Medicine Flashcards
commonest cause of c. diff diarrhea?
giving antibiotics e.g. clindamycin/cephalosporin/quinolones
Name 2 symptoms of pseudomembranous colitis?
Sign on flexi sig?
- systemic: fever, dehydration
- abdo pain, bloody diarrhea, mucus PR
Sign: yellow plaques on flexi sig
3 main causes of dysphagia?
- inflammatory
- GORD
- tonsilitis, pharyngitis - mechanical
- Luminal - food bolus
- mural - plummer vinson
- extra mural - lung cancer - motility
- local - achalasia
- systemic - systemic sclerosis/ CREST
What does dysphagia for solids and liquids indicate?
Motility disorder e.g. achalasia
if solids> liquids –> stricture
complications of gallstones (3)
- in gallbladder
- acute/ chronic cholescystitis - biliary colic with inflam
- biliary colic - stone in cystic duct or common bile duct
- carcinoma - common bile duct
- cholangitis
- obstructive jaundice
- acute pancreatitis - gut
- gallstone ileus
definition of colicky pain?
obstruction of a hollow viscus therefore when the smooth muscle in the walls of the viscus contracts to overcome the obstruction –> waves of pain
what does the foregut consists of?
where is the main referred to?
- lower 1/3 of oeseophagus –> ampulla of vater in duodenum
2. pain is referred to epigastrium
what does the midgut consists of?
where is the main referred to?
- 2nd part of duodenum to midway transverse colon
2. pain referred to periumbilical region
what does the hindgut consists of?
where is the main referred to?
- transverse colon to rectum
2. pain referred to suprapubic region
why is inflammation of visceral peritoneum more accurately located by site?
visceral peritoneum (which covers intra-abdominal organs) is innervated by somatic nerves
however, visceral pain isn’t well located as it travels along autonomic nerves which don’t have dermatomal representation so brain links it to physical areas that have same entry in spinal cord
difference between colicky pain and parietal pain?
colicky pain
- patient is moving about trying to get comfortable
parietal pain
- patient lies still as pain is worse on movement, coughing, inspiration.
- guarding (contraction of abdo muscles when palpated)
- rigidity (increased tone of abdo muscles).
- board like rigid tender abdomen is seen when peritonitits affects whole abdomen.
causes of small bowel and large bowel obstruction?
- Small bowel
- adhesions
- hernias - Large bowel
- colon cancer
- constipation
- diverticular disease
- volvulus
what does hartmann’s solution contain (4)?
- sodium chloride
- K
- Calcium
- lactate
Pre-op surgical assessment?
- History and exam
- PMH
Diabetics
- Increased risk of infection (would, chest, IV site, urine), perivascular disease, pressure sores, IHD
- if on oral hypoglycaemics or insulin they should stop this the night before and start a dextrose/insulin infusion (should be 1st on op list) e.g. Mix dextrose, K, insulin in a bag to give as an infusion = 500 ml of 10% dextrose, 10mmol KCL and 10 units Actrapid - Past surgical history
- nature and complications - Past anesthetics history
- hard intubation
- aspiration during aneasthesia
- malignant hyperpyrexia (rapid rise in temp after anesthetic drug leading to rigidity or even rhabdomyolysis. AD inheritance) - social habits
- smoking should stop to improve resp function
- IVDU could be high risk of infections e.g. hep - drug history
- Warfarin - if possible stop before and convert to heparin infusion
- aspirin and clopidogrel - stop 10 days before surgery
- OCP increased risk of DVT so stop 6w before and continue 2 weeks after (use alt.
- steroids - if dependent they need hydrocorisone injections perioperatively to prevent addisonian crisis
Post-op surgical assessment?
- Post-op pyrexia
- normal in 1st 48 hours after surgery
- afterwards need to look for cause including
- – wound - staph aureus and coliforms (tx with regular wound dressings and Antibiotics)
- – venous cannula
- – chest (if not clearing secretions properly)
- – legs - DVT
- – urine
- – rectal exam (pelvic abscess) - Bleeding
- primary = during op
- reactionary = end of op when wound looks dry then bleeds after due to not properly ligating bv
- secondary = few days after op due to infection. tx = take patient back to theatre - Poor urine output
- pre-renal = renal hypoperfusion
- renal = diagnosis of exclusion. call renal dr
- post renal
- – Most common. Due to anaesthetic drugs (if anticholinergics), pain, opiates.
- — If there’s suprapubic pain/ enlarged bladder
- — Tx:
- ———- Conservative w/ analgesia and privacy.
- ———- Catheter (urine volume > 500ml indicates post renal cause). If already have one then flush to make sure not blocked. If dark urine comes out in small amounts this is likely pre-renal cause.
- ———- Look at fluid balance charts. Fluid challenge with 500ml saline and if urine output improves = prenal
Surgical complications?
Immediate
- primary / reactive haemorrhage
Early
- Secondary haemorrhage
- VTE
- urinary retention
- Atelectasis
Late
- Scarring
- Neuropathy
What is the generic tx for ortho conditions?
- Modification of ADLs
- Physio
- Analgesia on WHO step ladder
- Steroid injection
- Arthroplasty
What type of murmur is MR?
Causes
Pan systolic
Associated with atrial fibrillation
Causes: LV dilatation (secondary to HTN), rheumatic heart disease, prolapse
What type of murmur is MS?
Cause
Mid diastolic
Cause: Rheumatic heart disease
What type of murmur is AS?
Cause?
Ejection systolic
Cause: calcification, bicuspid valve, rheumatic heart disease
What type of murmur is AR?
Cause?
Early diastolic
Causes:
- Bicuspid valve
- Connective tissue: marfan’s
- Autoimmune: ank spond, RA
- Infective endocarditis
Gene mutation in HOCM?
AD Mutation in gene encoding beta-myosin heavy chain protein
Common cause of sudden death in young athletes. signs = dyspnoea, palpitations, syncope, ejection systolic murmur, jerky pulse, double-apex beat,
Echo: asymmetrical septal hypertrophy, MR, diastolic dysfunction
Tx:
Medical: BB/CCB + Amiodarone + Anticoag
Surgical: Septal myomectomy/ ICD
Causes of Dilated cardiomyopathy?
Alcohol
Coxsackie B
Doxirubicin
Exam: High pulse, raised JVP, low bp, displaced apex beat, S3, oedema, hepatomegaly
Echo: systolic dysfunction, low ejection fraction
Tx:
Medical: ACEI, BB, diuretics, anticoag
Surgical: ICDs, LVAD, transplantation
Causes of restrictive cardiomyopathy?
Amyloidosis
Sarcoidosis
Post radiotherapy
Exam: features of RHF = oedema, ascites, hepatomegaly
Echo: diastolic dysfunction
TX: cause
What side do HNPCC (Lynch) tumours usually occur?
right and usually mucinous
What’s the difference between osteopenia, osteoporosis, osteomalacia, rickets?
Osteopenia: Loss in bone density, precursor to Osteoporosis.
Osteoporosis: there is a loss of bone density.
Osteomalacia: Adult form of Vitamin D deficiency = soft bones (no calcium)
Rickets: Child form of Vitamin D Deficiency = soft bones (no calcium)
Causes of RAD and LAD?
RAD = PE, anterolateral MI, RVH
LAD = Inferior MI, LVH
How are RVH and LVH seen on ECG? Causes?
- RVH = dominant R wave in V1 and deep S wave in V6
- Causes: Pulmonary HTN, MS, COPD - LVH = S wave in V1 and R wave in V6 > 35mm (3.5 large squares)
- Causes: HTN, AS, AR, MR
Causes of peripheral neuropathy (2)?
- Mostly motor signs
- Guillain barre
- Lead poisoning
- Hereditary sensorimotor neuropathy (charcot marie tooth) - Mostly sensory signs
- DM
- B12 (dorsal columns affected before distal parasthesia)
- Alcohol (sensory before motor)
Causes of 3rd nerve palsy?
- Medical
- DM
- HTN
- MS - Surgical = pupil dated as parasympathetic nerve fibres run on outside of CN III
- posterior communicating artery aneurysm
- SOL
- trauma
Ix: examine pupils, AVPU (bleed –> reduced consciousness), BM
Causes of ptosis?
- Unilateral
- horners
- 3rd nerve palsy
- myesthenia gravis - Bilateral
- myesthenia gravis
Is the pupil small? –> Horners
Is the pupil large? -> 3rd nerve
Is the pupil normal? -> pupil-sparing 3rd nerve or something else?
causes of CN VI palsy?
- DM
- HTN
- MS
- Raised ICP
a. Loss of retinal vein pulsation – earliest sign of raised ICP on fundoscopy
b. Reduced GCS
c. CN VI commonly affected as has longest intracranial course. Commonly gets pinched at the pterous temple bone. Pupil dilates early
d. Papilloedema – late sign
What is cushing’s triad?
Seen in raised ICP
- bradycardia, HTN, irregular breathing
Double vision:
- When is it worse?
- Which image is real
- Get it on walking downstairs
- When is it worse?
- looking on affected side - Which image is real
- outside image isn’t real - Get it on walking downstairs
- CN IV
Define spastic paraparesis? When do you see it? Causes (3)? Next steps (3)? Other questions (5)?
- Clasp knife rigidity = hard initially then eases of towards the end. velocity dependant. (rigidity is the same throughout)
- UMN - flexion of upper limbs, extension of lower limbs
Causes: cord compression, cervical spondylosis, MS, CVA
If patient comes with: Hypertonia in both leg, Reduced power both legs, Incr reflexes bilaterally, Ankle clonus
Next steps:
- check sensory levels and upper limb reflexes
- sacral sensation
- complete my examination by doing anal tone
Other questions:
- HAVE YOU NOTICED A CHANGE IN SENSATION WHEN YOU PASS URINE
- Urinary retention
- Faecal incontinence
- Saddle paraesthesia
- Erectile dysfunction
Weakness down left side, give 3 reasons for CXR?
- Stroke - aspiration pneumonia
- lung ca mets to brain
- CCF/HTN - enlarged heart
4 cardinal signs of bowel obstruction?
- abdominal pain
- constipation (no faeces or flatus)
- vomiting
- abdo distension
Borders of poster triangle in the neck?
A = SCM
P = trapezius
I = middle 1/3 of clavicle
Borders of anterior triangle in the neck?
A = midline of neck
P = SCM
I = inferior border of mandible
Causes of LBBB
- MI
- Aortic stenosis
- Dilated cardiomyopathy
What is BPPV
Debris blocking normal flow of endo lymph in labyrinth
What does the lateral femoral cutaneous nerve innervate?
lesion?
- lateral part of thigh
- can become trapped in inguinal ligament in obese people –> pain in lateral thigh (meralgia parasthetica) after standing for long periods
common peroneal nerve lesion?
lies cloes to fibula so can become trapped in below knee plaster cast/ fibular fractures –>
- lack of dorsiflexion -> foot drop -> high stepping gait
- loss of sensation of lateral leg and dorsum of foot (except lateral foot as supplied by sural nerve)
damage to sciatic nerve how? features?
- fracture dislocations of the hip/ misplaced gluteal injections
- paralysis of hamstrings (affects hip extension) and muscles of leg and foot + loss of sensation below knee laterally
how is the tibial nerve damaged? features?
- posterior dislocation of the knee
- loss of toe flexion, ankle inversion and ankle reflex + loss of sensation over plantar surface of foot. This leads to shuffling gait + atrophy of intrinsic muscles of foots leads to claw foot
how is the femoral nerve damaged? features?
- trauma/ hip dislocations. It’s lateral to femoral artery (NAVY)
- loss of knee extension + loss of sensation of anterior thigh and medial leg
cause of trendelendberg gait?
damage to superior gluteal nerve –> loss of hip abduction and pelvic dip
why may thyroxine be give to pts with papillary or follicular carcinoma?
because they’re TSH dependent so we give t4 to suppress endogenous TSH
what is plummer’s disease?
when multinodular goitre becomes toxic i.e. one nodule can start secreting t4 = toxic multinodular goitre
what’s the difference between strangulated and richter’s hernia?
strangulated is when bowel twists on itself -> reduced venous return -> oedema -> arterial supply is cut off -> ischaemia then necrosis and gangrebe. This leads to irreducible hernia which is tender, red and warm. Also features of obstruction.
richter’s hernia is strangulation of one side of bowel in hernia sac so no signs of obstruction
What are the oesophageal varices, caput medusa, anal varices made of?
= collaterals between between portal and systemic circulations
- oesophageal varices
- left gastric and oesophageal vein - caput medusa
- umbilical vein and superior + inferior epigastric veins - anal varices
- superior and inferior rectal veins
what do you do if you hear stridor (inspiratory grunting)
head tilt chin lift
difference between a single lumen cuffed endotracheal tube and a double lumen?
- single lumen - if patient having surgery under GA and needs a definitive airway. sits in trachea and allows for mechanical ventilation. cuffed end creates seal to prevent stomach aspiration
- double lumen - for intrathoracic surgery to allow one lung to be collapsed (for ease of surgery) and the other lung still ventilated
- note uncuffed is preferred in children so dont damage their trachea which isnt as strong
when is a cricothyrotomy indicated?
where?
- emergency situations where naso/oropharyngeal airway is contraindicated/ impossible and a tracheostomy would take too long e.g. airway obstruction, angioedema, foreign body
- incision through skin and cricothyroid membrane (below thyroid cartilage) and inserting a wide bore cannula
difference between bulbar palsy and pseudobulbar palsy?
- Bulbar palsy
- LMN disease of CN 9-12 (caused by MG, guillain barre, motor neurone disease)
- hypotonia, wasting, dysphagia, dysarthria and fasciculations of the tongue and reduced jaw jerk - Pseudobulbar palsy
- UMN - MS, brainstem tumour, brainstem stroke
- dysphagia, dysarthria, hypertonia, spastic tongue and increased jaw jerk
common causes of urinary retention?
Obstructive
- BPH
- prostate cancer
- urethral stricture
- drugs - nifedipine, anticholinergics, NSAIDS
Neuro
- spinal injury
- MS
Myogenic
- over-distension after anesthesia
Cause of hydronephrosis?
- Unilateral
- stone/ tumour retroperitoneal fibrosis - bilateral
- obstruction in urethra
= kidneys unable to excrete
common causes of bloody diarrhea?
- campylobacter jejuni
- salmonella
- shigella
Signs of TIA?
- contralateral motor deficits on face/limbs
- ipsilateral visual loss (amaurosis fugax) due to retinal artery occlusion by emboli
NB imp to perform carotid artery doppler and if > 70% stenosis -> carotid endarterectomy in 1st 2weeks
Preparation for surgery?
Anesthetist and book theater Bloods = clotting and Group and Save Consent DVT ECG if >55yo and cardiovascular risks
Initial management of fractures (6A’s)
Analgesia - morphine and metoclopramide
Assess neurovascular status (angiography if distal pulses impalpable)
Antiseptic - wash and cover with sterile soaked gauze
Align and reduce and splint
Antibiotics - augmentin IV
Antitetanus
Most dangerous complication of open fractures?
Clostridium perfringes
Wound infection, gas gangrene, renal failure
Tx: debride, benpen and clindamycin
Normal PR, QRS and QT intervals
PR = 120-200ms = 3-5 small squares
QRS = 120ms
QT = 380-420ms= 9-10 small squares
Causes of vertigo?
Peripheral - BPPV, meniere’s, labyrinthitis
Central - Acoustic neuroma, MS
Drugs - gentamicin, loop diuretics, metronidazole
