Other Flashcards
1
Q
Investigations for anaphylaxis following an attack?
A
- Allergen skin test
* IgE immunoassay
2
Q
Management for anaphylaxis?
A
- ABCDE
- IM adrenaline
- High flow oxygen
- Chlorpheniramine (antihistamine)
- Hydrocortisone
Observe every 6-12 hours
Repeat adrenaline every 5 mins on anterolateral aspect of middle third of thigh
3
Q
Presentation of aspirin (salicylate) overdose? Early and late.
A
Early
• Hyperventilation
• Tachycardia
• Tinnitus
Later
• Respiratory depression
• Lethargy
- Dehydration and hypokalaemia due to compensation to respiratory alkalosis (from hyperventilation)
- Leads to metabolic acidosis
4
Q
Investigations for aspirin overdose?
A
- ABG - respiratory alkalosis => metabolic acidosis
- U+Es - hypokalaemia
- Salicylate - positive or negative
- High PT
- High AST + ALT
ECG - flat/inverted T waves, U waves (hypokalaemia)
5
Q
What is multi-organ dysfunction syndrome?
A
- Progressive and potentially resersible physiological dysfunction of 2+ organ systems
- Induced by variety of insults including sepsis
6
Q
MODS is the final stage in a continuum beginning with what?
A
Systemic inflammatory response syndrome + infection
7
Q
What are the presentations of MODS, using the MOD score (4 stages)
A
Stage 1 • increased volume requirements • respiratory alkalosis • oliguria • hyperglycaemia
Stage 2 • tachypnoea • hypocapnia and hypoxaemia • moderate liver dysfunction • haematologic abnormalities
Stage 3 • shock • azotaemia (high nitrogen) • acid-base disturbance • coagulation abnormalities
Stage 4 • vasopressor dependent • oliguria/anuria • ischaemic colitis • lactic acidosis
8
Q
Symptoms and signs of opiate overdose?
A
- Constipation (chronic)
- Drowsiness (acute)
- Nausea and vomiting
- Loss of appetite
- Sedation
- Respiratory depression
- Hypotension and tachycardia
- Pinpoint pupils
9
Q
Investigations for opiate overdose?
A
- Therapeutic trial of naloxone
- ECG - in respiratory compromise, look for MI or QRS prolongation in propoxyphene overdose
- CXR - ARDS
10
Q
How much paracetamol can cause hepatic necrosis?
A
> 12g
but > 4g is overdose
11
Q
What is the most common intentional drug overdose in the UK?
A
Paracetamol
12
Q
Signs and symptoms of paracetamol overdose (with reference to timing)
A
0-24 hours
• Asymptomatic
• Mild nausea, malaise
24-72 hours
• RUQ pain
• Vomiting
• Hepatomegaly
72+ hours • Confusion (encephalopathy) • Jaundice • Renal angle tenderness • Coagulopathy • Hypoglycaemia
13
Q
Investigations for paracetamol overdose?
A
- Serum paracetamol - positive or negative, peaks at 4 hours
- ABG - elevated lactate
- Raised PT
14
Q
Outline duct ectasia
A
- Dilation of terminal breast ducts
- Creamy (yellow/green) discharge
- May leak into periductal tissues and cause periductal mastitis
- Tender lump around areola
15
Q
When is duct ectasia most common?
A
Menopause
16
Q
Outline duct papilloma
A
- Local epithelial proliferation in large mammary ducts
- Hyperplastic - benign tumour
- Blood stained discharge
17
Q
Investigations for benign breast disease?
A
Triple assessment
- Clinical examination
- Mammography over 35 years, ultrasound under 35 years
- FNA or biopsy
18
Q
What is the most common type of breast cancer?
A
Invasive ductal carcinoma
19
Q
Risk factors for breast cancer?
A
- Prolonged oestrogen exposure
- Age
- FHx
20
Q
Signs of breast cancer?
A
- Firm, irregular, fixed breast lump
- Peau d’orange
- Skin tethering
- Fixed to chest wall
- Skin ulceration
- Nipple inversion
- Paget’s disease of the nipple (eczema-like)
21
Q
On top of the triple assessment, what other investigations would you carry out for breast cancer?
A
- Sentinel lymph node biopsy - radioactive tracer injected into tumour
- Staging - CXR, liver USS, CT (brain/thorax), bloods
22
Q
Presentation of breast cyst?
A
- Smooth discrete lump
* May be fluctuant
23
Q
What does a fibroadenoma develop from and how does it present
A
- Develops from whole lobule
- Mobile, firm breast lumps
- Smooth
- Most common breast mass
24
Q
Risk of malignancy with fibroadenoma, breast cyst, duct papilloma?
A
Fibroadenoma - no increase
Breast cyst - increase
Duct papilloma - no increase
25
Management of fibroadenoma?
Conservative
Surgical if > 3cm
• Excision of fibroadenoma
• Mastectomy if large lesion
26
2 types of breast abscess?
* Lactational
| * Non-lactational (not pregnant or breastfeeding)
27
Cause of breast abscess?
S. aureus
28
Risk factor for breast abscess and mastitis (especially non-lactational)?
Smoking
29
How does a breast abscess present?
Both types:
• Fever
• Breast warmth and tenderness (general inflammation)
• Breast firmness
Non-lactational:
* History of previous infections
* Less pronounced systemic upset
* Scars or tissue distortion from previous episodes
* Signs of duct ectasia (e.g. nipple retraction)
30
Investigations for breast abscess?
1. Ultrasound - hypoechoic lesion
2. FNA
3. MC&S
31
Management for breast abscess?
• FNA (therapeutic drainage)
• Antibiotics
- lac: flucloxacillin
- non-lac: flucloxacillin + metronidazole
32
Management for mastitis?
1. Continue breastfeeding
2. If systemically unwell, nipple fissure, symptoms don't improve, +ve infection:
• Flucloxacillin for S. aureus
33
Outline BPPV (including cause)
* Vertigo on changing head position (e.g. gazing upward)
* Seconds to minutes (usually 10-20sec though)
* Associated with nausea
* Displacement of otoliths
34
Investigations for BPPV?
Positive Dix-Hallpike manoeuvre
35
Outline Meniere's disease (including cause)
Recurrent episodes of:
• Tinnitus
• Paroxysmal vertigo
• Unilateral fluctuating hearing loss
Bilateral symptoms may develop after a number of years
* Aural fullness
* Nystagmus and positive Romberg test
* Minutes to hours
• Disturbed homeostasis of endolymph
36
Investigation for Meniere's disease?
No diagnostic test
• Air and bone conduction for hearing
• Exclusion of other causes of symptoms
37
What is a classic feature of infectious mononucleosis in the peripheral blood?
Atypical lymphocytes
38
Features of infectious mononucleosis?
Triad:
• Sore throat
• Lymphadenopathy
• Pyrexia
* Palatal petechiae
* Hepatosplenomegaly
* Exudate on tonsils
* Jaundice in some
39
What happens to a patient with infectious mononucleosis who receives ampicillin/amoxicillin?
Maculopapular, pruritic rash
40
Investigations for infectious mononucleosis?
1. Bloods - lymphocytosis, raised AST/ALT
2. Heterophile antibodies - IgM agglutination of animals RBCs when mixed
3. Best - EBV-specific antibodies:
- viral capsid antigen antibodies rise first (IgM/IgG)
- nuclear antigen antibodies remain for life (IgG)
41
Management for infectious mononucleosis?
* Bed rest
* Paracetamol/NSAIDS
* Corticosteroids if severe
42
What is the mean age of presentation of a thyroglossal cyst?
5 years
43
Presentation of thyroglossal cyst?
* Midline, smooth, rounded swelling
* Between thyroid isthmus and hyoid bone
* Moves upwards on protrusion of tongue
* Can be transilluminated
* Painful if infected
44
Investigations for thyroglossal cysts?
None really needed
• TFTs if suprahyoid to exclude lingual thyroid
• Ultrasound/MRI - exclusion
45
Cause of tonsillitis?
* Usually viral
| * Can be bacterial - group A streptococci
46
Presentation of tonsillitis?
* Sore throat
* Painful swallowing
* Referral to ears
* Yellow exudate
* Swollen anterior cervical glands
Strep:
• Acute onset
• Headache
• Abdominal pain
47
Investigations for tonsillitis?
Not needed
• Throat culture - diagnostic
• Rapid strep antigen test - lower sensitivity but faster
48
What are the 2 main types of abscesses?
* Skin abscess
| * Internal abscess
49
Major risk factor for skin abscess?
IV drug use
50
Characterisation of internal abscesses?
* Pain in affected area / reffered
* Swinging fever
* Malaise
51
Investigations for visualising abscesses?
Ultrasound
52
Management for abscesses?
* Incision and drainage (check for foreign object before)
| * Antibiotics
53
What is Behcet's disease (including presentation)?
* Inflammatory multisystem disease
| * Often presents with orogential ulceration and uveitis
54
Investigations for Behcet's disease?
Clinical
• Pathergy test - skin prick in forearm, sterile pustule in 48 hours
• HLA-B51, complement levels, positive FHx
55
Difference between keratoconjunctivitis and blepharoconjunctivitis?
Keratoconjunctivitis - inflammation of conjunctiva + cornea
• Blepharoconjunctivitis - inflammation of conjunctiva + eye lid
56
What symptom suggests corneal involvement in conjunctivitis?
Photophobia
| keratoconjunctivitis
57
How is visual acuity affected in conjunctivitis?
It isn't
58
Signs of conjunctivitis?
* Conjunctival injection (blood shot)
* Dilated vessels
* Conjunctival chemosis - swelling
* Conjunctival follicles - collection of lymphocytes appearing as nodules
* Conjunctival papillae - associated with allergic immune response
59
Investigations for conjunctivitis?
Clinical
| Rapid adenovirus immunoassay
60
What is the most common mode of transmission of HIV (specifically)?
Heterosexual intercourse
61
Features of HIV in each of the 3 phases?
```
Seroconversion
• fever
• sore throat
• night sweats
• lymphadenopathy
• oral ulcers, rash, headache, diarrhoea
```
Early
• Apparently well
• Some with persistent lymphadenopathy
• Progressive minor symptoms e.g. weight loss
AIDS
• Secondary disease from immunodeficiency
62
```
What are the direct effects of HIV:
• Neurological
• Lung
• Heart
• Haematological
• GI
• Eyes
```
* Neurological - dementia
* Lung - lymphocytic interstitial pneumonitis
* Heart - cardiomyopathy
* Haematological - anaemia
* GI - anorexia
* Eyes - cotton wool spots
63
```
What are the secondary effects of HIV from immunodeficiency:
• Bacterial
• Viral
• Fungal
• Protozoal
• Tumours
```
* Bacterial - TB
* Viral - CMV
* Fungal - Pneumocystis jiroveci, oesophageal candidiasis
* Protozoal - toxoplasmosis
* Tumours - Kaposi's sarcoma
64
Investigations for HIV?
ELISA: enzyme-linked immunosorbent assay
65
What is the most serious and most common type of malaria?
Plasmodium falciparum
| parasite
66
Who has immunity to malaria? (4)
* Sickle cell trait
* G6PD deficiency
* Pyruvate kinase deficiency
* Thalassaemia
67
Symptoms and signs of malaria?
```
Cylical
• fever
• sweating
• rigors
(• cerebral - headache, disorientation, coma)
```
* haemolytic anaemia
* hepatosplenomegaly
68
Investigations for malaria?
* Thick and thin blood smears - detection of trophozoites/schizonts
* Bloods - anaemia, acidosis
* Urinalysis - protein
69
Diagnostic criteria for neutropenic sepsis?
Temp > 38
| Neutrophils < 0.5 x 10^9
70
Why can patients have neutropenic sepsis without a fever?
They may be on anti-pyretics or steroids
71
What is neutropenic sepsis a common complication of?
Chemotherapy for cancer - usually 7-14 days after
72
Investigation for neutropenic sepsis?
* FBC - neutropenia
| * Blood cultures - sepsis
73
What is cataracts?
Opacifications of lens
74
Most common cause of cataracts?
Normal ageing process
75
Symptoms and signs of cataracts?
* Reduced vision (including colour)
* Glare and halos around lights
* Loss of red reflex
* Hazy lens appearance
76
Investigations for cataracts?
1. Opthalmoscopy after pupil dilation: normal fundus and optic nerve
2. Slit-lamp examination of anterior chamber: cataract visible
77
Most common cause of curable blindness in the world?
Cataracts
78
What is glaucoma?
Optic neuropathy associated with raised intraocular pressure
79
What are the 3 primary causes of glaucoma?
* Acute closed-angle
* Chronic closed-angle
* Primary open-angle
Closed-angle: obstruction of outflow of aqueous humour
Open-angle: resistance to outlflow through trabecular network
80
Symptoms of acute closed-angle and primary open-angle glaucoma?
```
ACAG
• Painful red eye
• Vomiting
• Impaired vision
• Halos around lights
```
POAG
• Asymptomatic
• Peripheral visual field loss
81
Signs of acute closed-angle and primary open-angle glaucoma?
```
ACAG
• Loss of red reflex
• Red eye
• Fixed dilated pupil
• Tender and hard eye
• Cupped optic disc
```
POAG
• Usually no signs
• Optic disc may be cupped
82
Investigations for glaucoma?
ACAG
• Gonioscopy - diagnostic for angle closure
• Slit-lamp
• Perimetry
POAG
• Tonometry - most accurate for open angle
• Fundoscopy - flame haemorrhages, cupped disc
• Perimetry
83
What is uveitis?
Inflammation of iris and ciliary body
84
Causes of uveitis?
Infection e.g. HSV
```
Inflammatory disorders e.g.
• ankylosing spondylitis
• reactive arthritis
• IBD
• Behcet's disease
• Sarcoidosis
```
85
What is sympathetic opthalmia?
* Inflammation of contralateral eye weeks/months later
| * T cells detect same eye antigens from initial injury in the contralateral eye
86
Symptoms and signs of uveitis?
* Pain during accomodation
* Intense photophobia
* Red eyes
* Reduced visual acuity
* Ciliary flush
* Hypopyon - inflammation in inferior angle of anterior chamber
* Small irregular pupil due to adhesion of iris to lens
87
4 types of dementia in order of occurence?
1. Alzheimer's disease
2. Vascular dementia
3. Lewy body dementia
4. Frontotemporal dementia / Pick's disease
88
Presentation of the 4 types of dementia?
* Alzheimer's - memory deficits => motor/language/personality
* Vascular - stepwise, function deficit => memory
* Lewy body dementia - fluctuating consciousness, cognitive activities => falls and Parkinsonism. Visual hallucinations.
* Frontotemporal dementia - disinhibition, personality change
89
What are the 2 core symptoms for diagnosing major depression?
* Persistent sadness or low mood nearly every day
| * Loss of interests or pleasure in most activities
90
How long should symptoms have persisted in depression?
At least 2 weeks
91
How does depression present differently to dementia?
Depression
• Short history, rapid onset
• Sleep disturbance
• Global memory loss (rather than recent memory loss)
92
Assessment tools for depression? (3)
* Patient health questionnaire PHQ-9
* Hospital Anxiety and Depression (HAD) scale
* DSM-IV criteria
93
Management: smoking cessation
• Nicotine replacement therapy (gum/lozenge)
Then
• Varenicline - nicotinic receptor partial agonist
or
• Bupropion - NA + dopamine reuptake inhibitor, and nicotinic antagonist
Just before the stop date
94
How is management for cigarette cessation different for those smoking < 10 a day, or 'time to first cigarette' is ≤ 30 minutes
< 10 a day - as-needed nicotine replacement
TTFC ≤ 30 minutes - higher dose nicotine replacement
95
What characteristics increase risk of tumour lysis syndrome?
High cell turnover rate, rapid growth, chemo-sensitive tumours e.g. lymphoma
TLS is due to sudden lysis of tumours during treatment - most commonly lymphomas and leukaemias
96
Presentation of tumour lysis syndrome?
Hyperkalaemia - main intracellular ion
• arrhythmia
• muscle weakness/paralysis
Hyperphosphataemia - intracellular ion
• acute kidney failure due to calcium phosphate crystals
```
Hypocalcaemia - used to make calcium phosphate because of hyperphosphataemia
• convulsions
• arrythmias
• tetany
• numbness
```
Hyperuricaemia - purine degradation from nucleic acids
• gout
Lactic acidosis
