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What are the surviving sepsis guidelines? (first 6 hours, 5 marks)
- FBC, U+E, LFT, CRP, Serum Lactate
- Blood cultures prior to Abx
- Start broad spec ABX within 3 hrs of admission
- If hypotensive or lactate >4 start crystalloid and vasopressors aiming for MAP >65
- If Hypotesion refractory to fluids, insert central line and aim for CVP >8mmhg and SvcO2 >70
Respiratory causes of clubbing?
- Bronchial Carcinoma
- Suppartive lung disease : Bronchiectasis, empyema, cystic fibrosis, lung abcess
- Pleural Mesothelioma
Cardiac causes of clubbing?
- Congenital Cyanotic Heart disease
- Atrial myxoma
- Sub acute bacterial endocarditis
Gastro causes of clubbing?
- Oesophageal CA
Other causes of clubbing?
- Hyperthyroidism (thyroid Acropachy)
- (Unilateral clubbing can occur due to vascular abnorms in affected arm e.g. axillary artery aneurysm)
Haemophillia A is...?
- An X-linked recessive condition (thats why guys are more symptomatic and more likely to be)
- Women who are carriers can still have some symptoms (e.g. excessive menstrual blood loss)
- Mutation causes reduced Factor 8 activity and tendency to bleed.
- This tendency reduces with age.
- Joint haemorrghes are common, lead to bony ankylosis after repition.
What is the amount of unoxygenated Hb that has to be present in blood to cause cyanosis?
What is night glaring a typical feature of?
HONK. Whats the classic biochem profile
- V.high blood glucose
- V.high urinary glucose
- High plasma osmolality
- No ketones anywhere
An erythematous rash over the shins of a diabetic patient with waxy brown discoulouration in the middle?
Necrobiosis Lipoidica Diabeticorum
Cerebral blood flow is increased by... more than ...?
How much cardiac output does it consume...?
Is it autoregulated or autonomically controlled?
- CO2 more than O2
Haemophilus influeanzae is a...?
Gram -ve rod, commensal organism in the resp tract.
Klebsiella is a...?
- Gram -ve rod, commensal in the gi tract, commenst cause of pneumonia in alcoholics and aspirators.
- Often presents with a red currant jelly cough
- usually b-lactam resistant
- Gram -ve rod.
- Assoc contominated watersystems
- Infects old, immuno comp.
- Replicates inside macrophages
Which lung disease is most likely to produce which clinical sign...
Hyperesonance on percussion?
Cyanosis, chestwall recession, grunting and increased effort?
- Cystic fibrosis\ chronic allergic rhinitis
- Pneumothorax (simple\spontaneous\tension)
- Respiratory distress
Gum hypertrophy is a sign of?
- Phenytoin therapy
Hyperpigmented buccal mucosa and skin folds?
You are clerking a 75-year-old man with a history of ischaemic heart disease, diabetes and congestive cardiac failure who has presented with a six hour history of central chest pain and subsequent shortness of breath.His observations are: HR 130 regular, BP 180/80 mmHg, RR 32 and O2 88% room air.On examination he has a raised JVP at 5 cm and fine crepitations to the midzones, however only minimal ankle oedema.A chest x ray has been performed and demonstrated acute pulmonary oedema with cardiomegaly and a bat's wings appearance of the hilar.
How would you treat acutely? what if the pt was hypotensive?
- If hypertensive:
- Morphine (anxiolytic and venodilator)
- Nitrates (venodilate and offload heart)
- Furosemide (not a panacea but will be useful)
- CPAP (displaces fluid from lungs)
- If hypotensive:
- Need inotropes to restore cardiac funtion and push the blood out of the lungs and into the arterial side.
Causes of smooth hepatomegaly?
- Weil's disease
- Alcoholic fatty liver
Causes of Nodular hepatomegaly?
- Metastatic Disease
Side effects of Glitazones?
- Fluid retention! Avoid in cardiac failure
- Wt gain
- Decreased bone mineral density
S\E of Metformin
S\E of Sulfonylureas
- Photosensitivity rash
S\E of acarbose?
S\E of statins or Fibrates?
Muscle cramps and myositis
Diseases that cause gynaecomastia?
Anything that perturbs the testosterone to oestradiol ratio:
- Seminoma (any hcg secrerting tumor)
- Liver disease
Causes of AF?
- Mitral stenosis and other valvular
- Ischaemic heart disease
- Pulmonary embolism
- Cardiomyopathy and other structural
How would you risk stratify whther a patient with pneumonia can go home, needs Rx in amu or needs HDU admission?
- Confusion AMTS 8 or less
- Urea >7
- Resp rate >30
- BP less than 90sys or 60 dia
- 65 years or older
- 1-2 = home
- 2-3 = ward admission
- 4-5 = HDU
Causes of hypoglycaemia?
- Insulin\sulfonylurea overdose
- Alcoholic binge
- Aspirin overdose (along with ARF and cerebral oedema)
- Quinine therapy
What is bulbar palsy?
- The presentation of a lower motor neurone lesion affecting the nuclei of CN 9-12 in the MEDULLA (bulb).
- Presents with a FLACCID paralysis of swallowing muscles causing fasiculations of the tongue, dysarthria, dysphagai, absent palatal movement, aspiration pneumonia and a BOVINE COUGH.
Causes of bulbar palsy are?
- Motor neurone disease
If a patient presents with dysphagia and the barium swallow shows 'CORCKSCREW' oesophagus they have...?
Diffuse oesophageal spasm, best treated with Ca2+ antagonists, nifedipine or amlodipine because they are peripherally acting, whereas diltiazem and verapamil are central.
A girl being treated with metoclopramide loses voluntary control of her eyes and they point in different directions. Vision is intact. Whats happeneing and how do you reverse it?
Oculogyric crisis 2o to dopamine antagaonism from metoclopramide. This also occurs with anti-psychotic medication. Treat with procyclidine.
32 year old man presenting with a fine tremor which is interfering with his dexterity and he finds it very embarrasing. No abnormalities in gait or examination of PNS. What is it and how would you treat?
Essential tremor, B-blockers.
A 72-year-old female complains of a three month history of weakness and difficulty climbing stairs. On examination she has a waddling gait and proximal weakness with normal plantar responses. what do the symptoms suggest, what could cause this.
- Indicates a proximal myopathy (waddling + quads difficulty on stairs) not a neuro cause (normal plantars i.e. not reduced or upgoing).
- Causes = Vitamin d deficiency, Osteomalacia, Cushings, polymyositis and some electrolyte imbalances
Normal pressure hydrocephalus...
Wet, Wobbly, weak and weird.
Incontinent, Dyspraxic gait, muscle weakness, confused\demented.
A woman presents to the Emergency department with inability to extend the MCP joints of her right hand and wrist drop. These happened after she injured her right arm when she tripped and fell over on the pavement. She also has altered sensation over the region of the anatomical snuff box. The triceps reflex is present. Which nerve has been injured and where?
Radial nerve at the level of the nid-shaft of humerus (in radial groove)
A 25-year-old man is brought to the Emergency department with painful inability to use his left hand after being involved in a high-speed MOTORCYCLE accident.On examination, there is weakness of the wrist with inability to extend the wrist or fingers of his left hand. Extension of the elbow is also affected and triceps reflex is absent. Sensation is lost over the dorsum of the forearm. which nerve has been injured and where?
Injury to the radial nerve at the level of the axilla because triceps function is affected.
'.... On examination of the hands there are scaly erythematous papules affecting the dorsum of the hand and over the extensor surfaces of the knuckles.'
Gottron's papules of Dermatomyositis. Often assoc with a heliotrope rash of the face and thought of as being a paraneoplastic process.
On examination there is a spoon shaped deformity of the nails...? what is it, whats it assoc with?
Koilonychia, assoc. Fe deficiency anaemia
On examination there are bony swelling over the Distal interphalangeal joints...? what are they, what do they indiacte this patient might have?
Heberden's node, Osteoarthritis.
A 35-year-old female presents with a four month history of weight gain and amenorrhoea. Examination reveals slight galactorrhoea to expression. What endocrine test would you do?
B-hcg! shes probably bloody preggers innit!
A 32-year-old female presents with a year history of amenorrhoea and weight gain. She is hypertensive and is noted to have abdominal striae. what endocrine test would you do?
Dont just say cortisol level you pillock! the diurnal variation makes that unreliable! 24hr urinary free cortisol measurment is the most appropriate.
And if you said preggers read it again, shes been anovulatory for a year.
An 18-year-old female is referred with weight loss and amenorrhoea. She is noted to be sweaty and have a pulse of 110 bpm. what endocrine test would you do?
TFTs, probably hyperthyroid. Most commonly a primary causes so could be a solitary toxic nodule or multinodular toxic goitre or graves.
A 49-year-old male presents with headaches and increased sweating. He is noted to be hypertensive and have coarse facial features..
Oral glucose tolerance with GH measurment.
Concerning CSF, whats the protein, glucose and rbc\wcc concentration as compared to serum and whats the opening pressure?
- Protein is lower than serum
- Glucose is 2\3 of serum
- Should really be no wcc or rbc
- Opening pressure of <20cm of water
Pulseless upper limbs?
Nail pitting and onycholysis are a sign of?
Heberden's nodes are a sign of? which interphalangeal joint are they found in?
Osteoarthritis...Always in DIPs
Patient with an acute monoarthritis has a joint aspirate and microscopy in plane polarized light reveals negatively bifringent crystals, whats the diagnosis? what if the crystals were positively bifringent?
- Diagnosis = Gout (urate crystal arthropathy)
- If +ve bifringence then Pseudogout (calcium pyrophosphate crystal arthropathy)
A 22-year-old homosexual male is positive for IgM anti HBc antibody and hepatitis B surface antigens.What best describes his disease state?
IgM is an acutely produced Antibody and goes away once effective IgG is being produced by plasma cells.
The presence of surface antigen means there is HepB in host cells, so in both chronic and acute.
Patient presents with pain, conjuctivitis and photophobia in the left eye. Dendritic ulcer on the eye visualised clearly by fluorescein drop.
Whats the diagnosis?
How do you treat?
- Herpes simplex virus.
- Aciclovir drops for as long as it takes the ulcer to go away, and then 3 days more.
Digoxin toxicity causes...?
How would you treat?
- Nausea and vomiting, hypokalemia and arrythmias.
- Correct the hypoK and theyll be fine.
A 45-year-old farmer presents with excessive sweating, abdominal pain and diarrhoea. Whats the most likely ingested substance? how would you treat?
- Oraganophosphates, found in lots of pesticides and weedkillers hence farmers at risk.
- Organophosphates are 'irreversible' inhibitors of Acetylcholinesterase. Thats why you get all the parasymp signs.
Treat with atropine and Pralidoxime - rips the organophosphate off the ACHase and lets it work again.
Which type of fluid should never be used in patients with Head Injury?
5% dextrose or any fluid that is the equivalent of 'free water' will cause the serum to become HYPOsmolar and the water to go into the brain parencyma and cause further swelling.
A 10-year-old boy attends the Accident & Emergency department with a scalp laceration he sustained playing football. Examination confirms a superficial clean incised wound approximately 2 cm in length. Which would be the best way of managing this wound?
- Tissue adhesive glue.
- Wound must be clean and <3cm in length.
- Should not be used to for wounds around joints and eyes.
What ECG features of a gentleman presenting with Chest pain would necessitate referral to cardiology for PCA?
- St elevation of more than 1 mm in limbleads
- St elevation of more than 2 mm in chest leads
- New onset LBBB (thats why old ecgs are priceless)
Which dermatological lesions are assoc with Neurofibromatosis 1?
Which eye sign?
- Cafe au lait spots, axillary freckling, dermal neurofibromas and nodular neurofibromas.
- Dermal = purple and painless.
- Nodular = Parasthesiae when pressed. Connected to nerve trunks.
- Lisch nodules - eye lesions best seen with a slit lamp
What is Bacillus Cereus, where is it commonly found, how does it present.
Gram +ve rod, Bacteria commonly found on rice.
Causes profuse vomitting and diarrhoea within hours of ingestion. Harmless usually self limiting.
What is coomb's test, how does it work?
Test for autoimmune haemolytic anaemias. Take a patients blood, get rid of the serum, wash the RBCs, put them in a solution with Coomb's reagent (antihuman antibodies) and see if there's agglutination. It indicates that Ig molecules and complement factors are bound to the surface of the RBC.
If you want to start methadone...?
Start low go slow.
Third nerve palsies...
Painful and Pupil involvment = ?
Painless and no pupil involvment = ?
- Mononeuritis Multiplex
What Parkinson's + syndromes do you know?
- Shy-Dragers or Multi system atrophy:
- Parkinsons with loss of autnomic supply (parasymp) to various organs. Causes dry mouth, incontinenece, impotence, constipation, abnormal sweating. Ataxia also prevails.
- PSPParkinsons plus loss of vertical gaze, falls, neck stiffness, pseudobulbar palsy.
If a patient has G6PD defeciency, what triggers precipitate a haemolytic episode? and will they be male or female.
- Intercurrent illnes\infection.
- Broad Beans
- Much more likely to be male, x linked recessive.
Which clotting investigation will be deranged in the haemophilias?
7 ways of telling its a JVP and not a Carotid?
- Fills from above
- Multi waveform
- Hepatojug reflex
- Moves on respiration
- Moves on position
What is section 5(2) of the mental health act?
Any doctors right to detain an inpatient with a psychiatric illness for a period of 72 hours until an application for section 2 or 3 can be processed.
- Antimuscarinic action:
- Dry mouth
- Urinary retention
3 drugs that cause psoriasis?
What is DeQurvain's thyroiditis?
Post-URTI Inflammatory enlargment of the thyroid.
What is Rosacea? How do you treat it?
- Adult Acne.
- Rx = tetracyclines
How does Interstitial lung disease present? Signs
- The C's of cryptogenic fibrosing alveolitis:
- Fine end inspiratory crackles
- Decreased chest expansion
How does interstitial lung disease present? symptoms
- Dry cough
- SOB on exertion
- Wt loss (catabolic due to work of breathing)
Investigations you would do for interstitial lung disease and what youd expect?
- CXR - Ground glass appearence - a hazy, grainy appearance, a sign of current alveolitis. This is good you can treat.
- Reticulonodular shadowing - first signs of fibrosis.
- Honycombing - all the fibrosis joining up. bad times
- Spirometry - FEV1 and FVC decreased in proportion.
- Lung volumes - all reduced
- ABG and Sats for acute deterioration.
At what sat level and PaO2 do you say a patient is in respiratory failure?
What other conditions can present with a ground glass appearence on CXR?
Infections which cause lung fibrosis? and in which zone?
Upper zones - TB, Aspergillus,
Lower zones - Severe pneumonia
Where do emphysema (smoking) and emphysema (a1 antitryp) causes fibrosis and why?
Smoking - upper zones - suz better ventilated so smoke goes there does its thang
a1 antitryp - serine proteases in the blood go to the well perfused LOWER ZONES and destroy parenchyma and cause inflammation unchecked.
Causes of Autoimmune fibrosis?
- Rheumatoid - more commonly nodules and bronch.oblit.
- SLE - fibrosis and shrinking lung disease
- Systemic sclerosis
- Dermatomyositis - rapidly progressive, deadly
Drugs that can causes lung fibrosis?
- Nitrofurantoin - reversible
- Recreational drugs when inhaled
Side effects of amiodarone?
- Pulm Fibrosis
- Retroperitoneal fibrosis - characterised by medial bowing of the ureters - diagnosed by IVU
- Thyroid dysfunction
- Slate grey skin with photosensitivity
- Keratitic deposits behind retina causing visual disturbance
Hypersensitvity pneumonitis causes? how do you divide them up? give as much detail as you can.
- Inorganic - Coal pneumoconiosis, silicosis, asbestosis, berryliosis, crack lung.
- Organic -
- Farmers lung - caused by proliferaiton of thermophillic actinomyces in packed hay bales during storage and inhalation of released spores when they are un packed.
- Bird fancier's lung - caused by protein in bird faeces which becomes aerosolised when cleaned. NOT to be confused with psitacosis caused by chlamydia psiticai in parrot and canary faeces which causes a pretty horrible pneumonia and can mimic typhoid.
- Cotton workers lung, shrimp pickers lung, hot tub lung, malt workers lung, miller's lung, cheese washers lung,
Singh Vaughn Williams classification of Anti-arrythmics?
- Class 1 - Na blockers -
- 1a- procainamide, quinidine
- 1b - lidocaine, lignocaine, phenytoin
- 1c - flecanide
- Class 2 - Bblockers - Propanalol, bisoprolol
- Class 3 - K+ blockers - Sotalol, Amiodorone
- Class 4 - Ca2+ blockers - Diltiazem, Verapamil
- Class 5 - Others - Digoxin, adenosine, MgSO4
Which disease would you incestigate with anti-GAD antibodies for?
- Diabetes mellitus insulin dependent
- Stiff man syndrome
- Cerebellar ataxia
Microcytic anaemia? pnemonic and causes?
- Small - Sideroblastic
- Typically - Thallasemia
- Iron - Iron deficiency
Normocytic Anaemia? pnemonic and causes?
- Exclude - Endocrine - Hypopit\thyroid
- Chronic - Combined
- Anaemia - Acute blood loss \ Aplastic
Macrocytic? pnemonic and causes?
- My - Myeloid Dysplasia
- Blood - B12\folate\pernicious anaemia
- Has - Haemolytic
- Large - Liver disease
- Erythrocytes - Embryos
What is sarcoidosis?
A multi-organ non-caseating granulomatous disease. Commonly affects lungs.
Ix for sarcoidosis?
- CXR - Hilar lymphadenopathy, reticulonodular, cystic and bullous changes.
- Spirometry and Lung volumes.
- Tissue biposy of GASTROCNEMIUS - Granulomas containing mononeuc, polymorphs and t-cells.
- ACE levels - elevated in sarcoidosis.
- LFTs, U+E, TFT.
Rx for scabies?
Permethrin or Malathion
What is Alopecia Areata?
How can you manage it?
- Loss of hair on the scalp and rest of the body in round patches.
- Manage with steroid injections\creams.
Pain worse on passive dorsiflexion and not on active dorsiflexion?
Compartment syndrome. Obv a history of trauma or surgery is required too.
Osteogenesis Imperfecta presentation?
- Blue sclera
- Brittle bones
Causes of Blue Sclera?
- Anything that will thin the sclera...
- Osteogenesis imperfecta
- Ehlers danlos
- Chronic steroid use
- Pseudoxanthoma elasticum
- Fe deficiency
How would you clinically examine a suspected scaphoid fracture?
- Pressure 2cm distal to snuff box
- pressure on extended thumb\index finger.
Early and late complications of scaphoid fractures?
- Early - Avascular necrosis of proximal pole
- Non union
- Late - Osteoarthritis, wrist degen.
Most common parotid body tumor?
Is it benign or malignant?
How does it present?
- Pleomorphic adenoma. Benign but with malignant capability.
- Irregular surface, smooth edges.
What conditions cause mediastinal widening on a chest xray?
In simple terms, how do you work out if someone is physically fit for a surgery
- Can walk 20 meters
- Can climb a flight of stairs.
Rx for pneumococcal pneumonia?
What is a paraphimosis?
inability to pull the foreskin back over the glans penis once it has been retracted. must be done following catherterisation.
What is a hypospadia?
Abnormally located urethral meatus.
Signs and symptoms of testicular torsion?
- Pain redness swelling.
- Usually right testicle.
- Loss of cremasteric reflex (tactile pressure on medial thigh)
What is Cysteinuria? Whats the gentic pattern?
- A genetic condition in which the tubules are unable to resorb Cysteine, ornithine, arginine and lysine (COAL)
- Autosomal recessive
What kind of stones does a Proteus mirabilis UTI predispose to?
Struvite staghorn calculi
Acanthosis nigricans is associated with?
- Endocrine disease (acromegaly, Cushing's syndrome, insulin resistant diabetes mellitus)
- Paraneoplastic phenomenon (usually tumours of the GI tract, especially adenocarcinoma of the stomach).