Passmed stuff Flashcards
Most common cause of death following MI?
Ventricular fibrillation
Four weeks post MI, pulmonary oedema, ECG shows persistent ST elevation.
What is the diagnosis?
Left ventricular aneurysm
Ejection systolic murmurs
- Louder on expiration
- Aortic stenosis
- Hypertrophic obstructive cardiomyopathy
- Louder on inspiration
- Pulmonary stenosis
- Atrial septal defect
Pansystolic murmurs
Mitral / tricuspid regurgitation (tricuspid becomes louder during inspiration)
Ventricular septal defect
Early diastolic murmur
Aortic / pulmonary regurgitation
Mid-late diastolic murmurs
Mitral stenosis
Severe aortic regurgitation
What is electrical alternans pathopneumonic of?
Cardiac tamponade
Classical features of cardiac tamponade
Beck’s triad
- Hypotension
- Raised JVP
- Muffled heart sounds
Cardiac tamponade managment
Urgent pericardiocentesis
Management of congestive heart failure
- 1st line: Beta-blocker and ACE inhibitor: start one drug at a time. Beta-blockers (e.g. bisoprolol) and ACE inhibitors (e.g. ramipril) have been shown to reduce mortality
- 2nd line: Aldosterone antagonist (e.g. spironolactone)
Congestive cardiac failure
Despite bisoprolol, ramirpil and spironolactone, the patient is breathless at rest
What is the most appropriate next step?
- Cardiac resynchronisation therapy (CRT) or implantable cardioverter-defibrillator (ICD)
- (CRT involves biventricular pacing and forces both ventricles to contract in synchrony, thereby improving cardiac output)
- (An ICD is able to perform cardioversion, defibrillation and, in some cases, pacing)
- CRT or an ICD is generally indicated in: symptomatic patients with an ECG indicating ventricular dyssynchrony (e.g. QRS >120ms) AND LVEF <35%
- Digoxin: an alternative option, particularly for patients with atrial fibrillation and heart failure due to its inotropic effects. It does not improve prognosis in patients with heart failure
- Ivabradine: an alternative option if HR >75 bpm and LVEF <35%, and the patient is already on suitable medication (e.g. bisoprolol, ramipril and spironolactone)
- Sacubitril valsartan: if LVEF <35% (will replace ACEi)
Adjunctive management of congestive heart failure
- Fluid restriction: usually limited to <1.5L/day, but varies between patients
- Loop diuretic (e.g. furosemide): confers symptomatic relief of fluid overload but no improvement in prognosis
- Annual influenza vaccine and one-off pneumococcal vaccine
ST elevation in lead II, III and aVF
What type of infarction would cause these changes?
Which cornonary artery would be affected?
Inferior MI
Right coronary
ST elevation in V1-4
What type of infarction would cause these changes?
Which cornonary artery would be affected?
Anteroseptal
Left anterior descending
ST elevation in V4-6, I, aVL
What type of infarction would cause these changes?
Which cornonary artery would be affected?
Anteriolateral
Left anterior descending or left circumflex
ST elevation in I, aVL +/- V5-V6
What type of infarction would cause these changes?
Which cornonary artery would be affected?
Lateral
Left circumflex
Tall R waves V1-V2
What type of infarction would cause these changes?
Which cornonary artery would be affected?
Posterior
Usually left circumflex, also right coronary artery
A 2 day old premature neonate is born by emergency cesarean section for maternal illness. The baby is noted to become floppy and unresponsive.
What is the most likely neurosurgical cause?
Intraventricular haemorrhage
A 78-year-old man is brought to the emergency department by the police. He is found wandering around the town centre and is confused. His family report that he is usually well apart from a simple mechanical fall 3 weeks previously from which he sustained no obvious injuries.
Chronic subdural haematoma
A 75-year-old man has attended the falls clinic with a 1-month history of an increased frequency of falls. In the last month, he reports falling 5 times. Prior to this, he was independently mobile but now requires the assistance of a frame. He lives with his wife who says that he has brief episodes of confusion following by lucid periods. His past medical history includes hypertension, alcoholic fatty liver disease, and gout.
On examination, he has normal power and sensation in his upper limbs. He has a shuffling gait but there is generally good power in his lower limbs. His cranial nerve examination is unremarkable aside from being unable to abduct his left eye on the left lateral gaze.
What is the most likely diagnosis?
Subdural haematoma
What type of sensory loss is seen in a syringomyeloma?
Spinothalamic sensory loss - pain and heat
A 60 year-old male presents with clumsy hands. He has been dropping cups around the house. His wife complains he doesnt answer his mobile as he struggles to use it. His symptoms have been gradually deteriorating over the preceding months.
Diagnosis?
Degenerative cervical myelopathy
A 42-year-old woman is admitted to the vascular ward for an endarterectomy. Her CT report confirms a left temporal lobe infarct.
Visual field defect?
Right superior quadranopia
A 22-year-old man is referred to urology with possible urinary retention. He is passing huge amounts of urine. Post void bladder ultrasound is normal.
Visual field defect?
Lower bitemporal hemianopia
This patient has diabetes insipidus due to a craniopharyngioma.
A 53-year-old man is admitted to the vascular ward for a carotid endarterectomy. His CT head report confirms a left parietal lobe infarct.
Visual field defect?
Right inferior quadranopia
Parietal lesions cause a contralateral inferior quadranopia.
An 84-year-old woman on the stroke ward is being assessed by the occupational therapists for discharge home. Upon assessment there are abnormalities noted in her comprehension of tasks.
The patient is asked to follow two simple orders, to open and close her eyes and raise her right hand, which she does not do after being asked to do so. When asked to repeat 3 words and then a sentence she cannot and falls silent. When naming 3 objects (pen, paper, keys) she is fluent in her speech pattern, but is incomprehensible in content. Lastly, when asked to name as many animals as possible in 1 minute, she names 0 animals, but 20 random, unconnected words are spoken.
What is this type of dysphasia?
Wernike’s dysphasia
A 61-year-old woman presents to the emergency department with morning headaches, nausea and vomiting. An urgent CT head reveals a mass within the right frontal lobe. An MRI head is performed which shows what is likely a glioblastoma surrounded by oedema.
What medication is used in this context to treat oedema?
Dexamethasone
A 66-year-old man comes to see you as he has had numbness in his right hand which has gradually progressed over 48 hours and now he reports that the whole of his right-hand side is numb. You suspect that he is having a stroke and arrange a blue-light ambulance. 6 weeks later he comes to see you to thank your for your help and also discuss his medications.
Assuming there are no contraindications, which antiplatelet regimens is recommended following an acute ischaemic stroke?
Aspirin 300mg daily, then clopidogrel 75mg daily long term
Double vision going down stairs. Which cranial nerve is affected?
Trochlear
In status epilipticus, what medication should be given if not responding to benzodiazepines?
Phenytoin
Which electrolyte abnormality is most likely to occur following a subarachnoid haemorrhage?
Hyponatraemia (due to SIADH)
Cushing’s triad
- Widening of pulse pressure
- Respiratory changes
- Bradycardia
When would a CT head be required immediately following a head injury?
- GCS <13 on initial assessment
- GCS <15 at 2 hours post injury
- Suspected open or depressed skull fracture
- Signs of basal skull fracture (haemotympanum, panda eyes, CSF leakage from ear or nose, Battle’s sign)
- Post traumatic seizure
- Focal neurological deficit
- More than 1 episode of vomiting
Symptoms of normal pressure hydrocephalus
Triad of dementia, incontinence and disturbed gait
Investigation for SAH when head CT is normal?
Lumbar puncture 12 hours post onset of headache
Which medication is given in SAH to prevent vasospasm?
Nimodipine
Head injury with lucid interval. Diagnosis?
Extra-dural haematoma
Unilateral foot drop. Most likely diagnosis?
Common perineal nerve lesion
Bilateral foot drop. Most likely diagnosis?
Peripheral neuropathy
Weakened dorsiflexion, inversion and eversion of the ankle. Most likely diagnosis?
L5 lesion
A 34-year-old female presents with a thyroid nodule. She has a family history of thyroid disease and both her sisters have undergone total thyroidectomies. Her past medical history includes hypertension which has been difficult to manage.
Medullary carcinoma
This is a typical scenario for medullary carcinoma in which a phaeochromocytoma may also be present (due to MEN II). It may be inherited in an autosomal dominant fashion and affected family members may be offered prophylactic thyroidectomy.
An 18-year-old female presents with 3 nodules in the right lobe of the thyroid. Clinically she is euthyroid and there is associated cervical lymphadenopathy. She has no family history of thyroid disease.
Papillary carcinoma
Papillary thyroid cancer is the most common type of thyroid cancer and are the more common in females (M:F=1:3). Papillary tumours are more likely to develop lymphatic spread than follicular tumours.
A 53-year-old man with type 2 diabetes attends his GP for his annual diabetic check. He is currently taking Metformin 1g modified release twice daily with no issues. He has no other medical history. On examination he has a pulse rate of 67 bpm, a blood pressure of 141/83 mmHg and his body mass index is 53 kg/m². His most recent HbA1c is 69 mmol/mol.
Which anti diabetic agent would you add next?
Gliptin
DPP-4 inhibitors are useful in T2DM patients who are obese
59-year-old male with type 2 diabetes mellitus and hypertension presents to clinic for a check-up. You note his blood pressure to be 145/90mmHg. His current prescription includes ramipril. You note the following in his most recent blood results: HbA1c 63mmol/mol
Which of the following additional anti-hypertensives should you avoid prescribing in this patient?
Amlodipine Atenolol Indapamide Lercanidipine Doxazosin
Indapamide
Thiazide like diuretics worsen glucose tolerance.
Primary hyperaldosteronism is most commonly caused by?
Bilateral idiopathic adrenal hyperplasia
Phaeochromocytoma diagnostic investigation
24 hour urinary metanephrines
Phaeochromocytoma management
alpha-blocker (e.g. phenoxybenzamine), given before a beta-blocker (e.g. propranolol)
You are reviewing a 54-year-old man with type 2 diabetes that was started on metformin earlier this year. He is currently taken 500mg metformin three times daily. Prior to this, he had not tried any other medications.
Unfortunately, he tells you that since starting the metformin, he has developed watery diarrhoea and finds he is passing 5-6 watery stools per day. There is some intermittent crampy abdominal pain. He is otherwise well.
You agree that the symptoms are likely secondary to the metformin and unlikely due to another cause. You decide to stop the metformin. What should you do next?
Start metformin modified release
An 82-year-old man with a medical history of prostate cancer, asthma, and COPD comes to the emergency department. He is complaining of abdominal pain, bone pain, and general weakness. While doing some investigations, you notice that he has a shortened QT interval on ECG. What is the most appropriate initial management of the complication this man has?
IV 0.9% normal saline
Following this, bisphosphonates.
A 17-year-old boy visits his general practitioner as he is worried that he has not begun puberty. He reports that he has no growth of pubic, facial or underarm hair. He also reports that he has no sense of smell.
Examination reveals small testes and penis. His height is recorded as 6 foot 1 inch (185cm).
What is the most likely diagnosis?
Kallman’s syndrome
You are reviewing a 5-year-old girl whose mum has been concerned about a rash. This initially started on the trunk before spreading to the rest of the body. Mum thinks she has had a temperature for 1 or 2 days prior to this.
On examination, you note a generalised, rough-textured, pin-point rash. Her tongue has a white coating through which you can see some red papillae.
She has no significant past medical history and no known allergies.
What would be the most appropriate management in this case?
Oral phenoxymethylpenicillin
This a description of scarlet fever, a bacterial infection caused by Group A Streptococci. It is highly contagious and usually treated with antibiotics. NICE recommends phenoxymethylpenicillin first line and azithromycin in true penicillin allergy, although this may be different where you work depending on local microbiology policies.
Exam questions often mention a ‘sandpaper-like rash’ or a ‘strawberry tongue’ as described in this scenario.
If you work in England, Wales or Northern Ireland you should also notify the local health protection team (in Scotland scarlet fever is no longer a notifiable disease).
A 2-year-old boy is presented with multiple petechiae and excessive bruising on his shins. He was previously fit and well apart from a an illness two weeks ago which was diagnosed by the general practitioner as a viral upper respiratory tract infection and for which he was only given paracetamol. His symptoms today were only noticed by his mother half an hour ago. He is apyrexial. Investigations including blood smears reveal thrombocytopaenia with all other parameters reported as normal.
Which of the following is the most likely diagnosis?
Idiopathic thrombocytopenic purpura
Usually self limiting
A 4-year-old boy presents with his mother who is worried, as she notices that his urine is often a dark reddish colour. She is also concerned that he has begun to eat less and less over the past couple of weeks. On examination he is afebrile and there is no history of any recent illness. The mother mentions that his father and grandfather both had kidney trouble but is unsure of what their diagnosis was. Examination reveals a distended abdomen which is soft and non-tender. A palpable mass is felt in the right flank. What is the most likely diagnosis?
Wilms tumour
The majority of croup is caused by which virus?
Parainfluenza
A 9-month-old boy has been referred to you by the out of hours GP. His parents give a 24-hour history of increased work of breathing, coryzal symptoms, lethargy and reduced oral intake. On examination, you note fine inspiratory crackles and subcostal recessions. He is pyrexial (37.9ºC) and oxygen saturations are 91% in air.
Diagnosis?
Causative organism?
Age group commonly affected?
Managment?
Bronchiolitis
Respiratory syncytial virus (RSV)
Under 1 year old
Supportive
APGAR scoring system
You are called to see a 2 day-old neonate who was born 1 week premature following a premature rupture of membranes. He has failed to pass meconium in the first 24 hours and has begun vomiting. You witness one episode of vomiting during the examination which is stained green, which you suspect is bile. On examination he is irritable with an obvious distension of the abdomen but is apyrexial with normal oxygen saturations. Palpation of the abdomen causes further irritation but you are unable to feel any discrete mass. What is the most likely underlying condition?
Cystic fibrosis
A 5-year-old child presents to the emergency department complaining of right iliac fossa pain. On examination there is no rebound tenderness or guarding. Urine dipstick and routine bloods come back as normal. The mother reports that her daughter had a viral infection a few days ago.
What’s the most likely diagnosis?
Mesenteric adenitis
Mesenteric adenitis is inflamed lymph nodes within the mesentery. It can cause similar symptoms to appendicitis and can be difficult to distinguish between the two. It often follows a recent viral infection and needs no treatment
A 7-year-old boy presents to the GP as he does not seem to be developing in the same way as his classmates. He is now a lot taller than most of his friends and he has started to develop hair around his genitalia and armpits. On examination, his penis is also large for his age however his testes remain prepubertal, with a size of 2.4cm.
What is the most likely cause?
Adrenal hyperplasia
A mother brings her 14-month-old son into surgery. Since yesterday he seems to be straining whilst passing stools. She describes him screaming, appearing to be in pain and pulling his knees up towards his chest. These episodes are now occurring every 15-20 minutes. This morning she noted a small amount of blood in his nappy. He is taking around 50% of his normal feeds and vomiting ‘green fluid’ every hour. On examination, he appears irritable and lethargic but is well hydrated and apyrexial. On examination, his abdomen seems distended but no discrete mass is found.
What is the most likely diagnosis?
Intussusception
A 8-year-old boy presents to the GP as his mother is worried about a fever that is not settling with regular paracetamol and ibuprofen. He has had the fever for 7 days now.
On examination, he has a widespread erythematous rash on his torso and arms. In particular, his palms and soles of his feet are very red. There is conjunctival injection with no discharge. Tender cervical lymphadenopathy is palpated. You measure his temperature at 38ºC.
Diagnosis?
Investigation to screen for potential complication?
Kawasaki disease
Echocardiogram for coronary artery aneurysm
A 4-day-old girl who was diagnosed prenatally with Down’s syndrome and born at 38 weeks gestation presents with bilious vomiting and abdominal distension. She is yet to pass meconium.
What is the most likely diagnosis?
Hirsprung’s disease
A mother arrives at the paediatric emergency department with her 4-year-old boy. He has a fever and she has noticed raised nodes on his neck. She has given him paracetamol and ibuprofen but his temperature is not reducing. His lips have become extremely dry and cracked and his tongue red and slightly swollen. She has noticed that his feet are also red and puffy now, and he is developing a widespread fine rash. What is the most likely diagnosis?
Kawasaki disease
An 18 month old boy is brought to the emergency room by his parents. He was found in bed with a nappy filled with dark red blood. He is haemodynamically unstable and requires a blood transfusion. Prior to this episode he was well with no prior medical history. What is the most likely cause?
Meckel’s diverticulum
A 5-year-old boy from a travelling community presents to the Emergency Department with breathing difficulties. On examination he has a temperature of 38.2ºC, stridor and a toxic looking appearance. A diagnosis of acute epiglottitis is suspected. Which organism is most likely to be responsible?
Haemophilus influenzae
A 1-week-old infant is referred following episodes of vomiting, feeding intolerance , and abdominal distension. Examination reveals watery stools with specks of blood present within the nappy. An abdominal X-ray is requested which reveals gas cysts in the bowel wall. What is the most likely diagnosis?
Necrotising enterocolitis
A 3-day-old male is admitted to the neonatal unit with bilious vomiting and reduced feeding. He was born at 30 weeks gestation via an uncomplicated delivery. An abdominal X-ray is requested that shows intramural gas. Oral feeding is stopped and he is started on broad-spectrum antibiotics.
Which of the following is the most likely diagnosis?
Necrotising enterocolitis
A 12-year-old female presents to her GP with bilateral knee pain, swelling and stiffness. On examination, a salmon-pink rash is noted on the legs.
What is the most likely diagnosis?
Juvenile idiopathic arthritis
A 13-year-old girl presents to clinic with right knee pain. She is a keen hockey player but has had no recent injuries. On examination there is a painful swelling over the tibial tubercle. What is the most likely diagnosis?
Osgood-Schlatter disease (tibial apophysitis)
Seen in sporty teenagers
Pain, tenderness and swelling over the tibial tubercle
A three-year-old girl presents with her parents to the accident and emergency department. The parents are concerned that they’ve noticed a new widespread rash on her abdomen. The parents deny any history of trauma or recent infection.
On examination you note a petechial rash covering the anterior abdomen and to a lesser extent the posterior right forearm. The child looks pale and is not playing with the toys set out. You also find hepatosplenomegaly and cervical lymphadenopathy.
While waiting for blood results you dip her urine which proves unremarkable and take a tympanic temperature reading of 36.6º.
What is the most likely diagnosis?
Acute lymphoblastic leukaemia
A 5-year-old girl attends your GP surgery with her mother. She reports a five day history of a sore throat and fever. On examination you note a bright red tongue, flushed face and a rough dry erythematous rash on her neck.
What is the most likely diagnosis?
Scarlet fever
A strawberry tongue can be seen in both scarlet fever and Kawasaki disease. However given the history a diagnosis of scarlet fever is more likely.
Diagnostic features for Kawasaki disease requires a fever >5d with 4 of the following criteria: A) Conjunctival injection B) Mucous membrane changes (dry cracked lips, strawberry tongue) C) Cervical lymphadenopathy D) Polymorphous rash E) Red and oedematous palms/soles, peeling of fingers and toes.
A 4-year-old girl presents to the GP due to a persistent fever for the last 7 days that has not settled with regular paracetamol and ibuprofen. The mother describes that the child has been irritable and not eating or drinking as well as she usually does. On examination, a polymorphous blanching rash is seen on her abdomen. Her tongue is erythematous with a white coating and enlarged papillae. Tender cervical lymphadenopathy is palpated and her eyes are bilaterally erythematous but without discharge.
Diagnosis?
Treatment?
Kawasaki disease
High does aspirin
Managment of hyperkalaemia
All patients with severe hyperkalaemia (≥ 6.5 mmol/L) or with ECG changes should have emergency treatment
- IV calcium gluconate: to stabilise the myocardium
- insulin/dextrose infusion: short-term shift in potassium from ECF to ICF
- other treatments such as nebulised salbutamol may be given to temporarily lower the serum potassium
Further management
- stop exacerbating drugs e.g. ACE inhibitors
- treat any underlying cause
- lower total body potassium
- calcium resonium
- loop diuretics
- dialysis
What are the three stages of AKI?
KDIGO AKI stage 1
- ↑ creatinine 1.5-1.9 times, or
- ↓ urine output <0.5 mL/kg/hr for ≥ 6 hours
KDIGO AKI stage 2
- ↑ creatinine 2-2.9 times, or
- ↓ urine output <0.5 mL/kg/hr for ≥ 10 hours
KDIGO AKI stage 3
- ↑ creatinine >3 times, or
- ↓ urine output <0.5 mL/kg/hr for ≥ 24 hours
Haemolytic uraemia syndrome
Caused by?
Which medications increase the risk?
Triad?
Managment?
Shiga toxin (produced by O157 and shigella)
Antibiotics; Anti-motility (eg loperamide)
Acute kidney injury; haemolytic anaemia; thrombocytopenia
Supportive: antihypertensives; blood transfusion; dialysis
How much maintainance fluid in paediatrics?
For infants 3.5 to 10 kg the daily fluid requirement is 100 mL/kg. For children 11-20 kg the daily fluid requirement is 1000 mL + 50 mL/kg for every kg over 10. For children >20 kg the daily fluid requirement is 1500 mL + 20 mL/kg for every kg over 20, up to a maximum of 2400 mL daily.
Causes of metabolic acidosis with a normal anion gap?
- gastrointestinal bicarbonate loss: diarrhoea, ureterosigmoidostomy, fistula
- renal tubular acidosis
- drugs: e.g. acetazolamide
- ammonium chloride injection
- Addison’s disease
Causes of metabolic acidosis with a raised anion gap
- lactate: shock, sepsis, hypoxia
- ketones: diabetic ketoacidosis, alcohol
- urate: renal failure
- acid poisoning: salicylates, methanol
When should an ACE inhibitor be started in someone with CKD?
Albumin : creatinine ratio 70mg/mmol or more
A 55-year-old man presents to his GP with symptoms of anorexia, fatigue and swelling in his legs. Urea and electrolytes are performed showing a drop in his kidney function and a renal ultrasound is requested which shows bilaterally enlarged kidneys. He smokes 5 cigarettes a day and is a known IV drug user.
HIV associated nephropathy
Chronic HIV-associated nephropathy will have large/normal sized kidneys on ultrasound whereas most patients with chronic kidney disease have bilateral small kidneys
When should someone with haematuria be referred urgently?
Aged >= 45 years AND:
- unexplained visible haematuria without urinary tract infection, or
- visible haematuria that persists or recurs after successful treatment of urinary tract infection
Aged >= 60 years AND have unexplained nonvisible haematuria and either dysuria or a raised white cell count on a blood test
How can you differentiate between a primary and secondary cause of hyperaldosteronism?
If renin is high then a secondary cause is more likely (eg renal artery stenosis)
You are reviewing a 65-year-old in the renal clinic. He has been on haemodialysis for chronic kidney disease for the past 6 years. What is he most likely to die from?
Ischaemic heart disease
