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Phase 4 Question Knowledge > Medicine Knowledge > Flashcards

Medicine Knowledge Flashcards

1
Q

What does SAAG measure indirectly?

A

Portal pressure- can be used to determine if a patient’s ascitis is due to portal hypertension or other causes

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2
Q

Ascities causes if SAAG over 11g/L?

A

Liver disorders:
Cirrhosis/alcholic liver disease
Acute liver failure
Liver metastses

Cardiac:
Right heart failure
Constrictive pericarditis

Other causes:
Budd-Chiari syndrome
Portal vein thrombosis

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3
Q

Ascities causes if SAAG less than 11g/L?

A

Hypoalbuminaemia- nephrotic syndrome, severe malnutrition

Malignancy

Infections

Pancreatitis

Bowel obstruction

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4
Q

Management of ascities?

A

Reduce dietary sodium

Fluid restriction if sodium is <125mmol/L

Aldosterone antagonists e.g. spironolactone

Drainage if tense ascities- large volume paracentesis requires albumin cover to avoid paracentesis induced circulatory dysfunction

Prophylactic antibiotics

Transjugular intrahepatic portosystemic shunt (TIPS) in some patients

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5
Q

What are the features of idiopathic pulmonary fibrosis?

A

Progressive exertional dyspnoea

Bibasal fine end-inspiratory crepitations on auscletation

Dry cough

Clubbing

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6
Q

Idiopathic pulmonary fibrosis diagnosis?

A

Spirometery- classically a restrictive picture

Impaired gas exchange- reduced transfer factor

High resolution CT scan investigation of choice and required to make a diagnosis- ground glass or honeycombing seen on x-ray

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7
Q

Idiopathic pulmonary fibrosis management?

A

Pulmonary rehabilitation

Few medications give a benefit- small evidence pirfenidone

Many patients require supplementary oxygen and eventually a lung tranplant

Life expectancy of 3-4 years

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8
Q

Cluster headache management?

A

Acute- 100% oxygen
Subcutaneous triptan

Prophylaxis- Verapamil
(some evidence for tapering dose of prednisolone)

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9
Q

CKD and hypertension treatment?

A

ACEi first line - small fall in eGFR and small rise in creatinine is acceptable

Furosemide also useful, also lowers potassium, careful of dehydration

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10
Q

Types of necrotising fasciitis?

A

Type 1- mixed anaerobes and aerobes (often post surgery in diabetics) Most common type

Type 2- streptococcus pyogenesR

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11
Q

Risk factors for necrotising fasciitis?

A

Recent trauma/ burns/soft tissue infections

Diabetes mellitus- paticularly if treated with SGLT-2 inhibitors

IV drug use

Immunosuppression

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12
Q

Most common site for necrotising fasciitis?

A

Perineum

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13
Q

Features necrotising fasciitis?

A

Acute onset

Pain, swelling, erythema at the effected site- often presents as rapidly worsening cellulitis with pain out of keeping with physical features

Extremley tender with skin necrosis a late sign

Fever or tachycardia may be absent or occur late in presentation

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14
Q

Management necrotising fasciitis?

A

Urgent surgical debridement

IV antibiotics

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15
Q

Big side effect of spironolactone in men?

A

Gynaecomastia

Other causes:
Puberty
Syndromes with androgen deficiency: Kallman’s, Klinefelter’s
Testicular failure- mumps
Liver disease
Testicular cancer
Ectopic tumour secretion Hyperthyroidism
Haemodyalysis
Drugs

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16
Q

Drugs that cause gynaecomastia?

A

Spironolactone (most common)
Cimetidine
Digoxin
Cannabis
Finasteride
GnRH agonists- goserelin, buserelin
Oestrogens, anabolic steroids

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17
Q

What is the triad for nephrotic syndrome?

A
  1. Proteinuria
  2. Hypoalbuminemia
  3. Oedema
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18
Q

Causes of nephrotic syndome?

A

Primary causes: minimal change disease, focal segmental glomerulosclerosis (FSGS), membranous nephropathy

Secondary causes: DM, systemic lupus erythematosus (SLE), amyloidosis, infections (HIV, Hep B and C), drugs (NSAIDs, gold therapy).

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19
Q

Nephrotic syndrome and LMWH?

A

Loss of antithrombin 3 etc rise fibrinogen levels and predisposes to thrombosis- prphylactic LMWH required

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20
Q

Nephrotic syndrome and thyroid?

A

Loss of thyroxine- binding globulin lowers the total but not free thyroxine levels

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21
Q

Investigations for nephrotic syndrome?

A

Urine dipstick- proteinuria and microscopic haematuria

MSU to exclude UTI

Quantify proteinuria using early morning urinary protein:creatinine ratio or albumin: creatinine ratio.

FBC and coagulation screen

Urea and electrolytes

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22
Q

Amiodarone vs atropine?

A

Amiodarone bring the HR down

Atropine bring the heart rate up

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23
Q

Adverse signs in Peri-arrest bradycardia and the treatment required?

A

Shock- hypotension, pallor, sweating, cold clammy extremities, confusion or impaired conciousness

Syncope

Myocardial ischaemia

Heart failure

Atropine 500mcg is the first treatment in this situation- used up to a max of 3mg

If inadquate response also-
Transcutaneous pacing

Isoprenaline/adrenaline injection

Specialist led transvenous pacing if no response to above

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24
Q

Features of hepatitis A?

A

Flu-like prodrome

Abdominal pain- typically RUQ

Tender hepatomegaly

Jaundice

Deranged LFTs

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25
Q

What are the three types of multiple endocrine neoplasia (MEN)?

A

MEN type 1- 3 p’s- Parathyroid- hyperparathyroidism, Pituitary, Pancreas- insulinoma

MEN type IIa- 2 P’s- Parathyroid, Phaeochromocytoma

MEN type IIb- 1 P- Phaeochromocytoma

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26
Q

What are some red flag symptoms for trigeminal neuralgia?

A

Sensory changes
Deafness
FH multiple sclerosis
Age onset before 40
Pain only in opthalmic region

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27
Q

Management of trigeminal neuralgia?

A

Carbamazepine

Failure to respond=refer to neurology

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28
Q

Brief difference between Lambert-Eaton and Myasthenia Gravis?

A

Lambert-Eaton- Legs affected first/ gets better with movement- linked to SCLC

Myasthenia Gravis- eyes/ arms/ face affected first, worse with movement

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29
Q

Paraneoplastic features of small cell lung cancer?

A

ADH- SIADH

ACTH- Cushing’s

Lambert Eaton syndrome

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30
Q

Paraneoplastic features of squamous cell lung cancer?

A

Parathyroid hormone-related protein (PTH-rp) secretion causing hypercalcaemia

Clubbing

Hypertrophic pulmonary osteoarthropathy (HPOA)

Hyperthyroidism due to ectopic TSH

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31
Q

Acute management of SVT?

A

Vagal manoeuvres- valsalva manoeuvres- trying to blow into empty plastic syringe, carotid sinus massage

Intravenous adenosine- contraindicated in asthmatics- verapamil preferable

Electrical cardioversion

Prevention of episodes- beta blockers, radio-frequency ablation

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32
Q

Narrow complex vs broad complex tachycardia?

A

Narrow generally SVT- through normal conduction system- narrow QRS

Broad generally VT- outside normal conduction system- broad QRS

Exceptions SVT with abberrant conduction like BBB

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33
Q

Pain relief in palliative patients with renal failure?

A

Mild renal failure- oxycodone

Sever renal impairment- buprenorphine (or fentanyl) as not renally excreted

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34
Q

Starting treatment for pain relief in palliative medicine?

A

Regular oral modified release morphine with immediate release morphine for breakthrough pain- 1/6th normal dose

Laxatives prescribed for all patients starting strong opioids

Opioid caution in renal disease- oxycodone for mild-moderate, buprenorphrine/ fentanyl for moderate/severe

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35
Q

What is the main test used to screen for latent tuberculosis?

A

Mantoux test

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36
Q

What happens to sodium in SIADH?

A

Hyponatremia due to dilution from water retention

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37
Q

SIADH pathophysiology?

A

Excessive ADH secretion (vasopressin)- causes water retention and hyponatremia

Leads to decreased urine output- no signs of fluid overload due to equal distribution of fluid

Concentration of electrolytes in blood- particularly sodium- is depeleted

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38
Q

Causes of SIADH?

A

Malignancy- SCLC (also pancreas/prostate)

Neurological- stroke, SAH, subdural, meningitis

Infections- tuberculosis, pneumonia

Drugs- SSRIs, carbamazepine,

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39
Q

SIADH investigations?

A

Urine osmolality- inappropriately high when compared with serum osmolality

Urine sodium concentration- urine sodium concentration is high

40
Q

SIADH mangement?

A

Fluid restriction

Demeclocycline- reduces collecting tubule responsiveness to ADH

41
Q

What is Budd-Chiari syndrome?

A

Hepatic vein thrombosis

Causes:
Polycythemia rubra vera
COCP
Pregnancy
Thrombophilia also antiphospholipid syndrome

42
Q

What is the triad for Budd-Chiari?

A

Abdominal pain- sudden onset, severe

Ascities- abdominal distension

Tender hepatomegaly

43
Q

Investigation for Budd-Chiari syndrome?

A

Ultrasound with doppler flow studies

44
Q

What is Hashimoto’s thyroiditis?

A

Chronic autoimmune thyroiditis

Typically hypothyroidism but may be period of transient thyrotoxicosis

10x in women

45
Q

Features of Hashimoto’s thyroiditis?

A

Features of hypothyroidism

Goitre: firm, non-tender

Anti-thyroid peroxidase (TPO) and also anti-thyroglobulin (Tg) antibodies

46
Q

Things associated with Hashimoto’s thyroiditis?

A

Other autoimmune conditions- coeliac disease, T1DM, vitiligo

Development of MALT lymphoma

47
Q

What to do if cannot establish intavenous access in advanced life support?

A

Use intraosseous route to give drugs

48
Q

Chest compression to ventilation ratio in ALS?

A

30:2

49
Q

Defibrillation in ALS?

A

Single shock for VF/pulseless VT followed by 2 minutes of CPR

If cardiac arrest witnessed in a monitored patients then up to three successive stacked shocks rather than 1 shock followed by CPR

50
Q

Adrenaline in ALS?

A

Adrenaline given as soon as possible for non-shockable rhythms

In VF/VT cardiac arrests adrenaline given once chest compressions have restarted after third shock

Repeat adrenaline every 3-5 mins whilst ALS continues

51
Q

Amiodarone and ALS?

A

Amiodarone 300 mg should be given to patients who are in VF/pulseless VT after 3 shocks have been administered

A further dose of amiodarone 150 mg should be given to patients who are in VF/pulseless VT after 5 shocks have been administered

Lidocaine can be used as an alternative

(remember adrenaline needs to be given)

52
Q

Thrombolytic drugs and ALS?

A

Should be considered if a pulmonary embolus is suspected

If given, CPR should be continued for an extended period of 60-90 minutes

53
Q

Causes of a raised TLCO?

A

Asthma

Exercise

Male

Polycythemia

Pulmonary haemorrhage

54
Q

Causes of reduced TLCO?

A

Pulmonary fibrosis

Pneumonia

Pulmonary emboli

Pulmonary oedema

Emphysema

Anaemia

Low cardiac output

55
Q

What demographic does idiopathic intracranial hypertension occur in?

A

Obese, young females

Causes headaches/ blurred vision

56
Q

Risk factors for idiopathic intracranial hypertension?

A

Obesity
Female
Pregnancy
Drugs:
COCP
Steroids
Tetracyclines

57
Q

Features of idiopathic intracranial hypertension?

A

Headache

Blurred vision

Papillodema

Englarged blind spot

Sixth nerve palsy

58
Q

Management of intracranial idiopathic hypertension?

A

Weight loss

Acetazolamide

Repeated lumbar puncture

Surgery

59
Q

Most common precipitating factors for DKA?

A

Infection, missed insulin doses, MI

60
Q

Features of DKA?

A

Abdominal pain

Polyuria, polydipsia, dehydration

Kussmaul respiration

Acetone-smelling breath

61
Q

Diagnostic criteria for DKA?

A

Glucose > 11mmol/l or known DM
pH < 7.3
Bicarbonate < 15 mmol/l
Ketones > 3mmol/l or urine ketones ++ on dipstick

62
Q

Management of DKA?

A

Fluid replacement- isotonic saline used initially

Insulin- IV infusion started at 0.1 unit/kg/hour
Once blood glucose is < 14 mmol/l an infusion of 10% dextrose should be started at 125 mls/hr in addition to the 0.9% sodium chloride regime

Correction of electrolyte disturbance- Serum potassium often high on admission despite total potassium low, falls on treatment so add potassium into replacement fluids

Long-acting insulin continued, short-acting insulin stopped

63
Q

How is DKA resolution defined?

A

pH >7.3 and
Blood ketones < 0.6mmol/L and
Bicarbonate > 15 mmol/L

Both ketonemia and acidosis should have resolved within 24 hours

64
Q

Complications from DKA/treatment?

A

Gastric stasis

Thromboembolism

Arrhythmias secondary to hyperkalaemia/iatrogenic hypokalaemia

Iatrogenic due to incorrect fluid therapy: cerebral oedema*, hypokalaemia, hypoglycaemia

Acute respiratory distress syndrome

Acute kidney injury

65
Q

Which age group is most as risk of cerebral oedema in DKA?

A

Children/young adults- often need neuro observation- don’t overload with fluid

66
Q

What is Barrett’s oesophagus?

A

Metaplasia of the lower oesophageal muscosa, with the usual squamous epithelium being replaced by columnar epithelium

67
Q

Risk factors for Barrett’s oesophagus?

A

GORD
Male
Smoking
Central obesity

68
Q

Management of Barrett’s oesophagus?

A

High dose PPI

Endoscopic surveillance with biopsies- for patients with metaplasia not dysplasia- endoscopy every 3-5 years

If dysplasia of any grade is identified endoscopic intervention is offered

69
Q

What are the causes of anaemia in renal failure (CKD)?

A

Most significant- reduced erythropoietin levels- kidneys produce EPO

Reduced absorption of iron

More kidney specific reasons

70
Q

Management of anaemia in CKD?

A

Determination and optimisation of iron status should be carried out prior to the administration of erythropoiesis stimulating agents (ESA)

Oral iron should be offered, if not reached target in 3 months switch to IV iron, those on ESA usually require IV

ESAs such as erythropoietin and darbepoietin

71
Q

Glucose range for prediabetes?

A

HbA1c of 42-47mmol

Fasting glucose of 6.1-6.9

72
Q

Glucose range for diabetes?

A

> =48mmol HbA1c
=7mmol fasting glucose

73
Q

Management for prediabetes?

A

Lifestyle modification- exercise, diet, weight loss

At least yearly follow up with blood tests

Metformin for adults at high risk progressing towards T2DM despite lifestyle changes

74
Q

Features of a lower UTI in adults?

A

Dysuria
Urinary frequency
Urinary urgency
Cloudy/offensive smelling urine
Lower abdominal pain
Fever- typically low-grade in lower UTI
Malaise
In elderly patients acute confusion is a common feature

75
Q

Urine dipstick vs urine culture in lower UTI?

A

Urine dipstick- can be used to aid diagnosis in women under 65 years old with no risk factors for complicated UTI

Urine culture- should be sent in women >65, men or catheterised patients, reccurent UTI, pregnant patients

76
Q

Hypospelnism causes and features?

A

Causes:
Splenectomy
Sickle-cell
Coeliac disease
Graves’ disease
SLE
Amyloid

Features:
Howell-Jolly bodies
Siderocytes

77
Q

Diabetes diagnosis thresholds?

A

Fasting glucose greater than or equal to 7

Random glucose greater than 11.1 or after glucose tolerance test

If patient asymptomatic the criteria must be demonstrated on two seperate occasions

Also HbA1c above 48

78
Q

Conditions where HbA1c may not be useful for diabetes diagnosis?

A

haemoglobinopathies
haemolytic anaemia
untreated iron deficiency anaemia
suspected gestational diabetes
children
HIV
chronic kidney disease
people taking medication that may cause hyperglycaemia (for example corticosteroids)

(High turn over of RBC)

79
Q

What condition can cause a sudden deterioration following high pressure non-invasive ventilation?

A

Pneumothorax

80
Q

What are the types of pneumothorax?

A

Primary spontaneous pneumothorax- those occuring in tall, young individuals without lung disease

Secondary spontaneous pneumothorax- occurs in patients with pre-existing ling disease such as COPD, asthma, cystic fibrosis, lunch cancer

Traumatic pneumathorax- penetrating or blunt chest trauma

Iatrogenic pneumothorax- complication of medical procedures such as- thoracentesis, central venous catheter placement, ventilation- including non-invasive ventilation or lung biopsy

81
Q

What is a tension pneumothroax?

A

Severe pneumothorax resulting in the displacement of mediastinal structures

82
Q

Clinical features of pneumothroax?

A

Sudden symptoms: dyspnoea, chest pain: often pleuritic

Signs:
Hyper-resonant lung percussion
Reduced breath sounds
Reduced lung expansion
Tachypnoea
Tachycardia

In tension pnemothorax:
Respiratory distress
Tracheal deviation away from side of the pneumothorax
Hypotension

83
Q

First step in pneumothorax management?

A

Assess the size of the pneumothorax

No or minimal symptoms- conservative care, regardless of pneumothorax size

Symptomatic- assess for high-risk characteristics

84
Q

Management for symptomatic pneumothorax?

A

Determine if there are high risk characteristics:
Haemodynamic compromise (suggesting tension)
Significant hypoxia
Bilateral pneumothroax
Underlying lung disease
Over 50 with significant smoking history
Haemothorax

If no high risk patients offered a choice of conservative, ambulatory or needle aspiration

If high risk and safe to intervene- chest drain

85
Q

Pneumothroax conservative care summary?

A

Patient with primary spontaneous pneumothorax this is managed conservaively should be reviewed every 2-4 days as an outpatient

Secondary spontaneous managed conservatively should be monitored as an inpatient

86
Q

Ambulatory care for pneumothorax?

A

Use an ambulatory device that allows controlled escape of air with one way valve

87
Q

Needle aspiration for pneumothorax?

A

Chest drain should be inserted if unsuccessful

If resolved discharge and follow up as outpatient in 2-4 weeks

88
Q

Chest drain insertion?

A

Daily review as an inpatient

Remove drain when resolved

Discharge and follow up in outpatients after 2-4 weeks

89
Q

Persistent/recurrent pneumothroax?

A

Video-assisted thoracoscopic surgery (VATS) should be considered to allow for mechanical/chemical pleurodesis +/- bullectomy

90
Q

Discharge advice for pneumothorax?

A

Avoid smoking

Avoid flight for 2 weeks after

Scuba diving should be permenantly avoided

91
Q

What is acute interstitial nephritis?

A

Accounts for 25% drug induced AKI- inflammation in kidney

92
Q

Causes of acute interstitial nephritis?

A

Drugs- most common cause, particularly antibiotics- penicillin, rifampicin, NSAIDs, allopurinol, furosemde

Systemic disease- SLE, sarcoidosis, Sjogren’s syndrome

Infection

93
Q

What are the features of acute interstitial nephritis?

A

Fever, rash, arthralgia

Eosinophillia

Mild renal impairment

Hypertension

94
Q

Difference between IgA nephropathy and Post streptococcus glomerulonephritis?

A

PSGN develops 1-2 weeks after URTI

IgA nephropathy develops 1-2 days after URTI

95
Q

What criteria are used to calculate eGFR?

A

Serum creatinine

Age

Gender

Ethnicity

Factors affecting the result:

Pregnancy

Muscle mass (amputees, body builders)

Eating red meat 12 hours prior to the sample being taken

96
Q

CKD stages 1 and 2?

A

If no sign of kidney damage on other test/ kidneys look normal then there is no CKD

97
Q

CKD and anaemia?

A

CKD can cause a reduction in erythropeitin levels

This predisposes to LVH so can cause cardiovascular issues

Phase 4 Question Knowledge (30 decks)

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