Wednesday 11th

Question 1

Alcoholic ketoacidosis

Answer 1

• non-diabetic euglycaemic form of ketoacidosis
• alcoholics will not eat regularly and may vomit food > episodes of starvation
• Once malnourished, after an alcohol binge the body can start to break down body fat, producing ketones
• Metabolic acidosis
• Elevated anion gap
• Elevated serum ketone levels
• Normal or low glucose concentration
• IV saline and thiamine

Question 2

Alcohol excess are often deficient in thiamine

Answer 2

• cause Wernicke’s encephalopathy, a neuro-psychiatric condition causing ataxia, confusion, nystagmus and ophthalmoplegia
• Korsakoff psychosis

Question 3

hypoglycaemia

Answer 3

• over-administration of insulin/ sulfonylureas
• insulinomas
• Addison’s disease
• alcoholic ketoacidosis

Question 4

Diabetic ketoacidosis

Answer 4

• metabolic acidosis
• complication of type 1 diabetes
• present with hyperglycaemia
• treat with IV saline and insulin infusion

Question 5

Addison’s disease

Answer 5

• destruction of the adrenal cortex, resulting in glucocorticoid and mineralocorticoid deficiency
• present with nausea, vomiting and drowsiness, hyperpigmentation and weight loss
• acute exacerbation of Addison’s disease (e.g. from infection or steroid withdrawal) can lead to Addisonian crisis, resulting in hypotension and hypoglycaemia

Question 6

Addisonian crisis

Answer 6

IV hydrocortisone and 0.9% saline

Question 7

Hyperosmolar hyperglycemic state (HHS)

Answer 7

• complication of type 2 diabetes, resulting from hyperglycaemia
• diagnosing HHS requires hyperglycaemia in the absence of ketonaemia or acidosis
• hypovolaemia and hyperosmolarity
• treated with IV 0.9% saline and LMWH

Question 8

hypoglycaemia of blood glucose < 4mmol/L

Answer 8

Fast-acting carbohydrate

Question 9

anticoagulation treatment should not be used routinely for the treatment of acute stroke

Answer 9

risk of haemorrhagic transformation

Question 10

AF who develop a stroke or TIA (not haemorrhagic)

Answer 10

anticoagulation therapy started two weeks after the event

• warfarin
• or direct thrombin/factor Xa inhibitor

Question 11

Children with new-onset purpura should be referred immediately

Answer 11

investigations to exclude ALL and meningococcal disease

Question 12

suspected meningococcal disease

Answer 12

• high fever
• spreading purpura
• lethargy
• vomiting
• sudden deterioration

> > blood polymerase chain reaction testing (EDTA sample) for N.meningitidis to confirm a diagnosis

Question 13

Henoch-Scholein purpura

Answer 13

• multi-system vasculitis that can cause acute kidney injury
• A blood pressure and urine dipstick should be performed in all patients
• purpura is typically symmetrical, over extensor surfaces and over the legs and buttocks and they often have associated joint pain and swelling, and abdominal pain

Question 14

Dx: child presenting with purpura

Answer 14

• Meningococcal septicaemia
• Acute lymphoblastic leukaemia
• Congenital bleeding disorders
• Immune thrombocytopenic purpura
• Henoch-Schonlein purpura
• Non-accidental injury

Question 15

Dx: adults with purpura

Answer 15

• Immune thrombocytopenic purpura
• Bone marrow failure (secondary to leukaemias, myelodysplasia or bone metastases)
• Senile purpura
• Drugs (quinine, antiepileptics, antithrombotics)
• Nutritional deficiencies (vitamins B12, C and folate)

Question 16

Three main patterns of presentation may be seen in patients with peripheral arterial disease:

Answer 16

• intermittent claudication
• critical limb ischaemia
• acute limb-threatening ischaemia

Question 17

Intermittent claudication

Answer 17

• aching or burning in the leg muscles following walking
• patients can typically walk for a predictable distance before the symptoms start
• usually relieved within minutes of stopping
• not present at rest

Question 18

Assessment: Intermittent claudication

Answer 18

• check the femoral, popliteal, posterior tibialis and dorsalis pedis pulses
• check ankle brachial pressure index (ABPI)
  > 0.6-0.9 = Claudication
  > 0.3-0.6 = Rest pain
  > <0.3 = Impending
• duplex ultrasound is the first line investigation
• magnetic resonance angiography (MRA) should be performed prior to any intervention

Question 19

Carer’s allowance

Answer 19

• over 16 years old who spend at least 35 hours per week caring for someone
• Have been in England, Scotland or Wales for at least 2 of the last 3 years
• You normally live in England, Scotland or Wales, or you live abroad as a member of the armed forces
• You’re not in full time education or studying for 21 hours a week or more
• You earn no more than £110 a week (after taxes, care costs while you’re at work and 50% of what you pay into your pension)

Question 20

Non-means tested benefits

Answer 20

• Carer’s credit
• Attendance Allowance
• Personal Independence Payment and Disability Living Allowance (now converted to PIP)

Question 21

Alopecia areata

Answer 21

• presumed autoimmune condition
• causing localised, well demarcated patches of hair loss
• At the edge of the hair loss, there may be small, broken ‘exclamation mark’ hairs
• Managed conservatively: Hair will regrow in 50% of patients by 1 year, and in 80-90% eventually
• Other treatment options include:
  > topical or intralesional corticosteroids
  > topical minoxidil
  > phototherapy
  > dithranol
  > contact immunotherapy
  > wigs

Question 22

Reversible causes of cardiac arrest:

Answer 22

• Hypoxia
• Hypovolaemia
• Hyperkalaemia, hypokalaemia, hypoglycaemia, hypocalcaemia, acidaemia and other metabolic disorders
• Hypothermia
• Thrombosis (coronary or pulmonary)
• Tension pneumothorax
• Tamponade – cardiac
• Toxins

Question 23

non-shockable rhythm

Answer 23

absence of a carotid pulse in the presence of sinus tachycardia

Question 24

only shockable rhythms

Answer 24

• ventricular fibrillation

- ventricular tachycardia