Practice Paper 3 Flashcards
What is the treatment for acute coronary syndrome?
300mg aspirin Clopidogrel Treatment dose heparin b-blocker stat GTN spray Morphine
From LAZ:
o Admit to coronary care unit
o Oxygen, IV access, monitor vital signs and serial ECG
o GTN
o Morphine
o Metoclopramide (to counteract the nausea caused by morphine)
o Aspirin - 300 mg initially, followed by 75 mg indefinitely.
o Clopidogrel (300 mg initially, followed by 75 mg for at least 1 year if troponin positive or high risk)
o LMWH (e.g. enoxaparin)
o Beta-blocker (e.g. metoprolol)
Pt presents to gp with painless haematuria Has a recent history of a sore throat He is producing less urine and the urine is brown There are no other symptoms BP is 155/90 \+++ blood on urine dip High creatinine What do you suspect?
Nephritic syndrome triad:
- Hypertension
- Proteinuria
- Haematuria
What is nephritic syndrome?
Nephritic syndrome is a syndrome comprising signs of nephritis, which is kidney disease involving inflammation.
It often occurs in glomerulonephritis, which is characterized by a thin glomerular basement membrane and small pores in the podocytes of the glomerulus, large enough to permit proteins and red blood cells to pass into the urine
Whats the difference between nephritic syndrome and nephrotic syndrome?
Nephritic = both blood and protein move into urine Nephrotic = ONLY protein
Tell me about digoxin
Its used for the treatment of chronic heart failure
Its an inotrope
it does NOT improve survival
It works by blocking the na/k pump causing a rise in iIC na which via na/ca exchange increases the IC conc of ca and hence contractility (inotrope).
It hence increases the AV delay and the HR is indirectly slowed.
Define hodgkins lymphoma
Lymphomas are neoplasms of lymphoid cells, originating in the lymph nodes or other
lymphoid tissues.
Hodgkin’s lymphoma (15% of all lymphomas) is diagnosed histopathologically by the PRESENCE OF REED-STERNBERG CELLS (BINUCLEATE LYMPHOCYTES)
Whats the aetiology of Hodgkins lymphoma?
Unknown
EBV trigger in 50% (“glandular fever”)
Epidemiology of hodgkin’s lymphoma
MALES
bimodal: peaks at 20-30 and >50
What are the PC of hodgkins?
• Painless enlarging mass (unilateral)
o Most commonly in the neck
o Can also be in the axilla or groin
• The mass may become painful after ALCOHOL INGESTION
• B symptoms of Lymphoma
o Fever > 38 degrees - If this is cyclical it is referred to as Pel-Ebstein fever
o Night sweats
o Weight loss > 10% body weight in the past 6 months
- these are associated with a worst prognosis.
• Other symptoms
o Pruritis
o Cough
o Dyspnoea
Recognise the signs of Hodgkin’s lymphoma on physical examination
• Non-tender firm rubbery lymphadenopathy***
(may be cervical, axillary or inguinal)
• Splenomegaly (or sometimes, hepatosplenomegaly)
• Skin excoriations
• Signs of intrathoracic disease (e.g. pleural effusion, superior vena cava obstruction)
What is the staging for hdgkin
• Ann Arbor Staging
o I = single lymph node region
o II = 2+ lymph node regions on one side of the diaphragm
o III = lymph node regions on both sides of the diaphragm
o IV = extranodal involvement
o A = absence of B symptoms
o B = presence of B symptoms
o E = localised extranodal extension
o S = involvement of spleen
Define psoriasis
• A chronic inflammatory skin disease, which has characteristic lesions and may be complicated by arthritis
Recognise the PC of psoriasis
Recognise the presenting symptoms of psoriasis
• Itching and occasionally tender skin
• Pinpoint bleeding with removing scales (Auspitz phenomenon)
• Skin lesions may develop at sites of trauma/scars (Koebner phenomenon)
Recognise the sings OE for psoriasis
Recognise the signs of psoriasis on physical examination
• Discoid/Nummular psoriasis - symmetrical, well-demarcated erythematous plaques with silvery scales over extensor surfaces (knee, elbows, scalp, sacrum)
- Flexural psoriasis - less scaly plaques in axilla, groins, perianal and genital skin
- Guttate psoriasis - small drop-like lesions over trunk and limbs
- Palmoplantar psoriasis - erythematous plaques with pustules on palms and soles
- Generalised pustular psoriasis - pustules distributed over limbs and torso
- Nail Signs
How does psoriatic arthritis present
• Joint Signs M FIVE presentations of psoriatic arthritis
o Asymmetrical oligoarthritis
o Symmetrical polyarthritis
o Distal interphalangeal joint predominance
o Arthritis mutilans
o Psoriatic spondylitis
What are the main causes of subarachnoid haemorrhages?
- 85% - rupture of a saccular aneurysm at the base of the brain (Berry aneurysms)
- 10% - perimesencephalic haemorrhage
- 5% - arteriovenous malformations, bleeding diathesis, vertebral artery dissection
What are the main RF for subarachnoid haemorrhages?
• Risk Factors
o Hypertension
o Smoking
o Excess alcohol intake
o Saccular aneurysms are associated with:
• Polycystic kidney disease
• Marfan’s syndrome
• Ehlers-Danlos syndrome
What are the presenting symptoms of subarachnoid haemorrhage?
- Sudden-onset worst headache ever THUNDERCLAP
- Nausea/vomiting
- Neck stiffness
- Photophobia
- Reduced level of consciousness
Recognise the signs of subarachnoid haemorrhage on physical examination
Meningism :
o Neck stiffness
o Kernig’s sign
o Pyrexia
What do you expect to find on a LP of a sub. haem?
Xanthochromia = straw-coloured CSF due to breakdown of red blood cells
requires at least 6hrs to show up though - until the rbc break down.
What do you expect to find on a CT scan of sub. haem?
• CT Scan
Hyperdense areas in the basal regions of the skull (due to blood)
What investigations do you do for sub. haem?
• Bloods o FBC o U&Es o ESR/CRP o Clotting
• CT Scan
o Hyperdense areas in the basal regions of the skull (due to blood)
• Angiography - detect source of bleeding
• Lumbar Puncture
o Increased opening pressure
o Increased red cells
o Xanthochromia - straw-coloured CSF due to breakdown of red blood cells
What’s the antidote for paracetamol overdose?
N-acetylcysteine
Whats’s the antidote for opiate overdose?
Naloxone
What is the CURB65 score and what is it used for?
Used to asses severity/management of pneumonia Confusion Urea >7 RR>30 BP low 65< yrs old
On examining a patient with a weak regular pulse, ejection systolic murmur.
When they lean forward so you can palpate their apex beat in expiration they get flustered and complains of a sore back and SOB.
What are you thinking?
Aortic stenosis
Ejection systolic murmur is classic of aortic stenosis
Rheumatic fever is a rf - most comon cause wordlwide.
What is the most common cause of aortic stenosis?
Age related calcification
What are aortic stenosis complications?
Heart failure
Angina
Heyde syndrome (colonic angiodysplasia and lower GI bleed)
Explain the aetiology and risk factors of aortic stenosis
- Stenosis can be secondary to rheumatic heart disease (MOST COMMON WORLDWIDE)
- Calcification of a congenital bicuspid aortic valve
- Calcification/degeneration of a tricuspid aortic valve in the elderly
Recognise the presenting symptoms of aortic stenosis
• May be ASYMPTOMATIC initially
• Angina (due to increased oxygen demand of the hypertrophied left ventricle)
• SYNCOPE or dizziness on exercise (due to outflow obstruction)
–> classic elderly patient falls for no reason and comes to a&e then you discover aortic murmur.
• Symptoms of heart failure (e.g. dyspnoea, orthopnoea)
Recognise the signs of aortic stenosis on examination
Recognise the signs of aortic stenosis on examination
• Narrow pulse pressure
• Slow-rising pulse
• Thrill in the aortic area (only if severe)
• Forceful sustained thrusting undisplaced apex beat
• EJECTION SYSTOLIC MURMUR** at the aortic area, radiating to the carotid artery
• Second heart sound may be softened or absent (due to calcification)
• A bicuspid valve may produce an ejection click
What are the signs you expect to find for aortic stenosis on ECG?
• ECG Signs of left ventricular hypertrophy • Deep S in V1/2 • Tall R in V5/6 • Inverted T waves in I, aVL and V5/6 • Left axis deviation
LBBB signs
WilliaM v1,v6
Common AB and their side effects
Co-amoxiclav = cholestatic jaundice Erythromycin = diarrhoea Gentamicin = nephrotoxicity
What scoring system is used to predict risk of pressure sores in patients?
Waterlow
Define obstructive sleep apnoea
A disease characterised by recurrent prolapse of the pharyngeal airway and apnoea (cessation of airflow for > 10 s) during sleep, followed by arousal from sleep.
Also known as Pickwickian Syndrome
What’s obstructive sleep apnoea associated with?
Associated with: Weight gain - OBESE Smoking Alcohol Sedative use Enlarged tonsils and adenoids in children Macroglossia Marfan's syndrome Craniofacial abnormalities
How does obstructive sleep apnoea occur?
Occurs due to narrowing of the upper airways because of the collapse of soft tissues of the pharynx
This is due to decreased tone of the pharyngeal dilators during sleep
Recognise the presenting symptoms of obstructive sleep apnoea
TIREDNESS Excessive daytime sleepiness Unrefreshing or restless sleep Morning headaches Dry mouth Difficulty concentration Irritability and mood changes Partner reporting snoring, nocturnal apnoeic episodes or nocturnal choking
In an SBA what does “work in a shipyard” indicate?
Asbestos exposure
Define mesothelioma
Aggressive tumour of the mesothelial cells, which
usually occurs in the pleura (90%) but can also occur in other sites, such as the peritoneum, pericardium and testes.
Whats the RF of mesothelioma
ASBESTOS ** (shipyard exposure)
has a latent period of 50years
Summarise the epidemiology of mesothelioma
- RARE
- More common in ELDERLY (> 75 yrs)
- Asbestos exposure is documented in 70M80% of cases
- Latent period between asbestos exposure and mesothelioma may be up to 50 yrs
Recognise the presenting symptoms and signs of mesothelioma
• MOST COMMON symptoms:
o SOB
o Chest pain (dull, diffuse and progressive)
WORST ON INHALATION = pleural chest pain
o Weight loss
• Occasionally palpable chest wall mass
• Fatigue
• Fever
• Night sweats
• Clubbing (due to underlying asbestosis (pulmonary fibrosis))
• Signs of metastases (e.g. hepatomegaly, bone pain and tenderness)
What ix will you do for mesothelioma?
• CXR/CT
o Shows pleural effusion
o May show a pleural mass and rib destruction
- MRI and PET
- Pleural fluid - can be sent for cytological analysis and may be blood-stained
- Pleural biopsy
What would help distinguish between angina and myocardial infarction?
raised troponin levels = MI
What’s the classic presentation for colonic carcinoma on CT or barium enema?
apple core lesion
Whats the classic px of crohns on barium enema of the colon?
“cobble stoning” PATCHY throughout colon
rosy thorne ulcer
colonic strictures
Whats the classic px of UC on barium enema of the colon?
CONTINUOUS changes from recturm proximally
loss of haustra on plain film
colon appears shorter
Which sign would you NOT expect to see on a cauda equina pt?
Upgoing plantars- They should be normal
Upgoing plantars would indicate a lesion higher up.
Which nerve roots are compressed in saddle anesthesi
s3-s5
