• It is a breakdown product ->serum amyloid associated protein, an acute phase reactant that is elevated in chronic inflammatory states.
AA amyloid is found in conditions such as
• rheumatoid arthritis.
AL amyloid (primary amyloid) is
-breakdown product is immunoglobulin light chains.
AL amyloid is found in
• multiple myeloma
• Waldenstroms macroglobulinaemia
• idiopathic amyloidosis.
-Solitary cardiac involvement can be found in the elderly
-related to a breakdown product of pre-albumin.
Regarding amyloidosis, Death usually occurs due to
• cardiac or renal failure.
The Donnan equilibrium refers to
-> charged particles failing to distribute themselves evenly on either side of a semi-permeable membrane.
Ashman beats are
-wide complex QRS complexes,
->usually with a RBBB morphology
-follow a short R-R interval preceded by a prolonged R-R interval.
Drugs which cause cholestatic jaundice include:
• ACE inhibitors
• oral contraceptive pills
• ketocaonazole amongst others.
Heinz bodies are
->inclusions within red blood cells composed of denatured haemoglobin.
They can be caused by oxidant damage or inherited mutation. Causes include:
• G-6-PD deficiency
• NADPH deficiency
• Chronic liver disease
- osmolality 274 mOsm/L.
-125 mmol/l of chloride compared with 0.9% saline which contains 154 mmol/l.
-molecular weight 30,000.
Regarding Hepatitis B:
->60-65% show subclinical disease and recover fully.
-> 20-25% that contract it develop acute hepatitis.
-> 5-10% that contract it develop chronic hepatitis.
The anterior cruciate ligament passes from the
->anterolateral tibia ->medial side of the lateral femoral condyle.
The posterior cruciate ligament passes from the
->posteromedial tibia -> lateral side of the medial femoral condyle.
Women are significantly more prone to ACL injuries, the reason for this is
->unclear, but it may be due to hormone mediated differences in muscle tension as well as general anatomical and muscle strength related reasons.
The commonest mechanism of ACL injuries are
->rapid deceleration or landing.
->also occur as a consequence of hyperextension injuries and falls.
-immediate pain and rapid swelling following an ACL injury.
-often complain of hearing a pop.
-knee is unstable, loose and prone to giving way.
PTH increases the formation of
-> 1,25-dihydrocholecalciferol by increasing the activity of alpha-hydroxyls in the kidney.
The following are clinical signs of a basal skull fracture:
• Periorbital ecchymosis (Racoon eyes)
• Retroauricular ecchymosis (Battle's sign)
• CSF rhinorrhoea or otorrhoea
• 7th or 8th nerve palsy
A 3rd nerve palsy is indicative of a
->temporal lobe heamatoma or uncal herniation but not a basal skull fracture.
The receptor-> is the sensing component that monitors and responds to changes in the environment.
->The osmolarity is slightly less than the osmolality.
->The normal human reference range is 275-295 milli osmoles per kilogram.
->Calculated osmolarity is 2Na + 2K + glucose +urea.
->Alcohol is a cause of an elevated osmolar gap.
-> frequently asymptomatic.
-> Patients with oropharyngeal candidiasis often have a history of HIV infection.
->Approximately 10% of women experience repeated attacks without any precipitating risk factors.
-> Candida albicans is responsible for 50-60% of candida infections.
% third coronary artery named the posterior coronary artery.
• 4% people
The right coronary artery supplies the sino atrial node in
-> 60% of patients.
carpal tunel Anteriorly it is formed by
• transverse carpal ligament which runs from the hamate and pisiform bones medially to the scaphoid and trapezium laterally.
A total of 9 flexor tendons pass through the carpal tunnel. These are
• 4 from flexor digitorum profundus
• 4 from flexor digitorum superficialis
• one from flexor pollicis longus.
Long standing carpal tunnel syndrome leads to atrophy of some of the muscles of the
• the thenar eminence.
Regarding cavernous sinus thrombosis
• It is most usually infection on the face ->angular vein and into the sinus.
• Stahphylococcus aureus is the most common infectious microbe
• Sixth nerve palsy is most common.
Sinus Aseptic thrombosis is rare and usually occurs in the
• very young, very old or debilitated.
->incubation period is usually 7-10 days in infants and young children.
->If a patient displays an inspiratory whoop after coughing or posttussive emesis then the likelihood that the illness is pertussis is increased by four doubled.
->Erythromycin or azithromycin are first line treatments.
Ecthyma gangrenosum is a characteristic cutaneous manifestation of
-> pseudomonas septicaemia.
->Symptoms of campylobacter dysentery usually last 5-7 days.
->Standard treatment is with azithromycin as ciprofloxacin is no longer effective due to resistance.
Hypercapnia is a
->negative inotropic factor.
Alkalosis is a
->negative inotropic factor.
Each intestinal villus is approximately
-> 0.5-1.6 (millimetres) in length.
-> Congestive heart failure is a very rare known side effect.
A double dummy technique is used when interventions are very different. In such cases all subjects appear to receive both interventions, although one is a placebo, in order to maintain blinding.
Blind assessment is the assessment of outcome measures at the end of an intervention, without any knowledge of which treatment group received which intervention.
Regarding Heat Stroke
->suspected in patients that collapse after exercise.
->Mortality is around 10%.
->When core temperature is less than 39°C then active cooling should stop as hypothermia may occur.
->Anti pyretics such as paracetamol NO->should not be given. The most efficient way to cool the patient is to spray the naked patient with tepid water and blow air over them with fans.
Regarding the inferior vena cava
-> commences at the vertebral level L5.
-> diaphragmatic opening -> vertebral level T8.
->combines the results of several studies.
->attempts to access and review all of the pertinent articles in a particular field of study.
Regarding the clinical features of tuberculosis
->About 90% have an asymptomatic infection.
->“Ghon focus” is the primary site of infection in the lungs and is usually found
->either in the upper part of the lower lobe
-> the lower part of the upper lobe.
->Without effective treatment the death rate for active TB is up to 66%.
->Miliary tuberculosis has a high fatality rate (about 30%) even with treatment.
->Obstructive uropathy is a contraindication to their use.
->They should be used with extreme caution in known or suspected GI infections because of decreased GI motility and retention of causative organism and/or toxins.
-> Tachycardia is a common side effect.
Regarding the pterygoid venous plexus
->situated between the temporalis muscle and lateral pterygoid mucle.
->receives the middle meningeal vein.
->It becomes the maxillary vein.
->It communicates with the cavernous venous sinus, meaning that infections of the superficial face can spread and cause cavernous venous sinus thrombosis.
Factors affecting static lung compliance include
->age, size and body posture.
Dynamic lung compliance is
• the compliance of the lung at any given time during actual movement of air.
Static lung compliance is the
• change in volume for any given applied pressure.
Regarding cerebral blood flow
->The normal cerebral blood flow is approximately 50ml/100g/min.
->Cerebral blood flow represents approximately 14% cardiac output.
->An increase in carbon dioxide leads to cerebral vasodilatation.
-> relaxation of the ileocaecal valve.
In most capillary systems of the body there is a net filtration of fluid of about
->10% from the intravascular compartment to the extravascular compartment.
The lymphatic system returns approximately
-> approximately 8 litres of fluid.
The normal range for CD4 count is
-> useful in ventricular arrhythmias following a myocardial infarction.
->mainly excreted by
-> 95% metabolised by the liver and should be used with extreme caution in hepatic impairment.
Lidocaine Contraindication use with
-> and in all grades of heart block.
Regarding hepatitis B
-> More cases occur in males than females.
-> 50 – 100 times more infectious than the HIV virus.
Regarding helicobacter pylori
->Over 80% are asymptomatic.
->Over 50% of the world’s population harbour H pylori in their upper GI tract.
->Infected individuals have a lifetime risk of developing gastric cancer of 1-2%.
Regarding acute exacerbations of inflammatory bowel disease
->Oral corticosteroids should be used in the emergency department to treat moderate to severe exacerbations of Chron’s disease.
->Corticosteoids have a more rapid onset of action than salicylates.
->Immunosuppressants are commonly started in the emergency department.
->The landmark article of Truelove in 1955 showed a reduction in mortality from 24% in the placebo group to 7% in the steroid-treated group.
Plasma osmolality in healthy individuals is maintained very close to
-> 285mOsml/L by ADH.
Regarding the transmission of tuberculosis
->Cavitation on a chest radiograph is associated with a higher degree of infectiousness.
->spread by inhalation of infectious droplet nuclei.
->A person must inhale at least 10 bacteria to develop the infection.
-> When someone becomes infected, it takes 3-4 weeks before they become infectious enough to spread the disease to others.
B1 Selective Beta Blockers
-> MEA= Metoprolol-Esmolol-Atenolol.
Beta Blockers lipid soluble
-> PLEM= Propanolol-Labetalol-Esmolol-Metoprolol
Beta Blockers Water soluble
-> Sota Nadol hay un Corazon Ardiendo= Sotalol-Nadolol-Carvedilol-Atenolol.
In stage 1 hypertension treat patients
-> under 80 years who have stage 1 hypertension and target-organ damage (e.g. left ventricular hypertrophy, chronic kidney disease, hypertensive retinopathy), cardiovascular disease, renal disease, diabetes, or a 10 year cardiovascular risk ≥ 20%
->in the absence of these conditions -> advise lifestyle changes and review annually.
->For patients under 40 years with stage 1 hypertension but no overt target-organ damage, cardiovascular disease, renal disease, or diabetes
->consider seeking specialist advice for evaluation of secondary causes of hypertension.
Leiner’s disease is a C5 deficiency associated with
->wasting, chronic diarrhoea and widespread seborhhoeic dermatitis.
C3 deficiency leads to a problem with
• opsonisation and tends to present in early life with overwhelming infection by encapsulated organisms.
The shoulder is a ball and socket joint composed of 3 joints which are the
Normal anatomical shunts account for about
-> 1-2% of cardiac output.
Regarding Ureteric Colic
• Approximately 90% of urinary calculi are radio-opaque.
• most commonly consist of calcium oxalate and/ or calcium phosphate
• Microscopic haematuria is present in >80% of patients with ureteric colic.
• most common cause of the common cold.
• They preferentially grow at 33°C and hence infect the upper respiratory tract.
• Smoking increases the risk of respiratory infection by 50%.
• The incubation period is 12-72 hours.
Terminal arterioles are small vessels measuring
Post capillary venules are small vessels measuring
The components of a portal triad include a
• proper hepatic artery
• hepatic portal vein
• common bile duct
• lymphatic vessels
• branch of the vagus nerve.
Hepatic bile is composed of
• 10% bile salts.
Bile is important in the absorption of the fat soluble vitamins which are
• vitamins are D, E, K and A.
• activity against beta-lactamase producing organisms.
• used in the treatment of otitis externa.
• Cholestatic jaundice and hepatitis can rarely occur up to 2 months after treatment has stopped.
• used in the treatment of osteomyelitis.
Regarding the tarsal bones of the foot
• They are a cluster of 7 articulating bones.
• The largest bone of the tarsus is the calcaneus.
• arches of the foot are formed by the cuboid, navicular and 3 cuneiforms.
The talonavicular and calcaneocuboid joints form the
• transverse tarsal joint or Chopart’s joint.
Herpes simplex virus 1 causes
-> oral lesions in 80% of cases and genital lesions in 20%.
• It is an H1 receptor antagonist.
• Drowsiness and xerostomia are common side effects. Headache is an UNcommon side effect. True
• may rarely-> extra-pyramidal effects.
• Palpitations and arrhythmias are recognised side effects.
The normal pressure in the right ventricle during systole is
The normal pressure in the left ventricle during systole is
Regarding flexor pollicis brevis
• It has 2 heads which are the superifical and deep.
• primary action is to flex the proximal phalanx of the thumb.
The superficial heads are supplied by the
• median nerve.
The deep head is supplied by the
• ulna nerve.
Saliva approximately 20-25% is produced
• parotid glands.
submandibular glands produce about
• 70-75% of saliva in the oral cavity.
Saliva is made up of
• 98% water.
• antibacterial compounds such as hydrogen peroxide and immunoglobulin A.
Pregnant women should be offered a dose of
-> acellular pertussis containing vaccine between 28-38 weeks of the pregnancy.
Regarding cutaneous blood flow
• main function thermoregulation.
• Arteriovenous anastomoses involved in thermoregulation are mainly found in the hands, feet and face.
• Increase in cutaneous blood flow may be up to 30 times that of normal blood flow.
Regarding the glossopharyngeal nerve
• It exits the skull via the jugular foramen.
-> excretion is primarily hepatic and biliary.
->It reduces the clearance of other drugs including warfarin and digoxin.
->Patients on both warfarin and amiodarone should have their INR checked more frequently.
->Hypotension is an important side effect.
->It is contraindicated in torsades de pointes, as there may be an underlying prolonged QT which will be exacerbated by amiodarone.
The pons contains two centres which control the
• transition from inspiration to expiration
• these are the apneustic and pneumotaxic centres.
• Children with sickle cell who are infected ->osteomyelitis.
• They perish after being heated to 60°C for 12 minutes.
• Most people will recover without treatment.
• Some patients with salmonellosis will go on to develop reactive arthritis that can last for years.
In secondary active transport the
• electrochemical potential difference created by pumping ions out of the cell is used.
Regarding Publication Bias
Publication bias refers to the fact that
• studies with positive findings are more likely to be published than studies with negative findings.
• This leads to over-representation of positive studies in systematic reviews.
If there is publication bias present, then a funnel plot will be
• This is due to the absence of small negative results.
A Galbraith plot can be used to identify
• publication bias.
Cochran’s Q statistic can be used to
• eliminate heterogeneity.
• The incubation period is usually 16-18 days.
• Post pubertal males have a 30% risk of developing orchitis.
• 30% risk of developing orchitis.
• 4% of cases-> Pancreatitis
Test-retest reliability refers to
• the agreement between initial test results and further results of repeat measurements taken at a later date.
inter-rater reliability. The measure of this agreement is
• quantified by the correlation coefficient Kappa. Kappa can also be described as the chance-corrected proportional agreement statistic.
Cronbach’s α is a correlation coefficient that is used for
• It is used with complicated tests with several parts or for measuring several variables.
Split half reliability refers to the
• reliability of a test that is divided into two parts and tests the same material under similar circumstances.
The target saturations for patients at risk of hypercapnic respiratory failure, such as those with COPD or advanced cystic fibrosis.
• target oxygen saturations of 88-92%.
In most acutely ill patients oxygen saturations should be maintained at
Long term oxygen therapy should be considered in
• chronic obstructive pulmonary disease
• PaO2 < 7.3 kPa
• when breathing air during a period of clinical stability.
Assessment for long term oxygen therapy should not take place sooner than
• 4 weeks after an exacerbation.
Regarding clostridial gas gangrene
• Clostridium perfringens ->80-90% of cases
• myonecrosis can spread as fast as 2cm/hour.
• Systemic toxicity and shock can be fatal within 12 hours.
• Treatment ->debridement and excision with amputation necessary in many cases.
Regarding Thyrotoxic Crises
• Mortality is high at approximately 10%.
• It commences at the level -> 6th cervical vertebra.
• 23-25 cm long.
• Enters the abdomen through the diaphragm at the level ->10th thoracic vertebra.
• The head of the bed should be at 30-45°, as this brings the heart closer to the anterior chest wall.
Regarding pulmonary blood flow
• Mean pulmonary arterial pressure-> 12-15mmHg.
• Pulmonary vascular resistance is about 1/10 that of the systemic circulation.
• The total gas exchange capillary surface area is around 70m2.
• It is around 70m2.
• Pulmonary arterioles constrict in response to hypoxia.
->Adenosine is an endogenous purine nucleoside.
->It has an inhibitory effect on the central nervous system.
->The incubation period usually lasts 9-12 days.
->Approximately 1 in 1000 patients will develop encephalitis, which is fatal in about 10% of patients.
->Subacute sclerosing panencephaltis is a rare->late complication.
Regarding clostridial colitis
• use of proton pump inhibitors is associated with an increased risk.
• Increasing rates of community acquired clostridium difficile infection are associated with drugs used to suppress gastric acid.
Clostridium difficile is a commensal organism in
• 2-5% of the population.
Regarding the hard palate
Blood supply is mainly via the greater palatine artery.
nasopalatine nerve supplies the mucous membrane of the anterior part of the hard palate.
The greater palatine nerve supplies most of the hard palate.
-> It is a first generation cephalosporin.
->(Antibiotic associated colitis It is more common with 2nd generation cephalosporins.)
->About 0.5-6% of patients who are allergic to penicillin will be allergic to cephalexin.
->Agranulocytosis is a recognised complication.
The lumbar plexus
• formed by the ventral divisions of the first four lumbar nerves and contributions from the subcostal nerve.
lumbar Plexus-> does give rise to the
• genitofemoral nerve from segments L1-L2 -> cremaster muscle in the male.
• femoral nerve ->quadriceps femoris.
• obturator nerve -> adductor longus and brevis.
• It is less active against gram negative bacteria than benzylpenicillin .
• It is not active against beta-lactamase producing bacteria.
• used for the prophylaxis of rheumatic fever.
• Side effects include interstitial nephritis.
• The osmolarity is slightly less than the osmolality.
• The normal human reference range is 275-295 milli osmoles per kilogram.
• Calculated osmolarity is 2Na + 2K + glucose +urea.
• Alcohol -> elevated osmolar gap.
Klebsiella pneumonia has a mortality rate of
• 50% even with anti-microbial therapy.
Klebsiella is the second pathogen involved in
• urinary tract infections in older persons. second to E Coli.
Patients typically develop klebsiella pneumonia after
• aspirating oropharyngeal microbes.
Mortality rate of klebsiella pneumonia in alcoholics can be
• as high as 100%.
• It is used in the treatment of bipolar disorder -> in lithium resistant cases.
• Side effects are more common in the elderly.
• AV conduction abnormalities are a contraindication to use.
• SLE is a recognised side effect.
• 40% occur in children <4 years of age.
Secondary drowning refers to the
• deterioration of a patient that apparently survived successful resuscitation after submersion.
The most common predisposing factor to near drowning in the UK is
• alcohol intoxication.
% of deaths from drowning are due to dry drowning.
• Approximately 10-20%-> water -> larynx -> laryngospasm -> death by asphyxiation.
• responsible for 30%-40% of all acute respiratory tract infections in infants and children.
• incubation period is 1-7 days
Most commonly associated with croup.
Regarding carbon dioxide transport
• About 5 % of carbon dioxide is transported unchanged, simply dissolved in the plasma.
• About 10 % of carbon dioxide is transported bound to haemoglobin and plasma proteins.
Regarding the ankle joint
The ankle joint lateral complex of ligaments has 3 components.
• anterior talofibular ligament
• calcaneofibular ligament (much thicker and stronger than ant talofibular lig)
• posterior talofibular ligament.
The medial ligament complex ankle joint is divided into 2 portions.
• superficial and deep deltoid ligaments.
The most likely one to be injured during an inversion injury of the ankle.
• anterior talofiular ligament
Sick sinus syndrome is characterised by
• sinus pauses followed by junctional or other escape beats
Confidence intervals measure the
• degree of uncertainty around an estimate.
• The width of the confidence intervals measure the degree of uncertainty around the estimate.
The null hypothesis states that
• any difference in the results from two groups is due to chance.
If the P value is less than 0.05 the results are
• statistically significant. The P value refers to the probability of getting the observed results if the null hypothesis is correct.
Insulin glargine is a
• long acting insulin.
Insulin requirements may be decreased in those with
• coeliac disease.
• It arises from the lateral 2/3 of the superior nuchal line of the occipital bone.
• inserts into the galea aponeurotica.
• raise the eyebrows and wrinkle the forehead.
• innervated by the facial nerve.
Regarding gluteus minimus
• abduct the thigh at the hip.
• It gives an expansion to the capsule of the hip joint and is a local stabiliser of the hip.
• The anterior fibres medially rotate the thigh at the hip.
• innervated by the superior gluteal nerve
• encapsulated yeast.
• If the disease is confined to the lungs patients are usually immunocompetent.
• Cavitation is uncommon.
• Pulmonary cryptococcosis in an immunocompetent host may resolve without treatment.
This describes intention to treat analysis.
• all study participants are included in analyses regardless of whether or not they completed the study.
This describes last observation carried forward.
• the last recorded results of subjects that dropped out are carried forward to the end of the trial and incorporated into the final analysis of the results.
This describes per protocol analysis.
• only data from those patients who sufficiently complied with the trial protocol are considered in the analysis.
Regarding glomerular filtration rate
• Renal blood flow is approximately 20% of cardiac output.
• The glomerular filtration rate is approximately 120ml/min.
• glomerular filtration rate of less than 15ml/minute is a sign of renal failure.
• Proteins with a molecular mass of over 10kDa are not filtered at the glomerulus.
Regarding scalenus anterior
• from the transverse processes of the 2nd to 6th cervical vertebrae.
• innervated by the anterior branches of C5-C8.
Regarding gastric acid
• pH of 1.5 to 3.5 and is composed of hydrochloric acid (HCl), and large quantities of potassium chloride (KCl) and sodium chloride (NaCl).
Helicobacter infection in the stomach
• neutralises and decreases gastric acid secretion, to increase it’s own survival.
Regarding proton pump inhibitors
• irreversibly block the H+/K+ ATPase of the gastric parietal cells.
• reduce gastric acid secretion by up to 99%.
• Common side effects include headache and nausea.
• Long term use is associated -> hypomagnesaemia.
Transmisssion from an infected mother to a newborn is around
• Up to 20% of neonates with chlamydial conjunctivitis may develop pneumonia.
Homogeneity occurs when studies have
• similar results and any observed differences are due to random variation.
The Chi-squared test tests for
• heterogeneity. When used in a meta-analysis the tests shows whether any variation between the results is over and above that would be expected by chance.
can be used to adjust for heterogeneity in a meta-analysis.
• meta-regression analysis. For example meta-regression analysis can be used to see whether treatment effects are greater in studies of low quality than in studies of high quality.
What tests how sensitive the results of the analysis are to changes in the way it was done.
• sensitivity analysis. This is used to see if there would be a significant change in the results of a study if key decisions in the set up and methodology of the trial were changed.
Regarding the mandibular nerve
• It exits the middle cranial fossa via -> foramen ovale.
• It gives motor supply -> mylohyoid + anterior belly of digastric.
• It’s branch the lingual nerve also carries fibres from the facial nerve.
• It supplies the outer side of the tympani membrane, the auricle and the external auditory meatus.
Regarding meningococcal vaccines
• Immunisation is not recommended after the age of 25.
• Immunisation consists of two doses given at 3 and 4 months of age, with a booster dose at 12-13months.
• A single dose of meningococcal C conjugate vaccine is recommended for all individuals attending university regardless of age
In the UK almost all meningococcal disease is caused by