Panic Mode COPY Flashcards

Question

What are the diagnostic criteria for DKA?

Answer 1

glucose \> 11 mmol/l or known diabetes mellitus pH \< 7.3 bicarbonate \< 15 mmol/l ketones \> 3 mmol/l or urine ketones ++ on dipstick

Answer 2

* Fluid replacement * Insulin * Correction of electrolyte disturbance * Long-acting insulin should be continued, short-acting insulin should be stopped

Answer 3

most patients with DKA are deplete around 5-8 litres isotonic saline is used initially, even if the patient is severely acidotic Please note that slower infusion may be indicated in young adults (aged 18-25 years) as they are at greater risk of cerebral oedema. Please see JBDS example of fluid replacement regime for patient with a systolic BP on admission 90mmHg and over, (mnemonic = 122446)

Answer 4

an intravenous infusion should be started at 0.1 unit/kg/hour once blood glucose is \< 15 mmol/l an infusion of 5% dextrose should be started

Answer 5

* serum potassium is often high on admission despite total body potassium being low * this often falls quickly following treatment with insulin resulting in hypokalaemia * potassium may therefore need to be added to the replacement fluids * if the rate of potassium infusion is greater than 20 mmol/hour then cardiac monitoring may be required

Answer 6

pH \>7.3 and blood ketones \< 0.6 mmol/L and bicarbonate \> 15.0mmol/L both the ketonaemia and acidosis should have been resolved within 24 hours. If this hasn't happened the patient requires senior review from an endocrinologist if the above criteria are met and the patient is eating and drinking switch to subcutaneous insulin the patient should be reviewed by the diabetes specialist nurse prior to discharge

Answer 7

Complications may occur from DKA itself or the treatment: * 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**

Answer 8

* 25-30 ml/kg/day of water and * approximately 1 mmol/kg/day of potassium, sodium and chloride and * approximately 50-100 g/day of glucose to limit starvation ketosis So, for a 80kg patient, for a 24 hour period, this would translate to: 2 litres of water 80mmol potassium 0.9% saline if large volumes are used there is an increased risk of hyperchloraemic metabolic acidosis Hartmann's contains potassium and therefore should not be used in patients with hyperkalaemia

Answer 9

You will be offered a screening test for Down's syndrome, Edwards' syndrome and Patau's syndrome between 10 and 14 weeks of pregnancy. This is to assess your chances of having a baby with one of these conditions. Doesn't say for sure! You need follow up tests afterwards (amniocentesis and CVS) _Combined test_ A screening test for Down's syndrome, Edwards' syndrome and Patau's syndrome is available between weeks **10 and 14** of pregnancy. It's called the combined test because it combines an ultrasound scan with a blood test. The blood test can be carried out at the same time as the 12-week scan. If you choose to have the test, you will have a blood sample taken. At the scan, **the fluid at the back of the baby's neck** is measured to determine the "nuchal translucency". Your age and the information from these 2 tests are used to work out the chance of the baby having Down's syndrome, Edwards' syndrome or Patau's syndrome. Obtaining a nuchal translucency measurement depends on the position of the baby and is **not always possible**. If this is the case, you will be offered a different blood screening test, called the quadruple test, when you're **14 to 20** weeks pregnant. _Quadruple blood screening test_ If it was not possible to obtain a nuchal translucency measurement, or you're more than 14 weeks into your pregnancy, you'll be offered a test called the quadruple blood screening test between 14 and 20 weeks of pregnancy. This only screens for Down's syndrome and is **not as accurate as the combined test.**

Answer 10

The screening test will not tell you whether your baby does or does not have Down's, Edwards' or Patau's syndromes – it will tell you if you have a higher or lower chance of having a baby with one of these conditions. You don't need to have the screening, you can still get other tests such as the 12 week scan. Physical conditions may be picked up later in the pregnancy at future scan. The person performing the scan will always tell you if conditions are found. You will be offered an appointment to discuss the test results and the options you have. The charity Antenatal Results and Choices (ARC) offers lots of information about screening results and your options if you get a higher-chance result. You may decide to continue with the pregnancy and prepare for your child with the condition. Or you may decide that you do not want to continue with the pregnancy and have a termination. If you are faced with this choice, you will get support from health professionals to help you make your decision.

Answer 11

nuchal translucency measurement + serum B-HCG + pregnancy-associated plasma protein A (PAPP-A) Down's syndrome is suggested by ↑ HCG, ↓ PAPP-A, thickened nuchal translucency trisomy 18 (Edward syndrome) and 13 (Patau syndrome) give similar results but the PAPP-A tends to be lower

Answer 12

AFP Unconjugated Oestriol HCG Inhibin A

Answer 13

EPPMANDI Help help Self-harm/suicide before? Mood Psychosis

Answer 14

a combination of oral antiretrovirals (e.g. Tenofovir, emtricitabine, lopinavir and ritonavir) **as soon as possible** (i.e. Within 1-2 hours, but may be started up to 72 hours following exposure) **for 4 weeks**

Answer 15

serological testing at 12 weeks following completion of post-exposure prophylaxis reduces risk of transmission by 80%

Answer 16

Vaccinated already = Booster dose of vaccine Non-responder = hep B immune globulin plus vaccine

Answer 17

Human Normal Immunoglobulin (HNIG) or hepatitis A vaccine may be used depending on the clinical situation

Answer 18

monthly PCR - if seroconversion then interferon +/- ribavirin

Answer 19

3-12 weeks after infection

Answer 20

* sore throat * lymphadenopathy * malaise, myalgia, arthralgia * diarrhoea * maculopapular rash * mouth ulcers * rarely meningoencephalitis

Answer 21

Driving advice for type 1 diabetes: If you have had more than 1 hypo in the last 12 months you must not drive and inform the DVLA If you have had a hypo in the last 12 months you must not drive a lorry and you must notify the DVLA of every severe episode of hypoglycaemia If severe hypoglycaemia occurs whilst driving - stop driving and inform the DVLA Keep glucose treatments in car Check blood glucose before driving and every two hours Blood glucose should be more than 5 in order for you to drive

Answer 22

microaneurysms blot/flame haemorrhages hard exudates mottled mess of fine vesscotton wool spots venous beading/looping/dilation silver wiring neovascularisation (irregular vessels that are fragile and leak) - mottled mess of fine vessels

Answer 23

Optical coherence tomography or fluorescin angiography

Answer 24

Retinal oedema - develop at junction between normal and swollen retina Made up of lipoprotiens and lipid filled macrophages Hard exudates - yellow in colour - found close to the macula, distinct margins, result from blood vessel leakage Cotton wool spots are made from axonal debris - found close to the optic nerve - lighter in colour, margins are less distinct. Result from vessel occlusion as opposed to vascular leakage

Answer 25

https://www.youtube.com/watch?v=IWspTG9wIsU&ab\_channel=MeriVukicevicMeriVukicevic

Answer 26

Neovasculariation at the Irirs

Answer 27

Neovascularisation of the optic disc

Answer 28

Laser photocoagulation Anti-vegf Some patients with a lot of blood in the vitreous may require a vitrectomy

Answer 29

Before: * Don't drive to appointment * Bring glasses, contact lenses/solution * Bring sunglasses * Eat and drink as normal * During: * You'll be asked to read some letters on a chart first. * Drops are then put in your eyes. These may sting for a few seconds. The drops make your sight blurry after about 15 minutes. * When the drops start working, you'll be asked to look into a camera. The camera will not touch your eyes. * Pictures are taken of the back of your eyes. There will be a bright flash when a picture is taken. After: * You can go home when the test is finished. * For up to 6 hours after the test: * your sight may be blurry – do not drive until it goes back to normal * everything can look very bright – wearing sunglasses can help * You will not get your test result on the day. * You'll get a letter about your result within 6 weeks.

Answer 30

**Fundus photography** Slit lamp biomicroscopy (when photos are not suitable for the individual) Optical coherence tomography - if concerns of macular oedema

Answer 31

Stop smoking services staffed by expert advisers - one-to-one sessions or group services On your first session you can discuss why you smoke why you want to stop, decide on a quit date. You don't have to be sure about wanting to quit smoking when you attend. On first session they will also take a breath test - carbon monoxide in your body. Measuring carbon monoxide levels isn't about checking up on you. It's more to motivate you to stay smoke-free by showing how your body is already recovering Also medical therapy available on the NHS: Nicotine replacement therapy works out as a third of the price as the local pharmacy These are nicotine replacement products (including patches, gum, lozenges, inhalators and mouth and nasal sprays) and the stop smoking tablets Champix (varenicline) and Zyban (bupropion).

Answer 32

Fragile X Noonans Intraventricular haemorrhage Hydrocephalus (non-communicating = arnold chiari, aqueductal stenosis, dandy walker)

Answer 33

Edward Patau Downs Infections: Congenital cytomegalovirus infection Toxoplasmosis Congenital rubella syndrome Congenital Varicella Syndrome Zika virus Foetal alcahol syndrome Maternal hypothyroidism/malnutrition/placental insufficiency

Answer 34

monitor fetal well-being and allow early detection of fetal distress.

Answer 35

DR: Define risk C: Contractions BRa: Baseline rate V: Variability A: Accelerations D: Decelerations O: Overall impression

Answer 36

**_Maternal medical illness_** Gestational diabetes Hypertension Asthma **_Obstetric complications_** Multiple gestation Post-date gestation Previous cesarean section Intrauterine growth restriction Premature rupture of membranes Congenital malformations Oxytocin induction/augmentation of labour Pre-eclampsia **_Other risk factors_** Absence of prenatal care Smoking Drug abuse

Answer 37

10 minute intervals (10 squares)

Answer 38

Duration and intensity (probably frequency as well, i.e the number of waves in 10 minutes)

Answer 39

* Fetal hypoxia * Chorioamnionitis * Hyperthyroidism * Fetal or maternal anaemia * Fetal tachyarrhythmia

Answer 40

Postdate gestation Occiput posterior or transverse presentations

Answer 41

* Prolonged cord compression * Cord prolapse * Epidural and spinal anaesthesia * Maternal seizures * Rapid fetal descent

Answer 42

Normal variability is between 5-25 bpm.3

Answer 43

The baseline rate is the average heart rate of the fetus within a 10-minute window.

Answer 44

* Fetal sleeping: this should last no longer than 40 minutes (this is the most common cause) * Fetal acidosis (due to hypoxia): more likely if late decelerations are also present * Fetal tachycardia * Drugs: opiates, benzodiazepines, methyldopa and magnesium sulphate * Prematurity: variability is reduced at earlier gestation (\<28 weeks) * Congenital heart abnormalities

Answer 45

Accelerations are an abrupt increase in the baseline fetal heart rate of greater than 15 bpm for greater than 15 seconds

Answer 46

* The presence of accelerations is reassuring. * Accelerations occurring alongside uterine contractions is a sign of a healthy fetus. * The absence of accelerations with an otherwise normal CTG is of uncertain significance.

Answer 47

Decelerations are an abrupt decrease in the baseline fetal heart rate of greater than 15 bpm for greater than 15 seconds.

Answer 48

Early decelerations start when the uterine contraction begins and recover when uterine contraction stops.

Answer 49

This is due to increased fetal intracranial pressure causing increased vagal tone. It therefore quickly resolves once the uterine contraction ends and intracranial pressure reduces. This type of deceleration is, therefore, considered to be physiological and not pathological.

Answer 50

Variable decelerations are observed as a rapid fall in baseline fetal heart rate with a variable recovery phase. May not have nay relationship with uterine contractions

Answer 51

Usually caused by umbilical cord compression Variable decelerations can sometimes resolve if the mother changes position The presence of persistent variable decelerations indicates the need for close monitoring. Variable decelerations without the shoulders of deceleration are more worrying, as it suggests the fetus is becoming hypoxic.

Answer 52

Late decelerations begin at the peak of the uterine contraction and recover after the contraction ends.

Answer 53

* This type of deceleration indicates there is insufficient blood flow to the uterus and placenta. As a result, blood flow to the fetus is significantly reduced causing fetal hypoxia and acidosis. * Causes of reduced uteroplacental blood flow include: * Maternal hypotension * Pre-eclampsia * Uterine hyperstimulation

Answer 54

A prolonged deceleration is defined as a deceleration that lasts more than 2 minutes:

Answer 55

Severe fetal hypoxia Severe fetal anaemia Fetal/maternal haemorrhage A sinusoidal CTG pattern is rare, however, if present it is very concerning as it is associated with high rates of fetal morbidity and mortality.1

Answer 56

Reassuring Non-reassuring Abnormal You can read more about what these mean here: https://geekymedics.com/how-to-read-a-ctg/

Answer 57

External CTG: Doppler ultrasound probe/transducer—used to record the fetal heart rate. It is placed over the anterior fetal shoulder, usually in the left or right lower quadrant of the maternal abdomen in cephalic fetal presentation. Pressure transducer—placed over the uterine fundus in the mother’s epigastric region, monitoring the FREQUENCY of uterine contractions (not intensity). Internal CTG: **A wire electrode**, sometimes called a spiral or scalp electrode, is attached to the fetal scalp through the cervical opening and is connected to the monitor. To gauge the strength of contractions, a small catheter (called an **intrauterine pressure catheter or IUPC**) is passed into the uterus past the fetus

Answer 58

* Loss of height (getting shorter by an inch or more). * Change in posture (stooping or bending forward). * Shortness of breath (smaller lung capacity due to compressed disks). * Bone fractures. * Pain in the lower back.

Answer 59

**_There are many other risk factors and secondary causes of osteoporosis. We'll start by looking at the most 'important' ones - these are risk factors that are used by major risk assessment tools such as FRAX:_** ## Footnote history of glucocorticoid use rheumatoid arthritis alcohol excess history of parental hip fracture low body mass index current smoking **_Other risk factors_** sedentary lifestyle premature menopause Caucasians and Asians endocrine disorders: hyperthyroidism, hypogonadism (e.g. Turner's, testosterone deficiency), growth hormone deficiency, hyperparathyroidism, diabetes mellitus multiple myeloma, lymphoma gastrointestinal disorders: inflammatory bowel disease, malabsorption (e.g. Coeliac's), gastrectomy, liver disease chronic kidney disease osteogenesis imperfecta, homocystinuria **_Medications that may worsen osteoporosis (other than glucocorticoids):_** SSRIs antiepileptics proton pump inhibitors glitazones long term heparin therapy aromatase inhibitors e.g. anastrozole

Answer 60

Colles complete fracture of the radius bone of the forearm close to the wrist resulting in an upward (posterior) displacement of the radius and obvious deformity The fracture originates from a fall on the outstretched hand and is usually associated with dorsal and radial displacement of the distal fragment, and disturbance of the radial-ulnar articulation Colles' fracture is defined as a linear transverse fracture of the distal radius approximately 20-35 mm proximal to the articular surface with dorsal angulation of the distal fragment Radial styloid process comes to lie at same level or a little higher than the ulnar styloid process COMMONLY SEEN IN THE ELDERLY = PEOPLE WITH OSTEOPOROSIS

Answer 61

"Dinner Fork" Deformity History of fall on an outstretched hand Dorsal wrist pain Swelling of the wrist Increased angulation of the distal radius Inability to grasp object Signs and Symptoms- Pain, numbness, tenderness, bruising, deformity of wrist.

Answer 62

Malunion Shortening of radius Carpal tunnel syndrome Sudeck's atrophy Extensor pollicis longus tendon rupture

Answer 63

If the broken bone is in a good position, a plaster cast may be applied until the bone heals. If the position (alignment) of your bone is out of place and likely to limit the future use of your arm = Closed manipulation and reduction followed by immobilisation in plaster of paris cast for 4-6 weeks Surgical = open reduction and internal fixation (with metal pins, plates and screws) Alternatively If the soft tissues around the fracture are badly damaged, your doctor may apply a temporary external fixator. Open fracture requires urgent surgery, wound debridement and prophylactic antibiotics

Answer 64

The axillary lymph nodes, also known commonly as axillary nodes, are a group of lymph nodes in the axilla and receive lymph from vessels that drain the **arm**, the **walls of the thorax**, the **breast** and the **upper walls of the abdomen**.

Answer 65

Supplies superior oblique superior oblique is responsible for abduction (directed laterally from the nose), depression (inferiorly) and internal rotation (movement of the superior pole of the eye medially) of the eyeball Don't focus too much on the arrows on the picture below (they appear to show slight adduction, but superior oblique does abduction)

Answer 66

Trochlear nerve palsy commonly presents with vertical diplopia, exacerbated when looking downwards and inwards (such as when reading or walking down the stairs). Patients can also develop a head tilt away from the affected side.

Answer 67

They are commonly caused by microvascular damage from diabetes mellitus or hypertensive disease. Other causes include congenital malformation, thrombophlebitis of the cavernous sinus, and raised intracranial pressure.

Answer 68

A complete oculomotor nerve palsy will result in a characteristic down and out position in the affected eye. The eye will be displaced outward "exotropia" and displaced downward "hypotropia"; outward because the lateral rectus (innervated by the sixth cranial nerve) maintains muscle tone in comparison to the paralyzed medial rectus. The eye will be displaced downward, because the superior oblique (innervated by the fourth cranial or trochlear nerve), is unantagonized by the paralyzed superior rectus, inferior rectus and inferior oblique. The affected individual will also have a **ptosis**, or drooping of the eyelid, and **mydriasis** (pupil dilation).

Answer 69

teratogenic * maternal use of sodium valproate is associated with a significant risk of neurodevelopmental delay in children * guidance is now clear that sodium valproate should not be used during pregnancy and in women of childbearing age unless clearly necessary. Women of childbearing age should not start treatment without specialist neurological or psychiatric advice. P450 inhibitor gastrointestinal: nausea increased appetite and weight gain alopecia: regrowth may be curly ataxia tremor hepatotoxicity pancreatitis thrombocytopaenia hyponatraemia hyperammonemic encephalopathy: L-carnitine may be used as treatment if this develops

Answer 70

Certain drugs, particularly cannabis, cocaine, LSD or amphetamines, may trigger symptoms of schizophrenia in people who are susceptible.

Answer 71

auditory hallucinations, thought disorders, passivity phenomena and delusional perceptions

Answer 72

* impaired insight * incongruity/blunting of affect (inappropriate emotion for circumstances) * decreased speech * neologisms: made-up words * catatonia * negative symptoms: incongruity/blunting of affect, anhedonia (inability to derive pleasure), alogia (poverty of speech), avolition (poor motivation)

Answer 73

**ECG** **Coronary angiography** with follow up PCI if indicated **High sensitivity cardiac troponin** **Glucose** **FBC** - anaemia will influence antiplatelet therapy **Electrolytes, urea, creatinie and eGFR** (Potassium, calcium, and magnesium homeostasis is crucially important to prevent both bradyarrhythmias and tachyarrhythmias during the peri-infarct interval.) (renal function is necessary to guide titration of medications plus helps to guide contrast agent/contrast load used in PCI. Also helps to identify AKI after primary angioplasty) **CRP** **Serum Lipids**

Answer 74

The patient presents within 12 hours of onset of symptoms, and Primary PCI can be delivered within 120 minutes of the time when fibrinolysis could have been given.

Answer 75

**Aspirin 300mg** (75-100mg daily thereafter) Assessment of eligibility for coronary reperfusion **morphine sulfate**: 2.5 to 10 mg intravenously initially, followed by 2.5 to 10 mg if required (at a rate of 1-2 mg/minute) **Ondansetron/metoclopramide/cyclizine** CONSIDER **oxygen**: Give oxygen therapy only if saturations are \<90% on pulse oximetry CONSIDER **intravenous nitrate** (glyceryl trinitrate or isosorbide dinitrate) **Primary PCI** **P2Y12 inhibitor** **Parenteral anticoagulation** (Unfractionated heparin for patients undergoing primary PCI with radial access, Bivalirudin (a direct thrombin inhibitor) for patients undergoing PCI with femoral access, Enoxaparin. **CONSIDER glycoprotein 2b/3a inhibitor** **AMOONPPP (plus glyocprotein 2b/3a inhibitor)**

Answer 76

AMOONFPPA F = fibrinolysis (tenecteplase/alteplase. Streptokinase is second line) Parenteral anticoagulation is with unfractionated heparin, enoxaparin or fondaparinux (if streptokinase has been used) A = angiography (with PCI if fibrinolysis has faied) Use an ECG 60-90 minutes after administering fibrinolysis to assess whether it has been successful

Answer 77

**_Absolute contraindications_** History of intracranial haemorrhage or stroke of unknown origin at any time Ischaemic stroke in the last 6 months Central nervous system damage, neoplasm, or arteriovenous malformation Major trauma/surgery/head injury within the last 1 month Gastrointestinal bleeding within the last 1 month Bleeding disorder Aortic dissection Non-compressible punctures within the last 24 hours (e.g., liver biopsy, lumbar puncture) **_Relative contraindications_** Chronic oral anticoagulant therapy Pregnancy or within 1 week postnatal Refractory hypertension (systolic BP \>180 mmHg and/or diastolic BP \>110 mmHg) Transient ischaemic attack in the last 6 months Advanced liver disease Infective endocarditis Active peptic ulcer Prolonged or traumatic cardiopulmonary resuscitation.

Answer 78

This may be cardiac (e.g., myocarditis, aortic dissection, severe heart failure) or non-cardiac (e.g., pulmonary embolism, impaired renal function, underlying sepsis)

Answer 79

ECG High sensitivity troponin Chest X-ray FBC (thrombocytopenia increases risk of bleeding, anaemia often seen alongside NSTEMI) U and Es and creatinine (essential for determining grace score) Liver function - helps determine bleeding risk Blood glucose C reactive protein

Answer 80

Give up to three doses of translingual/sublingual glyceryl trinitrate before considering an intravenous glyceryl trinitrate infusion Anticoagulation = heparin

Answer 81

Anticoagulation = fondaparinux first line (2.5 mg subcutaneously once daily for up to 8 days (or hospital discharge if sooner))

Answer 82

* Changes to diet * Reduction of alcohol consumption * Smoking cessation * Weight management * Physical exercise.

Answer 83

Lid retraction Exophtalmos Ophthalmoplegia

Answer 84

Diffuse goitre Pre-tibial myxoedema Thyroid acropachy (digital clubbing, soft tissue swelling of hands and feet, periosteal new bone formation) Vitiligo

Answer 85

Heat intolerance Weight loss Palpitations Tremor Irritablilty Menstrual irregularity (oligomenorrhoea) Sexual dysfunction

Answer 86

TSH receptor stimulating antibodies (90%) anti-thyroid peroxidase antibodies (75%)

Answer 87

If either you or the patient does not want the examination to go ahead without a chaperone present, or if either of you is uncomfortable with the choice of chaperone, you may offer to delay the examination to a later date when a suitable chaperone will be available, as long as the delay would not adversely affect the patient’s health. 12 If you don’t want to go ahead without a chaperone present but the patient has said no to having one, you must explain clearly why you want a chaperone present. Ultimately the patient’s clinical needs must take precedence. You may wish to consider referring the patient to a colleague who would be willing to examine them without a chaperone, as long as a delay would not adversely affect the patient’s health. 13 You should record any discussion about chaperones and the outcome in the patient’s medical record. If a chaperone is present, you should record that fact and make a note of their identity. If the patient does not want a chaperone, you should record that the offer was made and declined.

Answer 88

* understand information relevant to the decision in question * retain that information * use the information to make their decision * communicate a decision. * Retain memory of decision “Adult”: means a person who has attained the age of 16 years “Incapable”: means incapable of: (a) acting: or (b) making decisions; or (c) communicating decisions; or (d) understanding decisions; or (e) retaining memory of decisions

Answer 89

Must consider it likely that: - Patient has a mental disorder - Becasue of their mental disorder their decision making ability is impaired Must also be satisfied that: - Detaiment is needed in order to decide medical treatment (CTO - medical treatment is available and would likely prevent deterioration or allevaite symptoms) - Risk to themselves or the others if not detained - It is necessary

Answer 90

* shock out of keeping with visible loss * pain constant * tender, tense uterus * normal lie and presentation * fetal heart: absent/distressed * coagulation problems * beware pre-eclampsia, DIC, anuria

Answer 91

* proteinuric hypertension * cocaine use * multiparity * maternal trauma * increasing maternal age

Answer 92

* SV up 30%, **HR up 15%** & cardiac output up 40% * **systolic BP** is unaltered * **diastolic BP is reduced** in the 1st and 2nd trimester, returning to non-pregnant levels by term * enlarged uterus may interfere with venous return which can lead to ankle oedema, supine hypotension and varicose veins

Answer 93

* Pulmonary ventilation up by 40%, tidal volume from 500 - 700ml (due to effect of progesterone on respiratory centre) * Oxygen requirements increase by only 20%, therefore over breathing leads to a fall in pCO2 - this can give rise to a sense of dyspnoea that may be accentuated by elevation of the diaphragm * BMR up 15% - this may be due to increased thyroxine and adrenocortical hormones - women may hence find warm conditions uncomfortable

Answer 94

* Maternal blood volume up 30%, mostly in 2nd half - red cells up 20% but plasma up 50% Hb falls * Low grade increase in coagulant activity * rise in fibrinogen and Factors VII, VIII, X * fibrinolytic activity is decreased - returns to normal after delivery (placental suppression?) * prepares the mother for placental delivery * leads to increased risk of thromboembolism * Platelet count falls * WCC & ESR rise

Answer 95

* blood flow increase by 30% * GFR increases by 30-60% * Salt and water reabsorption is increased by elevated sex steroid levels * Urinary protein losses increase

Answer 96

* serum levels of calcium and phosphate actually fall (with fall in protein) * ionised levels of calcium remain stable

Answer 97

Unlike renal and uterine blood flow, hepatic blood flow doesn't change **ALP raised 50%** Albumin levels fall

Answer 98

Braxton-Hicks

Answer 99

Postpartum pyrexia occurs in 5–7% of births. There are many possible causes, with infection related to childbirth being the most common. In women presenting with non-specific symptoms, the diagnosis of puerperal sepsis should be considered until proven otherwise, as puerperal sepsis can result in severe maternal morbidity and occasional mortality. Endomyometritis remains the most common infectious postnatal complication Causative infective organisms include group B strep, E.coli, staph aureus, strep pneumoniae, and clostridium welchii

Answer 100

NICE recommend, in conjunction with clinical judgement: ## Footnote consider home-based care for patients with a CURB65 score of 0 or 1 - low risk (less than 3% mortality risk) consider hospital-based care for patients with a CURB65 score of 2 or more - intermediate risk (3-15% mortality risk) consider intensive care assessment for patients with a CURB65 score of 3 or more - high risk (more than 15% mortality risk) Management of low-severity community acquired pneumonia amoxicillin is first-line if penicillin allergic then use a macrolide or tetracycline NICE now recommend a 5 day course of antibiotics for patients with low severity community acquired pneumonia Management of moderate and high-severity community acquired pneumonia dual antibiotic therapy is recommended with amoxicillin and a macrolide a 7-10 day course is recommended NICE recommend considering a beta-lactamase stable penicillin such as co-amoxiclav, ceftriaxone or piperacillin with tazobactam and a macrolide in high-severity community acquired pneumonia

Answer 101

* Alveolar oedema (perihilar/bat-wing opacification) * Kerley B lines (interstitial oedema) * Cardiomegaly (cardiothoracic ratio \>50%) * Dilated upper lobe vessels * Effusions (e.g. pleural effusions – blunted costophrenic angles)

Answer 102

ST elevation or depression T wave changes (peaked, flattened or inverted Poor R wave progression Pathological Q waves (greater than 25% of the height of the R wave)

Answer 103

Flattened P waves Widened QRS Tall tented T waves ST depressio nand prolonged PR interval may also be seen

Answer 104

Normal variant Myocardial infarction Pulmonary embolism Cor pulmonale Congenital heart disease Cardiomyopathy

Answer 105

Myocardial infarction Hypertension Conduction system fibrosis Cardiomyopathy

Answer 106

Three mechanisms: Insufficient caloric intake, Malabsorption, increased metabolic demand: Insufficient caloric intake: * Poverty * Neglect * Cleft lip/palate * Pyloric stenosis * Cerebral palsy Malabsorption: * Lactose intolerance/cows milk protein allergy * Coeliacs * Short bowel syndrome/NEC * Cystic fibrosis * Biliary atresia Increased metabolic demand: * Hyperthyroidism * Inflammatory bowel disease * Diabetes * Congenital heart defects * Chronic lung disease (bronchopulmonary dysplasia and bronchiectasis) * TORCH infections

Answer 107

**_Normal anion gap ( = hyperchloraemic metabolic acidosis)_** ## Footnote gastrointestinal bicarbonate loss: diarrhoea, ureterosigmoidostomy, fistula renal tubular acidosis drugs: e.g. acetazolamide ammonium chloride injection Addison's disease **_Raised anion gap_** lactate: shock, sepsis, hypoxia ketones: diabetic ketoacidosis, alcohol urate: renal failure acid poisoning: salicylates, methanol **_Metabolic acidosis secondary to high lactate levels may be subdivided into two types:_** lactic acidosis type A: sepsis, shock, hypoxia, burns lactic acidosis type B: metformin

Answer 108

Respiratory acidosis may be caused by a number of conditions: * COPD * decompensation in other respiratory conditions e.g. life-threatening asthma / pulmonary oedema * neuromuscular disease * obesity hypoventilation syndrome * sedative drugs: benzodiazepines, opiate overdose

Answer 109

Common causes * anxiety leading to hyperventilation * pulmonary embolism * salicylate poisoning\* * CNS disorders: stroke, subarachnoid haemorrhage, encephalitis * altitude * pregnancy

Answer 110

* vomiting / aspiration (e.g. peptic ulcer leading to pyloric stenos, nasogastric suction) * diuretics * liquorice, carbenoxolone * hypokalaemia * primary hyperaldosteronism * Cushing's syndrome * Bartter's syndrome

Answer 111

activation of renin-angiotensin II-aldosterone (RAA) system is a key factor aldosterone causes reabsorption of Na+ in exchange for H+ in the distal convoluted tubule ECF depletion (vomiting, diuretics) → Na+ and Cl- loss → activation of RAA system → raised aldosterone levels in hypokalaemia, K+ shift from cells → ECF, alkalosis is caused by shift of H+ into cells to maintain neutrality

Answer 112

Site of fracture Direction of fracture (transverse, oblique or spiral) Simple or comminuted Displacement or angulation of the distal fragment of the fracture Does the fracture line extend into the joint? ALSO rotation, shortening, joint space, joint cartilage Bone lucency

Answer 113

individual eating-disorder-focused cognitive behavioural therapy (CBT-ED) Maudsley Anorexia Nervosa Treatment for Adults (MANTRA) specialist supportive clinical management (SSCM). Family based therapy for adolescents

Answer 114

Low BMI Fear of gaining weight Disturbed body image Calorie restriction Binge eating / purging Laxitives, diuretics Amenorrhoea Fatigue, weakness, poor concentration Pre-occupied with thoughts of food Orthostatic hypotension GI symptoms (bloating/cramping/constipation) Changes to hair, skin and nails

Answer 115

DSM 5 diagnostic criteria for a diagnosis of bulimia nervosa: ## Footnote recurrent episodes of binge eating (eating an amount of food that is definitely larger than most people would eat during a similar period of time and circumstances) a sense of lack of control over eating during the episode recurrent inappropriate compensatory behaviour in order to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics, or other medications, fasting, or excessive exercise. the binge eating and compensatory behaviours both occur, on average, at least once a week for three months. self-evaluation is unduly influenced by body shape and weight. the disturbance does not occur exclusively during episodes of anorexia nervosa.

Answer 116

referral for specialist care is appropriate in all cases NICE recommend bulimia-nervosa-focused guided self-help for adults If bulimia-nervosa-focused guided self-help is unacceptable, contraindicated, or ineffective after 4 weeks of treatment, NICE recommend that we consider individual eating-disorder-focused cognitive behavioural therapy (CBT-ED) children should be offered bulimia-nervosa-focused family therapy (FT-BN) pharmacological treatments have a limited role - a trial of high-dose fluoxetine is currently licensed for bulimia but long-term data is lacking