodesis
What is biPAP used for?
biPAP, unlike CPAP, works on CO2 as well as oxygen. It is therefore key in treatment of type 2 respiratory failure
What are the 3 pillars of acute COPD exacerbation treatment?
Antibiotics, bronchodilators, steroids
Antibiotics for ‘walking’ (atypical) pneumonia?
Think of causes - LCM.
C is chlamydia.
Treat chlamydia with doxy or azithro.
Is a low RR in asthma a good thing?
No - low RR indicates decompensation and fatigue - they are in danger, need ICU.
Pulmonary hypertension can cause which type of murmur?
Tricuspid murmur
What would be part of a stroke workup?
ECG/Holter to check for AF
ECHO to check for clots/atrial dilation
Carotid Doppler
Which major circle of willis artery feeds the brainstem?
PCA
List 5 causes of peripheral neuropathy.
Diabetes
B12 deficiency
Alcohol
Chemo
Autoimmune
ABCDE
Autoimmune, B12, chemo, diabetes, ETOH
What is intussusception?
Intestine telescopes in on itself - common in kids
Which major circle of willis artery feeds the cerebellum?
PCA
How to clarify what someone means by being dizzy?
Do they mean lightheaded or do they mean the room/floor is spinning (vertigo).
List 3 major body systems impacted by methotrexate.
Lungs - ILD
Liver - toxicity
Bone marrow - pancytopenia
ALSO - fertility (teratogenic)
What is the worst side effect of poorly controlled celiac?
Lymphoma
What is the main electrolyte we care about in refeeding syndrome?
Phosphate (surg of ATP synthesis mops up all the phosphate)
How long after a stroke until someone can drive?
4 weeks after neuro deficits stop
List 4 causes of liver disease:
NAFLD, alcohol, haemachromotosis, hepatitis.
Why might ascites cause dyspnea?
Ascites physically limit chest expansion
Does NAFLD cause bilateral edema?
NO - only a fully cirrhotic liver will cause edema
What is hepato-renal syndrome and what is the prognosis?
Repeated kidney damage despite fluids due to splanchnic vasodilation. Patient will die without liver transplant.
Which IBD can be rectal sparing?
Crohns. UC really isn’t ever rectal sparing.
Why does weight loss help GORD?
Reduces intra-abdominal pressure
Aside from cancer, which other pathology may cause solids but not liquids to be trapped in esophagus?
Osephageal stricture
Bruising around the umbilicus is pathognomonic for?
PANCREATITIS. Cullen’s sign.
List 3 indicators of pancreatitis severity.
WCC raised.
Hypocalcaemia.
Hyperglycemia.
LDH increased.
What scan diagnoses cirrhosis?
Fibroscan
A raised alpha fetoprotein is indicative of which two diseases?
HCC and testicular cancer
Chronic pancreatitis will display which feature on X-ray?
Calcifications
What is the main investigation for pancreatic insufficiency?
Feacal elastase
A celiac patient presents with a rash, what is the likely diagnosis?
Dermatitis herpetiformis
List 3 causes of REALLY high AST/ALT
viral hepatitis
panadol overdose
ischemic liver
Antidote for panadol?
NAC - N-acetyl cysteine
What is DCR?
Direct Cardioreversion
Should steroids be used for stroke/cerebellar haemorrhage?
NO - the increased glucose from steroids will increase cerebral edema. Makes ICP worse
Which of the BASS Heart failure drugs cannot be given acutely? Which drug IS used acutely that is not part of BASS?
Beta blocker - decompensated heart needs the HR. Must wait till they have improved to give this (euvolemic).
Frusemide in acute setting.
What medication should always be given with prednisolone?
PPI due to ulcer risk
Compare the treatment of stable vs unstable VT.
Stable - pharmacological cardio reversion (amiodarone)
Unstable - DCR
Mnemonic for acute MI Tx:
MOANA
morphine
Oxygen
Aspirin
Nitrates
Anticoagulants
Name two main cardioversion drugs:
Amiodarone and sotalol
What is ‘electrical alternans’ on an ECG?
alternating amplitude of QRS pathognomonic of cardiac tamponade
What is pulsus paradoxus?
Drop in BP on inspiration associated with cardiac tamponade
What are the steps in DKA management?
- FLUID
- Insulin once rehydrated (risk of cerebral edema if glucose enters cells whilst patient is still dehydrated)
- Manage potassium level
- Address the cause
Is Hashimoto’s thyroiditis tender or non-tender?
Non-tender
Compare tonic-clonic and absence seizures.
Both are generalised seizures (occur across the entire brain) but tonic-clonic is the classic seizure and lasts around 5 minutes.
Absence seizures last up to 10 seconds and cause the patient to lose awareness, they zone out.
Compare an unaware focal seizure to a generalised absence seizure.
Unaware focal - often minutes long and may have stereotypical characteristics like lip smacking, picking, patting etc).
Absence seizures are very short, up to 10 seconds but present very similarly. They may not have the lip smacking etc but may have facial twitch
Does syncope cause convulsions?
It can! So don’t assume seizure without a careful history. Temporary hypoxia to the brain in syncope can cause convulsions.
Which seizure type is most common in children (under 8)?
Absence
Which history finding is specific to epilepsy?
Tongue biting
What are the 2 major differentials for seizure (not including syncope which doesn’t cause true seizure).
- TIA but loss of consciousness uncommon
- Pseudoseizure
What is a pseudoseizure?
Up to 40 minute long seizure that is psychogenic in origin and fluctuates in intensity for the 40 minutes.
What is the initial Ix for seizure and what is the best Ix?
CT head is first to ensure it’s not a stroke or bleed.
Then EEG is gold standard.
MRI will show nothing in epilepsy.
What does an EEG show in pseudoseizure?
nothing
List one medication you could use to treat a seizure whilst it is happening and one long term medication to prophylactically prevent seizure.
Acute - a benzo eg. midazolam
Long term - carbamazapine
What is the mechanism behind breastfeeding preventing ovulation?
Breastfeeding promotes prolactin production, prolactin inhibits GnRH so LH and FSH levels are suppressed, preventing ovulation.
What is the ‘triple test’ for a breast lump?
- History and exam
- Imaging - ultrasound and mammogram
- non-excisional biopsy
A lump in the breast in a young woman, often found during pregnancy, is likely to be what pathology?
Fibroadenoma.
They are hormonally responsive so often appear in pregnancy.
They may or may not be tender
A breast lump that appears over a matter of days and is very painful is likely to be which pathology?
A cyst
Odd discharge from the nipple is indicative of which group of breast pathologies?
Ductal pathology
Nipple retraction/dimpling is suspicious of which pathology?
Breast cancer (peu d’orange sign)
Which type of breast cancer is the most common?
Ductal adenocarcinoma of no specific type
What is a classic sign of breast cancer on mammogram?
Micro-calcifications
Which spinal column is checked by the Babinski reflex?
corticospinal tract
‘saddle anaesthesia’ is typical of which pathology?
Cauda equina
What is the most immediate course of action to take if you suspect urinary retnetion?
Catheter
List pathologies that could cause cauda equina compression in each of these layers: extradural, intradural but extramedullary, intramedullary.
extradural - abscess, bone/disc degeneration, metastatic tumour.
intradural but extramedullary - meningioma
intramedullary - glioma
Urinary incontinence is typical of which pathology?
Cauda equina. Though very late spinal compression will also present this way.
What is the most common bacteria that causes an epidural abscess?
Staph aureus
What is the treatment for spinal abscess?
Surgical drainage and broad spectrum antibiotics
A raised ICP associated with a astrocytoma should be treated with what drug?
steroids - though steroids are contraindicated in many other causes of raised ICP
Histology of a GBM will show which classic feature?
Pallisading necrosis
How do brain tumours tend to initially present?
With the raised ICP symptoms - especially headache and seizure, also drowsiness
New seizures in adult patients should always be treated as ______?
Brain cancer
Large ‘swirls’ on histo is typical of which pathology?
Meningioma
What spinal level is the umbilicus? (give both dermatome and physical level)
T10 supplies the umbilicus dermatome but the actual level is around L3-4.
List the 3 nerves of the hip joint
Femoral nerve, obturator nerve and superior gluteal nerve.
Which LFT is commonly raised in various bone pathologies?
ALP
What lifestyle change is KEY in hip osteoarthritis?
Weight loss
Compare the abdo x-ray findings of a distal vs proximal bowel obstruction.
Distal - most of the bowel will be dilated as it’s all backed up.
Proximal - most of the bowel will be normal
What is Riggler’s sign?
Two distinct gas bubbles where the gastric bubble is on X ray - one is the gastric bubble but the other is evidence of pneumoperitoneum.
What are the three major causes of colitis, how would you differentiate them?
The 3 I’s.
Inflammation - will be in context of IBD etc or in a young patient with new IBD.
Ischemia - flexures targeted as they are watershed areas
Infection
What is the KEY question to ask when a patient presents with macroscopic haematuria?
Painful or painless?
Painless = TCC
painful = likely to be a stone.
A young person with hypertension should really be screened for?
Renal artery stenosis
Tx for a post-op wound infection?
Drainage and Abx
What are the antibiotics used for acute pyelonephritis associated with hospitalisation?
Ampicillin/Amoxicillin with gentamycin or cipro.
If a patient needs Piptaz but has a penicillin allergy what would you give instead?
Cipro (PA cover) and vanc
What is the anticoagulation duration for DVT/PE?
3 months
What is the main treatment goal of osteoporosis?
Reduce fracture risk
List, in order, the treatment options for estrogen related osteoporosis.
- SERM eg. tamoxifen
- Bisphosphonates
- Denosumab
What is the most worrying side effect of bisphosphonates?
Osteonecrosis of the jaw
Why are bisphosphonates dangerous in CKD?
CKD leads to poor reabsorption of calcium leading to hypocalceamia (and secondary hyperparathyroidism), if bisphosphonates stop osteoclast activity there is a severe risk of hypocalcaeamia
What is secondary hyperparathyroidism?
Hypocalcemia with origins outside the parathyroid gland, typically renal disease. PTH is high in secondary hyperparathyroidism.
Fluffy consolidation around a joint or bone on X-ray in a young person with unilateral bone pain is likely to be?
Osteosarcoma
What are 3 surgical options for improving spinal canal stenosis?
Laminectomy, discectomy, vertebrectomy.
What are aperients?
Laxatives
What are hectic fevers and what pathology are they assoicated with?
Great swings in temperature - associated with abscesses
How will X-rays appear in infective knee pain eg. SA or OM
Totally normal until 1-2 weeks after the infection
What is the biggest risk of lowering glucose too fast in DKA?
Cerebral edema - low glucose in blood but maintained glucose in brain will cause water to move into the brain
What is the best imaging for a knee effusion?
Ultrasound
What colour aspirate is normal from a knee?
Translucent clear/yellow liquid
What is celecoxib and why would you use it?
A COX-2 selective NSAID. It has a lower risk of peptic ulcers (so good for long term) but can still cause renal damage like all NSAIDS
Which acute analgesia would you use for RA and which 3 medications would you use in the long term?
Acute - celecoxib
Long: methotrexate, folic acid, prednisolone.
List 7 side effects of methotrexate.
- hair loss
- liver toxicity
- leucopenia
- thrombocytopenia
- GI toxicity
- ILD
- pneumonitis
- NOTE - doesnt directly cause renal damage but is renally cleared so need to be careful
Which Mab would you start for RA if methotrexate was not enough?
A TNF Mab - infliximab or adalimumab
What are the 3 pillars of osteoporosis management?
Bisphosphonates, Vit D and Denosumab
How can steroids or NSAIDS cause pernicious anaemia?
Steroids and NSAIDS can cause gastritis if used for long enough. Gastritis will lead to poor functioning/release of intrinsic factor which will lead to a B12 deficiency and anaemia.
What are the 3 mainstays of acute gout treatment and what is a long term drug for gout?
Colchicine, NSAIDS and prednisolone.
Long term - allopurinol (never in acute setting as it can make it worse).
What does ferritin tend to do in infection/inflammation?
It goes up - body stores iron away in an effort to sequester it from potential iron-loving bacteria
Name the rash that can occur in celiac
dermatitis herpetiformis
Which infection classically causes Guillian Barre?
Campylobacter
Which two broad groups of infections tend to cause reactive arthritis?
GIT infections and STIs (and parvovirus)
What is a key modifiable factor for OA?
WEIGHT. Especially for knee OA.
What are the 4 key features of Giant cell Arteritis?
- scalp tenderness
- jaw pain
- new onset headache
- visual change
A patient with Giant Cell Arteritis with proximal shoulder/neck pain is likely to also have which ‘sister’ pathology?
Polymyalgia rheumatica
What is the key acute treatment for GCA?
Steroids
Gold standard for GCA diagnosis?
Temporal artery biopsy
Red aspirate from a joint indicates what? What about cloudy yellow/white aspirate?
Red - haemoarthrosis (trauma)
Cloudy - infection
Which set of symptoms is classic for GPA - granulomatosis with polyangitis?
Saddle nose/epistaxis
Dermatophytic fungal infections predispose to which bacterial infections?
Cellulitis
Burns patients risk which major pathogen?
Pseudomonas aurigenosa
What is the typical gas gangrene/nec fasc organism?
Strep Pyogenes
Compare spinal involvement in RA vs OA.
RA spinal involvement is rare.
OA spinal involvement very common
Are all RA sufferers sero-positive?
No, around 50% of RA patients are both anti-CCP and rheumatoid factor negative.
What is a worrying side effect of hydroxychloroquine as a DMARD?
Eye toxicity
What do the O and [ / ] symbols mean on an audiogram?
O = air conduction
[ / ] = bone conduction (straight like bones)
Which organisms tend to cause otitis externa and what is the Tx of choice?
Pseudmonas is the main one and Staph aureus.
Ciprofloxacin drops +/- steroids are a good first line
Why is it imperative to do a cranial nerve exam on otitis externa patients?
MALIGNANT OTITIS EXTERNA
- where otitis externa spreads to skull base and starts impacting cranial nerves
A neonate who has had a cold and been holding his ear whilst crying non-stop suddenly stops crying and is quite well aside from occasionally rubbing his ear and having ear discharge on his pillow. What is the diagnosis?
Otitis media with relief due to perforation.
Which group of organisms tend to cause otitis media?
Resp/pharyngeal organisms
Compare the pain caused by wiggling a patients ear in otitis externa vs media.
Externa - wiggling will cause pain
media - no pain
What is the typical antibiotic for otitis media?
Amoxicillin/augmentin
What is the only antibiotic eardrop appropriate for a perforation?
Ciprofloxacin - the rest are ototoxic
What is glue ear and what is the treatment?
An otitis media infection with effusion - pressure buildup.
Treatment is GROMMETS.
What is a cholesteatoma?
In the context of perforation, the outer ear’s squamous epithelium may grow into the middle ear causing PAINLESS OTORRHEA. Can burrow into brain so must be treated
What is the treatment for cholesteatoma?
Tympanoplasty +/- mastoidectomy
Unilateral ear pain with normal otoscopy is _______ until proven otherwise.
Head/neck cancer.
Due to involvement of cranial nerves which pass near ear.
How can otitis media cause facial palsy?
CN7 the facial nerve travels through the ear (think chordae tympani)
Ear pain with crusty lesions in ear canal and facial palsy is very suspicious for ____.
VZV (Ramsey Hunt if it impacts the facial nerve)
What is the treatment for Ramsey Hunt?
- steroids
- valcyclovir
- TAPE EYE SHUT !!!! - risk corneal damage if it cannot blink
Which gland does the facial nerve pierce?
Parotid
Vertigo for around a minute with no hearing involvement is typical of ____?
BPPV
What is the treatment for BPPV?
Epley maneouvre
Vertigo following illness is suspicious of?
Vestibular neuritis
Episodes of vertigo lasting hours with nausea and vomiting and tinnitus is typical of _______.
Meniere’s disease
If you suspected Meniere’s, which other diagnosis would you want to rule out and how would you do it?
Rule out acoustic neuroma. MRI.
If a growth moves on swallowing it is most likely related to which organ?
Thyroid
Compare leukoplakia and erythroplakia. What are they and what do they indicate in terms of future progression?
Leukoplakia - ‘white plaques’ - in mouth. pre-malignant for squamous cell carcinoma.
Erythroplakia - red plaques in mouth. MUCH worse. 50% chance of squamous cell progression.
Compare tonsillitis to peritonsilar abscess (quinsy).
Tonsillitis usually bilateral. Abx.
Quinsy one-sided and usually pushes tonsil forward or back. Can cause airway obstruction, very dangerous.
How could you differentiate EBV from tonsillitis?
EBV is more systemic with widespread lymphadenopathy as well as hepatosplenomegaly.
What is Ludwig’s angina and what typically causes it?
Dental abscess (typically due to dental work) that may push airway shut - can’t be sedated or go to imaging. Need tracheostomy.
24/7 hoarse voice even without prior strain is suspicious for?
Laryngeal cancer (SqCC)
Progressive dysphagia is suspicious for?
cancer
Key acute medications for upper airway obstruction?
Dexamethasone (ENTs Vitamin D) and adrenaline
What type of epithelia is in the upper resp tract?
Until the lungs, all of the upper resp tract (nose included) is pesudo-stratified columnar epithelium.
Remember the resp system is the opposite to the GIT where upper GIT is all squamous until columnar stomach. Inverse is resp.
Persistent and chronic middle ear effusions despite antibiotics are ____ until proven otherwise.
Nasal tumours
Name 3 signs of a skull base fracture.
- racoon eyes
- CSF leak from nose or ear
- blood behind eardrum
- subconjunctival haemorrhage
What is a septal hematoma?
Collection of blood (due to trauma) in the nasal mucosa. Can cut off blood supply to nose causing cartilage necrosis so must be drained in ED.
What is rhinitis medicamentosa?
Overuse of anti-mucus sprays leading to addiction/resistance.
List 3 causes of peripheral vertigo and 3 causes of central vertigo.
Peripheral: BPPV, labyrinthitis, Meniere’s, vestibular neuritis.
Central: vestibular migraine, stroke, MS.
Acoustic neuroma is more of a central one too.
What is the Dix Hallpike maneouvre?
A technique used to elicit rotational nystagmus in BPPV
RAPD can be caused by which two broad conditions?
Optic nerve pathology (eg. MS lesion) or ischemic retina.
What is the name of the colour blind test?
Ishihara test
An absent red reflex on fundoscopy of children is suspicious for?
Retinoblastoma
What is the easiest clinical way to detect refractory error (need for glasses)
Use of pinhole
What are cataracts and how do you treat them?
Lens opacity.
Take the lens out and put a new one in.
What is glaucoma and what are the two broad types?
Glaucoma = raised intra-occular pressure.
Primary open angle glaucoma
OR
acute closed angle glaucoma (emergency)
What is the key descriptor on history of primary open angle glaucoma?
Slow loss of peripheral vision.
What is the key descriptor of acute closed angle glaucoma on history?
Sudden visual loss often with ‘rainbows’ in eyes.
What are the two types of diabetic retinopathy and how do they appear on fundoscopy?
Non-proliferative - micro aneurysms (little red dots) and exudate (small cotton wool spots).
Proliferative - looks FUCKED. Like how you’d expect a tumour of the eye to look (though it’s not a tumour. New vessels forming all over the place in haphazard nets, hence ‘proliferative’
Name the key history finding and key fundoscopy finding of macular degeneration.
history - loss of central vision
fundoscopy - huge pale spot over macula like a cloud, can be full of dense cotton wool spots
Which medication treats macular degeneration?
Endothelial growth factor inhibitor
What are the 3 key signs of cranial nerve 3 pathology?
- ptosis
- ‘down and out’
- blown pupil
What is the most common cause of cranial nerve 3 palsy?
Aneurysm
What two descriptors of history/inspection indicate cranial nerve 4 pathology?
- trouble walking down stairs
- head tilt
What is the most common cause of cranial nerve 4 palsy?
Trauma
What is a macular ‘cherry red spot’ indicative of?
Retinal artery occlusion - must check carotids
If fundoscopy looks out of focus/blocked off/curtained - that is suspicous for _____.
Retinal detachment
Sudden blindness after partying = ?
Methanol
Which eye pathology may be the cause of visual loss in a person who wears contacts?
Microbial keratitis
Why might a beta-blocker be prescribed for ascites or varices?
Non-cardiac selective beta blockers are useful in HF/Liver failure to reduce fluid buildup (in this case reducing portal hypertension)
What is the key initial medication for a gastric bleed?
PPI
What is octreotide and what is it used for in terms of gastro pathologies?
A somatostatin analogue used for osephageal varices
What is the first medication to give in hyperkalemia?
Calcium
What demographic of patient commonly experience cardiac tamponade?
Post cardiac surgery patients
What is a Urine ETG?
test for ethanol metabolism - checks if someone has been drinking
Mnemonic for Child Pugh score?
ABCDE
Albumin, bilirubin, coagulopathy, distension and encephalopathy.
Remember by first 3 being measurable and latter 2 being clinical.
What are CPE?
Carbapenamase producing enterobacteriacae.
Why is urea important in a gastric bleed?
Digested blood from upper GI bleed is metabolised into urea. Will be high if bleeding into gut
List 3 common manifestations of autonomic dysfunction:
- Erectile dysfunction
- Postural BP drop
- gastroparesis
How does pancreatic insufficiency affect bowel movements?
DIARRHEA !!!!!
Textbook steatorrhea is good for exams but rarely happens in real life
Pancreatic back pain is usually described as ____.
Sharp
Do you empirically treat a suspected H.pylori infection?
No, you may as well wait for serology to come back before you give antibiotics in case you give the patient C.diff.
How would you know if someone was ‘fluid responsive’?
HR drop with IV fluid
Which drug forces an asthma attack during respiratory function tests?
Mannitol
What are DLCO and lung volume tests?
DLCO helps seperate obstructive causes of respiratory pathology (eg. separates emphysema from asthma).
Lung volumes is useful in restrictive lung disease.
What causes a Mallory-Weiss tear?
Increased abdo pressure - often due to vomiting.
What is the key electrolyte in re-feeding syndome?
Phosphate
What are the 3 steps for any upper GI bleed management?
- PPI (IV)
- Metaclopramide (empty gut)
- Gastroscopy
What are the 3 intervention options for a gastric ulcer on gastroscopy?
- Adrenaline injection
- Burn it
- Cut it
List 1 conservative and 1 surgical management for osephageal varices.
- octreotide
- banding on gastroscopy
What are the 2 key pathologies to monitor long term in liver failure?
Varices and HCC
What are the 2 key treatments for hepatic encephalopathy and how do they work?
Lactulose - laxative that forces ammonia in gut out through stool rather than being absorbed
Rifaximin - antibiotic for ammonia producing gut bacteria
Where are the different types of beta receptors located?
B1 - heart and kidneys
B2 - lungs
Name 2 non-cardiac selective beta blockers.
PCI (mnemonic)
Propanolol, Carvidelol Isn’t
(Isn’t cardiac selective
How long is DAPT continued after an MI?
1 year on aspirin and second agent, then just aspirin forever
Best diagnostic tool for myocarditis?
MRI
What are the Heart Failure chest X-ray findings?
ABCDE
Alveolar edema
B-lines
Cardiomegaly
dilated pulmonary vessels
Effusions (pleural)
What is TVD?
Triple vessel disease
Fun way to remember axis?
If 1 and avF are making a diamond together = eg. 1 is up and avF is down, then that is left because you wear a diamond on your left hand
What is adjuvant chemo for?
Chemo after surgical removal to mop up any micro-mets
What is the timeframe for febrile neutropenia post-chemo?
Around 7-10 days - the lifespan of a neutrophil.
What are 3 clinical signs of aortic regurg?
- collapsing pulse in the carotids
- widened pulse pressure
- S3 sound due to volume buildup
What is a PPM?
Permanent pacemaker
Which examination might be done in suspected Wernicke’s encephalopathy (aside from a GIT exam)
Cranial nerves - as often eye nerves are impacted.
Name 4 causes of normocytic normochromic anemia.
- haemolysis
- acute bleed
- anemia of chronic disease
- renal disease with low EPO
A slow rising pulse in the carotids is indicative of with pathology?
Aortic stenosis
What are the 2 broad causes of pernicious anemia?
- poor intrinsic factor function/release in stomach
OR - poor B12 absorption in ileum
What is typically the first sign of anemia?
tachycardia
What are the long term Heart Failure drugs?
BASS
Beta Blocker (not acutely)
ACEi/ARB
SGLT2 inhibitor
Spironolactone
(add frusemide acutely)
Aortic stenosis in young people is suspicious for which congenital issue?
Bicuspid aortic valve
How will you know if you have diuresed too much?
Creatinine will rise
What is the criteria for ST elevation on an ECG?
1mm in all leads except anterior leads which are 2/2.5 mm (women, men)
Scleroderma can cause which suite of complications?
CREST(OR)
Calcinosis
Reynauds
Esophageal dysmotility
Sclerodactyly
Telangiectasia
(Oxygen - ILD)
(R - renal damage)
leukonychia is a sign of?
Low albumin
What is an ‘escape beat’?
Backup conduction (eg. Purkinje’s) causing ventricular contraction
What are the 3 ECG findings of a STEMI?
- ST elevation
- reciprocal T wave inversion
- Q waves
Which IV medication lowers ICP?
Mannitol
What is type 3C diabetes and how is it managed?
Pancreatic insufficiency - managed the same as Type 1
How does diabetes insipidus impact urine?
Lack of ADH function leads to less water being re-absorbed. So urine is high in volume and very dilute.
How does diabetes insipidus impact serum sodium?
Water is being peed out so blood is concentrated - get a hypernatremia.
Treatment for neurogenic diabetes insipidus?
Exogenous ADH - desmopressin
What is the concern in regards to non-functioning pituitary macroadenomas?
Mass effect.
Non-functioning means they are not hormonally active.
What is the main complication of pituitary surgery that endocrinologists manage?
Diabetes insipidus
Name 3 long-acting insulins.
Optisulin, levemir, toujeo
If ketones are high (above 2) which would be the easiest next investigation to order?
ABG to check blood pH
What is the Type 2 equivalent of DKA and which is more dangerous?
HHS Hyperosmolar Hyperglycemic state - more dangerous than DKA as it is slow to resolve and usually occurs in already co-morbid patients
Which tests are most useful in diabetes inspidius?
Urines. More useful than bloods.
Very thirsty + peeing lots - should ring alarm bells for what condition?
Diabetes
What is the most common side effect of metformin and what is the major contraindication?
Side effect - GI upset - diarrhea
contraindication - renal damage (eGFR under 30 especially)
Pancreatitis is a contraindication for which diabetic drugs?
Anything that works on the incretin system: DPP4 inhibitors and GLP1 analogues
What are the main 2 concerns regarding sulphonylureas?
- hypoglycemic episodes
- weight gain
What is an insulin sliding scale?
Essentially just PRN rapid insulin on top of basal-bolus insulin to keep sugars under control
Compare aortic stenosis and aortic sclerosis on examination (3).
Stenosis radiates to the carotids whereas sclerosis doesn’t.
Stenosis lowers BP but sclerosis does not.
Stenosis causes a slow rising pulse, sclerosis does not.
Which types of heart block require a PPM?
symptomatic mobitz 2 and third degree heart block
Best investigation for endocarditis?
ECHO (blood cultures good too - 3 sets).
How does pancreatitis impact white blood cells and how does this reflect disease progression?
Acute pancreatitis causes a leukocytosis, especially a neutrophilia.
These neutrophils are involved in pre-mature activation of trypsinogen, causing the pancreas to essentially digest itself in acute pancreatitis.
How does prolactin impact periods?
Prolactin causes oligomennorhea or amenorrhea. Oligomenorrhea is common with functional pituitary macroadenomas that produce prolcatin (prolactinomas).
Prolactin inhibits GnRH thus stopping LH and FSH production thus inhibiting ovulation.
This makes sense in context - prolactin promotes lactation and lactation indicates to the body that someone is still nursing a child with reduced ability to grow a new one.
How does glucose impact growth hormone and how can this principle be used to diagnose a key endocrine pathology?
Glucose inhibits release of Growth Hormone. As such, an oral glucose tolerance test can be used to diagnose acromegaly as growth hormone levels will not reduce.
Which medication MUST be given following neurosurgical correction of Cushing’s disease?
Must give steroids - typically dexamethasone, because native ACTH producers have been asleep for so long due to adenoma that they need time to wake up and steroids will stop patient from entering iatrogenic Addison’s.
Can take 3-18 months.
When should you cease a patient’s basal insulin?
Never (at least not without endo input). Kept even for surgery.
Why is IV insulin given with dextrose.
Insulin is a limitless drug and if given straight into the blood it can easily turn hyperglycemic blood into a hypo - so glucose (dextrose) is given to offset that risk.
Does slow resp rate following an asthma attack mean the asthma has resolved?
No, it can mean the patient is fatigued and decompensating. ICU admission is needed at this time.
How may blood pH change over the course of a severe asthma attack?
Initially alkalotic as hyperventilation will cause CO2 to reduce rapidly.
As the patient decompensates the CO2 will build up leading to acidosis.
A body rash is _____ until proven otherwise.
Anaphylaxis
Which two medications ‘drive’ K+ into cells.
INSULIN (key one) and salbutamol - hence why salbutamol may cause hypokalemia.
Why is infection a common precipitant of DKA?
Infection raises cortisol levels in the body leading to greater gluconeogenesis.
What is the main diagnostic tool for myeloma?
Bone Marrow Biopsy (and blood film to an extent).
What is the number 1 oncological emergency? What is the treatment?
Febrile neutropenia, 7-10 days after chemo.
Do blood cultures then antibiotics (piptaz) within 30 minutes over fever onset.
Back pain that is not responsive to opioids is suspicious for?
Spinal compression, especially if history of cancer as boney mets are common.
What is the first immediate treatment given for suspected spinal compression?
Steroids
What is the treatment for cardiac tamponade that is cause haemodynamic instability?
Pericardiocentesis
SVC obstruction can occur due to which type of cancer and what are the symptoms?
Any thoracic/ENT cancer but typically lung cancer.
FACIAL swelling is a key feature, also get dyspnea etc.
Treatment for SVC obstruction?
Stent it
A right sided, ventricularly paced heart is likely to show which ECG abnormality?
Left Bundle Branch Block - electricity is coming in from right heart, makes the ECG thing the left sided conduction is just way shitter than the right, looks like LBBB.
What are Heberden’s nodes?
Osteophytes of the hands typical of osteoarthritis
What is the process that causes oesophagitis?
Acid reflux
Which pulmonary edema medication is contraindicated if the patient is hypotensive?
Nitrates
What is factitious hypothyroidism?
Use of thyroxine when not prescribed
What is Terlipressin used for?
to stop bleeding osephageal varies
Compare morning stiffness in inflammatory vs mechanical joint pain.
Can occur in both but tends to be brief in osteoarthritis but takes hours of movement to disappear in inflammatory conditions and pain will return on rest.
Is swelling more typical of an inflammatory or mechanical joint pathology?
Inflammatory
Compare the efficacy of paracetamol in inflammatory vs mechanical joint pain.
Paracetamol is shit in inflammatory, works well in mechanical.
Name four potential macroscopic changes to the hands in Rheumatoid arthritis?
- Rheumatoid nodules (if seropositive)
- Swan neck deformity
- Ulnar deviation
- boutenniere deformity
Name 4 pathologies that accompany rheumatoid arthritis in non-joint related systems and 1 pathology that often accompanies rheumatoid arthritis in the hands.
- scleritis (red eye)
- ILD/pulm fibrosis
- pleural effusion
- pericardial effusion
hands: reynauds
Which broad rheum category does psoriatic arthritis fit into? Which other diseases are in this categroy?
Spondyloarthropathies.
Includes AnkSpon, Reactive arthritis and enteropathic arthritis.
Aside from the joint pain and the skin changes, which feature is common and unique in psoriatic arthritis patients?
Impacts on nails - nail pitting and onycholysis
What is the most sensitive antibody for lupus and what is the most specific antibody for lupus?
Sensitive - ANA: 98% will have it positive
Specific: dsDNA
What is the genotype associated with ankspon?
HLAB27
How might lupus impact an FBE?
expect anemia due to anemia of chronic disease, NSAID use (bleed) or methotrexate usage
What is the mnemonic for remembering the impacts of reactive arthritis?
Can’t see, can’t pee, can’t climb a tree.
See - conjunctivitis
Pee - urethritis
Tree - arthritis
What demographic of patients experience enteropathic artheritis?
IBD patients
Does joint pain + fever always mean septic arthritis?
In an exam yes, in real life, no. Gout can cause fever.
What is the key clinical test for ank spon?
Schober’s test
Does a low serum uric acid exclude gout?
No, uric acid may just be being used up in gout area. High uric acid in serum is pretty specific for gout though.
The back pain in ank spon is often in the _______ area.
Sacro-iliac
Does a clear X-ray rule out a pelvic fracture?
no, they are often missed
What is the best imaging for a suspected epidural abscess?
MRI
What is indomethacin?
NSAID
What are the best first imaging requests for a suspected bowel obstruction?
Erect and supine abdo films
Why may someone with ascites experience tachypnea and hypernatremia?
Fluid is trapped in the portal system, so relatively hypovolemic systemically. Requires greater cardiac output and causes more concentrated sodium
How does hepatic encephalopathy impact sleep?
It can reverse the sleep cycle
What does an air bronchogram show?
Consolidation
Broadly, what are the treatment paths for a stable arrhythmia vs an unstable arrhythmia?
stable - can do medical management, if reversion is required try amiodarone and sotalol.
unstable - need DCR - shock the arrhythmia
A broad QRS indicates a problem originating in the ______.
Ventricles
How does magnesium help the heart?
stabilises cardiac membranes
A young person entering ventricular tachycardia is very suspicious for?
Wolff-Parkinson white
What is the treatment for Wolff-Parkinson White?
ablation
List 3 medications for overloaded AF?
The two classic AF drugs: rate control (BB) and anticoagulation (DOAC) + a diuretic for the fluid
What type of ECHO is used to check for cardiac clots in AF?
TOE
A post-op arrhythmia is typically due to ______.
Electrolyte derangement
Any bradyarrhythmia on ECG should be checked for _______.
inferior ischemia
What are the aggressive treatment strategies for bradyarrhythmias and tachyarrhythmias?
brady - PPM
tachy - shock
Which IV drug could you give for a bradyarrhythmia?
atropine
Why does reciprocal inversion happen in ischemia?
due to blockage of coronary artery, the other arteries will try and provide collateral flow to the hypoxic areas and in doing so will themselves become hypoxic leading to a sort of angina in their area hence the ST depression
Which medication is a common cause of myositis?
statin
ANCA is a test for which group of pathologies?
Vasculitis not including large vessel. Mostly used for small vessel vasculitis.
Snuffbox pain is typical of which pathology?
scaphoid fracture
Thenar wasting is typical of which pathology?
Carpal tunnel
How do most systemic autoimmune diseases damage the kidneys?
Immune complexes damage the glomerulus causing nephritis.
What are the big 4 ANA positive diseases?
SLE
Scleroderma
Sjrogen’s
Myositis
What is the typical myositis joint distribution?
typically proximal joints are affected rather than distal joints. So they have trouble getting up but are good once they’re up
What is the gold standard diagnostic tool for myositis?
muscle biopsy
How does ankspon impact the lungs?
stiffness in axial skeleton restricts expansion alongside autoimmune ILD
What is fecal calprotectin used for?
Marker of inflammation in the gut
What is the classic Atrial fibrillation rate control drug?
Metoprolol
What are the four key features of a diabetes PVD assessment?
- pulses
- ulcers
- cap refill
- hair growth
What is the target for rituximab?
CD20 on B cells
myositis + eyelid rash is suspicious for?
dermatomyositis
mouth ulcers are associated with which autoimmune disease?
lupus
List the 3 major causes of rapidly progressing glomerulonephritis.
SLE, Anti-GBM and GPA
What is the main difference between TB granulomas and granulomas from granulomatosis with polyangitis?
TB is caseating, GPA is non-caseating
Which spinal level controls the knee reflex?
L4 - L4 kick the door
Which spinal level controls the achilles reflex?
S1+S2 buckle your shoe
What is CPPD?
Pseudogout. Post-op knee pain is almost 100% of the time pseudogout
Why might prostate cancer raise ALP?
Boney mets - prostate cancer loves bone
A huge PSA is indicative of which pathology?
prostate cancer.
BPH/prostatitis will raise PSH but only modestly
Compare the fracture risk from prostate cancer boney mets vs myeloma boney mets.
lower fracture risk in prostate boney mets as the lesions are sclerotic rather than lytic in myeloma
STEMI criteria on ECG?
- 1mm ST elevation in all leads except anteriorseptal leads which are 2mm
- new LBBB
Mnemonic for broad treatment of STEMI or NSTEMI
BOATMAN
(think you have a heart attack and go to meet the boatman Charon)
Beta Blockera (within 24 hrs if not contraindicated)
Oxygen
Aspirin
Trigelcor/clopidigrel
Morphine
Anticoagulation
Nitrates
What is pulsus paradoxus?
Drop in BP on inhalation typical of cardiac tamponade
Aspects of fluid overload management?
- fluid restriction
- daily weights
- fluid balance chart
- diuretics
- UEC to monitor diuretic use
- address cause
Repeated pleural effusions or non-resolving pleural effusions may require which surgical intervention?
Decortication (VATS)
Bactrim in cancer patients is typically prescribed as prophylaxis for which condition?
PJP
What are the 3 findings on ECG for STEMI/NSTEMI?
- ST elevation/depression
- Q waves
- T wave inversion
COPD findings on CXR?
- hyperinflated
- flattened diaphragm
Sharp or shooting pain in the face should be highly suspicious for?
trigeminal neuralgia
What is pulmonary-renal syndrome and which two conditions often present this way?
Pulmonary haemorrhage + glomerulonephritis
Findings of haemoptysis/epistaxis alongside signs of renal damage (swelling, itch, nausea etc) though haematuria may be occult.
Typically Anti-GBM or GPA
If a type 1 diabetic was having a hypo episode and they were unconscious with no IV access, what might be a suitable first intervention?
Glucagon injection
Glomerulonephritis in pulmonary-renal syndromes may often cause which gross change to the urine?
Nothing, urine may look totally normal despite microscopic haematuria. Would need urinalysis to be sure.
Compare the RBCs from glomerulonephritis versus bladder/urothelial sources.
Bleeding through the glomerulus knocks RBCs out of shape so they are dismorphic. Urothelial RBCs are just regular RBCs
What is anti-phospholipid syndrome and what is the classic exam description?
A female with signs of lupus that is presenting with a PE or DVT that has had miscarriages in the past.
‘Vibrating tools’ are a very med school exam cause of which two conditions?
Reynauds and carpal tunnel
Bisphosphonates should be avoided in patients who experience which common condition?
Reflux/dysphagia as bisphosphonates cause osephagitis
Compare calcitriol to colecalciferol.
Calcitriol is already activated form, usually given CKD patients.
Colecaliferol is the inactive form.
Does renal damage contraindicate bisphosphonates?
yes, they are eGFR dependant
What are the 3 arms of myeloma diagnosis?
- blood smear
- protein electrophoresis
- bone marrow biopsy
What are the 3 tests looking for Cushing’s syndrome?
- saliva cortisol (midnight)
- 24 hr urine cortisol
- dexmeth suppression test
Use of denosumab may cause which effect in CKD patients? (excluding osteonecrosis and atypical fractures).
hypocalcemia
Why might longstanding RA impact anaesthetics?
Long standing RA may erode C1/C2 - impairing things like head tilt.
Pain in the knee that does not show any pathology on examination may be referred pain from the ___.
hip
What are the 4 key signs of base of skull fracture?
- racoon eyes
- csf leak
- haemotympanum
- battle’s sign (mastoid bruising)
Thoracic back pain is a red flag for?
Aortic Dissection - thoracic (between the scapula) back pain is really uncommon aside from this.
Which ECG conduction change is common in PEs?
new RBBB
Patella dislocation is a common cause of _______ on aspiration.
haemarthrosis
Which IBD is more likely to cause bleeding?
UC but both can
Acute anal bleeding, diarhhea and pain in the abdomen should be a red flag for _______. ___ is a common risk factor.
Acute mesenteric ischemia
AF
What are the 3 main extraintestinal manifestations of IBD?
- eyes - uveitis
- skin - pyoderma
- joints - enteropathic arthritis
Which 3 substances may be poorly absorbed in Crohns due to damage of the terminal ileum?
- ADEK vitamins
- b12
- bile salts
The poor bile salt reabsorption in Crohns may lead to what other pathology?
gallstones due to imbalance
Peri-anal fistulas are pathognemonic for?
crohns
Which IBD raises the cancer risk more?
both do but especially UC
What is a phase reactant ? Name two positive ones and one negative.
body substances that alter in periods of inflammation or infection.
positive - platelets and ferritin
negative - albumin
What is primary sclerosing cholangitis?
damage to the biliary system due to IBD that causes a cholestatic picture. bili ALP and GGT all up.
Is a colonoscopy still done in an IBD patient currently experiencing a bleeding flare?
no, perforation risk. Do flexible sigmoidoscopy instead
What are the ‘big ticket’ items when it comes to side effects of steroid use?
immune suppression
Osteoporosis
hyperglycaemia
What can pancreatitis do to the lungs?
ARDS
Broad steps in removal of a pancreatic gallstone?
Ultrasound and then ERCP
How could you tell the difference between a mechanical vs non-mechanical bowel obstruction on x-Ray?
Lack of transition point in non-mechanical
‘Mid-dilated irregular pupil’ is a phrase that indicates which pathology?
Closed angle glaucoma
A cherry red spot on fundoscopy indicates what pathology?
Central retinal artery occlusion
Watching TV in a dark room with sudden painful change in vision in one eye is a classic scenario for which condition?
Closed Angle glaucoma
How bad is the pain in retinal detachment?
Painless. - often asked in exams
‘Cell and flare’ is a phrase that indicates which eye pathology?
Anterior uveitis
A FOOSH is more likely to cause ____ in young patients and _____ in old patients.
Young: scaphoid fracture
Old: Colles fracture
Tachycardia, dryness, confusion, facial flush and visual changes are all components of which drug related syndrome?
Anti-cholinergic syndrome
Which are two major differentials for loss of consciousness aside from syncope/TLOC?
Seizure
Brain injury - bleed, stroke etc
Absence of a prodrome, loss of consciousness when supine and short duration are features of which type of syncope?
Cardiogenic
What is the typical cutoff value for high blood pressure?
140/90
What is the best investigation for renal artery stenosis?
Renal Artery Doppler
What is often the first urinalysis evidence of renal damage?
Proteinuria (ever before change in eGFR)
What is the blood test used to check for anaphylaxis?
Tryptan
What are the ABCs of shock resus?
A - airway - airway support
B - breathing - supplemental O2 or mechanical ventilation
C - cardiovascular - need 2 large bore IV cannulae, give IV crystalloid bolus (has come up on exam before)
TREAT CAUSE
+/- ICU inotropes
90% of chronic cough is due to which 3 conditions?
COPD, asthma and post-nasal drip
What is the key investigation for ILD?
High Resolution CT
Is wheeze or stridor more dangerous?
Stridor - requires intervention, often an emergency.
Which 3 clinical features may indicate an infective exacerbation of COPD?
More sputum, change in sputum colour, fever.
What are the 4 broad causes of peripheral edema?
Increased capillary permeability
Decreased oncotic pressure
Increased hydrostatic pressure
Lymphatic obstruction
What are the 2 causes of non-pitting edema?
Lymphatic obstruction OR myxedema (hypothyroidism)
A pulsatile liver is classicaly causes by which murmur?
tricuspid regurg
What is the relationship between AST and ALT in the following:
1. Chronic Liver disease except alcoholic
2. Alcoholic liver disease
3. Cirrhosis
- Chronic liver disease ALT>AST (think of damaged liver cells releasing ALT).
- Alcoholic (AST - A Shot Thanks)
AST>ALT - Cirrhosis - liver cells now dead, can’t properly make ALT but AST made in other places.
AST>ALT
List 4 ultrasound findings that may be found in a cirrhotic liver.
- nodular liver
- dilated portal vein
- retrograde flow through portal vein
- patent umbilical vein (ligamentum teres)
Bronze skin is typical of which condition?
Haemachromatosis
4 ways to treat ascites?
DRAT
Diuretic
Restriction - fluid and salt
Antibiotics for SBP
Tap if needed
Which coagulation factor is not made in the liver?
8
A ‘slow growing’ and ‘smooth’ testicular lump is typical of which testicular neoplasm?
Seminoma
Winging of the scapula is often a pathology of which nerve?
Long thoracic nerve
Pulmonary hypertension can cause which type of murmur?
Tricuspid murmur
What are some signs of cerebellar dysfunction?
DANISH
Disdiadochokinesis
Ataxia
Nystagmus
Intention tremor
Slurred speech
Hypotonia
Rectal sparing is typical of which type of IBD?
Crohns
How does hiatus hernia impact reflux?
Worsens/causes reflux
How do you manage a totally occluded carotid?
Not much you can do except protect the other patent carotid.
Thrombolysis and endarterectomy both not done in total occlusion.
Why is a PPI used in long term steroid use?
Steroids cause ulcers
What is domperidone?
Antiemetic and prokinetic with a similar MOA to metaclopramide.
3x histo findings for coeliac?
villous atrophy, lymphocytic infiltration, goblet cell hyperplasia
Which BSL level is considered a hypo for a diabetic?
Under 4.0
Do all septic patients have fever?
no. Cold sepsis.
What are the 2 main seeding mechanisms for endocarditis?
IVDU or tooth infection
Kernig’s sign and Brudzinski’s sign are both signs of?
meningitis
Which antibiotics are used ‘above’ the diaphragm and ‘below’ the diaphragm for anaerobes?
Penicillins above the diaphragm
Metronidazole below the diaphragm
What is the mainstay of treatment for cholangitis?
ERCP
Best imaging technique to visualise infective endocarditis?
TOE , but maybe a TTE initially
2 most common causes of CKD?
Hypertension and Diabetes
What are the two criteria (only one must be met) for an AKI?
Creatinine rise of over 1.5x baseline over 2 days
Urine output less than 0.5kl per kg per hr for 6 hrs
Steps in post-renal AKI management?
- try to catheter
- CTKUB
- Urology referral
Which drug is most closely related to nephrogenic diabetes inspidius?
Lithium
What is the relative serum sodium concentration in diabetes inspidius?
HIGH (ADH not functioning, not resorbing water, pee it all out, sodium in blood concentrates
Does use of synthetic ADH (desmopressin) help in central or nephrogenic diabetes insipidus?
Helps in central - replaces shit ADH made/not made by pituitary.
Useless in nephrogenic as problem is with kidney, not ADH.
How would you seperate diabetes insipidus from a psychogenic cause of polydypsia?
Water Deprivation test - what does it do to urine.
If urine returns to normal = psychogenic.
What are the type 1 diabetes antibodies?
Anti-GAD and anti-islet cell
What is the biggest risk of SIADH?
hyponatremia
splenomegaly in the absence of hepatomegaly is suspicious for?
infection eg. EBV or haem malignancy
thick and thin blood smear is a test for which disease?
malaria
What are the four broad causes of anemia?
- Non-production (aregenerative)
- destruction (haemolysis)
- Loss (bleeding)
- Sequestration
A-regenerative anemia is broadly due to one of which two factors?
Bone Marrow issue (broken factory)
OR
iron/b12/folate deficiency - no building blocks
If you clinically suspect blood loss but there is no evidence of bleeding, where should you check?
occult bowel bleed
What is one test that could immediately tell you if an anemia was productive or non-productive?
Reticulocytes
‘beefy red tongue’ is often associated with _____ deficiency.
B12, but also iron or folate deficiency.
petechiae are evidence of ______.
thrombocytopneia
List four investigations that would be ordered in establishing the cause of a severe anemia.
FBE –> Iron studies –> blood smear —> bone marrow biopsy
We usually transfuse blood in stable patients at a Hb from __ to __.
70-80
What is a significant level of unintentional weight loss?
more than 10% of body mass over 6 months
What are B symptoms?
Weight loss, fever, night sweats
How does refeeding syndrome work?
With already low electrolyte levels, the reintroduction of insulin into the system (following eating) forces potassium (and phosphate) into cells, resulting in dangerously low levels of ions in the serum
If gel electrophoresis shows a largely monoclonal population, what should be your primary differential?
B cell cancer
What is SPEP/UPEP in the context of myeloma diagnosis?
Serum + urine protein electrophoresis
Is bone marrow transplant used in myeloma?
yes. Autologous transplant is done often to relieve symptoms but is NOT curative.
An allograft is the only way to cure the disease but is not safe for majority of patients.
What is the key factor that decides if a patient with a fall is likely to have an intra-cranial haemorrhage?
use of anti-coagulants
Why is extreme tachycardia a risk (eg. from AF or SVT) (3 key reasons)
- heart not well perfused (less time in diastole
- heart not pumping properly - fluid buildup
- stasis of blood - clot risk
Why can people get pins and needles in hands/feet during hyperventilation?
Low CO2, leads to reduced pH, H+ swaps with K+, relative serum hypokalemia gives pins and needles
Compare the LOSS and LESS mnemonics for OA/RA
LOSS
L - loss of joint space
O - osteophytes
S - subchondral sclerosis
S - subchondral cysts
LESS
L - loss of joint space
E - erosions
S - soft tissue swelling
S - soft bones (osteopenia)
Why are allopurinol and azathioprine not used together? What is the exception?
risk of bone marrow suppression (the allopurinol makes the DMARD work too well)
Exception is Crohns.
Where is the back pain of an aortic dissection classicly located?
Thoracic - inbetween scapula
In a med school exam, tachycardia while asleep = ______.
Sinus arrythmia
‘tinkling bowel sounds’ is med school lingo for which condition?
small bowel obstruction
The iliac crests align with which vertebral level?
L4
Interventional treatment for haemachromatosis?
venesection (literally bleed them)
Why does an NSTEMI cause subendocardial damage?
Think of it like a watershed of the heart. Flow is still present in an NSTEMI it is just reduced, so there is enough flow to supply the areas closest to the artery. The thinner, farther away areas closer to the endocardium are hit the hardest - so they are damaged.
As opposed to a STEMI where all areas are damaged.
Explain the Ankle Brachial Index.
Reduced BP in feet compared to systemically due to atherosclerosis of peripheral vessels in PVD
Explain your 10 leaf tree for dysphagia.
Dysphagia - split into oropharynx and oesophagus.
Oropharynx causes: x4
- stroke
- Parkinson’s
- Zenkers
- cancer
Oesophagus split into motility or blockage.
Blockage: x3
- cancer
- stricture
-oesophagitis
Motility: x3
- achalasia
- scleroderma
- oesophagael spasm
Why do a CT scan for myasthenia?
To check for thymoma - a common cause of myasthenia
What is the meaning of ‘coryzal’ symptoms?
URTI symptoms
Best imaging for suspected aortic dissection?
CT aortogram. (MRI is actually best but may take ages)
Should you give aspirin immediately in a suspected stroke?
no, may be haemorrhagic
What is the thrombolysis window for a stroke?
4.5 hrs
Restless less syndrome is associated with which deficiency?
Iron
What are the 5 P’s of ischemic limb?
- pallor
- pulseless
- painful
- polar (cold)
- parasthesia
Range of temp for ‘low-grade fever’?
37.5-37.9
Which disease is a major contraindication to testosterone replacement therapy?
prostate cancer
Why does supplemental testosterone reduce sperm count?
testosterone negative feedback onto LH/FSH levels - responsible for sperm production
Neuropathic arthropathy is also known as __________?
Charcot’s foot
If an ulcer can be probed to the bone this is equivalent to a diagnosis of _______.
osteomyelitis
What is pseudohyponatremia in diabetes?
conc. of sodium looks low due to glucose sucking out the water from cells and diluting the blood.
What is the cornerstone of T2DM management?
weight loss
which key hormone varies in level when comparing primary Addisons to secondary Addisons?
Aldosterone.
Primary Addisons = adrenals shit. Low in both cortisol and aldosterone production.
Secondary Addisons = pituitary shit. Only low in cortisol, aldosterone fine because it’s tropic hormone is ANG2, not ACTH.
A renin:aldosterone ratio is a key test in which cause of hypertension?
Conn’s syndrome (hyperaldosteronism)
Describe the impact on ‘cup’ size in glaucoma.
On fundoscopy, the regular cup and optic disc will turn into a large, swollen optic disc with large cup (inner circle), lines may be blurred.
If CN3, 4 and 6 are all impacted as well as facial sensation, where is the damage likely to be?
Cavernous sinus - where CN 3, 4, 5 and 6 run through.
What is the ulnar nerve paradox?
The closer the damage of the ulnar nerve is to the wrist, the worse the claw hand.
‘closer to the paw, the worse the claw’
Absence seizures classicly affect which demographic?
Kids/teenagers
What is the main provoking factor for seizure?
sleep deprivation
Compare macula sparing vs non-sparing homonimous hemianopias.
Macula sparing = occipital lobe issue. Alternate vascular supply to area that integrates information from macula, so unharmed during stroke to occipital lobe.
Non-macula sparing = optic tract lesion. Complete homonimous hemianopia
A stroke that causes an inability to write, count and tell left from right, as well as homonimous hemianopia is likely to be in which area?
Dominant parietal lobe
How long should a post-stroke patient be on anti-platelets?
DAPT - for 3 weeks.
Then aspirin for life.
What are the two main neuromuscular diseases and how could you tell them apart from other neurological conditions like stroke?
myasthenia and MND.
These two have NO sensory findings.
Wolff Parkinson White in combo with AF is a situation wherein which drug class is absolutely contraindicated?
Anything that works on the AV node (Adenosine, Verapamil) due to risk of 1:1 conduction pathway. Eventual V fib.
What is a typical side effect of amlodipine that you might see on cardiovascular examination?
peripheral edema
A new LBBB is equivalent to a ____ until proven otherwise.
STEMI
What is the timeframe to thrombolyse an NSTEMI.
WE NEVER THROMBOLYSE AN NSTEMI
A young person with hypertension and hypokalemia is suspicious for?
Conn’s syndrome
Why is SAH more common in people with polycystic kidney disease?
It is a connective tissue disease, so aneurysms are more likely.
Which aspect of iron studies is most important?
Ferritin
Anemic men is highly suspicious of ______.
GIT bleed
If a neutrophil has more than 2-3 lobes it is described as ______. What causes this?
megaloblastic.
Caused by B12/folate deficiency.
What is the most common cause of megaloblastic anaemia?
Pernicious anaemia (autoimmune)
What is the best marker for haemolysis? What are some other markers?
best: LDH
others: haptoglobin, Hb, reticulocytes, unconjugated bilirubin
What is haptoglobin?
molecule made in liver to mop up free Hb, as free Hb is toxic to kidney. Low haptoglobin = high free Hb (or liver disease).
Primary polycythemia is due to which mutation?
JAK2 mutation
How does secondary polycythemia differ from primary on FBE?
Secondary only raises Hb, primary raises Hb, WCC and platelets.
What is the most common cause of secondary polycythemia?
hypoxia –> mass EPO release
If Hb, WCC and platelets are all high. What are the two main possible culprits?
polycythemia
OR
Bone marrow cancer
Mnemonic for CML?
Please Carry My Leukeamia KIT.
Philadelphia
C
M
L
Kinase
Imatinib
Tyrosine
Mnemonic for APML?
LISP ARMADA (L15P Armada)
L (the L of APML)
IS = 15 (chromosome)
P
A
Retinoic acid
M
Arsenic
D- DIC
A - Auer Rods
Lump in neck + pain drinking alcohol is med school code for which disease?
Hodgkins Lymphoma
How are heparin and clexane measured?
heparin via APTT
clexane via factor Xa levels
What is von Willebrand’s factor?
Joins factor 8 to platelets to allow clot formation on platelet plug
Which conditions often cause anterior uveitis?
IBD, reactive arthritis and ank spon (so really just link to spondyloarthropathies)
what is the acute treatment for anterior uveitis?
Steroid drops
dilatory eye drops - either with a catecholmine or an anti-muscarinic, often atropine.
What important finding may you find on cranial nerve exam for someone with optic neuritis?
RAPD
What are the 3 C’s of Addison’s Treatment?
cortisone (hydrocortisone)
crystalloid (rehydrate)
carbs (glucose)
Why does testosterone replacement therapy reduce fertility?
Testosterone negative feedback on LH/FSH - less sperm maturation.
A nuclear thyroid scan is best reserved for _____.
Thyrotoxicosis (hyperthyroidism)
which 3 conditions raise ALT over AST?
viral hepatitis, acute liver ischaemia and panadol overdose
A left homonimous hemianopia could be due to a ___ sided occipital lobe stroke
Right
A lesion in the temporal lobe may impact the ____ aspect of the optic tract, causing a ____ quadrantanopia.
Conversely, a lesion of the parietal lobe may impact the ____ aspect of the optic tract, causing a _____ quadrantanopia.
Temporal - outer - superior quadrantanopia
Parietal - inner - inferior quadrantanopia
THINK of it like this - the more lateral optic radiation relates to the most lateral lobe (the temporal lobe)
Treatment for retinal detachment?
Emergency surgery
Orbital fractures tend to fracture the ____ wall or the ____floor. These respectively carry risks of bleeding into the ____ and ____ sinuses.
Medial wall - ethmoid sinus
Orbital floor - maxillary sinus
Eye ‘floaters’ and ‘flashes’ are often a type of prodrome for which eye emergency?
Retinal detachment
Optic disc cupping is a key feature of which condition?
Glaucoma - increase in optic cup size
What is the acute management for asthma (mnemonic)?
POSS
Pred
oxygen
SABA
SAMA (ipratropium)
What is a common long-term treatment strategy for asthma?
Symbicort (steroid + laba), oral fluticasone and PRN Saba
What is the suffix for anti-muscarinics?
-tropium
Short term treatment for COPD exacerbation?
(SOAP)
SABA
OXYGEN
ANTIBIOTICS
PRED
Which antibiotics are used in an infective exacerbation of COPD?
BenPen IV and oral doxy
2 common side effects of anti-muscarinics?
dry mouth and constipation
What triple drug therapy is available for long term COPD treatment?
LABA/LAMA/steroid combo.
Tiotropium is what kind of medication?
LAMA
Mnemonic for long term management of COPD?
(Steroids) = mnemonic
SABA
transplant
endobronchial valve
rehab - pulmonary
oxygen
immunisations
drugs (triple LAMA/LABA/steroids combo)
smoking cessation
What would be 3 clinical indicators that an infective exacerbation of COPD was occuring?
- more SOB
- more sputum
- discoloured sputum
What is empyema?
Infection in a cavity, often the pleura
What is the relative protein level of transudate vs exudate?
Transudate is low in protein compared to exudate/serum, it is also low in LDH.
Light’s criteria
large unilateral pleural effusions tend to be due to either ____ or______.
cancer or infections
Where does an ICC insert to drain pleural fluid?
5th intercostal space in the mid-axillary line
What does it mean if an ICC does not ‘swing’?
ICC’s should swing, that is the fluid should move up and down the drain on respiration/cough. If it doesn’t it is either in the wrong place or it is blocked.
If you drained a pleural empyema and found reduced glucose and a reduced pH, what would you suspect?
anaerobic bacteria eating glucose and making lactic acid.
Pleural calcium plaques are often due to _____ exposure.
asbestos
Immunotoxicity due to immunotherapy is treated with ______.
steroids
Following a full neuro exam, what 3 things should be done for a patient with suspected spinal cord compression?
MRI, analgesia, steroids
What are the definitive options for oncological spinal cord compression?
surgical decompression + radiation
What is the time period for antibiotics for febrile neutropenia?
within 30 minutes
Why might myeloma make someone delirious?
Bone mets leading to hypercalcemia, psychic moans
Which medication could you consider in someone with hypercalcemia secondary to myeloma?
bisphosphonates
Why might tumour lysis syndrome cause death?
cells lysing releases potassium, can cause hyperkalemia
Which cancers tend to cause SVC obstruction?
lung and lymphoma
Compare lung cancers on histo
glandular - adenocarcinoma
pink - squamous cell
purple - small cell
Name one genetic cause of COPD
alpha-1 anti trypsin disease
Why may INR be low in cholestasis?
Cholestasis means bile cannot enter the GIT, so fat soluble vitamins, including vitamin K may not be absorbed.
List the 3 major causes of cirrhosis, 3 genetic causes and 3 autoimmune causes.
big 3: hep B, Hep c, alcohol (honorable mention to NASH)
genetic: wilsons, haemachromatosis and alpha 1 anti-trypsin
Autoimmune: autoimmune hepatitis, PSC, PBC
What are the 2 key follow ups for cirrhosis long term?
HCC - ultrasound
Varices - gastroscopy
Tx for haemachromatosis?
Venesection
AST>ALT typically suggests _____.
cirrhosis - think of ALT being the most liver specific enzyme, if liver is dead, the other areas of the body can still make AST (this isn’t how it actually is just a good way to think of it).
HCC can occur in cirrhosis of any cause, but only appears in the absence of cirrhosis due to _______.
HBV
Mnemonic for signs of liver decompensation?
CRAYON
C - coagulopathy
R - renal
A - ascites
Y - yellow
O - osephageal varices
N - nuts - encephalopathy - is actually sign of total hepatic failure
What are the 3 extra-intestinal manifestations of IBD?
Skin (pyoderma)
Joints (enteropathic arthritis)
eyes - uveitis
Ascites with a low protein count is likely due to ______.
Portal HTN (transudate)
What is the main risk in ascites?
spontaneous bacterial periotonitis
5 key things found on ultrasound for cirrhosis?
- nodular liver
- large spleen
- dilated portal vein
- reversal of flow in portal vein
- patent umbilical vein due to recannulisation of ligamentum teres
Why are NSAIDS and ACEi contraindicated in ascites?
ascites inherently risks kidneys due to hepatorenal syndrome, so will get double/triple whammy if use those medications
What test could reveal ACTIVE HCV?
PCR, a serum will only tell you if it has been in the body before, not if it is there right now
Macular degeneration tends to show which key finding on fundoscopy, and which aspect of vision tend to be impacted the most?
Drusen - giant yellow cloud over macula
CENTRAL VISION - because it is the macula that is damaged
Treatment for proliferative vs non-proliferative diabetic retinopathy?
proliferative - anti-VEGF
non-proliferative - BSL control
Cherry red spot is typical of which eye pathology?
central retinal artery occlusion
What are the 2 criteria for CKD (must meet one).
- eGFR below 60 for 2 years
- proteinuria or haeamaturia for 3 months
Mnemonic for complications of CKD?
Bone COMA
- Bone - renal osteodystrophy
- Cardiovascular disease
- oedema
- metabolic acidosis
- Anemia
2 types of dialysis and where you might use each?
peritoneal - at home
haemodialysis - in hopsital via fistula
Why do NSAIDS carry a risk of AKI?
they inhibit vasodilation of the afferent arteriole due to inhibiting prostaglandins
List a cause of post-renal AKI in men, women and both (1 each).
Men - BPH/prostate cancer
Women - pelvic cancer
Both - stones
Why might bisphosphonates cause AKI?
They can cause acute tubular necrosis (just like gentamycin)
What are the two criteria for AKI? (one must be met)
Urine output of less than 0.5ml/kg/hr for 6 hrs
1.5x creatinine rise for 7 days
Mnemonic for acute treatment of hyperkalemia?
DISC
Dextrose + Insulin
Salbutamol
Calcium Gluconate
Long term Tx for hyperkalemia?
Risonium
How could you monitor progression of AKI?
URINE - need catheter
A unique feature of CKD on histo is ________.
Thyroidisation.
Wherein the slide looks like thyroid follicles
Which respiratory conditions are worse during sleep?
All of them.
What are the diagnostic criteria for OSA?
More than 5 apnea episodes per hour during sleep (severe is over 30) as per the Epworth Sleep scale.
Narcolepsy is a deficiency in the neurotransmitter ______ and can be treated with _______.
Orexin
Modafinil
Nuchal rigidity is the medical term for ______?
neck stiffness
An acoustic neuroma may present with which 3 findings on cranial nerve exam?
facial nerve palsy
tinnitus
ipsilateral sensorineural loss
Why are lumbar punctures contraindicated in cranial masses?
Cranial masses typically cause raised ICP, so there is a risk of herniation
What are the 3 golden features of migraine (if 2/3 are present, 90% chance it is a migraine).
- nausea
- photophobia
- disability
What is the main differential for a migraine and how could you seperate these on history?
TIA,TIA comes on suddenly, migraine builds over around 5 minutes
What are medication overuse headaches?
headaches due to frequent headache treatment, especially opiods. Causes increase in pain receptors
ED treatment of migraine?
fluid and largactil (chlormazapine)
Papilledema + 6th nerve palsy without any findings on imaging but a high opening pressure on LP is likely to be?
Idiopathic intracranial hypertension
Which condition has a sentinel bleed and how does this present?
SAH - often have a similar but less severe headache a few days or weeks prior to the real main SAH.
why might an SAH patient have photophobia and neck stiffness?
Meningism due to blood pushing on the meninges
Why might a SAH patient have a blown pupil?
aneurysm impacting CN3
If CT is clear but you’re clinically convinced it is a SAH, what is your next step?
LP for xanthochromia
how would you look for a cranial aneurysm?
Cerebral angiogram
Post-SAH BP aim?
110-140 systolic, high enough to perfuse but low enough to not cause further rupture
Definitive Tx of SAH?
surgery (clip aneurysm) or endovascular coiling (more common)
Mnemonic for tx for raised ICP?
Surgeons Loosen my brain
Surgery
Lift head
mannitol - diurese
Breath - hyperventilation will reduced CO2 leading to vasoconstriction of the brain vessels
what are the two common neuro causes of foot drop and how could you seperate them on exam?
- L5 radiculopathy
- fibular nerve issue
seperate via foot inversion. THIS MAKES SENSE. the fibular nerve splits into two, in this case the foot drop is an issue with the deep fibular nerve which does foot dorsiflexion, it has nothing to do with inversion. Inversion is done by the tibial nerve, so absence of inversion must be a higher issue that is affecting multiple nerves - L5 radiculopathy.
Broadly, proximal muscle weakness is more indicative of _____ whereas distal muscle weakness is more indicative of ______.
proximal - myopathy
distal - neuropathy
A pathology in the anterior horn of the spine typically present with?
fasiculations
Brisk reflexes + muscle atrophy is alarm bells for which condition?
mixed UMN + LMN = MND.
Muscle weakness with either ptosis or diplopia is a classic presentation of?
myasthenia gravis
What is the pathophysiology of myasthenia?
autoimmune - antibodies target Ach receptor on post-synaptic muscle terminal. Clog up the receptors.
What blood test might reveal myasthenia?
autoantibodies: anti-Ach receptor and anti-MUSK
Aside from bloods, what tests should be done for suspected myasthenia?
CT to check for thymoma
nerve conduction studies (EMG)
List 4 classic findings for a patient with myotonic dystrophy.
- unable to relax muscles (eg. can’t release clenched fist)
- frontal baldness
- ptosis
- facial/neck muscle wasting
Muscle weakness with no sensory change indicates what kind of issue, and how would you further split this issue into potential categories?
weakness without sensory change = neuromuscular pathology.
is it in the spine - MND
is it between the nerve and muscle - myasthenia
is it in the muscle - muscular dystrophy, myositis, statin myalgia
Which feature could easily seperate MND from myasthenia?
MND never involves the eyes
What is the best way to diagnose Parkinson’s?
Give a levodopa challenge and see if they improve
Parikinson’s tends to be slow, more unilateral and responds well to dopamine. If a Parkinson-like presentation was fast, symmetrical or non-responsive to dopamine, what else could you consider.
Parkinson plus syndromes:
- vascular parkinsons (stroke affecting substantia nigra)
- Lewy Body dementia
list 8 non-motor features of Parkinsons
- anxiety/depression
- sleeping disorder - kick in sleep
- erectile dysfunction
- loss of smell (anosmia)
- orthostatic hypotension
- urinary issues
- constipation
Cogwheel rigidity and shuffling gait are typical of:
Parkinson’s
Treatment for Parkinson’s?
Levodopa with peripheral dopamine converter like Carbidopa or Benseraside
What is Rotigotine?
dopamine patch, useful when ain drug has to be ceased for reasons like surgery
What is important to tell patients regarding dopamine treatment?
it treats the motor symptoms but not the mental symptoms and it does not stop disease progression, it may wear off
What is a key non-pharmacological treatment for Parkinson’s?
rehab with physio, helps to prevent pneumonia and pressure sores
what allied health may be involved for a Parkinson’s patient?
physio for rehab
OT for aids, sleep hygiene
SPEECH PATH - for speaking and swallowing - KEY
psych - for mood
Plaques in the spine in MS are medcially called:
transverse myelitis (demyelination)
Which 3 investigations are key for MS?
- MRI spine
- MRI brain
- LP for oligoclonal bands
monoclonals may reactivate which dangerous virus?
JCV
How is Lambert-Eaton different to myasthenia and what is its typical cause
Lambert Eaton can be overcome with increased movement as opposed to the fatiguable weakness in myasthenia. Lambert Eaton tends to be paraneoplastic.
Name 3 Grave’s specific findings for hyperthyroidism.
- exopthalmos
- pre-tibial myxedema
- thyroid acropachy (clubbing)
1/3 of eyebrows missing is a classic feature of:
hypothyroidism
All connective tissue diseases are capable of causing which 3 conditions?
Reynauds, ILD, arthritis
What are the time limits for definitive ischemic stroke treatment.
within 4.5 hrs - thrombolysis
within 24 hrs - clot retrieval
what are the 3 broad causes of ischemic stroke that need investigation following a stroke.
cardioembolic - ECG, ECHO, Halter
carotid - doppler
watershed - hypotension
what are the 2 major risks factors that need to be kept in mind immediately following an ischemic stroke?
- haemorrhagic transformation
- aspiration pneumonia
- bonus points - reinfarct
Which antibiotic may cause a prolonged QT interval?
macrolides
Why must tetracyclines be taken sitting up?
osephagitis risk
Which two antibiotic classes are used for anaerobes? (think of the diaphragm)
penicillins above the diaphragm
metranidazole below
Which common analgesia agent can cause serotonin syndrome?
tramadol
azathioprine may cause _____ and _______.
pancreatitis and pancytopenia
How is clexane monitored?
anti factor 10a levels
Why does clopidogrel cause ‘less’ bleeding than aspirin?
still an anti-platelet but does not carry the risk of peptic ulcer due to its MOA.
what is indomethacin?
NSAID
Why are COX-2 inhibitors sometimes preferred for long term NSAID use?
less risk of ulcer, but still carries renal risk and cvd risk
why does sepsis cause death?
persistent hypotension causes systemic hypoxia
What are the 4 SIRS criteria?
all the t words and wcc.
Tachycardia
Tachypnea
Temperature
WCC raised
Timeline for antibiotics in sepsis?
within an hour
Ampicillin is great for targeting which group of bacteria?
enterococcus
After how long do post-surgical infections tend to arise?
about a week
What is shingles and does it need antibiotics?
RE-ACTIVATION of latent VZV (they must have been exposed before), it may need Abx if there is a secondary infection
List 3 encapsulated bacteria.
the 3 that cause meningitis; Hib, N.menin, strep pneumoniae
How often should IV cannulas be replaced?
every 2-3 days
Compare bacterial causes of vomiting with no diarrhea, watery diarrhea and bloody diarrhea.
vomiting alone - Staph aurues and bacillus ceres food poisoning
watery diarrhea - vibrio (the water bug gives watery diarrhea), ETEC, giardia
bloody - shigella, EHEC, campylobacter, salmonella
What is the magic CD4 count for AIDS defining illnesses to start appearing?
200
Aspergillus is famously associated with which group of patients?
lung transplant
Negative pressure room respiratory isolation is used for which disease?
TB
Why does lactate go up in DKA?
hypovolemia due to polyuria leads to hypoperfusion
Ideally, when should BSLs be checked at home?
before meals and before bed
4 pillars of DKA management?
- rehydrate - 1L of 0.9% NaCl via a large bore IV over 30 mins.
- slow K, monitor every 3 hrs
- actrapid insulin, (if insulin given IV should be accompanied with dextrose)
- find precipitant - AMI, infection or stress
2 actions of metformin?
- reduces liver gluconeogenesis
- increases peripheral insulin sensitivity
Which diabetic medications should be avoided if a patient has pancreatitis?
DPP4 and GLP1
When should SGLT2s be stopped and restarted RE surgery?
stopped 3 days before, restarted when the patient has returned to normal eating and drinking
If 3 hyperglycemic diabetic drugs fail to control HbA1c what is the next step?
insulin
equation to quickly calculate a person’s osmolality?
2xNa + glucose
What is the treatment for HHS and what is the BSL aim?
aggressive rehydration,
aim BSL 15-20 over first 24hrs
Steps in hypoglycemia management?
- oral quick carbs if conscious (eg. juice or jelly beans)
- if not awake, IV 50% dextrose via cubital vein OR glucagon IM
- long acting carbs - eg. sandwich or long dextrose infusion
- recheck every 30 mins
- find cause
Which hormone suppresses prolcatin?
dopamine
If the pituitary stalk is compressed, which pituitary product is the first to rise?
prolactin. Due to no dopamine being able to make it through stalk, so it cannot inhibit prolactin.
Which pituitary hormone may cause galactorrhea?
galactorrhea = lactation.
done by prolactin
Is there a definitive medical management for prolactinomas?
yes, dopamine agonists will reduce size of prolactinomas. eg. cabergoline
Which two hormones control GH levels?
GHRH - positive
somatostatin - negative
How is acromegaly diagnosed?
oral glucose tolerance test as glucose SHOULD inhibit GH.
Which surgery can be done on pituitary masses? eg. for acromegaly
transphenoidal hypohysectomy
Which 3 tests can be used to diagnose Cushing’s syndrome and which common blood test would you monitor regularly?
- midnight salivary cortisol
- 24 hr urine cortisol
- dexamethasone suppression test
monitor UEC for hypokalemia due to mineralocorticoid action of cortisol
Compare the level of aldosterone and cortisol in primary vs secondary adrenal insufficiency.
primary - shit cortisol and aldosterone
secondary (pituitary) - just shit cortisol
How does primary adrenal insufficiency impact potassium levels?
causes hyperkalemia due to absence of aldosterone
Best test to diagnose primary adrenal insufficiency?
synacthen test - synthetic ACTH given and see what it does to cortisol
What is the acute treatment of an Addison’s crisis?
CCC, crystalloid, carbs, cortisone.
- rehydrate, give glucose, and give replacement hydrocortisone
What medications should Addison’s patients be on long term?
hydrocortisone and fludrocortisone
Best test for Conn’s syndrome?
aldosterone:renin ratio
1 medical and 1 surgical treatment of Conn’s syndrome?
medical - spironolactone
surgical - remove the adrenal gland
Which 3 areas should you check if suspect MEN syndrome?
pheochromocytoma in adrenals, parathyroid hyperplasia and thyroid tumour.
Masses in which 2 organs should never be biopsied, but rather taken out as a whole?
testicle and adrenal gland
what is the medical treatment for pheochromocytoma until surgery can be performed?
alpha blockers
A patient with every fucking endocrine mishap is likely to have?
polyglandular autoimmune syndrome (PAS)
At what point should you do a nuclear scan for hypothyroidism?
never, unecessary unless lump
What is thyrotoxicosis?
hyperthyroidism
List 3 causes of thyrotoxicosis.
- Graves
- toxic nodular goitre
- too much iodine - eg. contrast or naturopathic medicine
Which other organ will be the same colour as a normal thyroid on nuclear scan?
salivary glands
compare causes of homogenous vs heterogenous darkening of thyroid on nuclear scan
homogenous - Graves - increased uptake across the entire thyroid
heterogenous - nodule
List 3 long term treatment options for hyperthyroidism.
- medical management with carbimazole
- iodine radioactive ablation
- surgical removal - only for malignancy or cosmetic
How long will it take to see change in TSH following treatment for thyroid?
at least 6 weeks, no point in checking sooner
When is thyroid ultrasound appropriate?
only if there is a lump/goitre
Thyroid cancer masses are often _____, _____, and _____.
solitary, ‘cold’ and solid.
is a hypoechoic thyroid nodule worrisome?
yes, no echo on ultrasound means it is solid, could be cancer.
What are the 3 big risks in a thyroidectomy/hemithyroidectomy.
- parathyroid damage
- recurrent laryngeal damage
- ENT bleeding
for the top 2, hemithyroid is ideal.
If thyroid cancer is present and has inflammed lymph nodes, what is the next step.
NEEDS a total thyroidectomy with radio ablation afterwards, a hemithyroid is not acceptable.
Which molecule can be measured after a total thyroidectomy + ablation to see if all of the cancer is gone?
thyroglobulin. Can’t use this in hemithyroid because you’ll still have half a thyroid to make thyroglobulin.
What is subacute thyroiditis and what is a giveaway that an exam wants you to consider this?
subacute thyroiditis = deranged TFTs following illness, typically URTI. Resolves in 6 weeks.
exam giveaway - they will give CRP/ESR
What imaging should be used for a retro-sternal thyroid mass?
ultrasound won’t work because it won’t penetrate the bone, need to do CT.
Does radioactive iodine treatment of a hot nodule cause ablation?
no, will localise to the nodule. Rest of the thyroid is functionally asleep so won’t take up iodine.
What is the one key feature that defines all forms of androgen deficiency?
low testosterone
Compare LH/FSH in primary vs secondary androgen deficiency.
primary - LH/FSH high
secondary - low
What is Klinefelter’s and is it primary or secondary?
primary androgen deficiency due to XXY chromosome pattern
Why is testosterone replacement dangerous in terms of clots? Which blood value would you monitor?
like estrogen, it is prothrombotic. Due to stimulating EPO, leads to mild polycythemia increasing blood viscosity.
Monitor haematocrit
What is the classic med school contraindication for testosterone replacement therapy?
Can you think of any others?
PROSTATE CANCER
others: desire to have a child, OSA.
Why does testosterone replacement therapy reduce fertility?
negative feedback on LH/FSH axis, FSH needed for Sertoli cells to nurture sperm
JAK2 mutation is linked to which disease?
primary polycythemia
What is malignant otitis externa?
a complication of otitis externa in immunocompromised patients that leads to a base of skull osteomyelitis
What is ‘glue ear’ and how would you treat it?
OME - otitis media with effusions
- grommets
- steroids
- abx
vestibular neuritis typically causes which type of nystagmus?
rotational
What are the 4 major causes of anaemia?
non-production
loss
destruction
sequestration
How could you further split up non-productive anaemia?
- lack of haemotinic factors
- bone marrow pathology
- low EPO
How can hypothyroidism impact MCV?
MCV raised - hypothyroidism can cause a macrocytic, non-megaloblastic anaemia
A blood film with too many WBC in a med school exam is probably _______.
leukemia, especially CML
What is hydroxocobalamin?
B12
One pharmacological and non-pharmacological treatment for B12 deficiency?
- dietician referral
- hydroxocobalamin IM
Anaemia with jaundice should raise alarm bells for?
haemolysis
Mnemonic for 5 key causes of haemolysis?
Good God Man Save Her
Gilbert’s - not technically haemolysis but similar
G6PD deficiency
Malaria
Sickle cell
Hypersplenism eg. EBV
3 key Ix to check for presence of haemolysis? + 2 Ix to check for the cause of haemolysis.
- LDH
- haptoglobin
- unconjugated bilirubin
check: Coomb’s test and blood film
What is a spherocyte?
a dysmorphic type of red blood cell that indicates hereditary/autoimmune haemolysis. Looks like a perfect red circle with no white in middle like a RBC should have.
Which food to avoid if you have G6PD deficiency?
legumes (beans)
Explain HCT and RDW.
HCT - concentration of cells in the blood, will go down in anaemia.
RDW - how different the cells are in shape. The higher the RDW the more variation in RBC size - not good.
Iron deficiency has which classic finding on blood film?
pencil cells
Name the next best test for each of these in the context of aneamia:
- low mcv
- normal mcv
- high mcv
low mcv - ferritin
normal mcv - reticulocytes
high mcv - b12/folate
What is the ferritin level in anaemia of chronic disease?
high (unlike true iron deficiency, as body is sequestering iron due to perceived threat)
What do iron studies show in thalassemia?
fuck all, totally normal
Name 4 major causes of iron deficiency.
- poor intake - diet
- bleeding
- malabsorption eg. coeliac
- sequestration eg. anaemia of chronic disease
A middle aged man with anaemia should promptly receive which two tests?
colonoscopy and faecal occult blood test
what is the antidote of dabigatran?
idarucizumab
Why is desmopressin (DDAVP) used in bleeding disorders?
it increases the amount of factor 8 and von willebrands in the blood so increases clotting.
DOACs are contraindicated in damage of which key organ?
kidney disease
What would you give to reverse aspirin/clopidogrel?
no direct antidote, would need to do a platelet transfusion
Explain the 3 types of von Willebrand disease.
type 1 - partial vwf deficiency
type 2 - normal vwf level but is is deficient in some way
type 3 - total vwf deficiency
Tx for von Willebrands?
- replace vWF
- desmopressin
What will APTT and INR look like for von Willebrand and haemophilia?
both have normal INR but raised APTT (as factor 8/9 are part of APTT intrinsic pathway)
Which factors are affected in Haemophilia A and B?
A - 8
B - 9
compare the inheritance pattern of haemophilia and von willebrands.
haemophilia - X linked - think alexi romanov
von willebrands - autosomal
What are the key treatments for haemophilia A vs B?
A - give factor 8
B - give prothrombin (contains 2, 9 and 10).
petechiae tend to be due to ________.
thrombocytopenia
Immune thrombocytopenia can be cause by one infectious agent, one group of autoimmune diseases and one lifestyle choice. List them.
EBV
ANA diseases
overintake of quinine
Quinine taken for lupus may cause ______.
bleeding due to thrombocytopenia
What is the KEY component to give someone in DIC?
You need to replace all of their coags but ESPECIALLY FIBRINOGEN. Give crypoprecipitate.
In Australia, fibrinogen is given as part of which drug?
cryoprecipitate
Rigors typically indicate ______.
bacteraemia
Is an isolated vomiting episode with a fever always indicative of a GIT infection?
No. Any infection can cause a vomit due to stress on the brainstem, this is especially true if there is no diarrhoea.
Staph aureus in the urine should always be treated as _______ and therefore you should always check for ______.
bacteraemia
endocarditis
Which imaging technique is commonly used to investigate a PUO?
PET scan
Compare a meningitis headache to a SAH headache.
SAH faster onset, meningitis may be the worst headache they’ve ever had but it may take hours to reach that point.
What would be easy way to check for raised ICP?
papilledema
2 main causes of viral meningitis?
enterococcus and HSV2
What is vanc for in meningitis?
beta lactam resistant strep pneumoniae
Do hospital workers needed post-exposure prophylaxis for meningitis?
no. Only for close contacts, especially people the patient lives with. Only for Hib or N.meningitidis, not strep.
What extra test would you run on the LP CSF from suspected meningitis?
Test CSF for HSV-1 via PCR
Sepsis can often cause pain in the ______.
thighs
List 6 causes of acute back pain.
- pyelonephritis
- malignancy
- epidural abscess
- slipped disc
- vertebral osteomyelitis
- vertebral fracture
erythema marginatum is a rash most associated with _______?
rheumatic fever
Compare the pharmacological management of valvular vs non-valvular AF.
non-valvular - use DOAC as anticoagulant
valvular (including AF secondary to valve disease like mitral stenosis) - need warfarin
The two definitive treatments for a diseased valve are?
valvuloplasty or replacement
What is the typical management of tricuspid regurg?
can usually be managed just with diuretics
‘new heart murmur’ is always _______ on exams.
infective endocarditis
dental seeded infective endocarditis tends to be caused by which bacteria?
strep viridans
What are the 2 key investigations for infective endocarditis ?
blood cultures x 3
ECHO
How should antibiotics be given in infective endocarditis?
long term via PICC
Live vaccines should be avoided in _______ patients.
immunocompromised
chronic traveller’s diarrhoea is often due to?
a parasite, typically giardia
ICT rapid test and thick and thin blood films are key investigations for?
malaria
Tx for malaria?
chloroquine + artemether-lumafantrine (artemisinin)
3x malaria prophylaxis options?
- doxy , continue for 4 weeks after
- malarone, expensive
- mefloquine, once weekly
An acute fever with a sunburn looking rash in a returned traveller is typical of ?
dengue virus
how could you seperate dengue and malaria on history?
malaria usually takes 4-6 weeks to incubate, dengue is less than 3 weeks, much more acute.
Enteric fever is caused by which bacteria?
salmonella
anal pain in a sexual history suggests?
herpes
3 initial STI investigations for an MSM patient with anal pain would include:
first pass urine, anal swab, throat swab.
Which Ix is most important in newly diagnosed HIV patients to check for their AIDS status?
CD4 count
What is the magic CD4 count number that leads to AIDS defining illnesses?
below 200
What is the most important Ix to monitor the efficacy of treatment in HIV + patients?
viral load
If a HIV viral load is high despite treatment, what is likely the issue and why is this a big problem?
poor medication adherence.
Can lead to HIV resistance
When first diagnosing a patient with HIV it is important to contact which other people?
contact tracing as well as blood/sperm bank donations.
A lump in the neck following commencement of HIV therapy may be due to which phenomena?
immune reconstitution syndrome
Name one histo finding specific to TB and one gross lung finding specific to TB.
- multinucleated giant cells (Langhan’s cells)
- caseating granulomas
Succussion splash is med school lingo for which pathology?
gastric outlet obstruction
Crossed tenderness is med school lingo for which pathology?
acute appendicitis (Rosving’s sign)
For AMI, what is the cut-off for PCI and thrombolysis?
PCI is 90 minutes
thrombolysis up to around 12 hrs
Shortening of the leg is typical of?
hip fracture
list the considerations for associated risks of spinal injury (canadian spine rules).
- fast drive
- sixty five
- sense deprive
- side to side (head)
What is the mnemonic for resus cases and which examinations/factors fit into each letter of the mnemonic?
ABCDDEFG
Airway - jaw thrust, chin lift, airway assessment, intubation, talking/awake
Breathing - O2 sats, RR, wheeze, cough, positioning, CXR, ABG
Circulation - BP, HR, perfusion, urine, ECG, fluid resus
Disability - temp, neuro exam, PEARL,
DONT EVER FORGET GLUCOSE
Compare simple vs comminuted fractures.
simple - one break, into 2 pieces.
Comminuted - crushed - many pieces.
List 3 types of common adult fractures
- transverse
- oblique
- spiral
Compare the terms displaced and angulated when it comes to fractures.
displaced - not in line with the rest of the bone (but still parallel)
angulated - in a different angle than the rest of the bone
List the immediate fracture steps in ED and the subsequent steps beyond ED.
ED: examination, analgesia, X-ray, re-align, splint (POP for wrist), re-X-ray.
Further: reduction, immobilisation, ortho referral/fracture clinic, keep the environment healthy.
What position should someone with a suspected hip fracture be kept in ?
supine
What is a potential side effect of a long time spent supine and immobilised, especially in old people?
deconditioning
2 risks of a scaphoid fracture?
- avascular necrosis
- a-union of the bones
Symptoms of fracture?
the hallmarks of inflammation. Pain, swelling, loss of function etc.
Which tendons control flexion of the DIP and PIP ?
DIP - flexor digitorum profundus (think D’s together)
PIP - flexor digitorum superficilias
Which tendons control the extensor aspect of the DIP and PIP?
DIP - terminal tendon
PIP - central slip
Which nerve controls the interosseus muscles of the hand?
ulnar
Which major arm nerve does not participate in muscle contraction above the wrist?
radial
A ‘small chip’ fracture is likely a sign of a pathology relating to a _______ or ________.
tendon or ligament
Name 4 things you would do for every wound laceration in the ED.
- X ray
- Abx
- analgesia
- tetanus shot
+/- referral for surgical washout
Best antibiotic for animal bite?
augmentin
When is the best time to suture a bite from a human?
never suture a human bite
How should an amputated body part be handled?
do not put it directly on ice.
Wrap it in saline gauze then put it in a plastic bag then put it directly next to ice.
X-ray the amputated limb too
Swelling of one finger is likely to be ________. How serious is this?
Tenosynovitis - surgical emergency.
If there is a risk of avascular necrosis with a NOF break, what would be the definitive management?
hemiarthoplasty - replace the femoral head
If you have a high clinical suspicion of a fracture but it is not evident on XR, what would you do?
CT
40% of anterior shoulder dislocations lead to temporary ________.
axillary nerve dysfunction
What are the Ottawa ankle/foot rules?
ankle - inability to walk + malleolar pain
foot - midfoot pain, 5th metatarsal base pain, inability to walk
What should always be done before a bone reduction?
X RAY
List some of the high risk factors that call for a head CT in the Canadian CT rules.
- over 65
- over 2 episodes of vomiting
- reduced GCS 2 hrs after the event
- suspected skull fracture
mild risks: amnesia before the event of over 30 mins, dangerous mechanism.
What is a total contraindication of reducing a shoulder dislocation in the ED?
if you suspect a fracture
Longer term management for shoulder dislocation?
sling for 2 weeks, re-xray
What is the pathophysiology of a subdural bleed?
tearing of a bridging vein
Compare the colour of sub-dural blood in acute, sub-acute, and chronic bleeds.
acute - white
sub-acute - grey
chronic - same dark colour as CSF
Most common 2 causes of SAH?
- berry aneurysm in anterior circulation
- trauma
Main risk factor for a primary intra-parenchymal brain bleed?
HTN
Which plane shows shoulder dislocations the best?
trans-axillary x-ray
Posterior dislocations are common following ________.
seizures
The patient hearing a ‘crack’ is warning bells for ______.
fracture
A twisting ankle injury may fracture the ________ alongside a local ankle fracture.
proximal fibula - always CHECK paired bones
How much saline (approx) can you give before you really need to start considering transfusion?
About 2L
A traumatic haemothorax may also be accompanied on CXR by fluffiness in the rest of the lung, these are likely ______.
Contusions
In trauma, tachycardia means _____ unless proven otherwise.
bleeding
Best immediate step for managing a bleeding area?
PRESSURE
What is eFAST?
a quick whole body ultrasound done by the ED bedside in a trauma case
What are the 4 categories of ED investigations to consider?
- bedside
- pathology
- imaging
- microbiology
Shock causes acidosis due to _____.
lactate
When do Q waves appear and what do they indicate?
1-24 hrs after AMI, look for delayed presentation AMI in shocked patient.
Longer term non-pharm management of an AMI?
- admit to cardiac care unit
- cardiac rehab
Does 0.9% saline tend to alter serum osmolality?
no, it is essentially isotonic.
How do diarrhoea and dehydration affect osmolality?
diarrhoea reduced sodium and water, so may look normal osmolality but clinically unwell.
regular dehydration will increase osmolality as water is scarce.
Giving 5% dextrose is the equivalent of giving ______.
Water. It will impact osmolality as it is just water, not salts.
How does intracellular volume change with a high serum sodium and a low serum sodium?
water follows sodium.
If its high, cell volume will decrease.
Low serum sodium - cell volume increase
Low urine sodium with normal levels of sodium should ring alarm bells for which condition and what is a common cause of this condition?
diabetes insipidus, often due to stroke.
Name 4 causes of hyponatremia. 1 psychological, 1 pathology, 2 pharmacological.
1 - psychogenic polydipsia
1 - SIADH
2 - thiazides and SSRIs
What are the steps in the de-escalation loop?
- listen
- agree
- explain
- repeat
List 3 ED sedation options for agitated patients and the aim in this scenario.
- dropiridol, midazolam, olanzipine.
aim is for them to be sedated but rousable
What is the medication used to improve cognition in Alzheimer’s and what is an important thing to tell patients?
- Donepezil - Ach-ase inhibitor
- it does not stop disease progression
Name the 2 main features of depression, one of which is required for diagnosis.
- anhedonia
- low mood
What investigation should be done before donepezil?
ECG
A risk in patients taking SSRI + tramadol is?
serotonin syndrome
Inattention is a key aspect of ______.
delirium
Agitated patients require which class of medications and list 3.
anti-psychotics.
Risperdone, Olanzipine, haloperidol
If anti-psychotics are contraindicated, what would you use?
Lorazepam
Benzos should be avoided in which pathology?
delirium
Anti-psychotics should ve avoided in which disease?
Parkinsons
How many doses of anti-psychotics is usually needed for a delirium episode?
usually just 1
Thought disorder + hallucinations/delusions is typical of ______.
Schizophrenia
Is delirium always aggressive and overt?
no, hypoactive delirium is often misdiagnosed as depression.
BPSD is a name for?
dementia
Compare the timeline of dementia vs delirium.
Dementia - slowly progressive without fluctuation.
Delirium - acute, fluctuating.
The double duct sign on CT is an indicator of which pathology?
pancreatic cancer
What is the triple therapy for treatment of h. pylori?
ACE
amoxicillin, clarithromycin, esomeprazole
4 components of a haemolytic screen?
- haptoglobin
- LDH
- unconjugated bilirubin
- reticulocytes
Differing BP between arms is a classic sign of which pathology?
aortic dissection
‘S4 gallop’ is a typical feature of which cardiomyopathy?
HOCM
Which maneouvres are used to diagnose/treat BPPV?
diagnose - dix hallpike
treat - epley
Which LFT value may be raised in ank spon?
ALP - the bone one
List one pharm and one pathological cause of diabetes insipidus.
- lithium use
- pituitary tumour
List 5 of the criteria for Ranson pancreatitis mortality.
- age
- LDH up
- WCC up
- glucose - up
- hypoglycemia
(also high AST randomly)
Mnemonic for the risks of too-rapid sodium level correction?
High to low your brain will blow (cerebral edema)
Low to high your pons will fry (pons damage).
List 3 pathological causes of SIADH.
- lung cancer - SCLC
- meningitis
- encephalitis
Which scan is the best for lymphoma?
PET
Antidote for paracetamol overdose?
N-acetylcysteine
Mnemonic for the reasons for dialysis?
AEIOU
Acidosis
Electrolyte disturbance
Intoxication
overload
Uremic symptoms
What is Lateral Medullary Syndrome and which subsequent syndrome does it cause?
PCA stroke impacting brainstem.
Causes Horner’s syndrome.
When should a carotid endarterectomy be heavily considered?
Beyond 70% stenosis
‘pulsating’ headache (in a med school exam) rules out which cause of headache and likely refers to which cause of headache?
rules out tension type headache.
likely refers to migraine.
improvement of leg pain by hanging the limb off the side of the bed is the typical scenario for which pathology?
critical limb ischemia
2 long term side effects of bisphosphonates and 1 short term?
2 - osteonecrosis of the jaw and atypical femoral fractures
short - GORD
Teleangiectasia is common in which type of skin cancer?
BCC
What is the pre-cursor to skin SCC?
actinic keratosis
Which monoclonal is commonly given for ulcerative colitis?
infliximab or adalimumab
How to treat raised ICP?
Surgeon Loosen My Brain Sir
- Surgery
- Lift head
- Mannitol
- Breathe - hyperventilate them
+/- Steroids if caused by a mass
3 symptoms of a Zenker’s diverticulum?
halitosis, regurgitation, feeling of lump in throat
Which type of eponymous cell is found in Hodgkins Lymphoma?
Reed Sternburg cells
A rash on the hands and feet is typical of ______.
Syphilis
A NOF can lacerate which leg artery?
medial circumflex
An increased amylase is indicative of which condition?
Pancreatitis
Which spinal level is aimed for in a spinal anaesthetic?
L3-5
Which medication can be used a medical management for passing kidney stones?
Alpha blockers - just as in BPH
Which 4 investigations would you order if you suspected testicular cancer?
USS + BCHG + alpha fetoprotein + LDH
A very high BHCG is indicative of which type of testicular cancer?
Choriocarcinoma (remember choroid is the tissue that nurtures the baby in a female, so equate the baby marker (BHCG) with a choroid cancer).
What is the breast triple test?
exam + imaging + biopsy
Headache worst at night or on waking are med school code for which pathology?
brain cancer
Best imaging for septic arthritis?
USS
mnemonic for RA treatment?
CAMP
Celecoxib
Adalimumab
methotrexate
pred as needed
Painless otorrhea should raise alarm bells for which pathology?
cholestotoma
What is the magic neutrophil number for febrile neutropenia?
less than 1.0
Which value is used to measure clexane efficacy?
factor Xa levels
Which ulcer type is most associated with granulation tissue?
Venous
How often is INR checked for warfarin?
4 weekly
What is AVNRT?
the most common type of supraventricular tachycardia, identified by regular tachycardia with no delta waves.
True seizures involve biting of which area of the tongue?
the sides! other types such as a psychogenic seizure may bite other areas such as the front.
Procedural memory is often spared in _______.
Alzheimers
Which type of dementia is best described as a stepwise decline?
vascular - worsens with each stroke
Which type of dementia may have hallucinations?
Lewy Body
What is a definitive intervention for non-proliferative diabetic retinopathy?
laser treatment
A cloudy peritoneal dialysis bag is indicative of?
infection/peritonitis
Seeing ‘halos’ around lights is typical of which eye pathology?
cataracts
Bouchard nodes, hallux rigidus and Heberden’s nodes are found in ____.
osteoarthritis
Do cranial nerve pathologies affect ipsilateral or contralateral sides of the face?
Ipsilateral (aside from CN4 which is the only one to decusate)
Which treatment is best for a person with a Hb below 70 who is symptomatic?
urgent RBC transfusion
Which breast lump is most common in women under 35 and does it cause discharge/lactation?
Fibroadenoma - no it does not.
What is Prehn’s sign? What is Prehn’s negative?
Prehn’s sign = the testicle lift to test torsion.
NEGATIVE - pain unrelieved by lifting which means it is likely torsion. Think of negative being the negative outcome.
Removal of the terminal ileum will likely affect absorption of B12 and which other substance?
bile salts
Which other joint pathology pre-disposes people to septic arthritis?
osteoarthritis
What is a red flag in migraine sufferers that would indicate they need further workup?
increased frequency or severity
A fever 24 hrs after surgery is likely to be due to _______.
common post-op fever due to trauma to body - infections/DVT don’t really show up for 3-7 days.
PPI use is a risk factor for hospital acquired _____.
pneumonia - raises apsiration risk
Treatment for epididymo orchitis?
antibiotics and elevation
Which medication class is generally contraindicated in heart failure?
calcium channel blockers
Which score is used to grade liver transplant candidates?
MELD score
Why is electric cardioversion contraindicated for AF that has been present for over 48 hrs?
clot risk
When should a colonoscopy be done for acute diverticulitis?
It shouldnt be done - may perforate the bowel. Just do a CT.
Pain on accomodation with a red, weeping, painful and photophobic eye is typical of which condition?
uveitis
CURB65 is a score for which pathology?
pneumonia severity
Which valvular pathology is often cause by HOCM?
aortic stenosis (functional)
‘impaired elasticity and proliferation of connective tissue’ describes which cardiomyopathy?
restrictive
Mesalamine (5-ASA) is a long term treatment for which disease?
IBD
‘Moth eaten’ areas of bone are typical of _______.
lytic lesions
‘immature neutrophils’ on blood film are typically of which blood cancer?
APML
Can epilepsy cause neuro damage or death?
yes both - neuro damage in status epiliepticus and sudden death can occur
An isolated thrombocytopenia on blood tests may be due to which disease?
immune thrombocytopenia purpura
Which type of dementia may barely affect memory?
fronto-temporal - impacts behaviour
Donepezil is used for?
Alzheimers
Which two medication classes should be avoided in Alzheimers?
benzos and anti-psychotics
Does parkinsons tremor tend to be symmetrical or asymmterical?
asymmetrical
violent sleep thrashing is typical of which disease?
Parkinsons
What is dyskinesia in Parkinsons?
Presence of involuntary movements typical of prolonged dopamine treatment.
Which medications are in symbicort?
budenoside and formetrol
Methacoline is used to diagnose which condition?
Asthma provocation test
Graves histology may show a metaplasia from ____ cells to _____ cells.
from cuboidal to columnar
Phosphate is mostly present as which molecule in the body?
H2PO4
How long can a CVC be left in?
5-21 days
What is the target of ciprofloxacin?
bacterial gyrase
What is the target of metranidazole?
bacterial DNA disruption
A headache triggered by cough or straining is typical of which pathologies?
Those that raise ICP - bleeds and mass lesions.
How does a ruptured AAA impact blood pressure?
Causes hypotension
What size AAA requires surgery (when symptomatic)?
above 5cm
List one surgical and medical treatment for achalasia.
surgical - myotomy
medical - botox
Regular feeling breast lumps in young women are likely to be ____ whereas in middle aged women they’re likely to be ______.
young - fibroadenoma
middle aged - fibrocystic disease
What is Paget’s disease?
Oozing/red/crusty nipple due to ductal carcinoma in situ
When does mastitis occur?
Red, painful nipple following breastfeeding.
A spinal anaesthetic is used for surgeries below the ______.
Umbilicus
What is the typical pain ladder for post-op analgesia?
paracetamol –> NSAID –> opiod
Which blood test could indicate compartment syndrome?
CK
Which dermatome is the back of the knee?
S2
A kidney stone above ____ in size is unlikely to pass naturally.
7mm
What is the best treatment for a kidney stone between 10 and 20mm?
stent and uretoscopy
Which type of diuretic is a risk factor for calcium renal stones?
loop diuretic
Long, thin, penicl-shaped stools are typical of which cancer?
rectal carcinoma
Why does COPD increase haemorroids risk?
repeated straining from coughing
Diffuse goitre is more descriptive of ______ whereas a painless, rubbery goitre is more typical of ______.
Graves is diffuse.
Hashimotos is rubbery.
Does Graves have Anti-TPO antibodies?
It can, they are quite non-specific.
What is propyluracil?
An alternate to carbimazole used in pregnant women.
A protruding lateral ear is a specific sign of which pathology?
Mastoiditis - due to untreated otitis media. They also have a tender mastoid process.
Which antibiotic is used in mastoiditis?
Cefotaxime
what is the typical cause of a Quinsy?
poorly/untreated tonsilitis
Where is an emergency tracheotomy placed anatomically?
Between the thyroid and cricoid cartilage (cricothyroid ligament).
What is a HINTS exam?
Head Impulse, Nystagmus, Test of Skew - a neuro exam done in vertigo to differentiate peripheral vs central vertigo.
What is the anti-histamine typcically used to treat vertigo?
Promethazine
When is it appropriate to stop the K+ infusion in DKA?
potassium levels over 5.5
When is it appropriate to commence insulin in DKA?
When K+ is above 3.5
Which anatomical feature puts someones at risk of glaucoma?
shallow anterior angle
Comodonal acne is commonly known as?
black and white heads
Female hormonal acne may be controlled by ______ alongside a retinoid and the OCP.
spironelactone
Which type of acne is the most at risk of scarring?
Acne conglobata
What are the first line treatments for osteoporosis?
Bisphosphonates or denosumab
‘rolled edges with an ulcerated core’ is a description of which skin cancer?
BCC
What is Bowen’s disease and which other disease is it often mistaken for?
Pre-malignant squamous cell lesion, often mistaken for psoriasis.
BRAF and MEK inhibitors as well as CTLA-4 and PD-1 inhibitors are all treatments for?
melanoma
How does tamoxifen help osteoporosis?
it doesnt really
Which type of muscle fibre is targeted in sarcopenia?
Type 2 (fast)
what is the initial management of critical limb ischemia?
anti-coag
Which stroke causes hemineglect?
Non-dominant stroke, often impacting parietal lobe. Typically right sided MCA stroke.
Why might hypoxia raise haemoglobin?
Secondary polycythemia - hypoxia causes kidney to make EPO to create more Hb.
How painful are first degree haemorroids?
not very
A ‘left parasternal impulse’ is a sign of ?
right ventricular strain
Which nerve roots supply the median nerve, ulnar nerve and radial nerve?
Median - C6-T1
Radial - C7 mostly but C5-T1 in reality, al, of brachial plexus.
Ulnar - C8 and T1
What is Beck’s triad and which condition does it relate to?
hypotension + elevated JVP + muffled heart sounds - all indicate cardiac tamponade.
Electrical alternans is med school code for which pathology?
tamponade
An old person with pain in the groin and anterior thigh may indicate?
hip pathology
Which skin cancer may have a keratin ‘horn’?
squamous cell carcinoma
How does parietal lobe impact vision?
Gives sense of spacial self direction and orientation. This is why damage to this area may cause hemineglect.
Pain in shoulder abduction from 60 to 120 degrees is typical of which pathology?
impingement syndrome
