Scales & Classifications

Question 1

Scale used to measure degree of disability due to breathlessness

Answer 1

MRC dyspnoea scale

1. Not troubled by breathlessness except on strenuous exercise
2. Short of breath when hurrying or walking up a slight hill
3. Walks slower than contemporaries on the level because of breathlessness, or has to stop for breath when walking at own pace
4. Stops for breath after about 100 m or after a few minutes on the level
5. Too breathless to leave the house, or breathless when dressing or undressing

Question 2

Scale for predicting mortality in community acquired pneumonia

Answer 2

CURB65

Confusion of new onset (defined as an AMTS of 8 or less) Blood

Urea nitrogen greater than 7 mmol/l (19 mg/dL)

Respiratory rate of 30 breaths per minute or greater

Blood pressure less than 90 mmHg systolic or diastolic blood pressure 60 mmHg or less

Age 65 or older

Question 3

Scale for classifying heart failure

Answer 3

New York Heart Association (NYHA) classification is used to grade the severity of functional limitations in a patient with heart failure:

class I no limitation of physical activity ordinary physical activity does not cause fatigue, breathlessness or palpitation (includes asymptomatic left ventricular dysfunction)

class II slight limitation of physical activity patients are comfortable at rest. Ordinary physical activity results in fatigue, palpitation, breathlessness or angina pectoris (symptomatically ‘mild’ heart failure)

class III marked limitation of physical activity although patients are comfortable at rest, less than ordinary activity will lead to symptoms (symptomatically ‘moderate’ heart failure)

class IV inability to carry out any physical activity without discomfort symptoms of congestive cardiac failure are present even at rest. Increased discomfort with any physical activity (symptomatically ‘severe’ heart failure)

Question 4

Grading system for muscle power

Answer 4

MRC scale for muscle power

0 No muscle contraction is visible.

1 Muscle contraction is visible but there is no movement of the joint.

2 Active joint movement is possible with gravity eliminated.

3 Movement can overcome gravity but not resistance from the examiner.

4 The muscle group can overcome gravity and move against some resistance from the examiner.

5 Full and normal power against resistance. Deep tendon reflexes

Question 5

Measurement of consciousness state

Answer 5

Glasgow Coma Scale Grades of

Best Motor Response 6 Carrying out request (‘obeying command’) -patient does simple things you ask. 5 Localising response to pain. 4 Withdrawal to pain - pulls limb away from painful stimulus. 3 Flexor response to pain - pressure on nail bed causes abnormal flexion of limbs - decorticate posture. 2 Extensor posturing to pain - stimulus causes limb extension - decerebrate posture. 1 No response to pain.

Grades of Best Verbal Response 5 Oriented - patient knows who and where they are, and why, and the year, season and month. 4 Confused conversation - patient responds in conversational manner, with some disorientation and confusion. 3 Inappropriate speech - random or exclamatory speech, with no conversational exchange. 2 Incomprehensible speech - no words uttered, only moaning. 1 No verbal response.

Eye Opening 4 Spontaneous eye opening. 3 Eye opening in response to speech - that is, any speech or shout. 2 Eye opening in response to pain. 1 No eye opening. return to history

Question 6

Sleep apnoea screening scale

Answer 6

Epworth daytime sleepiness scale

Sitting and reading Watching TV

Sitting still in a public place (e.g. a theatre, a cinema or a meeting)

As a passenger in a car for an hour without a break Lying down to rest in the afternoon when the circumstances allow

Sitting and talking to someone

Sitting quietly after lunch without having drunk alcohol In a car or bus while stopped for a few minutes in traffic

Question 7

Scale assessing whether or not to anticoagulate in AF

Answer 7

CHADSVASC

Congestive heart failure

Hypertension

Age ≥ 75 (2) Age 65-74 (1)

Diabetes mellitus

Stroke/TIA/thrombo-embolism(2)

Vascular disease

Sex Female

Question 8

Risk of bleeding with anticoagulants

Answer 8

HASBLED

Hypertension

Abnormal renal and liver function

Stroke

Bleeding

Labile INRs

Elderly

Drugs or alcohol

Hypertension: (uncontrolled, >160 mmHg systolic) Abnormal renal function: Dialysis, transplant, Cr >2.26 mg/dL or >200 µmol/L Abnormal liver function: Cirrhosis or Bilirubin >2x Normal or AST/ALT/AP >3x Normal Stroke: Prior history of stroke Bleeding: Prior Major Bleeding or Predisposition to Bleeding Labile INR: (Unstable/high INRs), Time in Therapeutic Range 65 years Prior Alcohol or Drug Usage History (≥ 8 drinks/week) Medication Usage Predisposing to Bleeding: (Antiplatelet agents, NSAIDs)

Question 9

Scale risk of adverse outcome following upper GI bleed

Answer 9

Rockall

Question 10

Mortality risk following hip fracture

Answer 10

Nottingham hip fracture scale - predicts 30day mortality following surgery

Age

Sex

Admission Hb

MMTS

Living in an institution

Number of comorbidities

Malignancy

Question 11

Whether to prescribe antibiotics in tonsillitis

Answer 11

Centor

History of fever

Tonsillar exudates

Tender anterior cervical adenopathy

Absence of cough

The modified Centor criteria add the patient’s age to the criteria: Age under 15 add 1 point Age over 44 subtract 1 point

-1, 0 or 1 point(s) – No antibiotic or throat culture necessary (risk of strep. infection <10%)

2 or 3 points - Should receive a throat culture and treat with an antibiotic if culture is positive (risk of strep. infection 32% if 3 criteria, 15% if 2)

4 or 5 points - Consider rapid strep testing and or culture. (Risk of strep. infection 56%) - IDSA and ASIM no longer recommend empiric treatment for strep based on symptomatology alone.

Question 12

Ankle fracture classifications

Answer 12

Weber

Question 13

Salter Harris classification

Answer 13

Fracture

Question 14

Open fracture classification

Answer 14

Gustillo-Anderson

Type I wound < 1 cm

Type II 1-10cm

Type III A > 10 cm, high energy adequate tissue for coverage includes segmental / comminuted fractures even if wound <10cm farm injuries are automatically Gustillo III

Type IIIB extensive periosteal stripping and requires free soft tissue transfer

Type IIIC vascular injury requiring vascular repair

Question 15

Rheumatoid classification

Answer 15

DAS28

Question 16

Asthma severity

Answer 16

Mild: No features of severe asthma PEFR >75%

Moderate: No features of severe asthma PEFR 50-75%

Severe (if any one of the following): PEFR 33 – 50% of best or predicted, Cannot complete sentences in 1 breath, Respiratory Rate > 25/min Heart Rate >110/min

Life threatening (if any one of the following): PEFR < 33% of best or predicted Sats <92% or ABG pO2 < 8kPa Cyanosis, poor respiratory effort, near or fully silentchest Exhaustion, confusion, hypotension or arrhythmias Normal pCO2

Near Fatal: Raised pCO2

Question 17

Lung cancer survival

Answer 17

NSCLC 5 Year Survival All NSCLC – 10-13%

Stage 1 following surgical resection – 60-70%

Stage II following surgical resection – 30-55%

Stage III – 7%

Stage IV – 1%

Question 18

Scale in suspected/ query PE

Answer 18

Wells score

Clinical signs and symptoms of DVT (minimum of leg swelling and pain with palpation of the deep veins) 3

An alternative diagnosis is less likely than PE 3

Heart rate > 100 beats per minute 1.5

Immobilisation for more than 3 days or surgery in the previous 4 weeks 1.5

Previous DVT/PE 1.5

Haemoptysis 1

Malignancy (on treatment, treated in the last 6 months, or palliative) 1

PE likely - more than 4 points

PE unlikely - 4 points or less

Question 19

Classification acute kidney injury

Answer 19

RIFLE

Risk: increased Cr x 1.5, decreased GFR>25% Urine output <0.5ml/kg/h x 6h

Injury: Crx 2, GFR >50%, UO <0.5ml/kg/hr x 12hr

Failure: Cr x 3, GFR > 75%, UO <0.5ml/kg/hr x24 or anuria

Loss: persistent ARF - complete LOF > 1 month

ESKD: complete LOF >3month

Question 20

Scale to predict mortality in hospital exacerbations of COPD

Answer 20

DECAF Dyspnoea Eosinophilia Consolidation Acidaemia atrial Fibrillation

Question 21

EGFR variables

Answer 21

CAGE - Creatinine, Age, Gender, Ethnicity

Question 22

Test for suspected acromegaly

Answer 22

Oral glucose tolerance test (OGTT) -

GH normally becomes undetectable following glucose challenge

Question 23

WHO performance status

Answer 23

0 - normal, fully active without restriction

1 - Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work

2 - Ambulatory and capable of all selfcare but unable to carry out any work activities. Up and about more than 50% of waking hours

3 - Capable of only limited selfcare, confined to bed or chair more than 50% of waking hours

4 - Completely disabled. Cannot carry on any selfcare. Totally confined to bed or chair

5 - Dead

Question 24

Dukes colon cancer staging

Answer 24

Dukes A - invasion but not through bowel wall

Dukes B - invasion through bowel wall penetrating muscular layer but not lymph nodes

Dukes C - involvement of lymph nodes

Dukes D - widespread metastases

Question 25

ASA grades

Answer 25

1. Normal and healthy
2. Mild systemic disease
3. Severe systemic disease
4. Systemic disease which is a constant threat to life
5. Moribund - not expected to survive 24h even with operation

Question 26

Scale to classify macroscopic appearance of gastric cancers

Answer 26

Bormann’s classification

Type I lesions—Pedunculated and exophytic.

Type II lesions—Ulcer craters confined to mucosa and submucosa.

Type III lesions extend into the muscularis.

Type IV lesions extend beyond the stomach.

Question 27

Acute pancreatitis - assess severity and predict mortality

Answer 27

Modified Glasgow Criteria valid for EtOH and gallstones

P = pO2

A = age

N = neutrophils (=WCC)

C = calcium

R = renal function (=urea)

E = enzymes (ALT/LDH)

A = albumin

S = sugar (=glucose)

Question 28

UC severity

Answer 28

Truelove and Witts criteria

Question 29

Classification of colonic perforation due to diverticular disease

Answer 29

The Hinchey classification - The classification is I-IV:

Hinchey I - localised abscess (para-colonic)

Hinchey II - pelvic abscess

Hinchey III - purulent peritonitis (the presence of pus in the abdominal cavity)

Hinchey IV - feculent peritonitis.

Question 30

Classification of rectal prolapse

Answer 30

full thickness (complete), where all the layers of the rectal wall prolapse, or involve the mucosal layer only (partial)

external if they protrude from the anus and are visible externally, or internal if they do not circumferential, where the whole circumference of the rectal wall prolapse,

or segmental if only parts of the circumference of the rectal wall prolapse present at rest, or occurring during straining.

Question 31

Classification peripheral artery disease - Fontaine

Answer 31

Fontaine Classification

Stage I – Asymptomatic. Of note: Fontaine stage I does in fact describe patients who are for the most part asymptomatic. Careful history may actually reveal subtle and non-specific symptoms such as paresthesias. Physical examination may reveal cold extremities and other signs of “subclinical” peripheral artery disease. More examples include bruits over blood vessels and lack of normal pulses.

Stage II – Intermittent claudication. This stage takes into account the fact that patients usually have a very constant distance at which they have pain: Stage IIa – Intermittent claudication after more than 200 meters of pain free walking. Stage IIb – Intermittent claudication after less than 200 meters of walking

Stage III – Rest pain. Rest pain is especially troubling for patients during the night. The reason for this is twofold: First, the legs are usually raised up on to a bed at night, thus diminishing the positive effect gravity may have had during the day when the legs were dependent. Second, during the night the lack of sensory stimuli allow patients to focus on their legs.

Stave IV – Ischemic ulcers or gangrene (which may be dry or humid).

Question 32

Classification peripheral artery disease - Rutherford

Answer 32

The Rutherford classification has seven stages:

Stage 0 – Asymptomatic

Stage 1 – Mild claudication

Stage 2 – Moderate claudication – The distance that delineates mild, moderate and severe claudication is not specified in the Rutherford classification, but is mentioned in the Fontaine classification as 200 meters.

Stage 3 – Severe claudication

Stage 4 – Rest pain

Stage 5 – Ischemic ulceration not exceeding ulcer of the digits of the foot

Stage 6 – Severe ischemic ulcers or frank gangrene

Question 33

Aortic Dissection Classification

Answer 33

Stanford classification The Stanford classification is divided into two groups, A and B, depending on whether the ascending aorta is involved.

Type A – proximal (70%); involves the ascending aorta and/or aortic arch, and possibly the descending aorta. The tear can originate in the ascending aorta, the aortic arch, or more rarely, in the descending aorta. It includes DeBakey types I and II.

Type B – distal (30%); involves the descending aorta or the arch (distal to the left subclavian artery), without the involvement of the ascending aorta. It includes DeBakey type III.

Question 34

Gangrene classification

Answer 34

Wet: tissue death + infection Dry: tissue death only - coagulative necrosis

Pregangrene: tissue on the brink of gangrene Gas gangrene: Clostridium perfringes myositis

Fournier gangrene is a type of necrotizing fasciitis or gangrene affecting the perineum

Meleney’s gangrene, or Meleney’s ulcer is a cutaneous condition that is a postoperative, progressive bacterial gangrene

Question 35

CEAP classification

Answer 35

Clinical, Etiological, Anatomical, and Pathophysiological (CEAP) classification for chronic venous disorders

Question 36

Hepatorenal syndrome classification

Answer 36

Type 1 HRS: rapidly progressive deterioration. Survival <2wks.

Type 2 HRS: steady deterioration. Survival around 6 months.

Question 37

Kings College Hospital Criteria in Acute Liver Failure - paracetamol induced

Answer 37

The King’s College Criteria identify two groups of patients that have a poor prognosis with acetaminophen induced liver failure:

Arterial pH < 7.3

or all of: PT>100s Cr>300uM Grade 3/4 encephalopathy

Question 38

Kings College Hospital Criteria in Acute Liver Failure - non-paracetamol

Answer 38

In patients with non-acetaminophen acute liver failure, the following criteria were identified as being associated with a poor prognosis:

INR greater than 6.5;

or, 3 out of 5 of:

Drug induced Age <1- or >40

Serum bilirubin > 300uM

1 week from jaundice to encephalopathy

PT>50s

Question 39

Child-Pugh Grading of Cirrhosis

Answer 39

Predicts risk of bleeding, mortality and need for treatment. Graded A-C using 5 factors:

Albumin Bilirubin Clotting Distension: ascites Encephalopathy Score >8 = significant risk of variceal bleeding

Question 40

Encephalopathy grading

Answer 40

1. Confused
2. Drowsy
3. Stupor
4. Coma

Question 41

Maddrey score

Answer 41

Predicts mortality in alcoholic hepatitis

Mild 0-5% 30d mortality

Severe 50% 30d mortality

1 year after admission

Question 42

Garden classification

Answer 42

stage I : incomplete fracture of the neck (so-called abducted or impacted)

stage II : complete without displacement

stage III: complete with partial displacement: fragments are still connected by posterior retinacular attachment; there is malalignment of the femoral trabeculae

stage IV : this is a complete femoral neck fracture with full displacement: the proximal fragment is free and lies correctly in the acetabulum so that the trabeculae appear normally aligned

Question 43

Seddon classification

Answer 43

Three types of neurological injury

1) Neuropraxia - temporary interruption without loss of axonal continuity
2) Axonotmesis - disruption of axon –> Wallerian degeneration
3) Neurotmesis - disruption of entire nerve fibre

Question 44

Classification extension supracondylar fractures of humerus

Answer 44

Gartland:

Type 1: non displaced

Type 2: angulated with intact posterior cortex

Type 3: displaced with no cortical contact

Question 45

Classification of brachial plexus injuries

Answer 45

Leffert classification of brachial plexus injury: It is based on etiology and level of injury and is as follows

I Open (usually from stabbing)

II Closed (usually from motorcycle accident)

IIa Supraclavicular

III Radiation induced

IV Obstetric

IVa Erb’s (upper root) - waiter’s tip hand;

IVb Klumpke (lower root)

Question 46

Dukes Criteria for infective endocarditis

Answer 46

Major Criteria:

A. Positive blood culture for Infective Endocarditis: Typical organism in 2 separate cultures. OR Persistently positive cultures (3 sets, at different times, from different places, at peak temperature).

B. Evidence of Endocardial involvement: Positive echocardiogram (Vegetation, abscess, prosthetic valve damage). OR New valvular regurgitation.

Minor Criteria:

1. Predisposition
2. Fever >38°C
3. Vascular / Immunological signs
4. Positive blood culture (But does not meet Major criteria)
5. Positive echocardiogram (But does not meet Major criteria) Definite Infective Endocarditis: 2 Major OR 1 Major, 3 Minor OR 5 Minor

Question 47

IQ scores for mild, moderate, severe ID

Answer 47

Mild 50-69

Moderate 35-49

Severe 20-34

Profound <20

Question 48

Tool to screen for delirium

Answer 48

Abbreviated mental test MMSE

Confusion Assessment Method

Clock drawing

Question 49

Assessment tool to assess suicide risk

Answer 49

SADPERSONS scale The score is calculated from ten yes/no questions, with one point for each affirmative answer:

S: Male sex

A: Age (<19 or >45 years)

D: Depression

P: Previous attempt

E: Excess alcohol or substance use

R: Rational thinking loss

S: Social supports lacking

O: Organized plan

N: No spouse

S: Sickness

This score is then mapped onto a risk assessment scale as follows: 0–4: Low 5–6: Medium 7–10: High

Question 50

Scoring system applied within 24 hours of admission of a patient to an intensive care unit

Answer 50

APACHE

Question 51

Classification of stroke

Answer 51

The Bamford/ Oxford classification system, is a simple bedside method of classifying acute ischaemic strokes. It uses the patients’ symptoms to classify which region of the brain has been affected, and once classified it allows for prediction of a patient’s prognosis.

1. Total Anterior Circulation Stroke (TACS) Higher Cerebral Dysfunction & Homonymous Visual Field Defect & Ipsilateral Motor +/- Sensory Deficit Mortality: 39% at 1 month, 60% at 1 year, Recurrence: Low Risk
2. Partial Anterior circulation stroke (PACS) 2 out of 3 of TACS Symptoms OR Higher Cerebral Dysfunction Alone OR Monoparesis Mortality: 4% at 1 month, 16% at 1 year, Recurrence: Very High Risk
3. Lacunar stroke (LACS) Motor Stroke OR Sensory Stroke OR Sensori-motor Stroke OR Ataxic Hemiparesis Mortality: 2% at 1 month, 11% at 1 year, Reccurrence: Low Risk
4. Posterior circulation stroke (POCS) Ipsilateral Cranial Nerve Palsy with Contralateral Motor Deficit OR Bilateral Deficit OR Disorder of Conjugate Eye Movement OR Cerebellar Dysfunction OR Isolated Homonymous Hemianopia Mortality: 7% at 1 month, 19% at 1 year, Recurrence: High Risk

Question 52

Assessing extent of burns

Answer 52

Wallace’s Rule of Nines: head + neck = 9%, each arm = 9%, each anterior part of leg = 9%, each posterior part of leg = 9%, anterior chest = 9%, posterior chest = 9%, anterior abdomen = 9%, posterior abdomen = 9%

Lund and Browder chart: the most accurate method the palmar surface is roughly equivalent to 1% of total body surface area (TBSA). Not accurate for burns > 15% TBSA

Question 53

Tool to screen for problem drinking

Answer 53

AUDIT questionnaire

Question 54

Screening tool for post-natal depression

Answer 54

The Edinburgh Postnatal Depression Scale may be used to screen for depression: 10-item questionnaire, with a maximum score of 30 indicates how the mother has felt over the previous week

score > 13 indicates a ‘depressive illness of varying severity’ sensitivity and specificity > 90% includes a question about self-harm

Question 55

Specific investigation in suspected Addison’s disease

Answer 55

ACTH stimulation test (short Synacthen test). Plasma cortisol is measured before and 30 minutes after giving Synacthen 250ug IM.

Adrenal autoantibodies such as anti-21-hydroxylase may also be demonstrated.

Question 56

Specific investigation in suspected Acromegaly

Answer 56

Oral glucose tolerance test is used to confirm a raised IGF-1: GH is normally inhibited by glucose. If the glucose load fails to suppress the GH level below 1.0 mcg/L this confirms the diagnosis of acromegaly.

Question 57

Tools recommended by NICE to assess risk of fragility fractures

Answer 57

FRAX or QFRACTURE tools

Question 58

DKA criteria

Answer 58

Glucose >11mmol/L

pH <7.3 or HCO3<15

Capillary ketones > 3mmol/L or ++ urinary ketones

Question 59

Definition of shock

Answer 59

Shock is a medical emergency in which the organs and tissues of the body are not receiving an adequate flow of blood. This deprives the organs and tissues of oxygen (carried in the blood) and allows the buildup of waste products. Shock can result in serious damage or even death.

Question 60

Sepsis definition and symptoms

Answer 60

Sepsis is the body’s overwhelming and life-threatening response to infection which can lead to tissue damage, organ failure, and death

Symptoms - SEPSIS

Shivering, fever, or very cold

Extreme pain or general discomfort

Pale or discoloured skin

Sleepy, difficult to rouse, confused

I feel like i might die

Short of breath

Question 61

Assessing severity of UC

Answer 61

Truelove and Witt’s severity index

Number of bowel movements per day

Blood in stool

Pyrexia (greater than 37.8oc)

Pulse >90bpm

Anaemia

Erythrocyte sedimentation