Miscellaneous Flashcards
What are the biochemical features of Tumour Lysis Syndrome?
Treatment of cancer results in lysis which releases components into bloodstream: raised phosphate raised potassium raised uric acid lowered calcium (chelated by elevated phosphate) raised creatinine (renal failure)
What is the MOA of Rasbirucase?
rh-Urate oxidase which converts uric acid into allantoin. Allantoin is water soluble thus more easily excreted by the kidneys
What is the most common form of Malaria?
M falciparum
What are the features of Malaria falciparum?
Fever >39C
Hypoglycaemia
Acidosis
Severe anaemia: TATT
Schizonts on blood film
What are the complications to be concerned of regarding malaria falciparum?
Cerebral spread: seizures/coma
Acute renal failure: blackwater fever (haemorrhaging of RBCs releasing Hb into urine)
ARDS
Hypoglycaemia
DIC
What is the most common non-falciparum malaria cause?
A. P falciparum
B. P malariae
C. P ovarle
D. P vivax
D
Which forms of malaria is associated with nephrotic syndrome?
A. P vivax
B. P malariae
C. P falciparum only
D. P malariae and P falciparum
D
A 55-year-old man presents with fever, fatigue, and chest pain. The patient was discharged after a successful mitral valve replacement 6 weeks ago. An urgent echo showed the presence of a new valvular lesion. Three sets of blood cultures are taken, and a diagnosis of infective endocarditis is confirmed.
Given the background, what is the most likely causative organism?
S epidermis
A 12-hour old baby girl is noted to have dysmorphic features, including webbing of the neck and wide-spaced nipples. She is also noted to have ‘puffy’ hands and feet. She is in the 10th percentile for length and weight.
There is no family medical history and, other than being small for gestational age, there were no abnormalities noted during pregnancy.
What cardiac condition is commonly associated with the likely underlying diagnosis?
CoA
You review a patient in the respiratory clinic who has a history of recurrent pulmonary embolism despite anticoagulation with warfarin.
What lung-specific, physiological change may be expected?
TLCO reduced
What drugs should be stopped in an AKI as they are nephrotoxic?
Mnemonic: NADA
NSAIDs ACEi Diuretics Aminoglycosides ARBs
A 23-year-old woman presents with dysuria, malaise, vaginal pain, fever, and myalgia. She consents to a vaginal examination which reveals multiple painful ulcerations around the vagina and perineum. Urinalysis reveals trace leukocytes, no nitrites, and microscopic haematuria. Swabs are taken and sent and a urine MCS is also sent.
Given the most likely diagnosis, what is the most appropriate treatment?
This woman has genital herpes. The painful nature rules out lymphogranuloma venereum.
Therefore it is a Genital Herpes caused by HSV-1 which requires an antiviral for 10 days.
Valaciclovir for BDS 10/7
A 27-year-old man presents to his GP feeling generally unwell complaining of joint pain and swelling. He returned from a walking trip in Thailand one month ago and one day after his return he developed severe watery diarrhoea and abdominal cramps that lasted for one week.
On examination he appears unwell and looks fatigued. He has large effusions of the left knee and right ankle along with tender planter fascia bilaterally. He also has tender metatarsophalangeal joints on both feet. On closer inspection of the feet he has a papular rash on the soles of both feet.
For the last week he has been taking regular paracetamol and ibuprofen with minimal improvement in symptoms.
Given the most likely diagnosis what is the most appropriate next step in this patients management?
This man has Reactive Arthritis
Therefore oral steroids required for 4/6/52
A 38-year-old woman presents with a litany of symptoms that have been ongoing for the past four months. These include weight gain, which particularly bothers her around the abdomen, with troubling purplish stretch marks, thin skin and easy bruising. She has been noticing increased swelling in her ankles and poor mood. In the diagnostic work-up, a range of laboratory tests is taken.
What is the expected electrolyte abnormality in this patient?
This woman has Cushing’s Syndrome.
The elevated cortisol is due to ectopic production or exogenous sources.
Cortisol may simulate aldosterone thus increased sodium reabsorption, potassium excretion. At high levels of potassium excretion, bicarbonate is absorbed.
This results in a metabolic alkalosis that is hypokalaemic thus Hypokalaemic metabolic alkalosis.
What are the features of severe acute asthma?
RR >25
HR >110bpm
PEF 33-50% of normal
Cannot complete sentences in one breath
A 68-year-old male presents to the Emergency Department with a two-hour history of crushing left-sided chest pain radiating to the jaw. He has a past medical history of dyslipidaemia and hypertension. You perform an electrocardiogram and serum troponin which confirm an anterior ST-elevated myocardial infarction (STEMI). The nearest primary percutaneous coronary intervention (PCI) centre is three hours away by ambulance and urgent fibrinolysis is therefore given in preference to PCI.
What is the most appropriate management plan regarding myocardial revascularisation of this patient?
Take ECG 60-90 minutes later and if no correction, transfer for PCI
What are the clinical features of Port wine stains?
Do they require treatment?
Unilateral
Deep red/purple (vascular birthmark)
Darken and raise over time
Not symptomatically, but potentially if Sturge-Weber Syndrome or psychosocial implications
Cosmetic camouflage
Laser therapy
What are the clinical features of a dermatofibroma?
Solitary firm papule resulting from trauma
5-10mm in size
Skin dimples on pinching skin
What are the clinical features of Mongolian blue spots?
Flat blue/grey skin markings occurring at birth/after
Base of spine/back
Dermal melanosis with melanocytes remain deep in dermis (red wavelengths of light absorbed and blue wavelengths reflected back from brown melanin pigment deep in dermis) - “Tyndall Effect”
What is Eisenmenger Syndrome?
Give the clinical features.
Reversal of L-to-R shunt in CHD due to pulmonary hypertension.
Murmur may not be heard Cyanosis Clubbing RV failure Haemoptysis/Embolism
What is Transposition of the Great Arteries?
Give the clinical features.
What is the management of this?
Congenital heart defect with failure in embryonic development.
Aorta leaves from RV
Pulmonary artery leaves LV
Cyanosis Tachypnoea Found S2 (ejection systolic murmur) RV impulse prominent CXR: Egg-on-side appearance
Must surgically correct.
Maintain patency of any shunt with PGEs
Surgically correct
Outline what a Stokes-Adams attack is?
Syncopal episodes occurring from cardiac arrhythmia - heart block or sick sinus syndrome
How may Syncope be classified?
Cardiac
- Arrhythmia
- Structural
- Others: e.g. PE; Myocarditis
Neural
- Vasovagal
- Situational
- Carotid sinus
Orthostatic syncope
- Autonomic failure
- Drug-induced
- Volume depletion
What is a femoral aneurysm?
How may it present?
Bulging weakness in wall of femoral artery
Pulsation in groin
Pain in leg/abdomen/back
Claudication symptom
Nerve compression (femoral nerve/obturator nerve)
What is Short Bowel Syndrome?
Give the clinical features.
Absence of functional SI
Fatigue Vomiting Thirst/Dry skin Bloating/Cramping Foul-smelling stool Weakness
When prescribing anti-emetics in palliative care, what should be considered?
Consider the cause of the N/V to be treated
Reduced motility (e.g. secondary to opioids) - Use metoclopramide / domperidone
Chemically mediated (e.g. secondary to hypercalcemia; opioids or chemotherapy)
- Ondansetron
- Levomepromazine
Visceral/serosal (secondary to constipation/oral candidiasis)
- Cyclizine
- Levopromazine
Raised ICP
- Cyclizine
- Dexamethasone (if metastases)
Vestibular (opioid related)
- Cyclizine
Cortical (e.g. anxiety/pain/fear)
- Benzodiazepines
- Cyclizine
When would you avoid oral anti-emetics in palliative care?
NBM Poor swallow Vomiting Malabsorption Gastric stasis
Therefore use IV route
How do you calculate the breakthrough dose of morphine?
1/6 of daily dose
What should be prescribed with opioids?
Laxatives
What opioid should be given in patients with renal impairment?
Moderate impairment: Oxycodone
Severe impairment: Buprenorphine; Fentanyl
What can be used to manage metastatic bone pain?
Opioid analgesia
Bisphosphonates
Radiotherapy
What are the side effects of opioids?
Respiratory depression
Nausea
Drowsiness
Constipation
How do you convert between oral codeine and oral morphine?
Divide by 10
How do you convert between oral tramadol and oral morphine?
Divide by 10
What are the differences in side effects between oxycodone and morphine?
Cf Morphine…
More constipation
Less sedation
Less vomiting
Less pruritus
How do you convert between oral morphine and oral oxycodone?
Divide by 2
How do you convert from oral morphine to subcutaneous morphine?
Divide by 2
How do you convert from oral morphine to subcutaneous diamorphine?
Divide by 3
What is the management for intractable hiccups?
Chlorpromazine
Dexamethasone (if hepatic lesions)
How is confusion managed in palliative care?
Sedatives
Haloperidol
Chlorpromazine
Levomepromazine
How are secretions managed in palliative care?
Hyoscine hydrobromide/Hyoscine butylbromide
Glycopyrronium bromide
When is neutropenic sepsis most likely to occur?
7-14 days following chemotherapy
Neutrophil count <0.5 x 10^9
Fever >38 C
Sepsis features
What is the management of neutropenic sepsis?
ABX: Pip/Taz
+
Specialist assessment
If still unwell after 48 hours - use alternative ABX e.g. Meropenum ± Vancomycin
A patient who is fully active is which WHO performance status?
A. 1
B. 0
C. 2
D. 3
B
A patient who is restricted in physical activity but ambulatory and able to carry out work is which WHO performance status?
A. 1
B. 0
C. 2
D. 3
A
A patient who is able to self care but unable to work, out of bed for 50% of the day is which WHO performance status?
A. 1
B. 0
C. 2
D. 3
C
A patient who is bedridden for >50% of the day is?
A. 1
B. 0
C. 2
D. 3
D
A patient who is completely disabled, unable to carry on self-care or leave chair is given which WHO performance status?
A. 1
B. 4
C. 2
D. 3
B
Which cancers are most commonly associated with hypercalcaemia?
Breast
Kidney
Multiple myeloma
Why might a magnet be placed over an ICD?
In the event that you are unclear whether an ICD has been deactivated, placing a large magnet over the device will temporarily deactivate the defibrillation function for the duration of time the magnet is in place. The magnet should therefore be securely taped over the ICD to prevent it slipping off the patient’s chest. If it turns out the ICD has been deactivated, the magnet will do no harm and can simply be removed once it is confirmed deactivation has taken place.
What are the criteria to certify a patient’s death?
Absence of pupillary response Failed response to pain Absence of central pulse Absence of heart sounds Absence of bowel sounds Check and confirm again at 5 minutes
Give the two predictors of mortality in the palliative patient group?
Deteriorating function
Surprise Question: Would you be surprised if this patient were to die in the next days/weeks/months?
Give two examples of deprivation of liberty.
Restraint being used to admit a patient to a hospital / care home when the patient has resisted admission
Medication being given by force against a patient’s will
Staff taking complete control over a person’s care and movements over a long period
Patients being prevented from seeing family or friends because the care home / hospital had restricted their access to them.
What does the DOLS Mental Capacity Act 2005 aim to do?
Aims to ensure patients in care settings are cared for in accordance to their wishes without restricting their freedom
Why may Glycopyrronium be preferred to Hyoscine hydrobromide?
Hyoscine hydrobromide is an antimuscarinic drug which will also dry secretions, it can cross the blood-brain barrier and cause agitation, so glycopyrronium might be preferable.
A 40-year-old with known rheumatoid arthritis, established on sulfasalazine and regular paracetamol and ibuprofen, is seen by her GP with ongoing low mood. Non-pharmaceutical interventions have been trialled with limited improvement and now the patient reports they feel their depressive symptoms are worsening.
As such the GP decided to commence the patient on an antidepressant.
What agent would increase this patient’s risk of a GI bleed the most, therefore, warranting a protein pump inhibitor as cover?
SSRI in combination with NSAID = increased risk
PPI should be prescribed
A 52-year-old man is admitted to hospital with acute pancreatitis. He drinks 90 units of alcohol per week. When is the peak incidence of delirium tremens following alcohol withdrawal?
72 hours
6-12 hours = symptoms (tremor, tachycardia, anxiety)
36 hours = seizures
72 hours = Fever, confusion, delusions, tremor and hallucinations
A 36-year-old man with a history of asthma and schizophrenia presents to his local GP surgery. He complains of ‘tonsillitis’ and requests an antibiotic. On examination he has bilateral inflammed tonsils, temperature is 37.8ºC and the pulse is 90/min. His current medications include salbutamol inhaler prn, Clenil inhaler 2 puffs bd, co-codamol 30/500 2 tabs qds and clozapine 100mg bd. You decide to prescribe penicillin.
What is the most appropriate further action?
FBC - Clozapine can cause agranolocytosis/neutropenia
A 23-year-old male has been on antipsychotics for the past few months. He has been suffering from a side-effect of this drug, that you grade as severe, which causes repetitive involuntary movements including grimacing and sticking out the tongue. This side-effect is known to arise only in individuals who have been on antipsychotic for a while.
Which medication is therefore most suitable to treat this side-effect?
Tetrabenzene - treats tardive dyskinesia
A 24-year-old woman is brought to the Emergency Department by her friend. The friend states she has been acting differently and can’t seem to concentrate on one thing at a time. He has noticed over the past few days that she hasn’t been sleeping as he can hear her walking around in the early hours of the morning. His main concern is that she has been coming home with multiple bags of very expensive looking shopping every day for the past 3 days.
The patient denies any hallucinations but states she feels great and wants to eat all the time. She has no past medical history and takes no medications.
What is the most likely cause of this patient’s presentation?
Hypomania
What are the clinical features of SSRI discontinuation syndrome?
increased mood change restlessness difficulty sleeping unsteadiness sweating gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting paraesthesia
A 36-year-old with a long standing history of schizophrenia presents to the emergency department in status epilepticus. Once he is treated, he tells the doctor he has been having a lot of seizures recently.
Which of the following medications is most likely to be causing the seizures?
A. Sertraline
B. Lithium
C. Clozapine
D. Onlazapine
C - Clozapine reduces the seizure threshold
Which factors give a poor prognosis of Schizophrenia?
strong family history gradual onset low IQ prodromal phase of social withdrawal lack of obvious precipitant
Joseph, a 55-year-old man, goes to his GP describing a lack of energy, low mood and lack of pleasure doing activities he normally enjoys for the past 10 days. According to ICD-10 criteria, how long must Joseph’s symptoms last to be classified as a depressive episode?
2 weeks
A 60-year-old man with chronic schizophrenia presented with nausea and vomiting. He receives metoclopramide for his symptoms. Twenty minutes later he becomes agitated and develops marked oculogyric crises and oromandibular dystonia.
What is the most appropriate drug to prescribe?
Procyclidine
A 27-year-old man presents to his GP with ongoing issues with sleep and admits that he has not been sleeping because of tension in his relationship with his girlfriend. He feels she is somewhat distant with him and is concerned that she is spending time with her former boyfriend who works in the same office as her.
On further questioning, he explains he has had several relationships in the past during which he felt as though they were not interested in him. He feels as though he will never be able to find the perfect partner therefore suffers from mood swings as a result. During the consultation, he reveals that he feels ‘alone in the world’ and that even his friends are ‘out to get him’, risk assessment reveals he does not have any suicidal thoughts but self-harms from time to time. A referral to psychiatry is made and subsequently he is diagnosed with borderline personality disorder.
What is the most appropriate treatment?
DBT
You are on a psychiatric liaison rotation, and have been asked to talk to an admitted patient with known bipolar disorder. Upon trying to take a history from him, you struggle to follow his stream of consciousness, as he keeps saying things like: ‘I went home to feed my cat – so fat I am, I really need to lose weight – I hate the postman, he always speeds in his red van, Dan is my best friend at work -‘. You suspect that his flight of ideas is linked only by rhyme or similar sounding words.
What is the medical term for this psychiatric symptom?
Clang associations
Outline the difference between Somatisation, Hypochondriasis, Conversion disorder, Fatitious disorder and Malingering.
Somatisation = 2+ Sx for 2+ years
Hypochondriasis = belief of disease without accepting medical tests e.g. Cancer
Conversion disorder = motor/sensory loss without consciously knowing
- No malingering
- No factitious
Factitious disorder = Munchausen’s with intentional production (insight)
Malingering = fraudulent simulation of symptoms to gain financially or in another way
A 75-year-old male presents to the acute medical unit with dyspnoea. He has a past medical history of chronic obstructive pulmonary disorder (COPD). On examination the patient has an SpO2 = 85%, blood pressure 100/65 mmHg, temperature = 38.6 C and widespread bilateral expiratory wheeze on auscultation. An arterial blood gas (ABG) sample reveals:
pO2 = 6.8 kPa pCO2 = 7.8 kPa pH = 7.31 HCO3- = 44 mmol/l
Acute on chronic Respiratory Acidosis
A 26-year-old male presents via ambulance to the emergency department of your local hospital following a motor vehicle accident. He was a restrained passenger. The paramedics have secured his c-spine before transporting him. He is complaining of chest pain and shortness of breath. A primary and secondary survey are undertaken and the following pertinent findings are reported:
Young, otherwise healthy looking male in clear pain and respiratory distress.
Glasgow coma scale (GCS) of 14.
Heart rate of 104/min.
Blood pressure of 94/50mmHg.
Respiratory rate of 24/min.
Oxygen saturation: 99% on 15L non-rebreather.
Temperature: 36.8 degrees.
There is a tender contusion on the anterior chest. No abnormal chest movements. JVP can been seen at the level of the earlobe. Auscultation reveals soft heart sounds and bibasal crepitations. There is air entry throughout both lung fields.
An ECG is performed.
Which of the following ECG findings is most likely to be reported in this patient?
Electrical Alternans
A 26-year-old male presents via ambulance to the emergency department of your local hospital following a motor vehicle accident. He was a restrained passenger. The paramedics have secured his c-spine before transporting him. He is complaining of chest pain and shortness of breath. A primary and secondary survey are undertaken and the following pertinent findings are reported:
Young, otherwise healthy looking male in clear pain and respiratory distress.
Glasgow coma scale (GCS) of 14.
Heart rate of 104/min.
Blood pressure of 94/50mmHg.
Respiratory rate of 24/min.
Oxygen saturation: 99% on 15L non-rebreather.
Temperature: 36.8 degrees.
There is a tender contusion on the anterior chest. No abnormal chest movements. JVP can been seen at the level of the earlobe. Auscultation reveals soft heart sounds and bibasal crepitations. There is air entry throughout both lung fields.
An ECG is performed.
Which triad is demonstrated here?
Beck’s Triad = hypotension + raised JVP + muffled heart sounds
A thirty-four-year-old man with ulcerative colitis is recovering on the ward 6 days following a proctocolectomy. During the morning ward round he complains to the team looking after him that he has developed pain in his abdomen. The pain started in the left iliac fossa but is now diffuse. It came on suddenly, overnight, and has gradually been getting worse since. He ranks it an 9/10. He has not opened his bowels or passed flatus since the procedure. He has had no analgesia for this.
On examination:
Blood pressure: 105/68 mmHg; Heart rate: 118/minute, regular; Respiratory rate: 12/minute; Temperature: 38.2 ºC; Oxygen saturations: 98%.
Abdominal exam: abdomen is distended and diffusely tender upon palpation and widespread guarding, indicating peritonism. No organomegaly or palpable abdominal aortic aneurysm. Kidneys are non ballotable. No shifting dullness. Bowel sounds are absent.
There is 250 mL of feculent matter in the abdominal wound drain.
The registrar requests an abdominal CT which demonstrates an anastomotic leak. What is the most appropriate initial management of this patient?
Take to theatre immediately
Jenna is an 18-year-old woman who was initially admitted with a fever and disseminated rash. She had not been previously vaccinated and was in contact with her 2-year-old cousin who had developed a fever and disseminated blisters and vesicles containing clear fluid. She began to have a fever and flu-like symptoms 2 weeks after seeing her cousin. Similar clear-fluid filled vesicles and blisters developed 3 days later and she was admitted for further observation.
After 3 days, she noticed that while most of her skin lesions are healing, one of the lesions on the thigh appears to be red and becoming hot to touch. An area of skin approximately 3x3cm was erythematous. The skin was marked and she was commenced on IV flucloxacillin. Over the coming 12 hours, the erythema around this lesion continued to spread. The pain around her leg increased in intensity, requiring morphine to take the edge off the pain. A blueish discolouration begins to develop around the rash.
Given the likely complication that has developed, what is the likely organism that has caused the complication?
GAS
Jenna is an 18-year-old woman who was initially admitted with a fever and disseminated rash. She had not been previously vaccinated and was in contact with her 2-year-old cousin who had developed a fever and disseminated blisters and vesicles containing clear fluid. She began to have a fever and flu-like symptoms 2 weeks after seeing her cousin. Similar clear-fluid filled vesicles and blisters developed 3 days later and she was admitted for further observation.
After 3 days, she noticed that while most of her skin lesions are healing, one of the lesions on the thigh appears to be red and becoming hot to touch. An area of skin approximately 3x3cm was erythematous. The skin was marked and she was commenced on IV flucloxacillin. Over the coming 12 hours, the erythema around this lesion continued to spread. The pain around her leg increased in intensity, requiring morphine to take the edge off the pain. A blueish discolouration begins to develop around the rash.
Given the likely complication that has developed, what is the likely diagnosis?
Necrotising Fasciitis
Chickenpox can predispose you to Nec Fasc
What is target blood pressure for a 56-year-old man with type 2 diabetes mellitus who has no end-organ damage, if using a clinic blood pressure reading?
<140/90 mmHg
A 32-year-old woman comes to surgery for her blood results. She is 25 weeks pregnant and has had her glucose tolerance test.
The results are as follows:
Fasting glucose = 7.3 mmol/L
2-hour glucose 8.5 mmol/L
What would be the most appropriate next step?
Fasting glucose > 7 thus insulin immediately
If fasting glucose < 7 then 1 week trial of diet and exercise may be given
A 43-year-old man is attending today following a referral from his GP. He has a history of poorly controlled hypertension and has come in today to have his aldosterone: renin ratio performed. The results showed high aldosterone and low renin levels. The patient also has a CT scan which shows bilateral hyperplasia of the adrenal glands.
How should this patient be managed?
This patient has a high aldosterone : renin ratio therefore there is elevated levels of aldosterone which feeds back to suppress renin.
Aldosterone levels increase sodium retention and potassium secretion thus hypertension occurs.
The cause is bilateral thus surgery not indicated, but something to antagonise the effects of aldosterone hence Spironolactone
A 29-year-old woman presents to the GP with her mother. She has been experiencing fatigue for 2 weeks which she says is unusual for her. She has multiple petechiae on her arms and legs and hepatomegaly on examination. Her vital signs are all normal, and she is not aware of having any long-term medical conditions.
Which of the following is the most appropriate management?
Refer to specialist urgently - suspected leukaemia
What are the clinical features of an atrial myxoma?
systemic: dyspnoea, fatigue, weight loss, pyrexia of unknown origin, clubbing
emboli
atrial fibrillation
mid-diastolic murmur, ‘tumour plop’
echo: pedunculated heterogeneous mass typically attached to the fossa ovalis region of the interatrial septum
An 85-year-old man is bought into hospital after developing severe abdominal pain at home. His family report that he has also seemed more confused today and is ‘off his legs’.
On examination, his abdomen is full with a large palpable bladder. A PR examination reveals a smooth, mildly enlarged prostate with an empty rectum. A bladder scan shows 1L of urine in his bladder.
His most recent prescription shows that he takes aspirin, fexofenadine, ramipril, paracetamol, prazosin and insulin.
What medication is most likely to have contributed to this presentation?
Fexofenadine - may cause urinary retention
A 16-year-old girl with cystic fibrosis is being reviewed for her annual check-up. She was diagnosed with cystic fibrosis 15 years ago.
She has a good exercise tolerance, minimal gastrointestinal symptoms and has not been hospitalised in the past year.
Her recent investigations show an iron-deficient anaemia on her blood work, and multiple positive sputum cultures for Burkholderia species. Her latest FEV1 is 650% of her predicted.
What feature of her history confers the greatest increase in mortality?
Chronic Burkholderia infection
A 23-year-old female with severe learning difficulties is brought into the emergency department by her parents following an accidental paracetamol overdose. She was found 40 minutes ago to have mistakenly ingested 16 grams of paracetamol after having been briefly unsupervised.
What is the best initial management of this patient?
Within 1 hour, can give Charcoal
Check serum Paracetamol levels to determine if above treatment line then give n-acetylcysteine
A 77-year-old male presents to the Emergency Department after waking in the morning with lower back pain and an inability to stand unassisted. He has a past medical history of metastatic lung cancer and is currently receiving palliative care for this. Examination of the lower limbs reveals severe neurological deficits of both legs.
Given the likely diagnosis, which of the following would be a late sign in this patient?
Urinary incontinence
A 47-year-old man is admitted to the hospital with severe knee pain, swelling and stiffness which began last night. He is unable to weight bear and is systemically unwell with a temperature of 39.3ºC. He undergoes joint aspiration to confirm the diagnosis.
How long of a course of antibiotics should be prescribed?
4-6 weeks for Septic Arthritis
What are the side effects of glucocorticoids?
Immunosuppression/Neutrophilia
Growth suppression
Psychiatric: Mania/Insomnia/Depression/Psychosis
Ophthalmic: Glaucoma/Cataracts
GI: peptic ulceration/pancreatitis
Dermatological: Acne
Endocrine: IGT/ Increased appetite/ Weight gain/ Hirsutism/ Hyperlipidaemia
Cushing syndorme: moon face; striae; buffalo hump
Why are steroids gradually tapered?
Long-term corticosteroids suppress the glucocorticoid axis therefore sudden withdrawal may lead to an Addisonian crisis
How long does steroid withdrawal symptoms last for?
Up to 2 weeks
What may be a protective factor in a paracetamol overdose?
Acute alcohol intake
Which patients are at increased risk of hepatotoxicity following a paracetamol overdose?
Patients taking enzyme inducing drugs (rifampicin, phenytoin, carbamazepine, chronic alcohol excess, St. John’s Wart)
Malnourished patients
When may charcoal be of benefit in a paracetamol overdose?
<1 hour
When should acetylcysteine be given in a paracetamol OD?
Staggered overdose
Plasma concentration above treatment line
How is acetylcysteine given?
Infuse over 1 hour - reduce risk of anaphylactoid reaction
What are the criteria for a liver transplant following paracetamol overdose?
Arterial pH <7.3 after 24 hours of ingestion
PT >100 seconds
sCr > 300umol/L
Grade III or IV encephalopathy
How may encephalopathy be graded?
I = irritable
II = confusion
III = incoherent/restless
IV = coma
What is the first line management of hepatic encephalopathy?
Lactulose first line ± Rifaximim for secondary prophylaxis
What is the underlying cause of hepatic encephalopathy?
Any liver pathology with excess levels of ammonia and glutamine which cause confusion, asterixis, constructional apraxia and raised ammonia levels with triphasic slow waves on EEG.
What is the first line treatment of Scleroderma associated renal injury?
ACEi
What are the clinical features of Ankylosing Spondylitis?
Back stiffness: morning, improves with activity
Reduced movement
Reduced chest expansion
"The A's..." Amyloidosis Apical fibrosis Anterior uveitis Aortic regurgitation Peripheral arthritis Achilles tendonitis
Give an example of a cluster A personality disorder?
Paranoid
Schizoid
Schizotypal
Give an example of a Cluster B personality type?
Antisocial
Borderline
Histrionic
Narcissistic
Give an example of a cluster C personality type?
Obsessive-Compulsive
Dependent
Avoidant
What are the clinical features of a paranoid personality disorder?
Hypersensitivity Questions loyalty Perceives attacks on character Does not trust Preoccupied with alt beliefs
Give the clinical features of a Schizoid personality disorder.
Indifferent to praise Solo activities Emotional coldness Few interest Few friends or confidants other than family Lack of desire for companionship Lack of interest in sexual interactions
What are the clinical features of Schizotypal personality disorder?
Schizophrenic features BUT insight
Odd beliefs and magical thinking
Ideas of reference
Unusual perceptual disturbances (pseudohallucinations)
Odd, eccentric behaviour
Lack of close friends other than family members
Inappropriate affect
What are the clinical features of antisocial behaviour?
No social norms Deception Impulsiveness Irritable Aggressive Disregard for patient safety
What are the clinical features of Borderline personality disorder?
Unstable interpersonal relationships - alternate between idolisation and devaluation Unstable self image Impulsivity Affective instability Chronic feelings of emptiness Difficulty controlling temper
What are the clinical features of histrionic personality disorder?
Inappropriate sexual seductiveness
Need to be centre of attention
Shallow expression of emotion
Relationships considered to be more intimate than they are
What are the clinical features of narcissistic personality disorder?
Grandiose self importance Preoccupation with unlimited success Sense of entitlement Opportunistic - takes advantage of others Lack of empathy Craves admiration Chronic envy
What are the clinical features of Obsessive-Compulsive personality disorder?
Occupied with details Perfectionism Must act on obsessions Not capable of disposing of worn out possessions Unwilling to pass on tasks Stingy with money and spending
What are the clinical features of avoidant personality disorder?
Avoidance of activity out of fear of rejection
Preoccuied with ideas they are being criticised
Restraint in relationship due to fear of ridicule
Views self a inept and inferior to others
Social isolation whilst craving social contact
What are the clinical features of dependent personality disorder?
Requires assurance from others
Lack of initiative
Efforts to gain support for others
Unrealistic feelings that they cannot care for themselves
Unrealistic fears of being left to care for themselves
When is a phimosis considered treatable?
2 years old
Give 3 RFs for Vulval carcinoma.
HPV
Immunosuppression
Lichen sclerosus
VIN
A 27-year-old woman presents to her general practitioner with a one month history of abdominal pain, bloody diarrhoea and weight loss. She is referred for colonoscopy and biopsy which shows a continuous area on inflammation confined to the mucosa and the presence of crypt abscesses.
Given her likely diagnosis, which of the following antibodies is most specific?
This lady has UC
pANCA may be raised in UC, but not in CD
A 65-year-old man is seen in the rheumatology clinic following an acute monoarthropathy that affected the metatarsophalangeal joint of his left big toe. Analysis of synovial fluid aspirated from the joint showed the presence of negatively birefringent crystals under polarised light. Following acute treatment to settle the inflammation, the rheumatologist decides to initiate prophylactic treatment with allopurinol to prevent recurrence.
What is the most appropriate medication to initiate alongside allopurinol?
Colchicine / NSAID cover for up to 6/12
Which of the following is not a poor prognostic marker for ALL?
A. Age <2 years
B. WBC >20 x 10^9/L at diagnosis
C. T or B cell surface markers
D. Female sex
D - Male sex is a poor prognostic marker
A 32-year-old sewage worker presents with a 3 days history of lower back pain, fever, myalgia, fatigue, jaundice and a subconjunctival haemorrhage. He has no past medical history and has not been abroad in the last 6 months.
Na+ 136 mmol/l
K+ 5.2 mmol/l
Urea 10 mmol/l
Creatinine 180 µmol/l
What is the most likely diagnosis?
Leptospirosis
What distinguishes labyrinthitis from vestibular neuritis?
Hearing - in vestibular neuronitis the patient may have a preceding URTI but no hearing changes
If the D-dimer is positive but nothing is found on US, what should be done?
Stop the DOAC and repeat US in 1 week
How is a Jarisch-Herxheimer reaction different to anaphylaxis?
Fever, rash, tachycardia following ABX due to endotoxin release following bacterial death
However, no wheeze or hypotension
What are cannonball metastases secondary to?
Renal cell cancer
In a premature baby, how do you calculate the corrected age for which a development milestone should be reached?
The corrected age of a premature baby is the age minus the number of weeks he/she was born early from 40 weeks
Which intracranial venous thrombosis is characterised by an empty delta sign seen on venography?
Sagittal sinus thrombosis
What are the clinical features of normal pressure hydrocephalus?
Dementia
Ataxia
Urinary incontinence
What are the complications of M pneumoniae infection?
Cold agglutins (IgM): haemolytic anaemia/thrombocytopenia
Erythema multiforme
Erythema nodosum
Neurological diseases: meningoencephalitis; GBS
Bullous myringitis
Hepatitis
Pancreatitis
Acute glomerulonephritis
What is the recommended dose of adrenaline in ALS in a patient with an arrest?
1mL of 1:1000 IV Adrenaline
