PassMedicine learning Flashcards
If a patient has a reduced AMTS (7/10) and low blood pressure a day post-operatively (hemicolectomy), what is the most common cause?
Hyponatraemia (U&Es will show low sodium levels)
What are the risk factors for surgical patients for DVT? (10)
- Surgery greater than 90 minutes at any site or greater than 60 minutes if the procedure involves the lower limbs or pelvis
- Acute admissions with inflammatory process involving the abdominal cavity
- Expected significant reduction in mobility
- Age over 60 years
- Known malignancy
- Thrombophilia
- Previous thrombosis
- BMI >30
- Taking HRT or COCP
- Varicose veins with phlebitis
What is classed as mechanical thromboprophylaxis? (4)
- Early ambulation after surgery is cheap and is effective
- Compression stockings (TED)
- Intermittent pneumatic compression devices
- Foot impulse devices
For prophylaxis VTE treatment pre-surgery, when is dabigatran used?
Used prohylactically in hip and knee surgery. It does not require therapeutic monitoring. It has no known antidote and should not be used in any patient in whom there is a risk of active bleeding
Why is unfractionated heparin sometimes used prophylactically?
It has a rapid onset and its therapeutic effects decline quickly on stopping and infusion. Its activity is measured using the APTT. If need be it can be reversed using protamine sulphate.
Which type of kidney stone is associated with an inherited metabolic disorder?
Cystine stones (inherited recessive disorder of transmembrane cystine transport leading to decreased absorption of cystine from intestinal and renal tubule)
What type of kidney stone is often a staghorn calculus with an alkaline urine?
Struvite (chronic infection with urease producing enzymes can produce an alkaline urine and formation of struvite stones)
What are struvite stones formed from? (3)
- Magnesium
- Ammonium
- Phopshate
What is the management for a patient who has been treated for acute pancreatitis, found to have a cystic lesion on the head of the pancreas, but is clinically stable?
Conservative management - it is a pancreatic pseudocyst. A raised amylase and a cystic lesion following pancreatitis is most likely to represent a pseudocyst. If a procedure would be required, then a radiological fine needle aspiration would be best suited.
What are the indications for draining a pancreatic pseudocyst? (3)
- Signs of infection
- Mass effect on abdominal organs
- Persistent pseudocyst 12 weeks beyond it developing
(often even when there are symptoms associated with the pseudocyst, it is still managed conservatively due to the procedural risks)
How may an anal or interspincteric abscess present?
A 24-48 hour history of increasingly severe ano-rectal pain. Patient may be febrile and the skin surrounding the anus may look normal if it is intersphincteric or red/show an abscess. They may not be able to tolerate a PR examination.
How may someone with a fistula in ano present?
With a history of offensive discharge from the anus, but otherwise well. There may be a defect visible. The discharge may be foul and patients should be listed for examination under anaesthesia
What is the most likely diagnosis for a 37 year old man presenting to A&E with severe central abdominal pain radiating to the back, vomiting on several occasions and guarding on examination.
Acute pancreatitis
What are the top characteristic exam features (conditions) for abdominal pain?
- Peptic ulcer disease
- Appendicitis
- Acute pancreatitis
- Biliary colic
- Acute cholecystitis
- Diverticulitis
- Abdominal aortic aneurysm
- Intestinal obstruction
What are the ‘unusual’ causes of abdominal pain that are important to remember?
- MI
- DKA
- Pneumonia
- Acute intermittent porphyria
What is the most common cause of bladder cancers in the developed world?
90% of bladder cancers in the developed world are due to transitional cell carcinomas
What is the most common cause of bladder cancer in the developing world and why?
Squamous cell carcinoma is the most common cause due to schistosomiasis
A 31 year old man with a diffuse lumpy swelling on the left side of his scrotum presents to clinic. There is no pain and testicle is normal. What is the most likely diagnosis?
A varicocele
What is the most likely diagnosis for a 44 year old man with a lump on his right testicle, it is discrete, soft and can be felt posterior to the right testicle.
Epididymal cyst
What is the most likely cause for a 75 year old man to have a swelling in his right scrotum that cannot be palpated above and is large and non-tender?
Inguinal hernia
What can be given IV to a patient with evidence of oedema on a head CT with the beginnings of mass effect, following a head trauma?
IV mannitol
What first line investigation is important to perform in someone presenting with priaprism not associated with sexual stimulation?
A cavernosal blood gas analysis
What does cavernosal blood gas analysis differentiate?
Differentiates an ischaemic and non-ischaemic priapism
What are the causes of priapism? (5)
- Idiopathic
- Sickle cell disease
- Erectile dysfunction medication (e.g. Sildenafil)
- Iatrogenic - antihypertensives, anticoagulants, antidepressants, recreational
- Trauma
Which type of priapism is a medical emergency?
Ischaemic priapism - aspiration of blood and infection of saline flush is first line management
Which anaesthetic muscle relaxant is contraindicated in patients with penetrating eye injuries or acute narrow angle glaucoma and why?
Suxamethonium - because it increases intra-ocular pressure
What is the most common type of prostate cancer?
Adenocarcinoma
Which nerve is affected if a patient has a blown/dilated pupil and a head trauma?
Third cranial nerve
Why does a third cranial nerve palsy occur with some head injuries?
If the head injury results in an uncal herniation - the uncus of the temporal lobe herniates under the free edge of the tentorium cerebelli. The herniated uncus compresses the third cranial nerve causing a surgical third nerve palsy, presenting as a dilated and unreactive pupil
What is the other name for an uncal herniation?
Transtentorial herniation
Which anaesthetic agent has anti emetic properties?
Propofol
Which agent reverses the action of midazolam?
Flumenazil
Which biologic therapy is used to treat patients with crohns disease?
Infliximab
Which biologic therapy is used to treat an unresectable GI stromal tumour if it is KIT positive?
Imatinib
Which organism most commonly causes cholangitis?
E.coli
What are the features of Charcot’s triad, associated with cholangitis?
- RUQ pain
- Fever
- Jaundice
What is the first line investigation for a testicular mass?
USS
If there is a suspicion of bowel perforation, what is the best investigation to perform?
An erect CXR
Which formula is used to calculate fluid resuscitation in a burns patient?
Parkland formula for 24 hours (4ml X TBSA X body weight kg) - 50% is given in the first 8 hours and 50% given in the next 16 hours.
When should an LP be performed to detect a SAH?
12 hours from the start of the headache
In a patient with an upper GI bleed and melaena, why would urea levels be raised?
An increased urea level occurs due to the breakdown of red blood cells in the stomach. - it is usually indicative of an upper GI bleed
What is hereditary haemorrhagic telangiectasia also known as?
Osler-Weber-Rendu syndrome
Although hereditary haemorrhage telangiectasia is an autosomal dominant condition, what % of cases can occur spontaneously without prior family history?
20%
What are the 4 main diagnostic criteria for HHT? (2 or more = possible diagnosis, 3 or more = definite)
- Epistaxis
- Telangiectasis
- Visceral lesions
- Family history
The telangiectasis associated with HHT affects certain sites on the body, where are they? (4)
- Lips
- Oral cavity
- Fingers
- Nose
What are the complications of hepatitis B infection? (4)
- Fulminant liver failure
- Hepatocellular carcinoma
- Glomerulonephritis
- Polyarteritis nodosa
How does tricuspid atresia present?
Systolic ejection murmur at the left upper sternal border with a prominent apical pulse
What are the side effects of rifampicin? (4)
- Discolouration of urine and tears - red/orange colour.
- Abdominal discomfort
- Hepatotoxicity
- Flu-like symptoms
What is the serious adverse effect associated with ethambutol?
Optic neuritis
What are the adverse effects associated with isoniazid? (3)
- Hepatits
- Peripheral neuropathy
- Agranulocytosis
What are the adverse effects associated with pyrazinamide? (4)
- Myalgia
- Arthralgia
- Hepatitis
- Hyperuricaemia
What is the first line medication for patients with glaucomas associated with raise intraocular pressure?
Prostaglandin analogue eyedrops = latanoprost
What is the aim of eye drops in treating open angle glaucoma?
To reduce intra-ocular pressure which in turn has been shown to prevent progressive loss of visual fields
What type of surgery may be performed for people with open angle glaucoma with refractory?
Trabeculectomy
What are the causes of erythema nodosum? (9)
- Strep infection - scarlet fever and rheumatic fever
- TB
- Lymphogranuloma venereum
- Mycoplasmia pneumonia
- Sulfonamides
- Crohn’s/UC
- Hodgkin’s and non-Hodgkins
- Pregnancy
- EBV, hep B, hep C and HIV
What is the most likely diagnosis for a 40 year old woman presenting with erythema nodosum, non-productive cough, joint pains and bilateral hilar lymphadenopathy on CXR?
Sarcoidosis
What electrolyte abnormality is often seen with sarcoidosis?
Hypercalcaemia
What is the most common cause of heel pain in adults?
Plantar fasciitis
How can mesenteric infarction present?
Sudden onset pain with vomiting and occasionally passage of bloody diarrhoea - the pain present is usually out of proportion to the physical signs
How is the anion gap calculated?
([Na+] + [K+] - [Cl] + [HCO3])
What is the anion gap used for?
To classify metabolic acidosis into either:
1. Raised anion gap (seen in DKA)
or
2. Normal anion gap seen in patients with diarrhoea due to GI bicarbonate loss
What medication is contraindicated if a patient requires GTN spray?
PDE 5 inhibitors e.g. sildenafil - concomitant use of both a nitrate and phosphodiesterase inhibitor may lead to significant hypotension and the potential to precipitate an MI.
What is seen on an ECG of someone with hypothermia?
Bradycardia with J waves, and sometimes prolonged PR, QT and QRS intervals.
Could also lead to VT, VF and asystole (temp <16 degrees)
What is the most likely treatment that has been given to a patient with CKD stage 5, suffering from new side effects including abdominal pain, back pain, muscle weakness and anxiety?
Calcium acetate - will have been given to treat hyperphosphataemia. The calcium acetate is a calcium-based binder which can lead to hypercalcaemia - hence the symptoms.
What is sarcoidosis?
A multisystem chronic inflammatory condition characterised by formation of non-caveating epithelioid granulomata at various sites of the body. It often affects the lungs and thoracic cavity.
At what age range is peak onset of sarcoidosis?
20s-40s
What are the systemic/constitutional upset symptoms associated with sarcoidosis?
- Fever
- Night sweats
- Malaise/fatigue
- Weight loss
- Heerfodr’s syndrome
What is Heerfodt’s syndrome?
Inflammation of the submaxillary/parotid glands with uveitis and facial nerve palsy
What % of people with sarcoidosis have lung involvement?
90%
What happens to the lungs in people with sarcoidosis?
There is usually a restrictive pattern seen with diffuse parenchymal lung disease, however airflow obstruction is also found and patients can present with:
- Dry cough
- Fever
- Dyspnoea
- Chest discomfort/pain
How can sarcoidosis affect the skin?
- Papules - brownish/red infiltrative plaques on the extremities and trunk
- Erythema nodosum
- Lupus pernio on the nose and cheeks (this is uncommon but pathognomonic)
What is Lofgren’s syndrome?
It is a combination of erythema nodosum with arthritis
What are the differentials for sarcoidosis? (9)
- RA
- Lymphoma
- Metastatic malignancy
- TB
- MS
- Lung cancer
- SLE
- Multiple myeloma
- Churg-Strauss syndrome
What is the treatment for a patient with known sarcoidosis who is experiencing headaches and a burning sensation in their eyes?
Corticosteroids e.g. oral prednisolone
What blood test can be used to determine if a seizure has occurred/differenitate between a pseudo-seizure?
Prolactin - elevated serum prolactin 10-20 minutes after an episode can be used to differentiate a general tonic-clonic/partial seizure from a non-epileptic pseudo seizure
What factors about a seizure may indicate it is in fact a pseudo seizure?
- Pelvis thrusting
- Crying after seizure
- Don’t occur when alone
- Gradual onset
In a male with a pelvic fracture and a high displaced prostate, with perineal oedema and a urine dipstick showing blood, what is the top differential?
A membranous urethral rupture
In someone with a pelvic fracture with abdominal pain, peritonism and not passing any urine, what is the top differential?
Ruptured bladder
What is the assessment tool used to differentiate between stroke and stroke mimics?
ROSIER - recognition of stroke in the emergency room scale
What is the Bamford classification? (3)
A way of classifying stroke using the following criteria:
- Unilateral hemiparesis and/or hemisensory loss of the face, arm and leg
- Homonymous hemianopia
- Higher cognitive dysfunction e.g. dysphasia
What are the 4 different types of ischaemic stroke?
- Total anterior circulation infarct - TACI 15%
- Partial anterior circulation infarct - PACI 25%
- Lacunar infarcts - LACI 25%
- Posterior circulation infarcts - POCI 25%
Which type of ischaemic stroke involves the middle and anterior cerebral arteries and involves all 3 of the Bamford criteria?
TACI
What symptoms, although cannot alone be used to differentiate, are more common in patients who have had a haemorrhagic stroke? (4)
- Decrease in level of consciousness
- Headache
- Nausea and vomiting
- Seizure
In pemphigus - which structure do antibodies target?
Desmosomes
What is pemphigus?
An autoimmune disease caused by antibodies directed against desmosomes. The antibodies target desmoglein 3, a cadherin-type epithelial cell adhesion molecule.
How does pemphigus present?
Generally in younger people with flaccid, easily ruptured vesicles and bullae and mucosal ulceration.