Senior Medicine Flashcards
Give 4 indications for urgent dialysis
Refractory hyperkalaemia
Pulmonary oedema + oligouria
Uraemic encephalopathy
Uncontrolled metabolic acidosis
Management of hypercalcaemic emergency
Assess including history, physical exam, fluid status, ECG, bloods (inc. calcium, phosphate, PTH, U&Es)
4-6 litres of NaCl over 24 hours
Zoledronic acid 4mg over 15 minutes
NB: For calcium serum levels:
<3.0 - mild, often asymptomatic
3.0-3.5 - moderate, may well be symptomatic, prompt treatment usually indicated
>3.5 - severe, emergency treatment required
RCEM guidelines:
https://www.rcem.ac.uk/docs/External%20Guidance/10R.%20Acute%20Hypercalcaemia%20-%20Emergency%20Guidance%20(Society%20for%20Endocrinology,%20Jan%202014).pdf
How should emergency hyperkalaemia be managed?
Continuous ECG monitoring
Give either calcium gluconate (10ml of 10%) or calcium chloride (10ml of 10%) by slow I.V. injection
Give insulin (10 units soluble) with 25g glucose over 15 minutes
Give salbutamol (10-20mg nebulised)
Monitor serum K+ and glucose
Consider dialysis
NB: the glucose may be given as 50ml 50% or 125ml 20% solution but the 50% solution carries extra risks in the case of extravasation
Renal Association guidelines:
https://renal.org/sites/renal.org/files/RENAL%20ASSOCIATION%20HYPERKALAEMIA%20GUIDELINE%202020.pdf
What is the threshold for severe/ emergency hyperkalaemia?
Above 6.5mmol/L
Mild: 5.5-5.9mmol/L
Moderate: 6.0-6.5mmol/L
Severe: >6.5mmol/L
NB: this varies in some institutions e.g. in North America it may be higher, but the values used here are taken from the BNF (see “management of hyperkalaemia):
https://bnf.nice.org.uk/treatment-summary/fluids-and-electrolytes.html
Which two causes of hypercalcaemia together account for 90% of cases?
Primary hyperparathyroidism
Hypercalcaemia of malignancy
Which of the following signs would classify an asthma attack as ‘severe’?
A. PEFR 60% of predicted B. Presence of confusion C. A RR of 28 D. A HR of 100bpm E. PaCO2 of 5.0 kPa on an ABG
C. A RR of 28
The full list of signs used to classify severity of asthma by BTS is provided below, but broadly speaking:
- If the patient is somewhat symptomatic but their obs are not significantly impacted, it is ‘moderate acute’
- If the HR and RR are elevated and the clinical picture is worrying, but the patient doesn’t seem in immediate danger, it is ‘acute severe’
- If there are signs of exhausted respiratory effort or cardiovascular compromise, it is ‘life-threatening’
- There is also ‘near-fatal’ asthma which is defined by raised PaCO₂ and/or requiring mechanical
ventilation with raised inflation pressures
Moderate acute asthma:
• increasing symptoms
• PEF >50–75% best or predicted
• no features of acute severe asthma
Acute severe asthma: • PEF 33–50% best or predicted • respiratory rate ≥25/min • heart rate ≥110/min • inability to complete sentences in one breath
Life-threatening asthma: • PEF <33% best or predicted • SpO₂ <92% • PaO₂ <8 kPa • ‘normal’ PaCO₂ (4.6–6.0 kPa) • altered conscious level • exhaustion • arrhythmia • hypotension • cyanosis • silent chest • poor respiratory effort
BTS guidelines has a good summary of acute management:
https://www.brit-thoracic.org.uk/quality-improvement/guidelines/asthma/
The F2 is called to see a 79 y/o woman on the ward as her NEWS score has increased from 4 to 7. She is day 3 post hemiarthroplasty for a R NOF#, and her saturations have dropped from 98 to 91 on RA. She is a known asthmatic, and auscultation reveals widespread expiratory wheeze indicative of an asthma attack. An ABG is taken first, and then she is given 2 5mg salbutamol nebulisers with 15L of O2. The ABG gives the following results:
pH: 7.33
PaO2: 9.4 kPa
PaCO2: 5.1 kPa
Which of the following is true?
A. The ABG indicates she is fatiguing
B. The nebulisers have not improved her condition
C. The ABG is reassuring - this is a moderate acute episode
D. She should be transferred promptly to a respiratory ward for CPAP
E. The most important next step is a stat dose of hydrocortisone
A. The ABG indicates she is fatiguing
A normal PaCO2 on an ABG in an acute asthma attack is worrying. This is because the patient should be hyperventilating to compensate for the bronchiole constriction. A normal PaCO2 indicates they are failing to compensate and CO2 is starting to build up, which indicates they are becoming fatigued.
‘B’ is incorrect because the ABG was taken before the nebulisers were started, and so cannot reflect their effect. This is significant because an ABG should ideally be taken before treatment starts to give an accurate picture of the patient’s condition.
‘C’ is wrong because of the normal PaCO2 in addition to the hypoxia and slight acidosis. This is in fact a ‘life-threatening’ acute attack.
‘D’ CPAP is not generally used in asthma attacks, there is a possbility that BiPAP may be useful but this requires further studies. Additionally, this patient is still acutely unwell and this is not the time to be transferring her to another ward, and there are other steps that have yet to be undertaken.
‘E’ is incorrect, but only just. A stat dose of 200mg hydrocortisone is important to give early, but is not the most important intervention this early on.
Which of the following is NOT an indication for an urgent (within 1 hour) CT head after a head injury?
A. A self-resolving generalised seizure shortly after the injury
B. A GCS of 14 2 hours after assessment in A&E
C. Battle’s sign (bruising over the mastoid process)
D. Any reduced GCS on assessment in A&E
E. A few episodes of vomiting post-injury
D. Any reduced GCS on assessment in A&E
GCS of less than 13 on admission is an indication for an urgent CT head. Realistically you would want to do a CT head on anybody with a reduced GCS coming to A&E with a head injury, but it is less urgent if their GCS is >13 on assessment.
The NICE criteria for a CT head within one hour of assessment in head injury patients are:
GCS less than 13 on initial assessment in the emergency department
GCS less than 15 at 2 hours after the injury on assessment in the emergency department
Suspected open or depressed skull fracture
Any sign of basal skull fracture (haemotympanum, ‘panda’ eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign)
Post-traumatic seizure
Focal neurological deficit
More than 1 episode of vomiting
A 17 year old girl is brought to A&E by her father with acute onset breathlessness. She is a known asthmatic who has been taking Fostair (LABA + ICS). She is struggling to complete sentences within 1 breath, has a resp rate of 34, and a heart rate of 143. She is now being given continuous oxygen-driven Salbutamol nebulisers but is still symptomatic and hypoxic with sats of 90%.
What is the most important next step in her management?
A. Give I.V. aminophylline B. Add nebulised ipratropium bromide C. Give nebulised magnesium sulphate D. Give a stat dose of hydrocortisone E. Give I.V. salbutamol
B. Add nebulised ipratropium bromide
This is a life-threatening attack (as evidenced by sats <92) and there has been a poor initial response to Salbutamol nebulisers, hence the next step is to add nebulised ipratropium bromide. It may also be appropriate at this time to give a single bolus of I.V. magnesium sulphate (though an infusion should only be given after consultation with a senior). Be sure to involve seniors early in scenarios with a seriously unwell patient.
Whilst you would want to give I.V. steroids as soon as is feasible, they will not start to help for a couple of hours, and in a life-threatening attack like this one, improving the breathing is more important.
p16 of the BTS guidelines has a good summary of acute management:
https://www.brit-thoracic.org.uk/quality-improvement/guidelines/asthma/
What is the standard urine output for a healthy person in an hour?
0.5-1.0 ml/kg/hr
A 39 y/o man is brought to A&E under blue lights after an RTC. When assessed in A&E: his eyes are closed but open in response to pain, he is speaking but the words are not organised into any sort of coherent sentence, and he withdraws from painful stimuli.
What is this man’s GCS?
9
GCS has 3 components: Movement, Voice, and Eyes. In this case:
M = 4
V = 3
E = 2
Thus his GCS is 9
Movement - 6: 6 - Moving and obeying commands 5 - Localises to pain 4 - Withdraws from pain 3 - Decorticate (abnormal flexion) 2 - Decerebrate (abnormal extension) 1 - No movement
Voice - 5: 5 - Speaking coherently and is oriented 4 - Coherent but disorientated 3 - Muddled words 2 - Sounds but no words 1 - No sounds
Eye - 4: 4 - Eyes open spontaneously 3 - Eyes open in response to voice 2 - Eyes open in response to pain 1 - Eyes do not open
A 57 y/o with COPD visits his GP as he is still experiencing significant and limiting SOB despite using his SABA. His inhaler technique is checked and is good. His spirometry testing and history have revealed no sign of asthmatic features.
How should this man’s medication be changed?
A. Prescribe a short course of oral prednisolone and reassess B. Prescribe a LABA and a LAMA C. Prescribe a LABA, a LAMA, and an ICS D. Change the SABA to a SAMA E. Prescribe a LABA and an ICS
B. Prescribe a LABA and a LAMA
COPD patients should also get an annual flu vaccine, one-off pneumococcal vaccine, pulmonary rehabilitation if indicated, and smoking cessation support.
Some COPD patients may take azithromycin prophylaxis for infective exacerbations (though they must be on optimal treatment and not smoking and still be having exacerbations).
Patients with frequent exacerbations should be given a course of antibiotics and prednisolone to take if they get sputum changes.
Here is a useful visual summary of stable COPD management (NICE May 2019):
https://www.nice.org.uk/guidance/ng115/resources/visual-summary-treatment-algorithm-pdf-6604261741
What is the best way to track changes in fluid status in a ward setting?
Daily weights
The F2 is bleeped to see a 29 y/o woman who is acutely short of breath. She is 2 days post-op for fixation of an ankle fracture. She is SOB and complaining of chest pain, and is tachycardic at 112bpm (though her ECG is otherwise normal) with a BP of 109/82. Her calf on the side of the affected ankle is tense, swollen, and painful. A standard set of bloods are taken, and a pregnancy test is negative. A CXR shows no abnormalities.
What is the most appropriate next action?
A. Perform urgent thrombolysis
B. Start rivaroxaban or apixaban and order a CTPA
C. Start a LMWH
D. Order a V/Q scan and give LMHW in the interim
E. Perform a compression Duplex USS of the affected leg
B. Start rivaroxaban or apixaban and order a CTPA
Patients presenting with signs of a PE ahould have an initial assessment as well as a CXR and probably an ECG. A Wells score can then be used to estimate the likelihood of a PE: this patient would have a Wells score of 9. Given the very likelihood of PE, baseline FBC, U&Es, LFTS, and clotting should be taken and either rivaroxaban or apixaban should be started before results are back. The patient should then have a CTPA assuming there are no contraindications.
If the CTPA is normal , order a proximal leg vein ultrasound scan.
Here is a very useful visual representation of the management of DVT and PE from NICE:
https://www.nice.org.uk/guidance/ng158/resources/visual-summary-pdf-8709091453
Full NICE guidelines:
https://www.nice.org.uk/guidance/ng158/chapter/Recommendations#anticoagulation-treatment-for-suspected-or-confirmed-dvt-or-pe
How long should anticoagulation continue after a PE?
At least 3 months, anticoagulation beyond this point will depend on co-morbidities and the cause of the PE
Unprovoked PEs will generally require a further 3 months of anticoagulation (6 total)
Which of the following ECG changes is most likely to be seen in a pulmonary embolus?
A. Atrial fibrillation B. Sinus tachycardia C. A large S wave in lead I, a Q wave in lead III, and an inverted T wave in lead III D. New RBBB E. New first degree heart block
B. Sinus tachycardia
The ECG is completely normal in 15-20% of cases. The so called “S1 Q3 T3” pattern associated with acute massive pulmonary embolus is relatively rare and not necessarily specific. Other non-specific ECG abnormalities are more common including sinus tachycardia, atrial fibrillation, first degree AV block and right bundle branch block. Left sided ECG abnormalities are unusual but may occur in acute massive pulmonary embolus.
A 68 year old man is brought to A&E by his daughter who is concerned he seems confused and generally unwell. She also states he has not passed urine today. His AMTS on admission is 6/10 (down from a baseline of 10/10) and a basic set of obs reveals: sats 94%, HR 110, RR 28, BP 86/60, and temp 38.2. The doctor notices the man coughing up green sputum during the clerking and orders a CXR, which reveals diffuse opacities in the lower zone of the left lung.
How should this man be managed?
A. Manage in the community with oral co-amoxiclav and encourage fluid intake
B. Manage in the community with oral levofloxacin and encourage fluid intake
C. Admit for at least 24 hours of observation, begin I.V. antibiotics and fluids, then switch to oral when improved
D. Admit to hospital, give I.V. fluids, give I.V. co-amoxiclav, and take blood cultures
E. Admit to hospital, initiate the Sepsis 6, give I.V. co-amoxiclav and clarithomycin, and contact ICU
E. Admit to hospital, initiate the Sepsis 6, give co-amoxiclav and clarithomycin, and contact ICU
This question gives you a chance to use the CURB-65 score, but is also an exercise in generally assessing how unwell a patient is. From the information given, this patient’s CURB-65 is 3 which indicates they need to be admitted to hospital and ICU involvement should be considered. There is no urea value given so the score may be 4, and likely is given the confusion and anuria.
Even ignoring the CURB-65, this patient is haemodynamically unstable, desaturating, and generally unwell which should prompt admission to hospital and senior/ critical care involvement. Given the clear signs of sepsis, the Sepsis 6 should also be initiated.
Antibiotic choice may vary by trust, but a common choice for severe pneumonia
CURB-65 classifications:
0-1: mild, manage in community
2: moderate, consider hosptial admission
3+: severe, admit to hospital and consider ICU involvement
The components of the CURB-65 score are: C - Confusion/ AMTS of 8 or less U - Urea of more than 7mmol/L R - Resp rate of 30 or more B - BP: systolic less than 90, or diastolic 60 or less 65 - Age of 65 or over
Summarise the treatment of COPD exacerbation requiring hospitalisation:
Nebulised salbutamol (O2 driven or medical air if acidotic/ hypercapnic)
I.V. theophylline if insufficient response to bronchodilators
Oral prednisolone 30mg for 5 days
Antibiotics if sputum becomes purulent
NIV if acidotic and retaining
Intubation if NIV does not resolve acidosis
A 16 year old girl is brought to see the GP by her father. She was feeling unwell the previous evening and is now feeling much worse. She has been nauseous and has vomited, and is visibly pale and feels clammy. She complains of headache and asks for the lights in the room to be turned down, and the GP notices a non-blanching rash on her leg.
What is the most appropriate next step?
A. Check allergy history, give I.M. Benzylpenicillin, and send her urgently to hospital
B. Perform fundoscopy and a neurological exam, and perform an LP if there are no signs of raised ICP
C. Prescribe a 7 day course of oral Amoxicillin and Ceftriaxone, with safety netting advise
D. Recommend bed rest, fluids, and analgesia, and safety net
E. Send her immediately to hospital and phone ahead asking for an urgent CT head
A. Check allergy history, give I.M. Benzylpenicillin, and send her urgently to hospital
This is a history of bacterial meningitis, a rapidly progressing infection that is not particularly common but is life threatening, with significant associated morbidity. In primary care the doctor should send the patient to hospital urgently, but should give one dose of Benzylpenicillin (or Cefotaxime if penicillin allergic) as long as this does not delay transfer to hospital.
Once at hospital the Sepsis 6 will be initialised, and the girl will be given Ceftriaxone and Amoxicillin initially, with a possible later switch depending on which organism is the cause.
NB: If the patient presents to A&E then an LP will ideally be done before initiating antibiotics, but it should not be allowed to delay antibiotic treatment
A 62 year old woman attends A&E with a 1 day history of sore throat and general malaise. She has a background of lymphoma for which she is currently receiving chemotherapy. Her obs are: HR 73, RR 18, temp 36.5, BP 115/75.
How should this patient be managed?
A. Prescribe oral antibiotics and arrange follow up in 24 hours
B. Contact her regular oncologist
C. Admit and start empirical I.V. antibiotics
D. Admit for a period of 24 hours observation
E. Take blood cultures and act on the results
C. Admit and start empirical I.V. antibiotics
In a patient undergoing chemotherapy, any illness should be treated with admission and sepsis protocol. This is because these patients develop neutropenic sepsis and detriorate very quickly, so even though this seems like an overreaction to the presentation, it is the right course.
If a patient has a penicillin allergy, what is the chance of them having also a cephalosporin allergy?
5-10%
A 45 year old woman presents to her GP with a 2 month history of progressive fatigue and malaise. A routine set of obs and blood tests reveal a low grade fever, a normocytic anaemia, and a mildly elevated CRP. She is sent to hospital where a CXR, sputum culture, urine MC&S, and stool MC&S are all normal. A urine dipstick does however reveal some microscopic haematuria, and on examination her spleen is enlarged.
Which of the following tests should be performed given the most likely diagnosis?
A. USS of the kidneys B. High-resolution CT chest C. Cystoscopy D. Echocardiogram E. Biopsy of the kidneys
D. Echocardiogram
This is a history of endocarditis, likely subacute. Subacute bacterial endocarditis is classically caused by Streptococcus viridans and is associated with dental surgery which allows passage of the bacteria from the mouth to the heart. The history will feature gradual general symptoms of being unwell, which together with microscopic haematuria (from septic emboli), anaemia, and splenomegaly is highly suggestive of endocarditis.
Endocarditis
NB: Subacute will have the more chronic features, which can be remembered using the ‘FROM JANE’ acronym:
F - Fever (also present in acute endocarditis)
R - Roth spots (haemorrhages visible on fundoscopy due to septic emboli)
O - Osler’s nodes (painful nodules on pads of fingers and toes caused by immune complex deposition)
M - Murmur (caused by bacterial vegetations on valves, may also be present in acute endocarditis)
J - Janeway lesions (non-tender red spots on palms and soles caused by septic microemboli)
A - Anaemia
N - Nail bed haemorrhage (splinter haemorrhages due to septic emboli)
E - Emboli (septic emboli e.g. that cause PE)
Which of the following would confirm a diagnosis of type II diabetes mellitus in a patient with typical symptoms?
A. Random plasma glucose of 9.2 mmol/L B. 2 hour post-load glucose of 9.0 mmol/L C. Fasting plasma glucose of 6.6 mmol/L D. Random plasma glucose of 10.2 mmol/L E. HbA1c of 50mmol/mol
E. HbA1c of 50mmol/mol
There are 4 test results than can be used to diagnose diabetes:
Fasting plasma glucose ≥7.0 mmol/L
Random plasma glucose ≥11.1 mmol/L (≥200 mg/dL) with diabetes symptoms such as polyuria, polydipsia, fatigue, or weight loss
2-hour post-load glucose ≥11.1 mmol/L (≥200 mg/dL) on a 75 g oral glucose tolerance test
HbA1c ≥48 mmol/mol (≥6.5%)
All of these require confirmation with a second test (same or a different test) unless the patient is symptomatic, though even then it may be wise to take a second test.
What is the ratio used to convert oral to IV morphine?
3:1, so an oral dose of 10mg is equivalent to an I.V. dose of 3.3mg. This is specific to morphine, and there are specific rates for other opioids.
The conversion of oral morphine to subcut is 2:1
A 62 year old woman is brought to A&E after tripping and falling while getting off the Tube. She is in significant pain and cannot weight bear. AP and lateral x-rays reveal a fractured neck of femur (#NOF). She has a background of COPD for which she has been taking oral prednisolone for the past 6 months. The #NOF is fixed with a THR, and she is told to take 10mcg Vitamin D daily and is given a 24 hour ECG halter. Her analgesia and COPD medications have been prescribed.
Which additional medication should be prescribed on discharge?
This woman should be prescribed a bisphosphonate e.g. Alendronate
Bisphosphonates are usually prescribed after falls resulting in #NOF, and are particularly important in this patient as she is taking long-terms steroids which are a big cause of osteoporosis. Add to this that this woman is post-menopausal and there is no mention of HRT, and she is high risk for osteoporosis.
This woman should also have a DEXA scan to quantify her probable osteoporosis. It is worth mentioning that she should probably have been prescribed a bisphosphonate when she started taking long-term steroids.
Which of the following would allow you to diagnose infective endocarditis under the Duke classification clinical criteria?
A. Two separate positive S. viridans blood cultures
B. New tricuspid regurgitation with a fever of 38.5 and Janeway lesions and Osler’s nodes on the hands
C. Two separate positive S. aureus blood cultures with septic pulmonary infarcts and a history of I.V. drug use
D. Roth spots, Janeway lesions, Osler’s nodes, and a previous history of rheumatic heart disease
E. One positive H. influenzae culture in an IVDU with a fever of 39, conjunctival haemorrhage, and Roth spots
B. New tricuspid regurgitation with a fever of 38.5 and Janeway lesions and Osler nodes on the hands
Although realistically you would strongly suspect infective endocarditis in every one of these cases, the Duke criteria are very specific in terms of what does and does not confirm it.
The Duke criteria is as follows:
To definitely diagnose infective endocarditis you must have either:
Pathological evidence (histology showing vegetations) or
Clinical evidence
Clinical evidence is divided into major and minor criteria. To confirm the diagnosis you need 2 major criteria, or 1 major and 3 minor criteria, or 5 minor criteria.
NB you need criteria from different categories e.g. Roth spots, Osler’s nodes, and glomerulonephritis would only count as 1 because they are all immunological phenomena.
Major criteria:
1) Evidence of microorganisms in the blood
NB: if S. viridans, S. bovis, HACEK group, S. aureus, enterococci, then only two separate cultures are needed. If other organisms are detected, then either two samples >12 hours apart are needed, or all 3 or the majority of 4 samples have to be positive
2) Evidence of endocardial involvement (signs on echocardiogram or new valvular regurgitation)
Minor criteria:
1) Predisposing heart condition or IVDU
2) Fever ≥ 38
3) Vascular events e.g. septic pulmonary emboli, Janeway lesions, intracranial haemorrhage
4) Immune events e.g. Roth spots, Osler’s nodes, glomerulonephritis
5) Blood cultures or biochemical evidence of active infection that does not meet the major criteria
6) Echo findings indicating infective endocarditis but not sufficient to meet the major criteria
NB: Infective endocarditis is considered ‘possible’ if there is 1 major and 1 minor criterion, or 3 minor criteria
Summarise the management of DKA
Stage 1: 0-60 minutes:
Resuscitate with 500ml boluses of 0.9% saline over 15 minutes each to achieve systolic >90mmHg
Then give fluid replacement as standard in DKA (1L over 1 hour, another 1L with K+ over the next 2 hours, another 1L with K+ over the next 2 hours etc.)
Give 50 units of fixed rate insulin made up to 50ml with 0.9% saline, at a rate of 0.1units/kg/hour
Stage 2: 60 minutes to 6 hours
Reassess and monitor (inc. fluid balance and obs)
Hourly capillary ketone and glucose measurement
Continue fluid replacement
Start VTE prophylaxis if appropriate
Identify cause or precipitant
Add 10% glucose infusion if glucose falls below 14.0mmol/L
There are further stages but this is the immediate critical summary.
Once the acidosis and ketonaemia have resolved, eating and drinking should be resumed and insulin should be switched to subcutaneous.
This website has the full guidelines, condensed management chart, and fluid prescribing guidelines:
https://www.diabetes.org.uk/professionals/position-statements-reports/specialist-care-for-children-and-adults-and-complications/the-management-of-diabetic-ketoacidosis-in-adults
Why might an HbA1c measurement be unreliable in renal failure patients?
Shortened erythrocyte survival is a feature of CKD and may result in an artificially lowered HbA1c
A 17 year old boy is brought to A&E by his mother with general unwellness and headache. He is photophobic with a stiff neck and the doctor suspects bacterial meningitis. He is given an LP and empirical antibiotics, and the Sepsis 6 is started. He recovers well and is now ready for discharge.
Which of the following measures should be taken?
A. He should be quarantined for one week after resolution of symptoms
B. His family, and all healthcare workers who had contact with him should be given Rifampicin 600mg BDS for 2 days
C. His family should be given one 500mg dose of Ciprofloxacin each
D. He should be kept off school for at least 2 weeks
E. He should be offered follow-up nasal swabbing for N. meningitidis
C. His family should be given one 500mg dose of Ciprofloxacin each
One element of bacterial meningitis that is often glossed over is the follow-up chemoprophylaxis of contacts. This is mainly for members of the patient’s household: healthcare workers don’t need prophylaxis unless there has been direct exposure of the mouth or nose to infectious droplets from a patient with meningococcal disease who has received less than 24 hours of antibacterial treatment.
Once recovered, there is no need for quarantining or swabbing the patient, and he can return to school when able (though this will depend on recovery and any sequelae).
Which 3 markers are required to diagnose diabetic ketoacidosis?
- Capillary blood glucose (CBG) of at least 11.0mmol/L or known diabetes
- Capillary blood ketones>3.0mmol/L or 2+ ketonuria
- Venous pH<7.3 and/or venous bicarbonate<15mmol/L
Why should metformin be stopped in patients with CKD and an eGFR of <30?
Because there is a significant risk of lactic acidosis in these patients if they take metformin
A 25 year old woman presents to her GP with pain and swelling of the skin immediately next to her right eye. The skin looks red and swollen, and is tender and hot to the touch. She denies any nausea, vomiting, or rigors, and her observations are normal.
How should this patient be managed?
A. Advise mild analgesia and rest, and safety net
B. Prescribe oral flucloxacillin
C. Prescribe oral flucloxacillin and arrange an opthalmology review within 1 week
D. Refer urgently to hospital where she should be given co-amoxiclav
E. Refer to hospital
D. Refer urgently to hospital where she should be given co-amoxiclav
This is a history suspicious for peri-orbital cellulitis; though the patient is well, the risk of intra-cranial infection is higher than normal and this patient needs admission to hospital and antibiotics. Co-amoxiclav is first line for peri-orbital cellulitis instead of the usual flucloxacillin.
What are the only 2 measures with strong evidence for improving long-term survival in COPD patients?
Which other non-pharmacological measures should be taken in COPD patients?
Smoking cessation and home oxygen therapy (if chronically hypoxic)
There is growing evidence that other measures may improve survival, but for now these are the only two well-evidenced ones:
https://thorax.bmj.com/content/65/4/284
Other measures:
A one-off pneumococcal vaccine and annual influenza vaccines
Pulmonary rehabilitation (after recent hospitalisation or has breathlessness making them walk slower than contempories on the level, or which makes them stop for breath when walking at their own pace)
Optimisation of co-morbitidites
Oral mucolytics (e.g. carbocysteine) if patient has trouble bringing up sputum
Azithromycin prophylaxis if they do not smoke and have optimised medical and non-medical treatment, but still have 4 or more exacerbations per year
An 18 year old girl is admitted to hospital with an acute exacerbation of her asthma: she is breathless and struggling to complete sentences in one breath. She is given oxygen-driven salbutamol and ipratropium bromide nebulisers and begins to show some improvement.
Which other medication should she be given as soon as possible?
Oral prednisolone 40-50mg daily orally for at least 5 days
I.V. hydrocortisone (100mg 6 hourly till converted to prednisolone) or I.M. methylprednisolone are acceptable alternatives if oral medication is unsuitable
NB: Regardless of steroids given for an acute exacerbation of asthma, the patient should take their preventer inhaler as normal
Summarise the treatment of an acute exacerbation of asthma:
Supplementary O2 as needed
5mg oxygen-driven (~6L/min) back-to-back nebulised salbutamol (reserve IV salbutamol for when inhaled is inappropriate)
Add 500mcg oxygen-driven nebulised ipratropium bromide if poor initial response OR if severe attack
At this point (if not earlier) definitely involve a senior
Consider single bolus of IV magnesium sulphate (senior decision)
IV aminophylline may be used but is unlikely to work (senior decision)
Involve ICU if severe or life-threatening attack that is not responding to treatment - the patient may need intubation and ventilation
BTS guidelines download (see p83 for acute asthma in adults):
https://www.brit-thoracic.org.uk/document-library/guidelines/asthma/btssign-asthma-guideline-2014/
What monitoring is necessary after acute assessment and initiation of treatment in an asthma attack?
Measure and record PEF 15–30 minutes after starting treatment, and thereafter according to the response
Measure and record PEF before and after nebulised or inhaled β2 agonist
Record oxygen saturation by oximetry and maintain arterial SpO2 at 94–98%
Repeat measurements of blood gas tensions within one hour of starting treatment if:
- the initial PaO2 is <8 kPa unless SpO2 is >92%; OR
- the initial PaCO2 is normal or raised; OR
- the patient’s condition deteriorates
Measure them again if the patient’s condition has not improved by 4–6 hours
Measure and record the heart rate
Measure serum potassium and blood glucose concentrations
Which of the following symptoms would make a diagnosis of COPD less likely if present?
A. Wheeze B. Productive cough C. Reduced exercise tolerance D. Chest pain E. Frequent seasonal chest infections
D. Chest pain
Chest pain and haemoptysis are two important symptoms to ask about in a history, because they are unlikely to occur in COPD and so suggest there is a different problem.
A 64 year old woman visits her GP for a follow-up appointment. She was diagnosed with an infective exacerbation of her COPD and started on amoxicillin and prednisolone, and advised to double the frequency of her inhaled SABA. She complains that her breathlessness has not improved, and that she is coughing more than before.
How should this patient be managed?
A. Advise her to attend A&E for more in-depth assessment
B. Take a sputum sample, and switch to an appropriate antibiotic on review of the results
C. Advise her to attend hospital for admission and inpatient treatment
D. Take a sputum sample and switch her to doxycycline
E. Add amikacin and re-review in 1 week
D. Take a sputum sample and switch her to doxycycline
This patient’s infection has not resolved on her initial antibiotic, but there is also no indication yet that she is sick enough to warrant hospital admission. In this scenario you should switch antibiotic. If this fails, then you would consider admission and/or specialist input.
Community treatment of COPD exacerbation:
Increase dose or frequency of SABA/SAMA bronchodilators
5 days of oral amoxicillin, clarithromycin, or doxycycline
5 days of oral prednisolone (probably no need for bone protection unless needing frequent courses e.g. 3/4 times per year)
Which of the following features would most support a diagnosis of ulcerative colitis (UC) over Crohn’s disease?
A. Fistula formation
B. Lower right quadrant pain
C. Presence of arthritis and erythema nodosum
D. Rectal involvement
E. Presence of clubbing and aphthous ulcers
D. Rectal involvement
Differentiating UC from Crohn’s is tricky, and can only be done definitively on biopsy. However there are some features than can be more suggestive of one over the other.
Lower right quadrant pain and fistula formation are both classically features of Crohn’s. The pain results from involvement of the ileum - common in Crohn’s but uncommon in UC. Fistula formation is associated with Crohn’s because it affects the full thickness of the bowel, whereas UC affects only the mucosa and submucosa and so is unlikely to cause a fistula.
Clubbing and aphthous ulcers are features of both UC and Crohn’s and are not a helpful way to differentiate. Similarly arthritis and erythema nodosum occur in both diseases. Extraintestinal manifestations are a little more common in Crohn’s than UC, but this is not reliable in clinically differentiating them.
Papers on extraintestinal manifestations of IBD:
https: //academic.oup.com/ibdjournal/article/21/8/1982/4602969
https: //www.ncbi.nlm.nih.gov/pmc/articles/PMC3127025/
A 25 year old woman presents to her GP with a 1 week history of spotting. Her last period ended 2 weeks ago and she usually has regular 28 day cycles. She has not been using contraception and has had 3 sexual partners in the past month. On examination there is some mucopurulent cervical discharge and the cervix appears inflamed.
Which diagnostic test should be performed next?
A. Urine dipstick B. NAAT C. Bimanual exam D. Urinary b-hCG E. Endocervical swab
B. NAAT
Nucleic acid amplification testing is the test of choice for chlamydia and gonorrhoea. This history could be either, thought the bleeding is more suggestive of chlamydia. Endocervical swabs can be used to get a sample for NAAT, but would probably be uncomfortable or painful in this patient particularly given the cervical inflammation. Furthermore they are no longer necessary because they are no more diagnostically useful than a lower vaginal swab with NAAT. A urinary b-hCG should always be considered in a woman of child-bearing age presenting in most settings, but is not going to diagnose the issue here.
Which of the following features is indicative of Crohn’s disease over ulcerative colitis?
A. Anti-ttg antibodies B. Positive faecal calprotectin C. Transmural inflammation D. Rose thorn ulcers E. Lead pipe appearance
C. Transmural inflammation
Anti ttg antibodies are a very sensitive and specific test for coeliac disease. Fetal calprotectin is a useful test for detecting IBD, but does not differentiate between Crohn’s and UC.
If nothing else, remember that Crohn’s affects the full thickness of bowel in non-continuous ‘skip lesions’, whereas UC causes severe mucosal and submucosal inflammation in a continuous fashion from the rectum proximally.
Summary:
Crohn’s:
Skip lesions present anywhere along the GI tract, most commonly in the terminal ileum. Causes transmural inflammation leading to strictures and fistulas. Features granuloma formation.
UC:
Continuous lesions begin at the rectum and move proximally. Causes inflammation of the mucosa and submucosa, and features mucosal ulcers, depletion of goblet cells, and crypt abscesses.
A 59 year old male presents to his GP with a 9 week history of productive cough. He was reluctant to visit but was convinced by his daughter when the cough did not resolve. His mucous has been green and is blood-streaked sometimes. On auscultation he has right-sided basal coarse crackles and end-expiratory wheeze. A sputum culture is positive for Pseudomonas, but his CXR is normal.
Given the likely cause, which diagnostic investigation is most useful?
A. High resolution CT scan B. HIV test C. Pilocarpine sweat test D. Spirometry E. ECG
A. High resolution CT scan
This is a history of bronchiectasis - a chronic condition involving dilatation and thickening of central and medium-sized bronchi due to a cycle of infection and inflammatory mediator release. 50% of cases in adults are idiopathic but a significant proportion are tied to cystic fibrosis or previous infection, e.g. with measles, tuberculosis, and whooping cough. More niche causes are disease such as Kartagener’s syndrome, primary ciliary dyskinesis, congenital immune deficiency, and yellow nail syndrome. Once bronchiestasis is established, the patient is more vulnerable to unusual lung infections e.g. with Haemophilus influenzae and Pseudomonas aeruginosa.
The key features of a bronchiectasis history are: persistent productive cough, haemoptysis, and recurrent chest infections. The infection with an unusual organism (Pseudomonas) is a clue, and the CXR can be misleadingly normal in bronchiectasis (though the tram-track sign indicative of airway thickening may be seen), hence a high-resolution CT is needed to visualise the airways (will show signet-ring sign).
An HIV test would be a good idea in this patient (and is in many) but HIV is not the main problem here. The sweat test is unlikely to be useful because this would be a very late age to present with cystic fibrosis (especially given the average life expectancy is mid 40s). Spirometry would be useful for COPD, but the haemoptysis and Pseudomonas make this unlikely. An ECG may be indicated here, but not as the main diagnostic investigation.
A 65 year old woman is brought to A&E by her husband with worsening confusion over 2 days. Her husband also states she had a fall, though didn’t hit her head. She is normally fit and well but her AMTS on admission is 7/10. She has not been urinating much all day. Routine bloods show the following:
Hb: 103g/L (115-165) WCC 8.7x10^9/L (4-11) Plt: 326x10^9/L (150x450) Urea: 16.3mmol/L (2.5-7.0) Creatinine: 174mcmol/L (74-107) Creatine Kinase: 286U/L (25-200) ALT 32IU/L (5-40) ALP 102IU/L (35-130) Ca 2.9mmol/L (2.2-2.6)
What is the likely cause of the AKI?
A. B. C. D. Dehydration E.
REVIEW*
A 45 year old man has a routine set of bloods taken by his GP, and his LFTs are incidentally found to be elevated:
ALT: 138 (0-50) AST: 63 (0-40) ALP: 104 (40-150) Bilirubin: 17 (3-22) Albumin: 38 (32-45) GGT: 72 (0-55)
He drinks alcohol most nights, but will generally only have a pint of beer per night. He has been well in himself with no symptoms and an abdominal exam is normal. The tests are repeated 3 months later and are essentially the same.
What is the most appropriate next step?
A. Measure serum AFP B. Give advice on limiting alcohol consumption C. Calculate an ELF score D. Order a CTAP E. Safety net and reassure
C. Calculate an ELF score
This is a history suspicious of non-alcoholic fatty liver disease (NAFLD) which usually presents as an incidental finding of a raised ALT and AST (ALT>AST) along with a raised GGT and occasionally a raised ALP. NAFLD is now the commonest cause of abnormal LFTs in the UK. NAFLD may lead to non-alcoholic steatohepatitis (NASH) where the fatty liver causes inflammation and this carries a risk of inflammation, fibrosis, and eventual cirrhosis.
Patients with suspected NAFLD should have blood tests to look for concomitant metabolic disease (lipids, Hba1c). Their risk of progression to advanced liver disease/ fibrosis is the most important factor here, and should be assessed using a score like the Enhanced Liver Fibrosis score (ELF). Imaging such as a liver USS may be helpful as increased echogenicity supports a diagnosis of NAFLD when interpreted in the context of being otherwise well with raised LFTs.
Management is conservative with risk factor modification, follow-up, and a target of 10% weight loss over 6 months. The main cause of death in NAFLD patients is cardiac disease, so risk factors such as diabetes, hypertension, and hypercholesterolaemia should be assessed for and managed.
Patients at high risk of fibrosis are referred to specialists who may use vitamin E or pioglitazone. 30-40% of patients with cirrhosis from NAFLD require transplantation.
‘A’ is a biomarker for hepatocellular carcinoma, which there are no features of in this history. ‘B’ is not necessary here as the patient is a mild drinker (though alcohol excess should be curbed in NAFLD to avoid exacerbating it).
‘D’ is not necessary here, and ‘E’ is negligent as you have not investigated or treated the patient.
A 53 year old man attends A&E with fever and abdominal pain. On examination his abdomen is tense and distended, with shifting dullness and a fluid thrill. An ascitic tap is performed and shows a serum-asictes albumin gradient (SAAG) of 18g/L.
Given this information, which of the following signs is most likely to be present?
A. Pleuritic chest pain B. Frothy urine C. Caput Medusa D. Unexplained weight loss and night sweats E. Severe epidural pain and vomiting
C. Caput Medusa
This is a 2 part question:
- Identify the cause of the ascites
- Recall the associated clinical sign
A SAAG > 11g/L is the threshold and is very useful for differentiating ‘transudative’ from ‘exudative’ ascites (though these terms are falling out of use). SAAG> 11 is a good indicator that the cause is portal hypertension. Inflammatory conditions cause a lower SAAG because the inflammation leads to production of protein which then sits in the ascites.
Inflammatory causes include tuberculosis, penumonia, pancreatitis, abdominal malignancy and ovarian inflammation. Nephrotic syndrome will also cause a low SAAG (as well as frothy urine - sign of proteinuria) because protein is lost through the kidneys. This results in a low gradient because though the ascitic protein is low, so is the serum protein.
A 26 year old woman presents with 1 week of vaginal discharge and pelvic pain. She denies any dysuria or inter-menstrual bleeding. She takes the OCP but admits to not using barrier contraception with recent new partners. A lower vaginal swab is taken for a NAAT test which shows N. gonorrhoeae infection.
How should this patient be managed?
A. Advise abstaining from sex for 2 weeks, notify former partners, and return if symptoms persist
B. Take another vaginal swab and give 1g IM ceftriaxone
C. Prescribe a single dose of IM gentamicin, plus oral azithromycin
D. Prescribe a single dose of 500mg oral ciprofloxacin
E. Prescribe a 1 week course of BDS 100mg Doxycycline
B. Take another vaginal swab and give 1g IM ceftriaxone
The extra swab should be taken for sensitivity testing in case the gonorrhoea is resistant. Ceftriaxone 1g IM is first-line if sensitivities are unknown. If the gonorrhoea is known to be sensitive to ciprofloxacin, then a one-off dose of 500mg can be given.
‘E’ is the first-line treatment for chlamydia. Erythromycin or azithromycin can be used in pregnant women, in whom doxycycline is contra-indicated.
A 55 year old woman visits her GP for her checkup 1 month after starting ramipril. Her U&Es have changed since her last test as follows:
Cr: 80 ¬> 98
K+: 3.9 ¬> 5.1
Na+: 142 ¬> 136
What action should be taken?
A. Stop ramipril temporarily B. Repeat U&Es in 2 weeks C. Reduce the dose of ramipril D. Switch rampiril for amlodipine E. Add spironolactone
B. Repeat U&Es in 2 weeks
Up to a 30% rise in creatinine is ok after starting or increasing the dose of ACEi, but does require re-checking the U&Es after 2 weeks if it is greater than 20%.
K+ is allowed to rise up to 5.5 without being concerning.
A 14 year old boy attends his GP with his mother for an asthma review. He is new to the practice, and the GP realises he was never formally diagnosed with asthma, but has been taking beclamethasone 2 puffs BD for the past 4 years. He says he has been suffering with an increased number of episodes of breathlessness over the past month.
What would be the most appropriate way to confirm his asthma diagnosis?
A. History and examination findings B. Serum IgE test C. Fractional exhaled nitric oxide testing D. Spirometry +/- reversibility testing E. Exercise and reversibility test
D. Spirometry +/- reversibility testing
NICE says that spirometry should be offered to all symptomatic patients with a suspicion of asthma over the age of 5 years. Testing for revesriblity by giving a SABA and repeating the spirometry may be helpful, especially in cases like this one where the child is symptomatic.
Fractional exhaled nitric oxide testing is a relatively new test which should ideally be offered to all patients aged 17 or older with query asthma. It can be considered where there is diagnostic uncertainty in younger patients, but the results may be disrupted if the patient is already taking inhaled corticosteroids.
An 82 year old woman presents to A&E with new onset facial swelling accompanied by dizziness, headache, and. She also describes a 5 week history of gradually increasing breathlessness. She has known small cell lung cancer for which she is receiving chemotherapy and radiotherapy. On examination there is oedema to the face, neck, and chest, and prominent veins in the neck and chest.
What is the most appropriate management option for this patient?
A. Give oral dexamethasone B. Give I.V. mannitol C. Give oral furosemide D. Give subcutaneous dalteparin sodium E. Give oral rivaroxaban
A. Give oral dexamethasone
This is a case of superior vena cava obstruction: one of the oncological emergencies (though there are non-malignant causes). SVC obstruction causes oedema and distension of the veins distal to the obstruction. The oedema causes breathlessness, cough, hoarseness and stridor (laryngeal oedema), and facial plethora. Confusion, stridor, and blurred vision are less common signs that occur only in severe obstruction.
Oral dexamethasone is given to reduce the swelling around the tumour to help alleviate the obstruction. Radiotherapy, chemotherapy, and stenting may all be used to relieve the obstruction more definitively. Acutely steroids will be given if there is airway obstruction, but there is some debate about whether they should be given initially in the absence of airway obstruction as they interfere with histpathological diagnosis.
BMJ Best Practice Guideline: https://bestpractice.bmj.com/topics/en-gb/848 Scottish guidelines (referenced on official Finals mock): http://www.palliativecareguidelines.scot.nhs.uk/guidelines/palliative-emergencies/Superior-Vena-Cava-Obstruction.aspx
