Miscellaneous

Question 1

What are the different leg pulses?

Answer 1

By the big toe - dorsalis pedis
By medial ankle - posterior tibial

Question 2

What is atopy and what are the atopic cdtns?

Answer 2

A predisposition to having hypersensitivity reactions to allergens.

Atopic cdtns: eczema, asthma, hay fever, allergic rhinitis and food allergies.

Question 3

What are the 3 main ways to test for allergy?

Answer 3

GS - Food challenge testing
Skin prick testing
RAST testing - bloods for total and specific IgE

Note: Skin prick and RAST assess sensitisation and not allergy and therefore van be unreliable and misleading.

Question 4

Tx of allergic reactions

Answer 4

1. Antihistamines (e.g. cetirizine)
2. Steroids (e.g. oral prednisolone, topical hydrocortisone)
3. Intramuscular adrenalin in anaphylaxis

Question 5

Describe type 1 hypersensitivity reaction according to Coombs and Gell classification + give an example

Answer 5

1. IgE ab’s to specific allergen trigger mast cells and basophils
2. They release histamines and cytokines
3. This causes an immediate reaction

Example: food allergy, asthma

Question 6

Describe type 2 hypersensitivity reaction according to Coombs and Gell classification + give an example

Answer 6

1. IgG and IgM antibodies react to an allergen and activate the complement system.
2. Leading to direct damage to the local cells.

Example: haemolytic disease of the new born and transfusion reactions.

Question 7

Describe type 3 hypersensitivity reaction according to Coombs and Gell classification + give an example

Answer 7

Immune complexes accumulate and cause damage to local tissues.

Example: SLE and RA

Question 8

Describe type 4 hypersensitivity reaction according to Coombs and Gell classification + give an example

Answer 8

1. Cell mediated hypersensitivity reactions caused by T lymphocytes.
2. T-cells are inappropriately activated, causing inflammation and damage to local tissues.

Example: organ transplant rejection and contact dermatitis

Question 9

Sx of allergic reaction

Answer 9

Rapid onset:
Urticaria - hives
Itching
Angio-oedema, with swelling around lips and eyes
Abdominal pain

Additional Sx:
Swelling of the larynx
Shortness of breath
Wheeze
Tachycardia
Light headedness
Collapse

Question 10

Once a diagnosis of anaphylaxis is established, there are three medications given to treat the reaction?

Answer 10

Intramuscular adrenalin, repeated after 5 minutes if required

Antihistamines, such as oral chlorphenamine or cetirizine

Steroids, usually intravenous hydrocortisone

Question 11

What should be measured in the blood to confirm anaphylaxis and within how many hours should this be measured?

Answer 11

Serum mast cell tryptase within 6 hours of the event.

Question 12

What are the RF for obstructive sleep apnoea? (3)

Answer 12

Middle age
Male
Obesity
Alcohol
Smoking

Question 13

Sx of obstructive sleep apnoea?

Answer 13

Episodes of apnoea during sleep (reported by their partner)
Snoring
Morning headache
Waking up unrefreshed from sleep
** Daytime sleepiness
Concentration problems
Reduced oxygen saturation during sleep

Question 14

What scoring scale is used if someone has obstructive sleep apnoea?

Answer 14

Epworth Sleepiness Scale

Question 15

Tx of obstructive sleep apnoea?

Answer 15

Conservative - stop alcohol/smoking, lose weight etc
CPAP machine

Surgery - surgical reconstruction of the soft palate and jaw - uvulopalatopharyngoplasty (UPPP)

Question 16

Define peripheral arterial disease (PAD).

Answer 16

Narrowing of the arteries supplying the limbs and periphery, reducing the blood supply to these areas - resulting in claudication

Question 17

Define intermittent claudication.

Answer 17

Sx of limb ischaemia - caused by obstruction of arterial flow

Occurs during exertion and relieved by rest

Crampy, achy pain in the calf (or thigh/buttock) associated with muscle fatigue which occurs after walking a certain distance

Question 18

Define critical limb ischaemia.

Answer 18

End stage PAD, inadequate supply of blood to a limb to allow it to function normally at rest.
Risk of losing the limb.
Pain at rest, worse at night when leg is raised.

Question 19

Define acute limb ischaemia

Answer 19

Rapid onset of ischaemia in a limb. Typically, this is due to a thrombus (clot) blocking the arterial supply of a distal limb.

Question 20

Typical sx of acute limb ischaemia

Answer 20

6 P’s:
Pain
Pallor
Pulseless
Paralysis
Paraesthesia (abnormal sensation or “pins and needles”)
Perishing cold

Question 21

Define gangrene.

Answer 21

Death of tissue specifically due to inadequate blood supply.

Question 22

What test is done to assess for peripheral arterial disease in the leg?

Answer 22

Buerger’s test

Question 23

What causes arterial ulcers and venous ulcers?

Answer 23

Arterial - caused by ischaemia secondary to an inadequate blood supply.

Venous - caused by impaired drainage and pooling of blood in the legs.

Question 24

Difference between appearance arterial and venous ulcers?

Answer 24

Arterial ulcers - smaller, deeper, well defined borders, have punched out appearance, occur peripherally, reduced bleeding, painful

Venous ulcers - occur after minor leg injury, larger, superficial, irregular + gently sloping borders, affect gaiter leg area (mid-calf down to ankle), less painful than arterial

Question 25

Ix of leg ulcers (arterial or venous)

Answer 25

Ankle-brachial pressure index (ABPI)
Duplex ultrasound – ultrasound that shows the speed and volume of blood flow
Angiography (CT or MRI)

Question 26

Intermittent claudication Tx?

Answer 26

Atorvastatin 80mg
Clopidogrel 75mg once daily (aspirin if clopidogrel is unsuitable)
Naftidrofuryl oxalate (peripheral vasodilator)

Surgery - Endovascular angioplasty and stenting

Question 27

Critical limb ischaemia Tx?

Answer 27

Urgent revascularisation can be achieved by:
Endovascular angioplasty and stenting
Bypass surgery
Amputation

Question 28

Acute limb ischaemia Tx?

Answer 28

Urgent referral:
Endovascular thrombolysis
or thrombectomy
Surgical thrombectomy – removing the thrombus
Bypass surgery
Amputation

Question 29

Define varicose veins

Answer 29

Distended superficial veins measuring more than 3mm in diameter, usually affecting the legs.

Question 30

How does varicose veins occur?

Answer 30

Veins contain valves → so allow blood flow in one direction to heart against gravity + prevent backflow

Incompetent valves → blood pool in veins and feet → dilation of superficial veins → varicose vein

Question 31

Sx of chronic venous insufficiency in legs + explain how do they happen

Answer 31

Blood pools in distal veins → pressure causes veins to leak blood, so:
1. Haemosiderin around shins (brown discolouration to lower legs) → Hb in leaked blood cx this

2. Venous eczema - blood pool → infl occurs → skin becomes dry + inflamed
3. Lipodermatosclerosis - skin + soft tissues become fibrotic/tight → thus lower legs become narrow + hard

Question 32

RF of varicose veins (4)

Answer 32

Increasing age
Family history
Female
Pregnancy
Obesity
Prolonged standing (e.g., occupations involving standing for long periods)
DVT

Question 33

Tests for varicose veins + how to do the tests?

Answer 33

1. Tap test – apply pressure to the saphenofemoral junction (SFJ) and tap the distal varicose vein - feel for thrills
2. Cough test – apply pressure to the SFJ and ask the patient to cough, feeling for thrills at the SFJ.
3. Trendelenburg’s test – with the patient lying down, lift the affected leg to drain the veins completely. Then apply a tourniquet to the thigh and stand the patient up

Thrills = damaged valve

Question 34

Tx of varicose veins?

Answer 34

Keep leg elevated
Compression stockings
Endothermal ablation
Sclerotherapy – injecting the vein with an irritant foam that causes closure of the vein
Stripping – the veins are ligated and pulled out of the leg

Question 35

What are the sx of hypercalcaemia and what ate the top two common causes of it?

Answer 35

Sx -
* Bones (bone pain)
* Stones (renal stones)
* Groans (abdo discomfort + constipation)
* Moans (psychiatric sx i.e. poor conc, mood and fatigue)

Causes:
1. Primary hyperparathyroidism
2. Malignancy