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
