Part 2 Set B
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Why is thrombophilia screening controversial in young stroke patients?
If they have had an arterial event, thrombophilias are unlikely as they tend to cause venous thrombosis.
High false positive rate, especially with antiphospholipid assays.
No consensus on optimal treatment.
What are the treatments for Lithium overdose?
At what levels do they apply?
- 3-4mmols = IV Saline with or without furosemide to induce diuresis and strict IO chart.
- Monitor serum sodium+osmolality as they will rise.
>4mmols = Dialysis
Poor prognostic indicators in Paracetamol overdose?
- Prothrombin > 100s
- PH<7.3 regardless of encephalopathy (15% survival)
- Creatinine > 300 with grade 3 or 4 encephalopathy (30% survival)
These are all indications for liver transplant
Which drug wud you use prophylactically to avoid post herpetic neuralgia?
Amitriptyline 25mg as soon as the rash appears,
can increase up to 75mg
What would you use a Paul-Bunnel test to exclude?
Recurrent haematuria occurring in close proximity to URTIs?
How would you investigate?
- IgA nephropathy
- Renal biopsy - IgAimmunofluorescence and C3 would be visualised
Treat with ACE inhibs and Steroids
What anibiotics can you use for atypical pneumonias?
What are the options for prophylaxis of meningitis close contacts?
In what order?
- Single dose Ciprofloxacin
- Rifampicin BD for 2 days (Not for girls on the pill as enzyme inducer)
- Single dose IM Ceftriaxone
What organism is commonly grown from joint aspirates of prosthetic joints?
Prolonged IV Abx at time of revision are effective.
Indications for Valve replacement in Aortic Stenosis?
Symptomatic, even at strenuous levels of exercise
Valve gradient of 50-60mmHg
Drugs that cause Raised trans-aminases (hepatitic picture)?
- Antibiotics - Co-amox, fluclox
- Anti-TB - Isoniazid, Rifampicin
- Cardiac drugs - Verapamil, enalapril, Atenolol
Risk factors for thyroid Ca?
- Endemic Goitre
- Hashimotos - Thyroid Lymphoma
- Previous Thyroid adenoma
What is the Imaging of choice in vertebral artery dissection?
What is the treatment if SAH is not present?
Anticoagulation to prevent thromboembolic sequelae.
Erythema and pustules forming around sights of venepuncture?
Pathergy sign - associated with Behcets
The combination of pulmonary haemorrhage and renal failure suggest Goodpastures and what else?
- Microscopic polyarteritis
- Essential mixed cryoglobulinaemia
What is Pulsus paradoxus?
What does it suggest?
A drop in BP on Inspiration. Must be greater than 10mmHg
- Anything that presses on the heart:
- Pericardial effusion
- Constrictive pericarditis
What is oral hairy leukoplakia?
- Adherent white plaques on the edge of the tongue
- Caused by reactivation of EBV in the presence of immuosuppresion
- No specific treatment, just need to treat the underlying cause. Usually HIV
What is warm AIHA?
What are the main causes?
Haemolysis that occurs at body temperature
EXTRAVASCULAR because it is usually IgG mediated and so is poor at activating complement but bettter at being mopped up by phagoctyes and kuppfer cells in the spleen and liver.
Idiopathic (50%), Lymphoproliferative disorders, Autoimmune disorders, Infection, Other neoplasms
What is Brucellosis?
Small intracellular pathogen - Brucella melitensis
- Endemic to cattle in central america
- Acuquired by drinking unpasturized milk and eating undercooked meat
- Bone pain, neuropsych symptoms, Hepatosplenomegaly and bone marrow supression
- Causes chronic disease if untreated
- Test of choice is bone marrow aspirate + culture as blood cultures can take 4-6 weeks
- 6 weeks of doxycycline with strep or rifampicin. Quinilones can also be used.
What is Meliodosis?
- Caused by Burkholderia pseudomaleii - gram negative organism found in soil and water
- Mainly in Thailand, the banana pancake trail and Australia
Presents acutely as atypical pneumonia or with bonejoint pain
Chronic form is very similar to TB and has been called 'Vietnamese TB'
Treat with high intensity IV phase and then an oral eradication phase.
What should you think about when a patient presents Post-RTA with a deviated tongue and taste abnormality?
Carotid artery dissection that's taken out the hypoglossal and the facial.
What is Histoplasmosis?
- A fungal disease
- Caused by Histoplasma capsulatum
- Slowly progressing form occurs in immunocompetent
- Acute disseminated form occurrs in the others
- Adrenals are commonly affected in disseminated form
- Grocott's silver stain will get you the diagnosis from an FNA or biopsy.
- Treat with Itraconazole
What role does Ketoconazole play in a patient with Cushings disease?
Decreases cortisol synthesis by inducing several P450enzymes.
Used to control BP and Serum glucose pre-surgically in the lead up to trans-sphenoidal surgery.
If an adverse event occurs to a patient in a clinical trial what does it imply for incidence numbers of that adverse effect in true populations?
Roughly about 10 times as many patients need to be studied in a trial versus the number needed to see 1 event.
Which features suggest Multiple Myeloma in a patient with monoclonal gammopathy?
- Lytic bone lesion
- Renal failure
- Bence Jones protein
What do renal transplant patients present with in the first 2 months after transplant?
Pharyngitis and flu-like illness.
Happens when a CMV negative recipient gets a kidney from a CMV positive donor.
Its a worry because it accelerates transplant failure.
Treat with IV Gancyclovir.
What %levels of COHb are clinically significant?
- >30% = Headaches and dizziness
- 40-60% = Syncope, tachycardia, tachypnoea, seizures
- >60% = Cardioresp failure and death
100% O2 via non-rebreathe and consider hyperbaric therapy.
What are chromogranin and synaptophysin good for?
Useful markers for neuroendocrine differentiation of neoplasms
Salient features of Somatostatinoma?
- Wt Loss
Salient features of VIPoma?
Large volume secretory diarrhoea
Salient features of Pancreatic Polypeptide tumors?
- Watery diarrhoea
- Chronic Duodenal ulcers
- Multiple endocrine tumors
Salient features of Glucagonomas?
- Mild glucose intolerance
- Necrolytic Migratory Erythema
- Psychiatric disturbance
- Thromboembolic disease
What is granuloma annulare?
What is it associated with?
A ring of small smooth papules on the hand and feet. Looks very much like urticaria but not itchy.
Assoc with Diabetes. Most common in women below the age of 30.
Absolute contraindications to Metformin?
- Renal impairment
- Liver impairment
- Basically anything that would make Lactic acidosis worse.
If a pregnant woman gets Slapped cheek disease what should you worry about?
Hydrops Fetalis (accumulation of fluidoedema in 2 or more foetal compartments)
Treatment options for glioblastoma multiforme?
- Surgical debulking
- Oral Alkylating agents
- Bevacizumab in clinical trials
Median survival = 1 year
Whats the optimum treatment in complete heartblock?
Dual chamber pacemaker
How does cyanide kill?
What are the possible treatments?
- Pulm odema
- CV collapse
- Dicobalt edetate first line
- sodium nitrite and sodium thiosulphate are alternatives.
What is the sine qua non of phenytoin toxicity?
- Horizontal nystagmus
- It is protein bound therefore haemodialysis and and plasmapheresis are of no use.
How do you differentiate the porhyrias on investigation?
- Urinary porphyrins are raised in all three acute porhyrias; AIP, hereditary coporphyria and Varigate porhyria
- Faecal porhyrins raised in Varigate and HCP only
- Serum porphyrins raised in Varigate only
Photo-sensitive skin lesions are present in Varigate and Porhyris cutanea tarda
How do you differentiate between methanol poisoning and ethylene glycol poisoning?
Methanol will bur disc margins and keep your calcium normal
What is Lutembacher's syndrome?
- Mitral stenosis with ASD - more common in women because more women have ASDs
- Causes mixed signs on CV exam (diastolic murmur, loud S1, left heave and tapping apex)
- Causes fatigue, SOB and AF in middle age.
- Needs op to prevent Eissenmengers
What types of HIT are there?
HIT1 - Occurs within 48-72hrs, Need to stop offending agent. Platelets dont drop below 100
HIT 2 - Occurs later than that platelets drop below 100, need to stop offending agent
In both cases chat to Haem about what agent next - lepirudin etc
Features of Arsenic poisoning?
Where in the environment is it commonly found?
- Sensorimotor polyneuropathy
- Gastrointestinal symptoms
- Hyperkeratosis of the palms
- Transverse lines on nail beds - Mees lines
Treat with penicillamine
Found in rodent pesticides, rice, drinking water, smelting occupations.
Why is pleural fluid pH the best test to confirm empyema?
Organisms in pus dont tend to grow in micro labs
pH <7.2 is what you're looking for
Translocations associated with haemonc?
t(8:14) = Burkitts, c-myc with an Ig heavy locus
t(15:17) = Acute promyelocytic leukaemia, PML-RAR
t(9:22) = ALL and CML - BCR-Abl
t(11:22) = Mantle cell lymphoma - cyclinD1 to Ig heavy locus
Risk factors for vertebral artery dissection?
- Ceiling painting
- nose blowing
- Spinal manipulation
- minor trauma
What is the difference between lateral medullary syndrome and medial medullary syndrome?
LMS = Ipsilateral facial dyaesthesia, dysarthria, hoarseness. Ipsilateral limb numbness + CONTRALATERAL loss of pain + temp. Vertigo, dysequilibrium, diplopia, dysphagia.
MMS = Contralateral weaknessparalysis (pyramidal tract damage before the decussation). Contralateral Numbess. Ipsilateral horners.
Cardiac markers in order of rising post-mi?
- My - Myoglobin
- Cat - CK
- Takes - Troponin
- LSD - LDH
Whats the most common abnormality found in people who have Hep C because they were transfused before the 80s?
- Isolated rise in ALT.
- Found incidentally
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