Term
| One year old child presents with generalised convulsion. Her fit has continued for 10mins. She has a temp of 40. What 4 actions would you perform immediately before giving specific medication? |
|
Definition
1. Airway - Ensure patent airway.
2. Breathing - high flow O2 therapy via trauma mask + pulse oximetry + auscultate for breath sounds
3. Circulation - large bore IV access, ABG, bloods
4. D - consciousness level, check pupils
5. E - check BM, for rash and reassess temp
6. Recovery position.
7. Measure vitals.
8. Call senior help. |
|
|
Term
| How can you stop a child who is fitting? |
|
Definition
|
|
Term
| What 1 investigation would you consider essential in a child with febrile convulsions? |
|
Definition
|
|
Term
| A child with febrile convulsions temperature remains high despite paracetamol. What other steps can be taken? |
|
Definition
Let them run about in minimal clothing at room temperature- so just a nappy in a toddler
The other key action is to identify the source of the fever- so clinical examination, and a urine sample for culture would be good. If a potentially bacterial source of infection were identified antibiotics would be appropriate, but not without identifying a source to treat. Many of these kids just have a viral infection. |
|
|
Term
| Following treatment for a febrile convulsion, what 2 pieces of advice would you give the parents about preventing another one? |
|
Definition
1. Remove excess clothing, give fluids, give antipyretics.
2. Stay with child at night. |
|
|
Term
| What is the prognosis for a child following a febrile convulsion? |
|
Definition
1/3 will have further febrile convulsions.
1-2% will develop epilepsy (this is population risk).
Febrile convulsions normally do not happen after 5 years of age. |
|
|
Term
| What investigations would help you determine whether renal failure is chronic or acute? |
|
Definition
1. FBC - anaemia (normochromic normocytic in CKD)
2. Renal USS - small (<9cm) kidneys or calculi
3. XRay
- Digital subperiosteal erosion
- Pepperpot skull
- Osteosclerosis "rugger jersey spine"
4. Renal bone disease (osteodystrophy) in CKD.
- Serum Ca2+ normal/low.
- Serum PO4- high.
- Serum PTH high.
- Serum Alk Phos high.
- XR findings as above. |
|
|
Term
| What clinical features or lab findings would help you decide whether a patient needs dialysis? |
|
Definition
1. Symptomatic uraemia despite Rx (inc pericarditis).
2. Fluid overload despite Rx.
3. Hyperkalaemia (>6.5) despite Rx.
4. Acidosis.
5. eGFR < 15ml/min (CKD stage 5 - End-stage renal failure). |
|
|
Term
| What 3 forms of renal replacement therapy are available? |
|
Definition
1. Haemodialysis.
2. Peritoneal dialysis.
3. Renal transplant. |
|
|
Term
| A lady with a painful red eye comes in. You suspect she might have MS. What investigations should you do and what results would you expect? |
|
Definition
1. MRI brain and spinal cord will demonstrate demyelinating plaques in the white matter of the right optic tract. Gadolinium labelling will enhance recent plaques. Old plaques may be found on the corticospinal tract (urinary symptoms).
2. LP will demonstrate oligoclonal banding, and protein.
3. Visual evoked potential would be delayed. |
|
|
Term
| What would you tell the patient about the prognosis and management of MS? |
|
Definition
1. The disease is not curable.
2. The disease course is relapsing and incompletely remitting. It eventually becomes progressive declination without remission. (Over 5-25 years). Reduced life expectancy.
3. You can remain active and not grossly disabled for much of the time.
4. IV steroids are used for acute attacks. They decrease severity and duration of the attack but have no effect on the long term outcome.
5. Muscle relaxants (for spasticity) and anticholinergics (for tremor) for symptomatic relief. |
|
|
Term
| What aetiological factors are associated with MS? |
|
Definition
1. Viral infection and inappropriate autoimmune reaction.
2. Genetics (eg having a relative with MS)
3. Environmental - living further from the equator |
|
|
Term
A 28 year old bank teller visits your GP surgery having received a verbal warning at his
work. He gives a year long history of worries that his receipts will not balance each day
to the extent that he has to check each transaction at least six times. Customers have
complained about his excessive slowness. What are these symptoms?
Name 2 possible diagnoses. |
|
Definition
Obsessions and compulsions.
1. OCD.
2. Personality Disorder Cluster C - Anxious - Anankastic (Obsessional) OR "Obsessive personality disorder".
3. Depressive disorder.
4. Psychotic disorder. |
|
|
Term
| List 5 characteristic features of obsessions and compulsions. |
|
Definition
Obsessions
1. Recurrent, persistent thoughts, impulses or images that cause anxiety and distress.
2. Thoughts, impulses, images are not simply excessive worries about real-life problems.
3. Pt. tries to suppress the thoughts, impulses, images or neutralise them with some other thought or action.
4. Pt. recognises that they are products of their own mind.
Compulsions
1. Repetitive behaviours performed in response to obsessions or according to rules that must be applied rigidly.
2. Behaviours are aimed at preventing distress or some dreaded event or situation that are not connected in a realistic way. |
|
|
Term
| What neurotransmitter system is thought to be most relevant in the genesis of obsessions and compulsions? |
|
Definition
|
|
Term
| What drug treatment is most effective for OCD? |
|
Definition
| SSRIs are the first line treatment (eg citalopram) but TCAs (eg clomipramine) are most EFFECTIVE |
|
|
Term
| Apart from carcinoma of the oesophagus, list 4 conditions which could cause dysphagia in any patient. |
|
Definition
Stroke
Parkinsons
Myasthenia gravis
Motor neurone disease
MS
Achalasia
Pharyngeal pouch
Foreign body |
|
|
Term
| What 2 features on a patients history would suggest a malignant cause of dysphagia? |
|
Definition
Sudden onset (days- weeks)
Dysphagia is rapidly progressive, not intermittent, from solids to liquids
Weight loss |
|
|
Term
| What 2 investigations would you request for someone with dysphagia? |
|
Definition
- barium swallow
- endoscopy (OGD) +/- biopsy |
|
|
Term
| What are the 2 main pathological types of oesophageal carcinoma? |
|
Definition
Adenocarcinoma
Squamous cell carcinoma |
|
|
Term
| What investigation is important before surgical resection for oesophageal carcinoma? |
|
Definition
| CT abdo, chest, pelvis for staging |
|
|
Term
| What 2 courses of action will help palliate symptoms of oesophageal carcinoma? |
|
Definition
Radiotherapy
Endoscopic ablation +/- stenting
Opiates for pain relief |
|
|
Term
| Name 3 likely causes for intermittent rectal bleeding other than rectal carcinoma |
|
Definition
Haemarrhoids
Anal fissure
Ulcerative colitis
Diverticular disease |
|
|
Term
Name 3 further features in the history you would seek to support a diagnosis of
rectal carcinoma |
|
Definition
Change in bowel habit.
Anorexia.
Weight loss.
PMH.
FH of Ca or FAP or HNPCC. |
|
|
Term
| What important factors do you need to consider to determine prognosis of rectal carcinoma? |
|
Definition
Stage:
Tumour size, depth of invasion.
Number of nodes involved and distance.
Metastatic disease?
Grade of tumour. |
|
|
Term
| What medical conditions can predispose to rectal carcinoma? |
|
Definition
FAP (familial adenomatous polyposis)
HNPCC(hereditary nonpolyposis colorectal cancer)
UC
Villous adenomas |
|
|
Term
A man is diagnosed with unstable angina. What drug therapy could he be started on? List
4 potentially beneficial drugs (2 marks) and give a reason for prescribing each (2 marks). |
|
Definition
Morphine - Reduces pain.
Nitrates - Venodilation to reduce preload, peripheral arterial vasodilation to reduce afterload, coronary artery vasodilation.
Aspirin - Prohphylaxis against stroke, reinfarction.
Statin - Reduces cholesterol level. |
|
|
Term
| List the 2 cardinal ECG features of an acute full thickness anterior myocardial infarction and outline their electrophysiological cause. |
|
Definition
On anterior leads:
ST elevation and reciprocal ST depression on inferior leads -ST segment represents the period of time between ventricular depolarisation and repolarisation. An acute infarct will cause this to be abnormal. "Current of injury".
New pathological Q waves - A transmural infarct causes a region of dead myocardium where there is no electrical activity. Therefore there is a electrical "window" through to the other side of the heart where the current is moving away from the electrode. |
|
|
Term
| What is a medically significant side effect of lithium? |
|
Definition
| Nephrogenic diabetes insipidus |
|
|
Term
| What is an anticholinergic side effect of tricyclic antidepressants? |
|
Definition
|
|
Term
| What is a medically serious side effect of monoamine oxidase inhibitors? |
|
Definition
| Hypertensive crisis with tyramine |
|
|
Term
| What 2 clinical features may occur as a result of the profuse diarrhoea that is caused by cholera? |
|
Definition
1. Tachypnoea.
2. Reduced skin turgor.
3. Sunken eyes.
4. Hypotension.
5. Reduced urine output. |
|
|
Term
| Given a history of travel to South america, what 4 organisms should be looked for as a cause of his diarrhoea? |
|
Definition
Shigella.
Campylocbacter.
Salmonella.
Amoebic dysentery.
E. Coli |
|
|
Term
| What organism causes cholera and how does the disease result following infection? |
|
Definition
Vibrio cholerae
- Secrete enterotoxin (an exotoxin) that causes massive release of isotonic fluid into the lumen. |
|
|
Term
| Apart from water replacement, name the 2 most important constituents in the IV replacement fluid that will help correct the sequelae of the profuse diarrhoea? |
|
Definition
|
|
Term
| What advice should be given to travellers to avoid diarrhoeal illness? |
|
Definition
1. Food and water hygiene precautions.
- Boil water or use chlorine tablets.
- Well-cooked food.
2. Vaccination. |
|
|
Term
| Other than fracture, name 2 other associated injuries which could cause hypotension in someone in a motorbike accident with a fractured pelvis? |
|
Definition
1. Splenic rupture.
2. Haemothorax.
3. Cervical spinal injury (loss of SYMP therefore hypotension, peripheral vasodilatation, bradycardia).
(NB: RARELY head injury, as Cushing's triad: Hypertension, Bradycardia, Bradypnoea.) |
|
|
Term
What is the significance of blood at the external urethral meatus and what clinical
examination will you perform to confirm your suspicion? |
|
Definition
Urethral injury.
PR looking for high-riding boggy prostate. |
|
|
Term
| Give 2 X-rays that should be carried out during evaluation of a polytrauma patient. |
|
Definition
CXR (AP supine).
Pelvic Xray (AP) |
|
|
Term
Accepting that there are no other associated injuries (than fractured pelvis), describe 2 forms of treatment
that you would you use to treat the uncontrolled haemorrhage in this patient? |
|
Definition
Blood transfusion
Compression bandages
External fixation of the pelvis
Pelvic angio with embolisation |
|
|
Term
| What is the overall mortality rate associated with a pelvic fracture? |
|
Definition
| With haemorrhage - 35-55% |
|
|
Term
| Name 2 causes of death following a pelvic fracture. |
|
Definition
1. Fat embolus causing respiratory failure.
2. Hypovolaemia leading to multiple organ failure (kidneys, heart, brain).
3. Infection. |
|
|
Term
| What is the jaundice that would be the most concerning in a newborn? |
|
Definition
| Haemolytic jaundice from Rhesus alloimmunisation. |
|
|
Term
| What investigations should be performed to investigate jaundice in a neonate? |
|
Definition
1. Serum bilirubin (for baseline level to assess response to treatment)
2. Blood packed cell volume
3. Blood group (mother and baby)
4. Coombs' test - interpret the result taking account of the strength of reaction, and whether mother received prophylactic anti-D immunoglobulin during pregnancy |
|
|
Term
| What is the treatment for neonatal jaundice? |
|
Definition
|
|
Term
| What are 2 complications of phototherapy? |
|
Definition
1. Dehydration
2. Loose stools
3. Skin rash |
|
|
Term
| What other more invasive treatment option is available if phototherapy failus? |
|
Definition
|
|
Term
| What is the most important consequence of failing to adequately treating the jaundice? |
|
Definition
Kernicterus - necrosis of neurons in brainstem
Causes paralysis of upward gaze and sensorineural hearing loss |
|
|
Term
| 6yr old boy has a sudden onset abdominal pain and is feeling hot. He has right iliac fossa pain with rebound tenderness and a temp of 37.3. List 3 potential causes for these symptoms. |
|
Definition
Appendicitis
Gastroenteritis
Meckels Diverticulum
Mesenteric adenitis |
|
|
Term
| Give 2 features which, on further questioning, would support a diagnosis of appendicitis. |
|
Definition
Migration of pain from central abdomen to become localised in RIF
Anorexia |
|
|
Term
| What features on examination would support a diagnosis of appendicitis? |
|
Definition
Rovsing's sign - greater pain felt in RIF on palpation of LIF
Tenderness over McBurney's point |
|
|
Term
| A child with suspected appendicitis suddenly develops widespread severe abdominal pain and becomes shocked. BP is now 70/40. What is the most likely cause? |
|
Definition
| Perforated appendix causing peritonism |
|
|
Term
| Give 2 findings on examination/investigation which would support a diagnosis of perforated appendix. |
|
Definition
Air under the diaphragm on erect chest Xray
Rigid, board-like abdomen on palpation |
|
|
Term
| What 2 therapeutic measures might be performed in a child with perforated appendix? |
|
Definition
IV antibiotics
Urgent laparotomy |
|
|
Term
Apart from orthostatic (postural) hypotension, suggest 3 other disorders which are
likely to cause a fall with brief loss of consciousness? |
|
Definition
1. Dysrhythmia.
2. Carotid sinus hypersensitivity.
3. Aortic stenosis.
4. Vasovagal (situational) syncope, e.g. cough. |
|
|
Term
On examination you find that a patient's blood pressure drops markedly on standing up and
she feels faint. Suggest 2 factors which should be considered that might be
aggravating this change? |
|
Definition
1. Iatrogenic - overmedication with anti-hypertensives.
2. Dehydration.
3. Autonomic nervous system dysfunction (with age, DM, multi-system atrophy with Parkinson's Plus). |
|
|
Term
| List 2 non-drug measures which can control postural hypotension. |
|
Definition
1. Good hydration
2. Standing up slowly
3. Raising head of the bed to reduce nocturia
4. Support stockings |
|
|
Term
| What type of drug therapy would you prescribe in an effort to alleviate symptoms of postural hypotension? |
|
Definition
1. Low dose fludrocortisone (corticosteroid)
2. Alpha1-agonist (midodrine) |
|
|
Term
An elderly patient with postural hypotension improves on treatment and you plan discharge. What other factors will
you consider in your plans? Suggest 2. |
|
Definition
1. CCA - Housing situation - number of steps etc. Ability to perform ADLs.
2. Physio and OT.
3. Review dosage of medication with GP. |
|
|
Term
Your patient has a severe headache of sudden onset. He was
previously well and there is no other significant history. He is now unconscious and
his breathing is impaired. What are your differentials? |
|
Definition
1. Subarachnoid haemorrhage (with bleeding that has extended into the brain).
2. Meningitis/Encephalitis
3. Intracerebral haemorrhage |
|
|
Term
| What is the most important investigation in someone with reduced consciousness and a possible subarachnoid haemorrhage? |
|
Definition
|
|
Term
| What acute event could be precipitated by a lumbar puncture? |
|
Definition
Coning.
Downward shift of brain due to sudden decrease in ICP.
Medulla forced into foramen magnum, causing depression of respiration and other vital functions.
Happens when LP performed on pt. with raised ICP. |
|
|
Term
Sadly, within 24 hours of presentation, in spite of appropriate management,
your patient’s general condition deteriorates to a point at which brain stem
death is pronounced. Organ donation is contemplated. What medical
conditions would preclude organ donation? List two. |
|
Definition
1. Transmissible infection that will adversely affect the recipient e.g. HIV, CJD
2. Active haematological or visceral neoplastic disease |
|
|
Term
The consultant in charge of the patient’s case is talking to the family about the
concept of brainstem death. What key points need to be covered? Suggest two. |
|
Definition
1. The pt's basic vital functions cannot function by themselves due to death of the part of brain that controls them. Their vital functions are being supported by mechanical means.
2. The pt. will not improve because the death of the brainstem tissue is irreversible.
3. Verified by 2 doctors at 2 different occasions.
4. Organ donation. |
|
|
Term
| What STIs would produce symptoms of dysuria? |
|
Definition
1. Chlamydia (60% asymptomatic)
2. Gonorrhoea |
|
|
Term
| You have a patient with a possible STI. List 2 additional relevant questions you would wish to ask the patient. |
|
Definition
1. Has she noticed any vaginal discharge?
2. Any blood in the urine?
3. Lower UTI Qs - urgency/freq/smelly urine
4. Upper UTI Qs - loin pain/fever/chills
5. Painful intercourse?
6. Any systemic symptoms eg fever? |
|
|
Term
| What 2 examinations would you wish to undertake in a female patient with a possible STI? |
|
Definition
Vaginal examination w/ speculum
Bimanual palpation of vagina |
|
|
Term
| What investigations would you perform in someone with a possible STI and dysuria? |
|
Definition
1. Urine dipstick.
2. MSU for microscopy + culture + sensitivity.
3. High vaginal swab (for discharge, e.g. candida, trachomonas, bacterial vaginosis) and endocervical swab (for STI) for M + C.
4. Blood sample (syphilis, hepatitis, HIV following counselling) |
|
|
Term
Assuming she has a sexual infection and has received appropriate treatment for this,
list 4 factors that would be important in the next stage of her management. |
|
Definition
1. Contact tracing + inform sexual contacts.
2. Advise and recommend use of contraceptive including barrier method.
3. Counsel on risk of complications following STI and how to prevent STI.
4. Post-Rx follow-up visit w/ test of cure.
5. GUM clinic referral |
|
|
Term
| What is adjustment disorder? |
|
Definition
| An adjustment disorder occurs when an individual is unable to adjust to or cope with a particular stressor, like a major life event. Since people with this disorder normally have symptoms that depressed people do, such as general loss of interest, feelings of hopelessness and crying, this disorder is also sometimes known as situational depression. Unlike major depression however, the disorder is caused by an outside stressor and generally resolves once the individual is able to adapt to the situation |
|
|
Term
| What is brief reactive psychosis? |
|
Definition
The psychiatric term for psychosis which can be triggered by an extremely stressful event in the life of an individual.
'BRP is characterized by delusions, hallucinations, catatonic symptoms, and strange speech, but the symptoms last for a very short period (one day to one month) after which the individual returns to full normal functioning' |
|
|
Term
| What is delusional disorder? |
|
Definition
| patients present with circumscribed symptoms of non-bizarre delusions, but with the absence of prominent hallucinations and no thought disorder, mood disorder, or significant flattening of affect.[1] For the diagnosis to be made, auditory and visual hallucinations cannot be prominent, though olfactory or tactile hallucinations related to the content of the delusion may be present |
|
|
Term
| What is factitious disorder? |
|
Definition
Conditions in which a person acts as if they have an illness by deliberately producing, feigning, or exaggerating symptoms.
People with this condition may produce symptoms by contaminating urine samples, taking hallucinogens, injecting themselves with bacteria to produce infections, and other similar behaviour. |
|
|
Term
|
Definition
| excessive preoccupancy or worry about having a serious illness. This debilitating condition is the result of an inaccurate perception of the body’s condition despite the absence of an actual medical condition |
|
|
Term
| What is somatoform disorder? |
|
Definition
| Characterized by symptoms that suggest physical illness or injury – symptoms that cannot be explained fully by a general medical condition or by the direct effect of a substance, and are not attributable to another mental disorder (e.g. panic disorder) |
|
|
Term
| 83yr old woman with 2 week Hx of obstructive jaundice. Diabetic for 2 months and lost 7kg. Pale stools and dark urine. What 2 investigations would you order? |
|
Definition
- Blood tests (FBC, U&Es, LFTs)
- Abdominal USS
- Pancreatic CT |
|
|
Term
| 83yr old woman with 2 week Hx of obstructive jaundice. Diabetic for 2 months and lost 7kg. Pale stools and dark urine. What are the 2 main diagnoses to consider? |
|
Definition
- pancreatic cancer
- gallstones |
|
|
Term
| What are 3 complications of an ERCP? |
|
Definition
- pancreatitis
- haemorrhage from sphincterotomy
- ascending cholangitis
GENERAL
- Bleeding
- Perforation
- Infection e.g. Acute Cholangitis
- Aspiration Pneumonia |
|
|
Term
83yr old woman with 2 week Hx of obstructive jaundice. Diabetic for 2 months and lost 7kg. Pale stools and dark urine.
Cytology reveals malignant cells. What 3 management options would you like to discuss with your patient? |
|
Definition
1. RESECTION
Not appropriate for most patients because of disease stage and co-morbidity
For the patient in this question, as they have obstructive jaundice the neoplasm is going to be in the pancreatic head or ampulla so pancreaticoduodenectomy (Whipple’s) or pylorus preserving pancreaticoduodenectomy are the likely procedures
2. ONCOLOGY
Neoadjuvant or Palliative Chemotherapy (Gemcitabine)
Radiotherapy is not commonly used for the primary tumour but possibly for metastases
3. PALLIATIVE
Symptom control i.e. decompression of biliary tree (stent via ERCP or PTC), analgesia, anti-emetics and nutritional supplementation |
|
|
Term
| What side-effect of haloperidol would cause neck pain and face twisting to one side? |
|
Definition
|
|
Term
| What is the underlying action of Haloperidol that causes dystonia and in which brain region does it occur? |
|
Definition
- D2 receptor antagonism
- The Nigrostriatal dopamine pathway in the brain |
|
|
Term
| What are 3 side effects of by D2 receptor antagonism? |
|
Definition
- Tardive Dyskinesia
- Akathisia (restlessness)
- Parkinsonism |
|
|
Term
| Name 2 management strategies to counteract the side-effects of D2 receptor antagonism. |
|
Definition
Stop Haloperidol and switch to an atypical antipsychotic e.g. Aripiprazole
Lower the dose of Haloperidol |
|
|
Term
| Name 2 antipsychotic drugs least likely to cause D2 receptor antagonist side-effects. |
|
Definition
- Aripiprazole
- Clozapine |
|
|
Term
| What are the 3 main symptoms of parkinson's disease? |
|
Definition
- Tremor
- Rigidity
- Bradykinesia |
|
|
Term
| What 2 drugs can be used in combination with L-dopa to enhance it's activity? |
|
Definition
COMT-inhibitor: e.g. entacapone, tolcapone:
used as an adjunct to L-dopa (increases half life of the drug)
monoamine oxidase (MAO) inhibitors. These drugs slow the breakdown of dopamine that occurs naturally in the brain and dopamine produced from levodopa. |
|
|
Term
| How do drugs used in combination with L-dopa enhance it's activity? |
|
Definition
A COMT inhibitor is a drug that inhibits the action of catechol-O-methyl transferase. This enzyme is involved in degrading neurotransmitters. => reduces half life of L-DOPA
Monoamine oxidase (MAO) inhibitors. These drugs slow the breakdown of dopamine that occurs naturally in the brain and dopamine produced from levodopa |
|
|
Term
| Give 2 major adverse effects of chronic L-dopa administration. |
|
Definition
- On-Off Phenomenon
- End-of-Dose Dyskinesia
- Cardiovascular Effects i.e. Arrhythmia, Palpitations, Postural Hypotension, Syncope
- Hallucinosis |
|
|
Term
| Suggest 2 drugs that can be used as alternatives to L-dopa therapy. |
|
Definition
- Dopamine Receptor Agonists e.g. Ropinirole
- MAO-B Inhibitor e.g. Selegiline
- Anticholinergics e.g. Amantadine
- Catechol-O-MethylTransferase (COMT) Inhibitor e.g. Entacapone |
|
|
Term
| A 2 month old baby comes in with a boggy swelling on the right side of his scalp after a fall. What is the most likely cause of the skull swelling? |
|
Definition
| Haematoma or subdural haemorrhage |
|
|
Term
| What is the most likely underlying mechanism for a 2 month old baby to have a head haematoma? |
|
Definition
| Trauma (non-accidental injury ie shaken baby syndrome) |
|
|
Term
| What medical investigations should you do for a baby with a possible head injury? |
|
Definition
- Bloods → FBC (subdural bleed → ↓ Hct/↑WCC), Coag Screen (may be underlying bleeding disorder)
- LFTs → for assessment of NAI
- Imaging → Cranial CT, Cranial US, Cranial MRI, Skeletal Survey (NAI) |
|
|
Term
| As the FY1 in A&E, what would you do when the parents want to take home their baby with a possible NAI? |
|
Definition
- Seek senior advice immediately
- Inform parents that due to the nature of the injury you need to ask a senior colleague to review child
- When speaking to senior colleague you would inform them of your suspicion and ask them to review |
|
|
Term
| What features would you look for on opthalmic examination of a baby with a possible NAI of the head? |
|
Definition
|
|
Term
Name 3 other professionals or resources outside the hospital that might provide important
information to elucidate the diagnosis in a child with a possible NAI |
|
Definition
- Social Workers
- Health Visitor
- GP |
|
|
Term
| List 2 complications of preterm rupture of membranes. |
|
Definition
1. Chorioamnionitis (infection).
2. Preterm labour.
3. Congenital pneumonia (of newborn).
Fetal distress/death.
Placental abruption. |
|
|
Term
| A lady has had a pre-term rupture of membranes and you perform a speculum examination. What should you look for and what investigations would you perform during the examination? |
|
Definition
1. High vaginal swab for culture (e.g. chlamydia trachomatis).
2. Cervical effacement and dilatation.
3. Look at colour of and smell amniotic fluid (draining through cervix) |
|
|
Term
List 3 variables that you would wish to monitor to try and identify the
onset of complications of premature rupture of membranes? |
|
Definition
Chorioamnionitis:
1. WCC and CRP.
2. Maternal temperature.
Preterm labour:
3. CTG to monitor fetal heart rate and uterine contractions.
4. Dilatation of cervix. |
|
|
Term
| In the first 4 hours after delivery, what respiratory signs would sugest RDS? |
|
Definition
Nasal flaring
Intercostal drawing |
|
|
Term
| A patient has suspected meningococcal septicaemia. Give 2 examples of appropriate antibiotics which should be administered immediately by the GP and which route? |
|
Definition
Intramuscular benzylpenicillin
Intravenous ceftriaxone |
|
|
Term
| What 4 microbiological tests can identify meningitis? |
|
Definition
- Blood culture + PCR
- Blood gram stain + microscopy
- CSF culture + PCR
- CSF gram stain + microscopy |
|
|
Term
| What are the 2 public health implications of a suspected case of meningococcal sepsis? |
|
Definition
- Bacterial meningitis is a notifiable disease
- There is a legal requirement to notify public health
- The patient’s close contacts need to be traced and offered prophylaxis |
|
|
Term
| What is the main limitation of the currently available vaccine for bacterial meningitis? |
|
Definition
| The vaccine is only for meningococcal group C and not the other serotypes |
|
|
Term
| Patient has a TSH that is undetectable (<0.05mU/L). What diagnosis does this indicate? |
|
Definition
| Thyrotoxicosis most likely due to primary hyperthyroidism |
|
|
Term
| Why is TSH low in hyperthyroidism? |
|
Definition
- TSH is produced by the anterior pituitary, and stimulates production of thyroid hormones (T3 & T4)
- Increased thyroxine inhibits the hypothalamic-pituitary-thyroid axis as part of a -ve feedback loop
- The above results is ↓ production of TSH |
|
|
Term
| Outline the pathogenesis of Graves Disease. |
|
Definition
- Autoantibodies to the TSH receptor thyroid follicular epithelial cells are created
- These autoantibodies stimulate inappropriate activation of thyroid hormone production |
|
|
Term
Outline 3 treatment options for a patient with Graves disease (½ mark each), and provide one specific side
effect that you would warn the patient about for each treatment option. |
|
Definition
- Anti-thyroid Drugs e.g. Carbimazole or Propylthiouracil → can cause agranulocytosis
- Radioactive Iodine → may cause initial worsening in hyperthyroid symptoms
- Thyroidectomy → likely hypothyroidism needing lifelong thyroxine treatment
- Propranolol → exercise intolerance |
|
|
Term
| List 5 factors for coronary artery disease. |
|
Definition
- Asian Ethnicity
- Smoker
- Hypercholesterolaemia
- Hypertension
- Male |
|
|
Term
| List 4 drugs for unstable angina and a reason for prescribing each. |
|
Definition
- Atenolol (beta blocker) → ↓ BP, HR and controls angina
- Simvastatin → ↓ cholesterol and ↓ mortality
- Amlodipine (Ca channel blocker) → ↓ BP by vasodilation and controls angina
- Ramipril (ACE inhibitor) → ↓ BP and ↓ mortality
- Morphine → controls pain and helps patient feel at ease
- Aspirin → anti-platelet and ↓mortality
- Nitrates →↓ BP by vasodilation and controls angina
- Clopidogrel → anti-platelet and ↓ mortality |
|
|
Term
| List the 2 cardinal ECG features of an acute full thickness anterior myocardial infarction and outline their electrophyiological cause. |
|
Definition
1. ST Elevation:
- Normal muscle is polarised (normal-potential) during diastole and only depolarised during the
action potential
- However, MI triggers depolarisation of the muscle with resetting of the baseline of the affected leads causing abnormal currents to flow between adjacent depolarised and polarised tissues i.e. “current of injury”
2. Pathological Q Waves:
- An initial downward movement of the QRS is a Q wave
- Pathological Q waves occur after an MI and have a width of ≥1 small box and a depth >25% of the total QRS height
- They occur due to the “myocardial window” i.e. the area of old myocardial infarction is
electrically silent and acts as a window meaning that the lead recording from that site sees
activity from the opposite side of the heart, which is moving away from the lead causing a downward deflection (the q wave). |
|
|
Term
|
Definition
Leukaemia is a progressive, malignant disease of the blood-forming organs, characterised by distorted proliferation and development of leukocytes and their precursors in the blood and bone marrow.
- Haematological Malignancy
- Presence of neoplastic haemopoietic cells in the bone marrow +/- peripheral circulation |
|
|
Term
| What is the most common type of leukaemia in children? |
|
Definition
| Acute lymphoblastic leukaemia |
|
|
Term
| What is the philadelphia chromosome? |
|
Definition
| a specific chromosomal abnormality that is associated with chronic myelogenous leukemia (CML). It is the result of a reciprocal translocation between chromosome 9 and 22 |
|
|
Term
| Which type of adult leukaemia is the philadelphia chromosome most commonly associated with? |
|
Definition
| Chronic myeloid leukaemia |
|
|
Term
| Apart from the Philadelphia chromosome, which other chromosomal abnormality predisposes children to leukaemia? |
|
Definition
|
|
Term
| What 3 investigations should be done to confirm leukaemia? |
|
Definition
Bone marrow aspirate
FBC
Peripheral blood film |
|
|
Term
A girl with leukeamia is prescribed allopurinol, why is this?
What electrolyte abnormality is the oncologist trying to avoid by prescribing allopurinol? |
|
Definition
To prevent Tumour Lysis Syndrome.
Hyperuricaemia. |
|
|
Term
| What is the definition of a stroke? |
|
Definition
A rapidly developing focal neurological deficit of vascular origin lasting over 24 hours or resulting
in death. |
|
|
Term
| Suggest 4 risk factors for stroke |
|
Definition
- Hypertension
- Atrial fibrillation
- Diabetes mellitus
- Smoking
- Previous TIA/stroke
- male
- high cholesterol |
|
|
Term
| A CT scan reveals an area of ischaemia. Explain the pathogenesis of this type of stroke. |
|
Definition
- Narrowing of the supplying blood vessels (thrombus or embolus) causes reduced blood flow (and thus oxygen and glucose) to an area of the brain
- There is a central area of necrosis surrounded by a penumbra that may be salvageable if blood supply is re-established
- The ischaemic cascade is initiated causing inflammation and oedema that results in tissue damage
- This leads to glutamate toxicity and cell membrane permeability changes thus activating destructive enzymes |
|
|
Term
Symptoms: weakness on right side of body, confusion, slurred speech.
What artery is likely to have been affected by this stroke? |
|
Definition
| Left middle cerebral artery |
|
|
Term
| List 4 significant non-neurological complications of stroke. |
|
Definition
- Aspiration pneumonia
- DVT/PE due to immobility
- Communication difficulties due to dysphasia and dysarthria
- Depression
- Bed sores due to immobility |
|
|
Term
| Outline 2 management options for a patient with a stroke that the Occupational Therapist would be able to help with. |
|
Definition
- Home assessment and adaptations where appropriate
- Physical and cognitive deficit screen and provision of aids where needed |
|
|
Term
| What are the features of biliary colic? |
|
Definition
Pain is steady, starts rapidly, becomes intense and lasts at least 30 minutes and up to several hours.
Many patients complain of right upper quadrant pain, right flank pain, or even mid chest pain with cholelithiasis. There may be radiation to the back and shoulders and other concomitant symptoms such as vomiting and diarrhea. Fatty foods can provoke biliary pain |
|
|
Term
| What are the features of acute cholecystitis? |
|
Definition
Pain in the right upper quadrant or epigastric region. Symptomatically it differs from biliary colic by the presence of an inflammatory component (fever)
This pain is initially intermittent, but later usually presents as constant and severe
Referred pain may occur in the right scapula region
This may also present with the above mentioned pain after eating greasy or fatty foods such as pastries, pies, and fried foods.
This is usually accompanied by diarrhea, vomiting and nausea. The gallbladder may be tender and distended. |
|
|
Term
| Symptoms of acute pancreatitis? |
|
Definition
severe epigastric pain (upper abdominal pain) radiating to the back
nausea
vomiting
diarrhoea
loss of appetite
high temperature (Fever)
chills (shivering)
hemodynamic instability, which include shock
tachycardia (rapid heartbeat)
respiratory distress
peritonitis |
|
|
Term
| What are the symptoms of acute renal colic? |
|
Definition
The pain typically begins in the abdomen and often radiates to the hypochondrium or the groin. The pain is often colicky (comes in waves) due to ureteric peristalsis, but may be constant.
Described as the worst pain ever. |
|
|
Term
| Symptoms of carcinoma of stomach? |
|
Definition
Stage 1 (Early)
Indigestion or a burning sensation (heartburn)
Loss of appetite, especially for meat
Abdominal discomfort or irritation
Stage 2 (Middle)
Weakness and fatigue
Bloating of the stomach, usually after meals
Stage 3 (Late)
Abdominal pain in the upper abdomen
Nausea and occasional vomiting
Diarrhea or constipation
Weight loss
Bleeding (vomiting blood or having blood in the stool) which will appear as black. This can lead to anemia.
Dysphagia; this feature suggests a tumor in the cardia or extension of the gastric tumor in to the esophagus. |
|
|
Term
| Symptoms of crohns disease? |
|
Definition
It primarily causes abdominal pain, diarrhea (which may be bloody if inflammation is at its worst), vomiting (can be continuous), or weight loss.
Growth failure in children
Uveitis
Can lead to obstruction, fistulae, or abscesses |
|
|
Term
| What are the symptoms of gallstone ileus? |
|
Definition
Symptoms of ileus include, but are not limited to:
moderate, diffuse abdominal discomfort
constipation
abdominal distension
nausea/vomiting, especially after meals
lack of bowel movement and/or flatulence
excessive belching |
|
|
Term
| What are the symptoms of a hiatus hernia? |
|
Definition
Protrusion (or herniation) of the upper part of the stomach into the thorax through a tear or weakness in the diaphragm.
Causes:
dull pains in the chest, shortness of breath (caused by the hernia's effect on the diaphragm), heart palpitations (due to irritation of the vagus nerve), and swallowed food "balling up" and causing discomfort in lower esophagus until it passes on to stomach |
|
|
Term
| Symptoms of pancreatic cancer? |
|
Definition
Pain in the upper abdomen that typically radiates to the back(seen in carcinoma of the body or tail of the pancreas)
Loss of appetite (anorexia) or nausea and vomiting
Significant weight loss (cachexia)
Painless jaundice
diabetes
depression
symptoms of metastases |
|
|
Term
| Symptoms of a perforated peptic ulcer? |
|
Definition
A perforated peptic ulcer causes sudden, intense and steady pain
An ulcer severe enough to cause a perforation can also cause noticeable bleeding. Vomit that looks bright red or contains reddish-brown clumps or dark contents that resemble coffee grounds indicates bleeding caused by an ulcer. Other signs of bleeding include the presence of blood in the stool or passing black, tarry stools.
Fever
Abdominal swelling
Septic shock |
|
|
Term
|
Definition
| dult-onset Still's disease is a systemic inflammatory disease. The classic presentation is the triad of persistent high spiking fever, joint pain and a distinctive salmon-colored rash |
|
|
Term
| What are the symptoms of polymyalgia rheumatica? |
|
Definition
The classic symptoms include:
Pain and stiffness (moderate to severe) in the neck, shoulders, and hips, which inhibits activity, especially in the morning/after sleeping.
Fatigue and lack of appetite (possibly leading to weight loss) are also indicative of polymyalgia rheumatica.
Anaemia
An overall feeling of illness
Low-grade (mild) fever |
|
|
Term
| What is reactive arthritis? |
|
Definition
Reactive arthritis is classified as an autoimmune condition that develops in response to an infection in another part of the body.
Because common systems involved include the eye, the urinary system, and the hands and feet, one clinical mnemonic for Reiter's syndrome is "Can't see, can't pee, can't climb a tree."
The arthritis that follows usually affects the large joints such as the knees causing pain and swelling with relative sparing of small joints such as the wrist and hand |
|
|
Term
| What are the symptoms of psoriatic arthritis? |
|
Definition
Common symptoms of psoriatic arthritis include:
Pain, swelling, or stiffness in one or more joints.
Joints that are red or warm to the touch.
Sausage-like swelling in the fingers or toes, known as dactylitis.
Pain in and around the feet and ankles, especially tendinitis in the Achilles tendon or Plantar fasciitis in the sole of the foot.
Changes to the nails, such as pitting or separation from the nail bed.
Pain in the area of the Sacrum (the lower back, above the tailbone) |
|
|
Term
| What are the signs of adrenal insufficiency? |
|
Definition
severe abdominal pains
vomiting
profound muscle weakness and fatigue
depression
extremely low blood pressure (hypotension)
weight loss
kidney failure
changes in mood and personality
shock
Hyponatremia
Hyperkalemia
Hypercalcemia
Addison's can present with tanning of the skin that may be patchy or even all over the body. Characteristic sites of tanning are skin creases (e.g. of the hands) and the inside of the cheek |
|
|
Term
| What are the symptoms of Paget's disease? |
|
Definition
| An elevated level of alkaline phosphatase in the blood in combination with normal calcium, phosphate, and aminotransferase levels in an elderly patient are suggestive of Paget's disease. |
|
|
Term
|
Definition
Conn's syndrome is an aldosterone-producing adenoma characterized by the overproduction of the mineralocorticoid hormone aldosterone by the adrenal glands
Aldosterone causes increase in sodium and water retention and potassium excretion in the kidneys, leading to arterial hypertension (high blood pressure)
Increased aldosteronism will lead to hypernatremia and hypokalemia
The hydrogen ions that are exchanged for sodium are generated by carbonic anhydrase in the renal tubule epithelium causing increased production of bicarbonate. The increased bicarbonate and the excreted hydrogen combine to generate a metabolic alkalosis. |
|
|
Term
| What are the symptoms of Graves disease? |
|
Definition
Graves' disease is characterised by:
hyperthyroidism
diffuse goitre:
usually only moderately enlarged
thrill or bruit may be detected on account of increased vascularity
extrathyroid features:
Graves' ophthalmology - 40% of cases
pretibial myxoedema - 5% of cases
thyroid acropachy - rare
onycholysis - rare |
|
|
Term
| What are the symptoms of a branchial cyst? |
|
Definition
| usually presents as a smooth, slowly enlarging lateral neck mass that may increase in size after an upper respiratory tract infection |
|
|
Term
| What are the symptoms of horners sydrome? |
|
Definition
Signs that are found in patients on the affected side of the face include:
- partial ptosis (drooping of the upper eyelid from loss of sympathetic innervation to the superior tarsal muscle, also known as Müller's muscle
- upside-down ptosis (slight elevation of the lower lid)
- anhidrosis (decreased sweating on the affected side of the face)
- miosis (small pupils)
- enophthalmos (the impression that the eye is sunk in)
- loss of ciliospinal reflex
- bloodshot conjunctiva, depending on the site of lesion. |
|
|
Term
| What are the symptoms of myasthenia gravis? |
|
Definition
| Muscles become progressively weaker during periods of activity and improve after periods of rest. Muscles that control eye and eyelid movement, facial expressions, chewing, talking, and swallowing are especially susceptible. The muscles that control breathing and neck and limb movements can also be affected. |
|
|
Term
| Symptoms of neurosyphilis? |
|
Definition
Abnormal gait
Blindness
Confusion
Dementia
Depression
Headache
Incontinence
Irritability
Numbness in the toes, feet, or legs
O/E:
Abnormal reflexes
Muscle atrophy
Muscle contractions |
|
|
Term
| What causes bitemporal hemianopia? |
|
Definition
Bitemporal hemianopia most commonly occurs as a result of tumors located at the mid-optic chiasm. Since the adjacent structure is the pituitary gland, some common tumors causing compression are pituitary adenomas and craniopharyngiomas.
Also another relatively common neoplastic etiology is meningiomas. An etiology of vascular origin is an aneurysm of the anterior communicating artery which arise superior to the chiasm, enlarge, and compress it from above. |
|
|
Term
|
Definition
secretes excessive amounts of the free (not protein bound, and circulating in the blood, thyroid hormones, triiodothyronine (T3) and/or thyroxine (T4)
increased heat production - warm, moist skin, heat intolerance
telangiectasia, palmar erythema, pretibial myxoedema, onycholysis
weight loss, increased appetite, increased frequency of bowel movement but frank diarrhoea is uncommon; steatorrhoea may occur; dyspepsia; like juvenile-onset diabetes mellitus, may cause a decrease in weight despite an increased appetite
oligomenorrhoea
tachycardia, exertional dyspnoea, hyperdynamic circulation; systolic hypertension is common and diastolic hypertension can occur in up to 30% of patients
tiredness, irritability, nervousness
fine tremor, hyperkinesia
there are eye signs in Graves' disease |
|
|
Term
| What symptoms would an occipital lobe infarct cause? |
|
Definition
The most common presentation of an occipital lobe lesion is of a visual field defect:
cortical blindness
Anton's syndrome (form of cortical blindness in which the patient denies the visual impairment)
prosopagnosia (inability to recognise familiar faces despite having normal visual acuity and visual fields)
visual agnosia
homonymous hemianopia with or without involvement of the macula
visual hallucinations may accompany migraine and epilepsy - these are elementary, appearing as patterns such as zig-zags and flashes and filling the hemianopic field; in comparison, temporal lobe visual hallucinations are formed, complex, and fill the entire visual field.
visual illusions - micropsia - objects appear smaller - and macropsia - objects appear larger |
|
|
Term
| What are they symptoms of a 3rd nerve (oculomotor) palsy? |
|
Definition
The eye is incapable of movement upwards, downwards or inwards, and at rest the eye looks laterally and downwards owing to the overriding influence of the lateral rectus and superior oblique muscles respectively. The reduced response of levator palpebrae superioris results in ptosis - a drooping of the upper eyelid.
pupil may be fixed and dilated, and accommodation lost |
|
|
Term
|
Definition
Optic atrophy is the result of progressive optic nerve disease.
Loss of vision, either central or peripheral, is the only symptom.
The optic disc is pale and white. |
|
|
Term
Older men (e.g. over 60) are generally affected by different testicular tumours
from the younger age group. Name 2 types of neoplasm in the testis that
would be likely to present in this age group. |
|
Definition
1. Lymphoma (most common in >60yrs).
2. Spermatocytic seminoma. |
|
|
Term
What is the most
usual site of metastases from a testicular tumour? |
|
Definition
Local: Scrotal ulceration.
Lymph: Para-aortic lymph nodes.
Mets: Lungs* (and Liver). |
|
|
Term
| What symptoms would you expect in appendicitis? |
|
Definition
1. Pain began in the umbilical region.
2. Nausea and vomiting.
3. Movement worsens pain.
4. Anorexia.
5. Constipation or diarrhoea. |
|
|
Term
| How would you treat a ruptured appendix? |
|
Definition
1. Abx.
2. Opiate analgesia.
3. Appendicectomy.
4. IV fluids. |
|
|
Term
| 23 year old woman with frequent episodes of diarrhoea. She is short and thin and her bowel motions are often pale and foul smelling. This has been a recurring problem for most of her adult life and it is suspected that she has coeliac disease. We are asked to give 3 differentials. |
|
Definition
Lactose intolerance
IgA deficiency
Chronic pancreatitis
Giardia infection |
|
|
Term
| How does a DEXA scan work? |
|
Definition
2 X-ray beams: (1 mark)
one measures density of bone and soft tissue
the second measures the density of soft tissues alone.
The two are subtracted leaving the bone density (1 mark) |
|
|
Term
| What is an afferent pupillary defect? |
|
Definition
1) Affected pupil is unreactive to light (direct reflex is absent)
2) Consensual reflex is also absent
3) Affected pupil and intact pupil constrict when light is shone into the unaffected pupil (consensual reflex in affected eye is normal) |
|
|
Term
| A patient is screaming in agony from his ankle injury. What would you give him for pain relief? |
|
Definition
| Immediate release opioid- Morphine sulphate |
|
|
Term
|
Definition
| Is an anaesthetic gas consisting of 50% nitrous oxide and 50% oxygen |
|
|
Term
| What patients should not be given entonox in an emergency setting? |
|
Definition
Patients with:
- bowel obstruction
- pneumothorax
- have been scuba diving recently
Because N2O diffuses into air-containing spaces, causing pressure. |
|
|
Term
| What is the most appropriate investigation for an ankle injury with no pulse? |
|
Definition
| X ray of the ankle AP and lateral views |
|
|
Term
| What additional measures would you take to make a patient with a possible ankle fracture more comfortable before he goes for an Xray? |
|
Definition
| Reduce and immobilise the fracture in a back slab |
|
|
Term
| How should a fractured/dislocated ankle be treated? |
|
Definition
Short leg cast if reducible
Otherwise open reduction and internal fixation |
|
|
Term
| Your patient with an ankle fracture is immobilised in plaster for 6 weeks. What possible complications are likely in this time? |
|
Definition
DVT/PTE
Non-union
Muscle atrophy
Compartment syndrome |
|
|
Term
| Patient presents with 2hrs history of severe upper abdominal pain and vomiting. She is tachycardic but haemodynamically stable. The abdomen is tender with guarding in the upper part. Bowel sounds are diminished. What are likely diagnoses? |
|
Definition
Peptic ulcer perforation
Cholecystitis
Acute pancreatitis |
|
|
Term
| Patient presents with 2hrs history of severe upper abdominal pain and vomiting. She is tachycardic but haemodynamically stable. The abdomen is tender with guarding in the upper part. Bowel sounds are diminished. What key investigations should you perform? |
|
Definition
FBC - ?infection
U&Es, LFTs
Serum amylase/lipase - ?pancreatitis
Erect chest xray - ?pneumoperitoneum
Ultrasound of RUQ |
|
|
Term
| After a patient with severe RUQ abdo pain's initial assessment, but before definitive treatment, what 4 urgent measures would you take? |
|
Definition
Analgesia + antiemetic
O2 therapy
IV access and fluids
On going monitoring of vital signs
If pancreatitis is excluded - prescribe broad spectrum antibiotics |
|
|
Term
| List 3 likely non-traumatic causes of pain and swelling of a knee joint in a 7 year old boy. |
|
Definition
INFLAMMATORY
- juvenile idiopathic arthritis
- bursitis
- henoch-shonlein purpura
INFECTIOUS
- septic arthritis
- reactive arthritis
- osteomyelitis
MALIGNANCY (unlikely)
- osteosarcoma
- primary bone tumour |
|
|
Term
| How can you assess pain in a child who refuses to talk to you and clings to his mother? |
|
Definition
Faces pain scale - get the child to point to how they feel
FLACC
- ranks face, legs, activity, cry, consolability from 0-2 to determine severity of pain in children from 2months-7years
Alder hey traige pain score
- observational scale based on cry/voice, facial expression, posture, movement, colour |
|
|
Term
| What would you look for on examination of a painful, swollen knee?? |
|
Definition
- joint tenderness
- swelling/deformity
- restricted movement
- warmth/redness |
|
|
Term
| You consider aspirating a painful, swollen knee. What other investigations would you want to take? |
|
Definition
Bloods
- culture, FBC (increased WCC?), CRP/ESR
Imaging
- ultrasound to guide aspiration
- plain XR (not diagnostic but can be used as a baseline) |
|
|
Term
| What are 4 possible causes of rectal bleeding in a 70 year old man? |
|
Definition
- haemorrhoids
- anal fissure
- diverticular disease
- infective colitis |
|
|
Term
| What urgent investigation would you do to confirm a diagnosis of rectal carcinoma? |
|
Definition
| Rigid sigmoidoscopy +/- biopsy |
|
|
Term
| If rectal carcinoma is confirmed, what 4 additional investigations would you like to undertake and why? |
|
Definition
Blood tests - FBC (anaemia/baseline assessment)
- LFTs (?hepatic mets)
Colonoscopy - check for synchronous tumour as this influences operative procedure type
Staging CT - chest/abdo/pelvis for mets
Transrectal endoscopic US - superior to CT/MRI for T-staging |
|
|
Term
| What iatrogenic factor can cause acute angle closure glaucoma? |
|
Definition
| Tropicamide drops (anticholinergic) short-acting, relatively weak mydriatic used to dilate the pupil for examining the fundus of the eye. |
|
|
Term
| What drugs may be of benefit in osteoporosis? |
|
Definition
Biphosphonates (zoledronate)
Parathyroid hormone peptides (teriparatide) |
|
|
Term
| What would you tell a schizophrenic patient's mother about her going back to university? |
|
Definition
- as she has capacity you are legally obligated to follow her wishes
- julie has not made it clear that her mother can be informed about the details of her rx
- you cannot discuss julie's case with her without julie present and consent being given
- 1/3 recover, 1/3 relapse, 1/3 will never recover |
|
|
Term
| What are the features of primary biliary cirrhosis? |
|
Definition
- autoimmune condition
- destruction of the bile ducts of the liver
- bile builds up in the liver (cholestasis) and over time damages the tissue - this can lead to scarring, fibrosis and cirrhosis
- more common in women
- Fatigue
- Pruritus (itchy skin)
- Jaundice
- ascites
- xanthelasma |
|
|
Term
| What are the features of primary sclerosing cholangitis? |
|
Definition
Primary sclerosing cholangitis (PSC) is a disease of the bile ducts that causes inflammation and subsequent obstruction of bile ducts both at a intrahepatic (inside the liver) and extrahepatic (outside the liver) level.
The inflammation impedes the flow of bile to the gut, which can ultimately lead to cirrhosis of the liver, liver failure and liver cancer. The underlying cause of the inflammation is believed to be autoimmunity; and more than 80% of those with PSC have ulcerative colitis
PSC is characterized by recurrent episodes of cholangitis (infection of the bile ducts), with progressive biliary scarring and obstruction.
- Severe jaundice
- intense itching
- Malabsorption (especially of fat) and steatorrhea (fatty stool)
- hepatosplenomegaly |
|
|
Term
| What are the signs of polycystic liver? |
|
Definition
| Polycystic liver disease (PLD) usually describes the presence of multiple cysts scattered throughout normal liver tissue, in association with polycystic kidney disease. |
|
|
Term
| What are the features of metastatic liver disease? |
|
Definition
- Hepatomegaly
- Tenderness
- Cachexic
- Ascites
- Jaundice
- Pyrexia- up to 10% of patients
- ALP and gamma glutamyl trandspeptidase elevated
In 50% of all cases of primary tumor is gastrointestinal tract, other common sites include the breast, ovaries, bronchus and kidney. |
|
|
Term
| What are the symptoms of lymphoma? |
|
Definition
Lymphadenopathy or Swelling of lymph nodes - It is the primary presentation in Lymphoma.
B symptoms - Can be associated with both Hodgkin's lymphoma and non-Hodgkin's lymphoma. It consists of:
- Fever
- Night sweats
- Weight loss
Other Symptoms:
- Loss of appetite or Anorexia
- Fatigue
- Respiratory distress or Dyspnoea
- Itching |
|
|
Term
| What are the symptoms of hepatocellular carcinoma? |
|
Definition
Most cases of HCC are secondary to either a viral hepatitis infection (hepatitis B or C) or cirrhosis (alcoholism being the most common cause of hepatic cirrhosis).
HCC may present with
- jaundice
- bloating from ascites
- easy bruising from blood clotting abnormalities
- loss of appetite
- unintentional weight loss
- abdominal pain, especially in the RUQ
- nausea, emesis, or fatigue |
|
|
Term
| What are the symptoms of fatty liver? |
|
Definition
Large vacuoles of triglyceride fat accumulate in liver cells
Fatty liver can be considered a single disease that occurs worldwide in those with excessive alcohol intake and those who are obese
Accumulation of fat may also be accompanied by a progressive inflammation of the liver (hepatitis)
Patients are usually asymptomatic and there may be no hepatomegaly
- occasionally a patient may have an enlarged, smooth, firm liver |
|
|
Term
| What is autoimmune hepatitis? |
|
Definition
| The patient is classically a young female. They may present with signs of chronic liver disease (cirrhosis, low albumin, spider nivae etc.) or acute hepatitis (25% present with fever, jaundice, painful hepatomegaly etc.). Commonly, the patient will have amenorrhoea - this may be the presenting complaint. |
|
|
Term
| What are the features of alcoholic liver disease? |
|
Definition
Term that encompasses the hepatic manifestations of alcohol over consumption, including fatty liver, alcoholic hepatitis, and chronic hepatitis with hepatic fibrosis or cirrhosis
Patients may present with non-specific digestive symptoms, such as anorexia, morning nausea with dry retching, diarrhoea, and vague right upper quadrant abdominal pain. |
|
|
Term
Hx - sudden sharp lower back pain
- increases on coughing/sneezing
- radiates to his left leg and toes
O/E - has numbness of the dorsum of left foot + cannot extend his toes
- forward flexion of lumbar spine is markedly restricted
Which disc is involved and which nerve root is being compressed?
What abnormality would you expect to see when examining the patient's knee and ankle reflexes? |
|
Definition
Disc - L4/L5
Nerve root - L5
There would be no abnormality |
|
|
Term
| What 2 signs and symptom combinations might suggest a central disc prolapse? |
|
Definition
Bilateral leg pain / weakness
Urinary retention / incontinence
Reduced anal tone/perineal sensory loss
*Commonly, the foot becomes flail with loss of dorsiflexion of the foot (L4) and toes (L4,5), and of eversion and plantarflexion (S1). The ankle jerks are usually absent on both sides. |
|
|
Term
| Name 3 drugs used for the inital treatment of a patient with a prolapsed intervertebral disc? |
|
Definition
Paracetamol
Ibuprofen
Tramadol |
|
|
Term
| What investigation can confirm a diagnosis of prolapsed disc? |
|
Definition
|
|
Term
| What can paramedical staff offer to support treatment in this condition? |
|
Definition
Physiotherapists - rehabilitation, eg, with the learning of isometric exercises and proper methods of lifting
Occupational therapists - to teach proper lifting technique, ensure safety in the workplace |
|
|
Term
| What surgical treatment can be offered for prolapsed intervertebral discs? |
|
Definition
Microdiscectomy is a minimally invasive procedure where a portion of a herniated nucleus pulposus is removed by laser while using a microscope
Complications
- infection
- recurrent disc herniation |
|
|
Term
| Patient has an increased T4 level and very low TSH level. What is the most likely pathological mechanism causing thyrotoxicosis in this instance? |
|
Definition
| Grave's disease - autoimmune condition resulting in production of IgG TSH receptor autoantibodies = overstimulation of thyroid hormone |
|
|
Term
| Name 8 signs you might see on examination of someone with thyrotoxicosis. |
|
Definition
- exopthalmos
- tachycardia
- palmar erythema
- fine tremor
- pretibial myxoedema
- onycholysis
- atrial fibrillation
- goitre
- lid lag |
|
|
Term
| Apart from beta-blockers, what drugs are commonly used for managing thyrotoxicosis? |
|
Definition
Carbimazole
Polythiouracil
(anti-thyroid drugs) |
|
|
Term
| What is the most serious side effect that a patient may develop on anti-thyroid drugs? What should the patient be aware of that may signal the development of this condition? |
|
Definition
Agranulocytosis
Sore throat, mouth ulcer, fever or any serious infection |
|
|
Term
| What options are available for more definitive treatment of thyrotoxicosis? |
|
Definition
Radioactive iodine
Thyroidectomy |
|
|
Term
| A 25yr old is admitted with a 1 week history if diarrhoea with blood through the stool. What are common causes of these symptoms? |
|
Definition
Bacterial/viral gastroenteritis
Ulcerative colitis
Infective colitis (eg C. Diff infection following antibiotic use) |
|
|
Term
| What investigations could help clarify the cause of bloody diarrhoea? |
|
Definition
Bloods - FBC, ESR
Blood and stool cultures - exclude infective causes
Sigmoidoscopy +/- biopsy
Abdominal X-ray - may reveal fluid levels, gas- filled loops or loss of gas in parts where the loops are inflamed |
|
|
Term
| Biopsy suggests mucosal inflammation with crypt abscesses. What is the most likely diagnosis? |
|
Definition
|
|
Term
| What classes of drugs might be used to treat ulcerative colitis? |
|
Definition
Aminosalicylates (eg sulphasalazine)
Corticosteroids (eg prednisolone)
Thiopurines (eg azathioprine)
Ciclosporin/Infliximab |
|
|
Term
| If someone with ulcerative colitis deteriorates despite drug treatment, what urgent operation may be appropriate? |
|
Definition
proctocolectomy with permanent ileostomy
(colectomy) |
|
|
Term
| What clinical signs may be present in someone with infective endocarditis? |
|
Definition
MACROSS-JHP
- Murmur
- Anaemia, abscess
- Clubbing
- Roth spots (Oval, pale, retinal lesions surrounded by haemorrhage detected on fundoscopy)
- Osler's nodes (small painful lesions on pads of fingers/toes)
- Splinter haemorrhages
- Splenomegaly
- Janeway's lesions
- Haematuria
- Petechiae |
|
|
Term
| What are the 2 most likely organisms to be implicated in infective endocarditis?? |
|
Definition
Staphylococcus aureus
Streptococcus viridans |
|
|
Term
| What abnormality would you expect to find in the urine of someone with infective endocarditis and why does this occur? |
|
Definition
| Haematuria due to glomerulonephritis or renal infarct |
|
|
Term
| Other than IV drug abuse, what can cause infective endocarditis? |
|
Definition
Dental surgery
Catheterisation
Peripheral/central lines
Immunosuppression
Pre-existing valvular disease (rheumatic, congenital)
Prosthetic heart valve |
|
|
Term
| What 2 investigations are mandatory to confirm the diagnosis of infective endocarditis? |
|
Definition
Blood cultures - 3 sets taken 1 hour apart and from different places before initiating antibiotics
Transthoracic echocardiogram - detect vegetation |
|
|
Term
| What is the most likely cardiac lesion to be responsible for a pansystolic murmur, loudest at the left sternal edge and elevated JVP with giant "v" waves and tender pulsatile hepatomegaly? |
|
Definition
|
|
Term
| What 3 areas will you cover in a drinking history? |
|
Definition
QUANTITY
- how much he drinks each week
OCCUPATION
- drinking affecting his job?
FAMILY/FRIENDS
- does he remain in contact with them
- does he drink similarly to his friends |
|
|
Term
| List 5 features of alcohol dependence syndrome. |
|
Definition
COMPULSION
- feeling the strong desire to drink
WITHDRAWAL
- withdrawal symptoms (shakes, palpitations)
LOSS OF CONTROL
- unable to control drinking behaviour
LOSS OF TOLERANCE
- drinking more to get the same effect
PRIORITISING DRINKING
- making it the most important part of life
PERSISTING DESPITE NEGATIVE EFFECTS
- continuing to drink even though it causes problems |
|
|
Term
| What 2 laboratory investigations would you use to confirm excessive alcohol use? |
|
Definition
gamma-GT, ALT, AST (increased):
Gamma-GT, in particular, is closely correlated with alcohol consumption and is sometimes used to monitor drinking behaviour.
carbohydrate-deficient transferrin (CDT):
a highly sensitive test for heavy drinking - reduced concentrations found in serum after regular, excessive alcohol intake |
|
|
Term
| Give 4 long-term neurological sequelae of long term alcohol abuse |
|
Definition
Wernicke's encephalopathy
Korsakoff's psychosis
Peripheral neuropathy
Alcohol-related dementia |
|
|
Term
| Give 4 psychiatric long term sequelae of long-term alcohol abuse |
|
Definition
Depression
Anxiety
Amnesia
Personality disorder
Alcoholic hallucinosis |
|
|
Term
| What is Dressler's syndrome? |
|
Definition
Dressler's syndrome is a secondary form of pericarditis that occurs in the setting of injury to the heart or the pericardium (the outer lining of the heart). It consists of a triad of features, fever, pleuritic pain and pericardial effusion.
Dressler's syndrome is also known as postmyocardial infarction syndrome |
|
|
Term
| What are the features of pericarditis? |
|
Definition
Chest pain is the most characteristic symptom:
- sharp and well localized
- relieved by leaning forward
- sometimes pain may radiate to left shoulder, or down the arm or into the abdomen
- there may be a pleuritic element - pleuropericarditis |
|
|
Term
| What are the features of papillary muscle rupture? |
|
Definition
Symptoms of myocardial rupture are recurrent or persistent chest pain, syncope, and distension of jugular veins.
Causes mitral regurgitation. |
|
|
Term
| What are the signs of cardiogenic shock? |
|
Definition
- Anxiety, restlessness, altered mental state due to decreased cerebral perfusion and subsequent hypoxia.
- Hypotension due to decrease in cardiac output.
- A rapid, weak, thready pulse due to decreased circulation combined with tachycardia.
- Cool, clammy, and mottled skin
- Distended jugular veins due to increased jugular venous pressure.
- Oliguria (low urine output) due to insufficient renal perfusion if condition persists. |
|
|
Term
| What are the symptoms of a pericolic abscess? |
|
Definition
Clinical features of a pericolic abscess include:
- history of diverticular disease
- continuous left iliac fossa pain
- systemically unwell - swinging pyrexia, tachycardia - may present as PUO or septicaemia
- on examination, abdominal findings range from localised tenderness in the left iliac fossa to localised peritonitis
- purulent diarrhoea - the abscess may spontaneously drain into the colon |
|
|
Term
| What is a rectal villous adenoma? |
|
Definition
Villous adenoma is a type of polyp that grows in the colon and other places in the gastrointestinal tract.
These can also lead to secretory diarrhea with large volume liquid stools with few formed elements. They are commonly described as secreting large amounts of mucus, resulting in hypokalaemia in patients. On endoscopy a "cauliflower' like mass is described due villi stretching. |
|
|
Term
Your patient has frequent episodes of diarrhoea. Initial examination reveals that she is short and
thin. Further questioning discloses that her bowel motions are often pale coloured and foul smelling. You suspect coeliac disease. What are your differentials? |
|
Definition
- cystic fibrosis
- Whipple's disease
- Chronic pancreatitis
- lactose intolerance |
|
|
Term
| List 2 investigations that would help to diagnose coeliac disease. |
|
Definition
Jejunal biopsy:
- demonstrates characteristic histological lesion e.g. partial / subtotal villous atrophy
Immunology:
- gold standard blood test is endomysial antibodies
- also, elevated IgA antibodies to gliadin in 75-95% of patients
Imaging:
- barium follow through may show mucosal oedema and thickened jejunal folds
- ultrasound may show splenic atrophy |
|
|
Term
| What features on a biopsy would be suggestive of coeliac disease? |
|
Definition
Subtotal villous atrophy
Crypt hyperplasia |
|
|
Term
| Are typical biopsy appearances diagnostic for coeliac disease? |
|
Definition
| No, you also need autoantibody in serology testing |
|
|
Term
| How would you treat coeliac disease and what investigation would you do after treatment? |
|
Definition
Gluten-free diet.
Serology test: should show reduced autoantibody level. Anti tTG levels will drop.
Repeat biopsy would show reversal of pathology. |
|
|
Term
| What are 2 major adverse effects of chronic L-dopa administration? |
|
Definition
On-off phenomenon
End of dose dyskinesia
Nausea + GI upset
Hallucinosis |
|
|
Term
| Suggest 2 drugs that can be used as an alternative to L-Dopa. |
|
Definition
Dopamine receptor antagonists
- ropinirole
MAO-B inhibitor
- selegiline
Anticholinergic
- amantadine |
|
|
Term
| List 4 important symptoms you should enquire about if you think a patient has pre-eclampsia. |
|
Definition
Severe headache
Visual disturbance (blurring, flashing lights)
Discomfort in upper abdomen
Peripheral oedema |
|
|
Term
| What information would be relevant from the pregnant lady's booking attendance in suspected preeclampsia? |
|
Definition
Previous BP
Past hx of preeclampsia |
|
|
Term
| What bedside investigation would you perform in someone with suspected preeclampsia? |
|
Definition
| Urinalysis for proteinuria |
|
|
Term
| Give 3 blood investigations in preeclampsia. |
|
Definition
Haematocrit
Platelets
Urate
LFTs |
|
|
Term
| The BP of a lady with pre-eclampsia increases over the next 24hrs and biochemical abnormalities persist. What is the best treatment for this condition? |
|
Definition
|
|
Term
| List the complications of preterm rupture of membranes |
|
Definition
Preterm labour
Infection (chorioamnionitis)
Foetal distress/death
Placental abruption
Cord prolapse |
|
|
Term
| What would you do on a sterile speculum examination of someone with preterm rupture of membranes? |
|
Definition
Look for
- amniotic fluid draining through cervix
- degree of cervix dilation
- check for offensive yellow/brown discharge
Investigations
- high vaginal swab for infective agents (chlamydia trachomatis)
- chorioamniocentesis |
|
|
Term
| What 3 variables would you wish to monitor to try to identify the early onset of possible complications following a preterm rupture of membranes? |
|
Definition
Preterm labour
- dilation of cervix, urterine contractions, foetal heart rate
Chorioamnionitis
- maternal temperature, increased WCC/CRP, uterine tenderness
Foetal distress on CTG |
|
|
Term
| What signs in a baby suggest RDS? |
|
Definition
Cyanosis
Nasal flaring
Intercostal indrawing
Subcostal recession |
|
|
Term
| How would you assess the severity of an acute asthma attack from the history? |
|
Definition
What her normal PEFR is (to compare)
Whether she can finish a sentence in one breath
What her consciousness level is (GCS) |
|
|
Term
| What 4 clinical factors should you establish on examination of a patient with an acute asthma attack to assess the severity of the attack? |
|
Definition
Mental status (is she confused?)
Presence of cyanosis
Oxygen sats
Presence of breath sounds (silent chest = life threatening)
HR > 110 indicates attack
(Bradycardia indicates life-threatening)
RR >25 indicates attack
(Low resps indicates life-threatening) |
|
|
Term
| In someone with an acute asthma attack, what immediate investigations would you perform in A&E and what abnormality in each would cause you concern? |
|
Definition
Current PEFR - expected >75% mild, >50% severe, <33% life-threatening
Oxygen saturation - hypoxia
ABG - hypoxia, hypocapnia, uncompensated acidosis
Chest Xray - infection |
|
|
Term
| What 3 categories of treatment would you consider for a patient with an acute asthma attack? |
|
Definition
Oxygen therapy - via high flow mask
Bronchodilators - either nebulised or IV based on severity (5mg salbutamol)
Steroids - 40mg oral prednisolone or if cannot swallow 200mg IV hydrocortisone |
|
|
Term
| Patient has pain and swelling in calf following hip surgery. What is the diagnosis? |
|
Definition
|
|
Term
| Name 3 important causes of DVT |
|
Definition
Older age
Immobilization
Major orthopaedic surgery in the lower limb
In general
- smoking
- previous thrombo-embolism
- obesity
- malignancy
- pregnancy
- dehydration
- contraceptive pill/HRT |
|
|
Term
| What are the 3 factors composing Virchow's triad? |
|
Definition
1. Stasis of blood flow
2. Hypercoagulability of blood
3. Endothelial injury/dysfunction |
|
|
Term
| What prophylactic measures are recommended to prevent DVT following hip replacement? |
|
Definition
Compression stockings to encourage blood flow
Prophylactic subcutaneous LMWH - to reduce coagulability of blood
Early mobilization - to encourage blood flow |
|
|
Term
| What is the most serious complication that can result from this problem? |
|
Definition
|
|
Term
| What features of a breast lump suggest malignancy? |
|
Definition
Lump - non-tender
Skin changes - peau d'orange, dimpling, ulceration
Nipple changes - inversion (new)
Discharge - bloody
Associated - lymphadenopathy
General features - weight loss, anorexia, malaise |
|
|
Term
| What 2 investigations would help diagnose a breast cancer? |
|
Definition
Mammogram or US imaging of lump
FNA or core biopsy of lump |
|
|
Term
| Name 2 main surgical approaches to treating breast cancer. |
|
Definition
Mastectomy with axillary sampling/clearance
Wide local excision with axillary sampling/clearance |
|
|
Term
| What 3 pieces of core histological information will be required to decide further treatment of a breast cancer following mastectomy? |
|
Definition
| Tumour size Tumour grade Lymph node involvement Her2 status Completeness of excision Vascular invasion Steroid receptor status |
|
|
Term
| How does endometriosis present? |
|
Definition
Endometriosis is a common cause of chronic pelvic pain, and can also cause deep Dyspareunia, dysmenorrhoea and Subfertility. The obvious sign is bleeding from odd places, and indeed depending on the site of the lesion you can get haematuria, rectal bleeding, bleeding from the skin, or even in the eyes!
If a chocolate cyst ruptures, then you get signs of an acute abdomen, acute pain, tenderness, fever etc.
All of the symptoms tend to be cyclical in response to circulating hormones; however some may persist for periods. |
|
|
Term
|
Definition
Usually refers to ectopic endometrial tissue (the inner lining of the uterus) within the myometrium (the thick, muscular layer of the uterus).
The Endometrial implants that grow into the wall of the uterus bleed during menstruation, (the same as endometrial tissue bleeds) is discharged vaginally as menstrual bleeding. The vaginal pressure can be severe enough to feel like the uterus is trying to push out through the vagina, like the last stage of labor when the baby's head pushes into the cervix.
Other symptoms include;
Intense debilitating pain all the time and/or
Acute & increasing pain at menstration and ovulation
Strong 'contraction' feel of uterus
Abdominal cramps
A 'bearing' down feeling
Pressure on bladder
Dragging sensation down thighs and legs
Heavy bleeding and flooding |
|
|
Term
| How does cervical cancer present? |
|
Definition
Non-menstrual bleeding is the typical presentation
In the early stages, the tumour is a firm mass that will exhibit contact bleeding
In more advanced disease:
Post coital bleeding
Inntermenstrual bleeding
Post menopausal bleeding
Offensive, blood stained vaginal discharge
Abnormal bleeding in pregnancy – then a cervical lesion needs to be excluded
Very advanced disease:
Backache
Leg pain
Oedema
Haematuria
Bowel changes
Weight loss |
|
|
Term
| How does carcinoma of the uterus present? |
|
Definition
| Unusual or postmenopausal bleeding may be a sign of a malignancy including uterine sarcoma and needs to be investigated. Other signs include pelvic pain, pressure, and unusual discharge. A nonpregnant uterus that enlarges quickly is suspicious. |
|
|
Term
| How does carcinoma of the vagina present? |
|
Definition
| If there are symptoms, they are commonly abnormal vaginal bleeding, which may be postcoital, intermenstrual, prepubertal, or postmenopausal. Other, less specific signs include difficult or painful urination, pain during intercourse, and pain in the pelvic area. |
|
|
Term
|
Definition
Fibroids, particularly when small, may be entirely asymptomatic. Symptoms depend on the location of the lesion and its size.
Important symptoms include abnormal gynecologic hemorrhage, heavy or painful periods, abdominal discomfort or bloating, painful defecation, back ache, urinary frequency or retention, and in some cases, infertility. There may also be pain during intercourse, depending on the location of the fibroid. During pregnancy they may be the cause of miscarriage, bleeding, premature labor, or interference with the position of the fetus. |
|
|
Term
| What are the symptoms of a prolactinoma? |
|
Definition
Those that are caused by increased Prolactin levels are:
Amenorrhea
Galactorrhea (infrequent in men)
Loss of axillary and pubic hair
Hypogonadism, gynecomastia, erectile dysfunction (in males)
Those that are caused by mass effect are:
Bitemporal hemianopsia (due to pressure on optic chiasma)
Vertigo
Nausea, vomiting |
|
|
Term
| What does the 3rd cranial nerve do? |
|
Definition
| Controls most of the eye's movements, including constriction of the pupil and maintaining an open eyelid by innervating the levator palpebrae superioris muscle. |
|
|
Term
| WHat does the 4th cranial nerve do? |
|
Definition
The trochlear nerve (the fourth cranial nerve) is a motor nerve that innervates a single muscle: the superior oblique muscle of the eye.
The actions of the superior oblique muscle are (1) depression of the eyeball, especially when the eye is adducted; and (2) intorsion of the eyeball, especially when the eye is abducted.
Injury to the trochlear nerve cause weakness of downward eye movement with consequent vertical diplopia (double vision). The affected eye drifts upward relative to the normal eye, due to the unopposed actions of the remaining extraocular muscles.
The patient sees two visual fields (one from each eye), separated vertically. To compensate for this, patients learn to tilt the head forward (tuck the chin in) in order to bring the fields back together.
the diplopia gets worse when the affected eye looks toward the nose |
|
|
Term
| How would compression of the optic chiasma present? |
|
Definition
| When there is compression at optic chiasm the visual impulse from both nasal retina are affected, leading to inability to view the temporal, or peripheral, vision. This phenomenon is known as bitemporal hemianopsia. |
|
|
Term
| What are the signs of optic neuritis? |
|
Definition
Major symptoms are:
- sudden loss of vision (partial or complete)
- sudden blurred or "foggy" vision
- pain on movement of the affected eye
The vision might also be described as "disturbed/blackened" rather than blurry, as when feeling dizzy. Many patients with optic neuritis may lose some of their color vision in the affected eye (especially red), with colors appearing subtly washed out compared to the other eye |
|
|
Term
| How does acute glomerulonephritis present? |
|
Definition
The disease classically presents in children and young adults as sore throat followed a couple of weeks later by oliguria, haematuria, hypertension, and slightly abnormal renal function.
The disease is self-limiting, and 90% of patients will spontaneously recover. Treatment generally involves the control of blood pressure, reduced fluid and salt intake, and in some cases the use of antibiotics and diuretics. |
|
|
Term
| How does chronic glomerulonephritis present? |
|
Definition
| The two main presenting features are haematuria and proteinuria. Chronic glomerulonephritis may also present as acute or chronic renal failure, or nephritic or nephritic syndromes. |
|
|
Term
| What is nephrotic syndrome? |
|
Definition
| Nephrotic syndrome is characterized by high protein excretion, peripheral edema, and metabolic abnormalities |
|
|
Term
|
Definition
It is most frequently seen after lymph node dissection, surgery and/or radiation therapy, in which damage to the lymphatic system is caused during the treatment of cancer, most notably breast cancer.
Symptoms may include severe fatigue, a heavy swollen limb or localized fluid accumulation in other body areas, including the head or neck, discoloration of the skin overlying the lymphedema, and eventually deformity (elephantiasis). |
|
|
Term
| What is Sturge-weber syndrome? |
|
Definition
| Associated with port-wine stains of the face, glaucoma, seizures, mental retardation, and ipsilateral leptomeningeal angioma. It is characterized by abnormal blood vessels on the brain surface. Normally, only one side of the brain is affected. |
|
|
Term
| How does cystic fibrosis present? |
|
Definition
| The hallmark signs and symptoms of cystic fibrosis are salty tasting skin, poor growth and poor weight gain despite a normal food intake, accumulation of thick, sticky mucus, frequent chest infections, and coughing or shortness of breath. |
|
|
Term
| What is neurofibromatosis? |
|
Definition
Neurofibromatosis type 1 is the most common form of NF, accounting for up to 90% of all cases.
Two or more neurofibromas on or under the skin, or one plexiform neurofibroma (a large cluster of tumors involving multiple nerves); neurofibromas are the subcutaneous bumps characteristic of the disease, and increase in number with age.
Freckling of the groin or the axilla (arm pit)
Café au lait spots
Skeletal abnormalities |
|
|
Term
| What is lumbar canal stenosis? |
|
Definition
Lumbar spinal stenosis (LSS) is a medical condition in which the spinal canal narrows and compresses the spinal cord and nerves at the level of the lumbar vertebra. This is usually due to the common occurrence of spinal degeneration that occurs with aging. It can also sometimes be caused by spinal disc herniation, osteoporosis or a tumor.
Lumbar spinal stenosis results in low back pain as well as pain or abnormal sensations in the legs, thighs, feet or buttocks, or loss of bladder and bowel control.
Pseudoclaudication, now referred to as neurogenic claudication, typically worsen with standing or walking and improve with sitting. |
|
|
Term
| What is spondylolisthesis? |
|
Definition
Spondylolisthesis is the anterior or posterior displacement of a vertebra or the vertebral column in relation to the vertebrae below.
General stiffening of the back and a tightening of the hamstrings, with a resulting change in both posture and gait. The posture will typically give the appearance that the individual leans forward slightly and/or that they are suffering from kyphosis. A result of the change in gait is often a noticeable atrophy in the gluteal muscles due to lack of use. |
|
|
Term
| What is ankylosing spondylitis? |
|
Definition
The typical patient is a young male, aged 20–40; however, the condition also presents in females. The condition is known to be hereditary. Symptoms of the disease first appear, on average, at age 23 years. These first symptoms are typically chronic pain and stiffness in the middle part of the spine or sometimes the entire spine, often with pain referred to one or other buttock or the back of thigh from the sacroiliac joint.
In 40% of cases, ankylosing spondylitis is associated with an inflammation of the eye (iritis and uveitis), causing redness, eye pain, vision loss, floaters and photophobia. |
|
|
Term
| 3 minutes after a transfusion a patient develops lumbar pains, rigors, dyspnoea and hypotension. What is the name of this complication of the transfusion? |
|
Definition
| Acute haemolytic transfusion reaction |
|
|
Term
| What is the most likely procedural reason that an acute transfusion reaction would occur? |
|
Definition
|
|
Term
| What immediate steps need to be taken following an acute transfusion reaction? |
|
Definition
1. Stop the transfusion while maintaining venous access
2. Notify the blood bank |
|
|
Term
| What 3 treatments might a patient require following an acute transfusion reaction? |
|
Definition
High flow oxygen
IV fluids
Diuretics |
|
|
Term
| What might you detect in the urine of someone with an acute transfusion reaction? |
|
Definition
|
|
Term
| What are the complications of blood transfusions? |
|
Definition
Allergic/anaphylactic reaction
Febrile non-hemolytic reaction
Transfusion related acute lung injury
Transfusion associated volume overload
Infection |
|
|
Term
| An elderly woman looks pale, falls and briefly loses consciousness. No focal weakness or abnormal movements. She makes a full recovery each time. What 3 disorders are likely to causes these symptoms? |
|
Definition
Complete heart block
Sinus arrest
Non-sustained ventricular tachycardia
Vasocagal syncope |
|
|
Term
| What can aggravate orthostatic hypotension? |
|
Definition
Antihypertensive medication
Anaemia
Over-diuresis
Polypharmacy
Age |
|
|
Term
| List 2 non-drug measures which can control postural hypotension. |
|
Definition
Standing up gradually
Staying well hydrated
Elevating the head of the bed while sleeping |
|
|
Term
| What types of drug therapy would you consider prescribing in an effort to alleviate symptoms of orthostatic hypotension? |
|
Definition
Synthetic corticosteroid with increased mineralocorticoid action
eg fludrocortisone 0.2mg TDS for 1 week
This drug causes a retention of salt and water and may also result in an increased adrenoreceptor sensitivity.
Other drug therapies used in vasovagal syncope include beta-blockers and disopyramide |
|
|
Term
| Your elderly patient with orthostatic hypotension improves on treatment and you plan discharge. What other factors do you need to consider? |
|
Definition
Medication review
Occupational therapy assessment
Dietetic assessment - food and fluids |
|
|
Term
| What is the definition of a stroke? |
|
Definition
| A focal (or at times global) neurological deficit lasting more than 24h or leading to death with a presumed vascular aetiology |
|
|
Term
| What are risk factors for stroke? |
|
Definition
- hypertension
- AF
- diabetes
- smoking
- previous stroke/TIA
- increasing age
- oral contraceptive pill use
- coagulopathy
- sedentary life
- high cholesterol
- male
- asian descent |
|
|
Term
| Explain the pathogenesis of an ischaemic stroke. |
|
Definition
- narrowing of the supplying BVs (thrombus or embolus) causes reduced blood flow (and thus oxygen and glucose) to an area of the brain
- there is a central area of necrosis surrounded by a penumbra that may be salvageable if blood supply is re-established
- the ischaemic cascade is initiated causing inflammation and oedema that results in tissue damage
- this leads to glutamate toxicity and cell membrane permeability changes thus activating destructive enzymes |
|
|
Term
| What artery is affected by a stroke that causes - weakness on right side of body, confusion, slurred speech? And on CT shows ischaemia in the left parietal cortex consistent with a recent cerebral infarct? |
|
Definition
| Left middle cerebral artery |
|
|
Term
| List 4 significant non-neurological complications of stroke. |
|
Definition
Aspiration pneumonia
DVT/PE due to immobility
Communication difficulties due to dysphasia + dysarthria
Depression
Bed sores due to immobility |
|
|
Term
| How would the occupational therapist be able to help someone with a stroke? |
|
Definition
Home assessment and adaptations
Physical and cognitive deficit screen and provision of aids where needed |
|
|
Term
| A lady with AF comes in with a loss of vision in her left eye, not painful, previous episodes recovered, symptoms came on <30mins, no headache. What is the likely cause? |
|
Definition
|
|
Term
| Name 2 causes of painless loss of vision. |
|
Definition
Retinal vein occlusion (sudden)
Retinal detachment (sudden)
Vitreous haemorrhage (sudden)
Neo-vascular cause or atrophic age-related macular degeneration (gradual)
Chronic open-angle glaucoma (very gradual)
Optic neuropathy (esp. non-arteritic ischaemic ON which causes sudden painless loss of VA)
Diabetic retinopathy (gradual loss)
NOT MS
NOT CVA |
|
|
Term
| What 2 points from the history (A lady with AF comes in with a loss of vision in her left eye, not painful, previous episodes recovered, symptoms came on <30mins, no headache.) help you distinguish the possible causes of vision loss in this patient? |
|
Definition
AF - increases risk of retinal artery occlusion
Absence of headache - excludes giant cell arteritis
Sudden onset - differentials narrowed |
|
|
Term
What features on the opthalmic examination would be important for you to note in this patient?
(A lady with AF comes in with a loss of vision in her left eye, not painful, previous episodes recovered, symptoms came on <30mins, no headache) |
|
Definition
- decreased visual acuity
- afferent pupillary defect
- cherry red spot at macula
- pale fundus
- cattle trucking in retinal arterioles |
|
|
Term
| What investigation would you perform on the carotid artery in someone with retinal artery occlusion? |
|
Definition
| Carotid stenosis is usually diagnosed by color flow duplex ultrasound scan of the carotid arteries in the neck. |
|
|
Term
| What is aspergillus fumigatus? |
|
Definition
Aspergillosis is a fungal condition, caused by Aspergillus fumigatus.
Illness occurs in cases of allergic reaction, immune suppression, or in previously damaged lung.
Aspergillus species are also associated with causing:
asthma
otomycosis
extrinsic allergic alveolitis
cerebral infarctions or brain abscesses, endocarditis, and problems in the ears and sinuses |
|
|
Term
| What is chlamydia psittaci? |
|
Definition
Chlamydia psittaci is the organism responible for the development of psittacosis, an atypical pneumonia.
It a rickettsial type of organism transmitted from infected birds either of the psittacine type, e.g. from parrots, budgerigars or parakeets, or from other species, e.g. pigeons.
Features of a gradual onset include malaise, increasing fever, and muscular pains. Initially, the cough is dry but a mucoid and bloody sputum may occur as the disease progresses. Hepatomegaly and splenomegaly are common. A faint macular rash resembling the spots of typhoid fever may be seen on the abdomen. |
|
|
Term
| What are the features of coxiella burnetii? |
|
Definition
Following an incubation of 14 to 26 days, there is a 'flu- like illness, characterised by:
headache and fever - predominant
raised temperature - 38 to 41 degrees centigrade
chills, malaise, anorexia
respiratory and gastrointestinal symptoms occur late with dry cough, chest pain, crackles after about 5 days
hepatosplenomegaly is common with biochemical evidence of hepatitis
entire course rarely exceeds 2 weeks - usually, 3 to 6 days - may resolve spontaneously
endocarditis may result - especially of the aortic valve |
|
|
Term
| What is haemophillus influenzae? |
|
Definition
Haemophilus influenzae is a small Gram- negative bacillus.
Haemophilus influenzae type B capsulated strains may cause:
- meningitis - tends to run a subacute course, particularly in children. Subdural effusions are prone to develop. This is the most common presentation of invasive disease.
- epiglottitis
- pneumonia
- septic arthritis
- cellulitis
Otitis media is caused by a non-capsulated strain of Haemophilus. |
|
|
Term
| What is legionella pneumophilia? |
|
Definition
Legionnaire's disease is a severe form of pneumonia caused by the gram negative bacterium Legionella pneumophila.
Legionnaire's disease should be suspected if the patient presents with three of the following:
prodromal virus-like illness
initial dry cough, confusion, diarrhoea
hyponatraemia
leukocytosis
Possible clinical features include:
abrupt onset of malaise, headache, myalgia and weakness
fever with rigor and temperature up to 40 deg.C appear 24 hours later after onset
cough - initially dry; becomes productive in half of patients; may be haemoptysis
half of cases develop gastrointestinal symptoms - nausea, vomiting, diarrhoea and abdominal pain
altered mental status - including confusion, lethargy, disorientation, hallucinations, depression, or coma |
|
|
Term
| What is mycoplasma pneumoniae? |
|
Definition
Mycoplasma pneumonia is implicated in about 6% of pneumonias in the UK. Infection occurs in 3 to 4 year cycles in temperate climates and chiefly affects children and young adults, causing an atypical pneumonia characterised by an influenza-like respiratory illness of gradual onset with headache, malaise, fever and cough.
Clinical features include:
- peak rate of infection in autumn and early winter
- initial influenza-like disease with headache, fever, malaise, myalgia, diarrhoea and fatigue - often develop several days before the onset of respiratory problems; the malaise and fatigue may persist for long after the acute illness
- cough - initially dry and often insignificant; usually becomes productive with a mucoid and purulent sputum; often paroxysmal, disturbing sleep; may be absent in one-third of cases
- isolated crackles or areas of wheezing may be heard over one of the lower lobes
- subsegmental atelectasis and small effusions often detectable in the absence of prominent chest symptoms |
|
|
Term
| What is pneumocystis carinii? |
|
Definition
In Europe and North America, Pneumocystis carinii is the most common cause of pneumonia in patients who are antibody positive for HIV. It occurs when the CD4 positive count falls below 200 and up to 80% of all AIDS patients will suffer from P. carinii pneumonia at some stage. In Africa however P. carinii pneumonia is relatively unusual with tuberculosis being more common.
Pneumocystis carinii pneumonia starts insidiously with symptoms of:
breathlessness - so called silent breathlessness
dry cough
There may also be tachypnoea, though chest crackles or other physical signs are rarely present. There may however be other signs of HIV infection such as oral thrush and weight loss. |
|
|
Term
| What is pseudomonas aeruginosa? |
|
Definition
Primary pneumonia due to Pseudomonas aeruginosa in healthy individuals is rare.
Infection normally develops in debilitated individuals with pre-existing lung disease, such as bronchiectasis, chronic bronchitis or cystic fibrosis, or following an aspiration pneumonia induced by sedation or endotracheal intubation.
Secondary infection usually develops after the eradication of more sensitive flora with antibiotics and in patients with neutropaenia due to cytotoxic chemotherapy.
Pseudomonas pneumonia is of considerable clinical significance in patients with cystic fibrosis since it correlates with worsening clinical condition and increased mortality. |
|
|
Term
| What conditions does staphylococcus aureus cause? |
|
Definition
These include:
skin lesions
impetigo
scalded skin syndrome
paronychia
cellulitis
surgical sepsis
septicaemia
food poisoning
enterocolitis
pneumonia
toxic shock syndrome
septic arthritis |
|
|
Term
| What is streptococcus pneumoniae? |
|
Definition
Pneumococcus is probably the most common and most important pathogen amongst the streptococci. It is a normal commensal of the upper respiratory tract.
Pneumococcus is a Gram-positive lanceolate diplococcus that shows draughtsman colonies.
Diseases caused by pneumococci include:
- community acquired pneumonia - the most common cause
- acute exacerbations of chronic bronchitis, sinusitis, otitis media, and conjunctivitis
- meningitis - especially in skull fracture from sinuses, etc.
- septicaemia and "occult bacteraemia" - in febrile children and endocarditis
- septic arthritis |
|
|
Term
| What is antisocial personality disorder? |
|
Definition
People with antisocial personality disorder exhibit traits of:
- impulsivity
- high negative emotionality
- low conscientiousness
- associated behaviours including irresponsible and exploitative behaviour, recklessness and deceitfulness
- manifest in unstable interpersonal relationships, disregard for the consequences of one's behaviour, a failure to learn from experience, egocentricity and a disregard for the feelings of others
- many people with antisocial personality disorder have a criminal conviction and are imprisoned or die prematurely as a result of reckless behaviour |
|
|
Term
| What is borderline personality disorder? |
|
Definition
Features include
- impulsivity, unpredictability
- unstable and intense interpersonal relationships, with inappropriate, sudden outbursts of anger and loss of temper with suicidal gestures, self mutilation and fighting
There may be chronic feelings of loneliness and boredom, resulting in a striving to be in company. There may be confused identity and goals
- pattern of sometimes rapid fluctuation from periods of confidence to despair, with fear of abandonment and rejection, and a strong tendency towards suicidal thinking and self-harm
- also transient psychotic symptoms, including brief delusions and hallucinations, may be present
- associated with substantial impairment of social, psychological and occupational functioning and quality of life
- particularly at risk of suicide |
|
|
Term
| What is generalised anxiety disorder? |
|
Definition
GAD is a common disorder, of which the central feature is excessive worry about a number of different events associated with heightened tension.
The anxiety and worry are associated with at least three of the following six symptoms (with at least some symptoms present for more days than not, for the past 6 months):
- restlessness or feeling keyed up or on edge
- being easily fatigued
- difficulty concentrating or mind going blank
- irritability
- muscle tension
- sleep disturbance |
|
|
Term
| What is post traumatic stress disorder? |
|
Definition
PTSD is characterised by:
delayed onset of symptoms
intense and prolonged psychological disturbance
The stressor which precipitates a PTSD is often of such a magnitude that the patient's coping strategies and defense mechanisms are overwhelmed. Examples of potent stressors include warfare, natural disasters and rape.
- re-experiencing Phenomena
- physiological reactivity to cues
- psychogenic amnesia
- markedly diminished interest in significant activities
- detachment or estrangement feelings
- restricted range of affect
- sense of a foreshortened future
- increased arousal (at least two required)
- hypervigilance
- exaggerated startle response
- symptoms lasting for at least one month
- the traumatic event results in clinically significant distress, interfere with social, occupational or other important areas of functioning |
|
|
Term
| List 3 common causes of severe upper GI blood loss |
|
Definition
Bleeding peptic ulcer
Mallory-Weiss tear
Oesophageal varices
Oesophagitis/duodenitis/gastritis |
|
|
Term
What 4 steps should you take in the inital management of a patient with haematemesis, low BP, high HR within the first 15 minutes of arrival?
(excluding FBC, U&Es, cross-match, clotting screen and clinical exam) |
|
Definition
- get senior help
- get IV access: insert 2 large bore cannulae into each antecubital fossa
- give 2 litres of warmed normal saline as quickly as possible
- consider giving l-2 units of blood
- catheterise
- notify surgeons, consider emergency endoscopy |
|
|
Term
| What 3 monitoring instructions would you ask the nurses to carry out once the patient is stable? (in haematemesis patient) |
|
Definition
|
|
Term
| What 4 investigations would you use to help you assess the maternal condition in a 24 year old primigravida with BP 145/105 and proteinuria? |
|
Definition
- FBC → Platelets (may be decreased, which may suggest HELLP – a subtype of severe pre-Eclampsia
characterised by Haemolysis (H), elevated liver enzymes (EL) and low platelets (P))
- LFTs → Transaminases (part of HELLP)
- U&Es → Creatinine (elevation may indicate underlying renal disease or (rarely) development of failure)
- Coag
- Uric Acid |
|
|
Term
| What 3 ways can ultrasound imaging be used to assess the fetal condition? |
|
Definition
GLAD
Growth - head circumference, abdominal circumference
Liquor volume - quantify
Activity - fetal movements + breathing
Doppler ultrasound of umbilical artery |
|
|
Term
| Other than ultrasound, what investigation would help reassure you about fetal wellbeing? |
|
Definition
| Cardiotocography provides a simultaneous record of the foetal heart rate and magnitude of uterine contractions |
|
|
Term
| How can the administration of steroids help the survival of the pre-term infant? |
|
Definition
Reduces risk of developing respiratory distress syndrome by stimulating production of pulmonary surfactant.
Reduces risk of necrotizing enterocolitis
Reduces risk of intraventricular haemorrhage |
|
|
Term
| What are the symptoms of pre-eclampsia? |
|
Definition
- occurs after 20 weeks gestation
- hypertension
- proteinuria
- oedema |
|
|
Term
| What are the risk factors for pre-eclampsia? |
|
Definition
- nulliparity
- age 40 years or older
- pregnancy interval of more than 10 years
- family history of pre-eclampsia
- previous history of pre-eclampsia
- body mass index 30 kg/m2 or above
- pre-existing vascular disease such as hypertension
- pre-existing renal disease
- multiple pregnancy |
|
|
Term
| List 6 possible causes of rectal bleeding in a 70 year old man. |
|
Definition
Haemorrhoids
Rectal tumour
Anal tumour
Anal fissure
Diverticular disease
Colitis
Angiodysplasia |
|
|
Term
| What urgent investigation would you require for a patient you suspect has rectal cancer? |
|
Definition
Protoscopy with rigid sigmoidoscopy.
This will enable identification of bleeding haemorrhoids or a rectal cancer, and can be performed at the bedside in A&E. |
|
|
Term
| If a diagnosis of rectal cancer is confirmed, what 4 additional investigations would you like to do and why? |
|
Definition
Colonoscopy - diagnostic, can control bleeding using adrenaline/diathermy/clipping
Contrast-enhanced CT of the chest, abdomen and pelvis - should be offered to all patients who are diagnosed with colorectal cancer to estimate the stage of the disease
MRI to assess the risk of local recurrence to all patients with rectal cancer unless it is contraindicated
Endorectal ultrasound to patients with rectal cancer if MRI shows disease amenable to local excision or if MRI is contraindicated
Blood tests - liver enzymes, calcium, alkaline phosphatase levels (for possibility of liver or bone metastases) |
|
|
Term
| A patient comes in with a painful red eye of sudden onset, with no Hx of foreign body or trauma. What 4 questions would you ask to establish a differential diagnosis? |
|
Definition
- What is the discharge like? (none, sticky, purulent, watery, white/stringy)
- What does the pain feel like? (e.g. gritty or severe)
- Has she got any associated visual changes? (e.g. haloes, decreased visual acuity)
- Any photophobia? (Uveitis/Corneal Ulcer)
- Any nausea or vomiting? (Glaucoma)
- Any recent eye drops to examine the retina? (Glaucoma) |
|
|
Term
| What 2 tests do you use to evaluate vision? Briefly decribe how you do them. |
|
Definition
1. Visual acuity - 6m Snellen chart at 6m, cover one eye at a time and read the letters until they can't read the next row. Glasses on.
2. Visual fields - Cover one eye at a time. Cover own eye as well. Ask pt. when they can see white hatpin coming in from the periphery. Test all 4 quadrants. |
|
|
Term
| What signs would you expect on examination of someone with acute closed angle glaucoma? |
|
Definition
- a stony hard eye marked pericorneal injection
- a semi-dilated, non-reacting pupil
- a hazy corneal reflex
- the anterior chamber is narrowed
- the pupil is oval (with a vertical long axis)
- high intra ocular pressure (40 – 80 mmHg)
- visualisation of the fundus not possible |
|
|
Term
| How would you treat acute angle closure glaucoma? |
|
Definition
1. Acetazolamide IV 500mg
- Carbonic anhydase inhibitor
- Decreases fluid formation, lowering intraocular pressure.
- As long as no contraindications (sickle cell anaemia, renal, kidney, adrenal failure (e.g. Addison's), sulphonamide allergy.
2. Pilocarpine 4% drops
- PARA-mimetic.
- Muscarinic receptor agonist.
- Causes miosis.
Surgery if chronic.
Prophylaxis for other eye as usually predisposed. |
|
|
Term
| What 4 features on inspection of the legs would you look for to confirm fractured neck of femur? |
|
Definition
1. Shortened leg on affected side.
2. External rotation of affected hip.
3. Pain radiates to knee.
4. Tenderness on palpation over greater trochanter.
5. Swelling of thigh (haematoma formation).
6. Inability to weight bear on affected side.
7. Pain on passive movement. |
|
|
Term
| What is the anatomical significance of a intra-capsular hip fracture? |
|
Definition
| In an intra-capsular fracture, the retinacular vessels which are the blood supply for the femoral head can be cut off and cause avascular necrosis. |
|
|
Term
| Which two areas are routinely screened for the presence of osteoporosis using a DEXA scan? |
|
Definition
| The lumbar spine (L1-L4) and at the femoral neck, where osteoporotic fractures are most likely to occur |
|
|
Term
| How does a DEXA scan work? |
|
Definition
| X-Rays from two sources are directed at the relevant area of the patient. The bone mineral density can be determined by measuring the absorption of the X-rays by the bone. |
|
|
Term
| Give 2 drug therapies that may be of benefit in osteoporosis. |
|
Definition
Therapies which retard bone resorption include:
oestrogen replacement therapy
bisphosphonates (alendronate)
calcitonin
Therapies which stimulate bone formation include:
calcium and vitamin D supplements
calcitriol
parathyroid hormone (teraparatide) |
|
|
Term
| How would you treat an undisplaced intra-capsular hip fracture? |
|
Definition
|
|
Term
| How would you treat a displaced intra-capsular hip fracture? |
|
Definition
Internal fixation (younger patients)
Total hip arthroplasty |
|
|
Term
| What surgical operation would be most appropriate for an extra-capsular hip fracture? |
|
Definition
| Displaced/undisplaced - internal fixation + prophylactic antibiotics + analgesia + rehabilitation |
|
|
Term
| What are the first rank symptoms of schizophrenia? |
|
Definition
- auditory hallucinations:
- hearing thoughts spoken aloud
- hearing voices referring to himself / herself, made in the third person
- auditory hallucinations in the form of a commentary
- thought withdrawal, insertion and interruption
- thought broadcasting
- somatic hallucinations
- delusional perception
- feelings or actions experienced as made or influenced by external agents |
|
|
Term
| Name 3 of the dopamine pathways in the brain. |
|
Definition
Mesolimbic pathway
Mesocortical pathway
Nigrostriatal pathway |
|
|
Term
| Why can a typical neuroleptic drug cause a tremor? |
|
Definition
| The drugs have an ability to block dopamine receptors in the brain. This causes extrapyramidal side-effects in patients, which include unsteady Parkinson's disease-type movements, body rigidity and involuntary tremors |
|
|
Term
| What are extra-pyramidal side effects? |
|
Definition
Acute dystonic reactions: muscular spasms of neck – torticollis, eyes – oculogyric crisis, tongue, or jaw; more frequent in children
Akathisia: A feeling of motor restlessness
Akinesia: inability to initiate movement
Pseudoparkinsonism: drug-induced parkinsonism (cogwheel rigidity, bradykinesia/akinesia, resting tremor, and postural instability; more frequent in adults and the elderly). Although Parkinson's disease is primarily a disease of the nigrostriatal pathway and not the extrapyramidal system, loss of dopaminergic neurons in the substantia nigra leads to dysregulation of the extrapyramidal system. Since this system regulates posture and skeletal muscle tone, a result is the characteristic bradykinesia of Parkinson's.
Tardive dyskinesia: involuntary asymmetrical movements of the muscles, this is a long term chronic condition associated with long term use of antipsychotics. |
|
|
Term
| What is the treatment and prognosis for schizophrenia? |
|
Definition
It is vital they continue to take their medication as symptoms are likely to return.
If the patient begins to experience voices or other symptoms, they should call their doctor.
Even with treatment, patients often remain symptomatic and few patients can function independently between acute episodes.
Social skills training, CBT, cognitive remediation, and social cognition training address several key components of social rehabilitation, which in conjunction with psychopharmacology contribute to domains of functional recovery and ultimately are promising approaches to helping patients achieve better outcomes beyond symptom stabilisation |
|
|
Term
| Why do you need regular blood tests when taking clozapine? |
|
Definition
| You need a FBC to check for agranulocytosis - low WBCs (possible side-effect of clozapine). |
|
|
Term
| What 3 clinical signs would you expect to find on a respiratory examination of someone with a pneumothorax? |
|
Definition
Dyspnoea
Hyperresonance on affected side
Hyperexpanded on affected side
Absent/diminished breath sounds on affected side |
|
|
Term
| What groups of patients are at increased risk of developing spontaneous pneumothorax? |
|
Definition
- history of cigarette smoking
- Marfan's syndrome
- homocystinuria
- family history of pneumothorax
Patients with primary spontaneous pneumothorax tend to be tall, slender, and young males. |
|
|
Term
| What factors need to be taken into account when considering aspiration treatment of spontaneous pneumothorax? |
|
Definition
The size of the pneumothorax
- <2cm = observation and O2 therapy
- >2cm = aspiration
Whether it is primary or secondary
- secondary = hospitalisation + chest tube thoracostomy |
|
|
Term
| Your patient has a spontaneous pneumothorax. He becomes increasingly breathless and distressed. What complication should you consider? |
|
Definition
|
|
Term
| What physical signs other than breathlessness and distress would you associated with tension pneumothorax? |
|
Definition
Deviated trachea (away from affected side)
Cyanosis
Tachycardia
Tachypneoa
Hypotension |
|
|
Term
| Where are the costal blood vessels? How can you avoid them? |
|
Definition
In the neurovascular bundle along the bottom of ribs.
Avoid by inserting chest drain along the superior surface of a rib.
"Safe zone"
- 4th-6th intercostal space.
- Behind pec. major.
- Anterior to mid-axillary line.
Lidocaine. |
|
|
Term
| Apart from infection, what can cause seizures? |
|
Definition
Hypoglycaemia
Electrolyte imbalance (hypo/hypernatremia)
Cocaine, amphetamines, heroin, phencyclidine, and GHB
Space occupying lesion
Drug withdrawal e.g. alcohol
Head injury
(Others: Stroke, Hypoxia, Syncope, Hyperglycaemia etc.) |
|
|
Term
| If you suspect a patient has bacterial meningitis, what should you do immediately? |
|
Definition
| Start IV antibiotics (ceftriaxone 2g) |
|
|
Term
| What would your management plan be for someone with suspected bacterial meningitis (other than routine blood tests)? |
|
Definition
- CT Brain - No LP due to possible raised ICP – indicated by seizure
- Blood cultures and PCR
- Coagulation Screen
- Contact HDU or ITU |
|
|
Term
| What are 4 common complications of bacterial meningitis? |
|
Definition
Septic shock
Raised ICP
Hearing loss
Cognitive and behavioural problems
Subdural effusion
Seizures |
|
|
Term
| What agency should you inform if someone has bacterial meningitis? |
|
Definition
|
|
Term
| List 5 indicators of dehydration. |
|
Definition
Decreased skin turgor
Dry mucous membranes
Low urine output
Increased capillary refill
Sunken anterior fontanelle
Severe
- ↓ Level of Consciousness
- Drinking poorly/not at all
- ↓ Skin Turgor (visible for >2 seconds)
- Circulatory Collapse e.g. weak rapid pulse, cyanosis, ↓BP, ↑RR, sunken anterior fontanelle |
|
|
Term
| How does vomiting cause an uncompensated metabolic alkalosis? |
|
Definition
- Vomiting causes loss of HCl
- Excessive vomiting causes hypochloraemia
- Hypochloraemia promotes bicarbonate resorption and reduces bicarbonate secretion in kidneys
- Result is excess bicarbonate producing metabolic alkalosis |
|
|
Term
| What investigations would you do in a 5 week old baby who is vomiting had has visible gastric peristalsis and a pyloric tumour? |
|
Definition
Abdominal ultrasound - shows thickened pyloric muscle thickness >4mm
Barium meal swallow - in infantile pyloric stenosis, a barium meal will show delayed gastric emptying, a dilated stomach and a narrowed and attenuated pyloric canal - the 'string sign'. |
|
|
Term
| What is the treatment for pyloric stenosis? |
|
Definition
|
|
Term
| A lady presents with pink frothy sputum, SOB, tachycardia and fine crackles in both lung bases. What 2 immediate interventions would you take? |
|
Definition
Give 100% oxygen through a facemask
Sit her up |
|
|
Term
| What would be your treatment for acute heart failure? |
|
Definition
intravenous loop diuretic:
40-80 mg frusemide
intravenous opiate analgesia:
5 mg diamorphine over 5 min
vasodilator therapy:
GTN
treatment of arrhythmias:
may require DC cardioversion or intravenous anti- arrhythmic therapy
digoxin:
cautious intravenous administration if the above fail
venesection:
a pint may be removed from a moribund patient who fails to respond to the above
inotropes (if hypotensive):
dobutamine infusion
dopamine infusion |
|
|
Term
| What 3 abnormalities on a chest X-ray would support a diagnosis of acute left ventricular failure? |
|
Definition
ABCDE:
- Alveolar Oedema
- Kerley B Lines (thin linear pulmonary opacities caused by fluid or cellular infiltration into the interstitium of the lungs)
- Cardiomegaly
- Dilated Prominent Upper Lobe Vessels
- Pleural Effusion |
|
|
Term
| What cardiac lesion is likely to be responsible for a pansystolic murmur at the apex? |
|
Definition
|
|
Term
| List 3 possible causes for a patient with left ventricular failure to deteriorate. |
|
Definition
Lack of compliance with medical treatment
Volume overload
Infection
Severe brain insult
After major surgery
Reduction of renal function
Asthma
ACS
Acute arrhythmia (eg AF) |
|
|
Term
| What are the features of acute appendicitis? |
|
Definition
abdominal pain
anorexia
right lower quadrant tenderness
adolescence or early adulthood
nausea
vomiting
fever |
|
|
Term
| What are the features of biliary colic? |
|
Definition
- pain is steady, starts rapidly, becomes intense and lasts at least 30 minutes and up to several hours
- many patients complain of RUQ pain, right flank pain, or even mid chest pain with cholelithiasis
- there may be radiation to the back and shoulders and other concomitant symptoms such as vomiting and diarrhea |
|
|
Term
| What are the features of cholecystitis? |
|
Definition
Acute gallbladder inflammation, and one of the major complications of cholelithiasis or gallstones.
previous episode of biliary pain
RUQ pain
positive Murphy's sign
abdominal mass
right shoulder pain
anorexia
nausea
vomiting
jaundice
fever |
|
|
Term
|
Definition
Intussusception is a major cause of intestinal obstruction in young children and is defined as "the prolapse of one part of intestine into the lumen of an immediately distal adjoining part"
Most often occurs in infants between 3 and 12 months of age, peaking at approximately 6 months of age.
Presentation often includes colicky abdominal pain, flexing of the legs, fever, lethargy, and vomiting. Blood per rectum/currant jelly stool, hypovolaemic shock. |
|
|
Term
| What is irritable bowel syndrome? |
|
Definition
A chronic condition characterised by abdominal pain associated with bowel dysfunction.
Symptoms:
abdominal discomfort
alteration of bowel habits associated with pain
abdominal bloating or distention
normal examination of abdomen |
|
|
Term
| What are the symptoms of a large bowel obstruction? |
|
Definition
Surgical emergency where a mechanical interruption (either complete or partial) occurs to the flow of intestinal contents, with multiple potential causes (e.g., malignant colorectal disease, benign stricture).
Symptoms:
colicky abdominal pain
abdominal distention
tympanic abdomen
change in bowel habits
hard faeces
empty rectum
soft stools
recent weight loss
rectal bleeding
abnormal bowel sounds
palpable rectal mass |
|
|
Term
| What are the symptoms of mesenteric ischaemia? |
|
Definition
abdominal pain
nausea
vomiting
diarrhea
heart rate > 100 |
|
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Term
| What would you expect on history and examination of someone with a duodenal ulcer? |
|
Definition
- acute onset of severe epigastric pain, nausea, vomiting, and loss of appetite
- melaena or bright red blood from rectum
- episodic epigastric pain relieved by eating
- referred pain to shoulders secondary to diaphragmatic irritation
- tachycardia, fever, epigastric tenderness, rigid abdomen, guarding, rebound tenderness, and occult or frank blood in stool |
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Term
| What are the symptoms of a ruptured AAA? |
|
Definition
| Classical triad of pain in the flank or back, hypotension and a pulsatile abdominal mass |
|
|
Term
| What are the features of acute laryngitis? |
|
Definition
Fever
hoarse voice
dysphagia
sore throat
odynophagia
cough
oropharyngeal white-grey exudates
hx of vocal abuse |
|
|
Term
| What are the features of apthous ulcer? |
|
Definition
| Painful open sore in the mouth characterized by a break in the mucous membrane |
|
|
Term
| What are the features of chronic laryngitis? |
|
Definition
| hoarseness lasting >3 weeks |
|
|
Term
| What are the features of croup? |
|
Definition
symptoms increasing with agitation
distinctive seal-like barky cough
age 6 months to 6 years
abrupt onset of symptoms
symptoms worse at night
hoarse voice
respiratory distress (sternal/intercostal indrawing, stridor) |
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|
Term
| What are the features of epiglottitis? |
|
Definition
Epiglottitis is a cellulitis of the supraglottis causing a potential airway emergency
rapid onset of high fever
sore throat
inability to control secretions
classic tripod positioning
difficulty breathing
irritability
cherry red swelling at tongue base |
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|
Term
| What are the features of infectious mononucleosis? |
|
Definition
cervical or generalised lymphadenopathy
pharyngitis
malaise
fever
splenomegaly
hepatomegaly
rash
jaundice
myalgia |
|
|
Term
| What are the features of laryngeal carcinoma? |
|
Definition
assoc/w smoking and alcohol
age >40 years
vocal changes
hoarseness
dysphagia
odynophagia (painful swallowing)
cervical lymphadenopathy
cervical mass
supraglottic or glottic mass
lesional erythroplasia, ulceration, necrosis, or bleeding |
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Term
| What are the features of a quinsy? |
|
Definition
- collection of pus beside the tonsil
- symptoms start appearing two to eight days before the formation of an abscess
- Severe unilateral pain in the throat
- Pyrexia above 103 degree F (39ºC)
- Unilateral Earache
- Odynophagia and difficulty swallowing saliva
- uvula displaced towards the unaffected side |
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|
Term
| What are the features of a squamous cell carcinoma of the tonsil? |
|
Definition
In older patients, asymmetric tonsils (also known as asymmetric tonsil hypertrophy) may be an indicator of virally infected tonsils, or tumors such as lymphoma or squamous cell carcinoma.
Oropharyngeal cancer is predominantly (90%) a squamous cell carcinoma arising from the subsites of the oropharynx: the base of tongue, soft palate, palatine tonsillar fossa and pillars, and lateral and posterior pharyngeal wall.
Signs include sore throat, oral pain, dysphagia, weight loss, neck mass, and trismus |
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|
Term
| What are the features of tonsilitis? |
|
Definition
Acute infection of the parenchyma of the palatine tonsils
pain on swallowing
fever (>38°C)
tonsillar exudate |
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|
Term
| What is ankylosing spondylitis? |
|
Definition
An inflammatory arthritis predominantly affecting the sacroiliac joints and axial spine
Inflammatory back pain is the hallmark clinical feature. This is defined as back pain that is of insidious onset, is worse in the morning, and improves with exercise |
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|
Term
| What is enteropathic reactive arthritis? |
|
Definition
Acute form of spondyloarthritis is associated with STI’s and acute diarrhoea. Usually occurs shortly after the initial infection, although it is still an autoimmune reaction.
- Acute, asymmetrical, polyarthritis
The classic triad of:
Conjunctivitis – can’t see
Non specific urethritis – can’t pee
Acute arthritis – can’t bend the knee |
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|
Term
|
Definition
- acute onset, severe joint pain
- MTP is the joint affected in >65% of patients
- Also often affects the PIP’s and DIP’s
- Warm, red, swollen, tender, painful joints
- Pyrexia is also often present
- typically lasts about 7 days and can resolve itself |
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|
Term
| What is lateral epicondylitis? |
|
Definition
Tenderness approximately 2 cm distal and anterior to the lateral epicondyle. They report pain during resisted wrist and digit extension, and during passive wrist flexion with the elbow extended
Exacerbated by repetitive activities |
|
|
Term
|
Definition
- gradual onset
- joint pain and stiffness
- provoked by movement of the affected joint, and relieved by resting the joint
- Stiffness is typically worse after long periods of inactivity
- Joint line tenderness
- Limited range of movements
- Joint crepitus on movement
- Bony swelling |
|
|
Term
| What is psoriatic arthritis? |
|
Definition
- Psoriatic arthritis is a chronic inflammatory joint disease associated with psoriasis
- Usually an oligoarthritis (2-5 joints, usually asyymetrical), usually weight bearing joints
- Osteolysis – perhaps the most characteristic sign. As the bone in the fingers is lost, there may be telescoping of the fingers
Spinal involvement – typically at the sacrum |
|
|
Term
| What is rheumatoid arthritis? |
|
Definition
- Pain and stiffness worse in the morning and after rest
- Early morning pain and stiffness may last several hours
- same joints are affected on both sides of the body
- Typically it affects the peripheral joints, and there is inflammation of the joint (synovitis). Deformity is common
- symmetrical swollen distal joints
- Often warm and tender joints
- rarely affects the hips
- Typically the joint of the hand (MCP, DIP and PIP’s)and the distal metatarsals of the foot
- nodules
- muscle wasting |
|
|
Term
| What is septic arthritis? |
|
Definition
Any joint that is hot, red and tender is a septic joint until proven otherwise! You must aspirate these joints! Septic arthritis can rapidly cause irreversible joint damage.
Patient often (but not always) has systemic fever, and raised inflammatory markers (ESR and CRP) |
|
|
Term
| What is trochanteric bursitis? |
|
Definition
- pain at site of bursa
- tenderness to palpation at site of bursa
- decreased active range of motion
- lateral hip pain
- pain at the extremes of hip rotation, abduction, or adduction
- pain of contraction of the hip abductors against resistance
- pseudoradiculopathy: pain radiating down the lateral aspect of the thigh |
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|
Term
|
Definition
| Pseudogout can result in arthritis of a number of joints. Most common is the knee, but it can also involve the wrists, shoulders, hips, and/or ankles. Pseudogout usually affects only one or a few joints at a time. The "attacks" of joint inflammation, characterized by acute joint swelling, warmth, stiffness, and pain, may last for days to weeks and can resolve spontaneously. |
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|
Term
| What is benzhexol? What are it's side effects? |
|
Definition
Antiparkinsonian drug of the antimuscarinic class
Also commonly used to treat extrapyramidal side effects occurring during antipsychotic treatment
Side effects -
CNS : Drowsiness, vertigo, headache, and dizziness are frequent.
Peripheral side effects : Blurred vision, dry mouth, impaired sweating, abdominal discomfort, and constipation are frequent. |
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|
Term
|
Definition
Drug in the sulfonylurea class used to treat type 2 diabetes mellitus. It is a long-acting 1st generation sulfonylurea
Can cause rashes and photoallergy and long episodes of hypoglycaemia. |
|
|
Term
| What is cyclophosphamide? |
|
Definition
The main use of cyclophosphamide is with other chemotherapy agents in the treatment of lymphomas, some forms of brain cancer, leukemia and some solid tumors.
Cyclophosphamide has severe and life-threatening adverse effects, including acute myeloid leukemia, bladder cancer, and permanent infertility, especially at higher doses |
|
|
Term
|
Definition
| Member of the class of drugs known as calcium channel blockers, used in the treatment of hypertension, angina pectoris, and some types of arrhythmia and prevention of migraine |
|
|
Term
|
Definition
Angiotensin converting enzyme (ACE) inhibitor used in the treatment of hypertension and some types of chronic heart failure.
Most common side effects include hypotension, dizziness when standing up, and dry cough. |
|
|
Term
|
Definition
Penicillamine is used as a form of immunosuppression to treat rheumatoid arthritis. It works by reducing numbers of T-lymphocytes, inhibiting macrophage function, decreasing IL-1, decreasing rheumatoid factor, and preventing collagen from cross-linking
Bone marrow suppression, dysgeusia, anorexia, vomiting and diarrhea are the most common side effects. |
|
|
Term
|
Definition
Antiarrhythmic agent used for the medical treatment of cardiac arrhythmias.
It is a sodium channel blocker which blocks open sodium channels and prolongs the cardiac action potential (outward potassium (K+) currents may be blocked). This results in slowed conduction, and ultimately the decreased rate of rise of the action potential, which may result in widening of QRS on ECG.
Adverse effects include rash, myalgia, hypersensitivity reactions (fever, agranulocytosis), drug-induced lupus erythematosus (particularly in slow-acetylators), and proarrhythmic effects (e.g., torsades de pointes). |
|
|
Term
|
Definition
| Sulfasalazine is used in the treatment of inflammatory bowel disease, including ulcerative colitis and Crohn's disease. It is also indicated for use in rheumatoid arthritis and used in other types of inflammatory arthritis (e.g. psoriatic arthritis) where it has a beneficial effect. |
|
|
Term
| What is craniopharyngioma? |
|
Definition
| Craniopharyngioma presents with diplopia, vision loss, headaches, and short stature |
|
|
Term
| What are the signs of hypothyroidism? |
|
Definition
| Fatigue, cold intolerance, dry skin, hair loss, constipation, lethargy, and weight gain suggest hypothyroidism. |
|
|
Term
| What are the signs of Cushing's syndrome? |
|
Definition
Recent weight gain, acne, mood swings, and headaches may be present with Cushing's syndrome.
easy bruising, new striae, history of asthma or inflammatory conditions that are treated with glucocorticoids |
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|
Term
| What are the signs of Prader-Willi syndrome? |
|
Definition
| obesity, small hands and feet, learning difficulties, proportionate small stature |
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|
Term
| What are the signs of crohn's disease? |
|
Definition
abdominal pain, diarrhoea, joint pains, bloody stools
proportionate short stature, poor weight for height ratio, pallor, abdominal distension and tenderness, skin rashes, arthritis, |
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|
Term
| What is atrophic vaginitis? |
|
Definition
Inflammation of the vagina (and the outer urinary tract) due to the thinning and shrinking of the tissues, as well as decreased lubrication. This is all due to a lack of the reproductive hormone estrogen.
Genital symptoms include
- dryness
- itching
- burning
- soreness
- pressure
- white discharge
- malodorous discharge due to infection
- painful sexual intercourse
- bleeding after intercourse
Urinary symptoms include
- painful urination
- blood in the urine
- increased frequency of urination
- incontinence
- increased likelihood and occurrence of infections |
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|
Term
| What are the symptoms of a bladder calculus? |
|
Definition
severe lower abdominal and back pain, difficult urination, frequent urination at night, fever, painful urination and blood in the urine. The majority of individuals who are symptomatic will complain of pain which comes in waves. The pain may also be associated with nausea, vomiting and chills.
More common in men with prostate enlargement, those with catheters in, and those who are paralysed (stagnates urine). |
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Term
| What are the symptoms of detrusor instability? |
|
Definition
It usually presents with a sudden urge to urinate that is very difficult to delay and may be associated with leakage. Other features include:
Frequency of micturition
Nocturia
Abdominal discomfort
Urge incontinence |
|
|
Term
| What are the symptoms of faecal impaction? |
|
Definition
There can be fecal incontinence and paradoxical or overflow diarrhea (encopresis) as liquid stool passes around the obstruction.
Complications may include necrosis and ulcers of the rectal tissue.
Abdominal pain and bloating could also be present depending on the severity of the condition. Loss of appetite can also occur. |
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|
Term
| What are the symptoms of a urethral stricture? |
|
Definition
Obstructive voiding symptoms namely:
- Decreased force of urinary stream
- Incomplete emptying of the bladder
- Urinary terminal dribbling
- Urinary intermittency
- Deflected urinary stream
- Increased frequency of micturition
- Acute or chronic retention of urine
- Hydronephrotic signs due to back pressure |
|
|
Term
| What is urinary retention with overflow? |
|
Definition
| Urinary retention with overflow occurs when the bladder is full and the patient passes small amounts of urine frequently |
|
|
Term
| What are the symptoms of a UTI? |
|
Definition
burning on urination
frequent urination |
|
|
Term
| What are the symptoms of a uterine prolapse? |
|
Definition
vaginal protrusion/bulge
sensation of vaginal pressure
pelvic pain
urinary incontinence
urinary retention
constipation
disordered defecation
sexual dysfunction
lower back pain |
|
|
Term
|
Definition
| Cataract is a clouding of the lens inside the eye which leads to a decrease in vision. It is the most common cause of blindness and is conventionally treated with surgery. Visual loss occurs because opacification of the lens obstructs light from passing and being focused on to the retina at the back of the eye |
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|
Term
|
Definition
Open-angle: It is painless and does not have acute attacks. The only signs are gradually progressive visual field loss, and optic nerve changes
Closed-angle: sudden ocular pain, seeing halos around lights, red eye, very high intraocular pressure (>30 mmHg), nausea and vomiting, suddenly decreased vision, and a fixed, mid-dilated pupil. It is also associated with an oval pupil in some cases |
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|
Term
| What is diabetic retinopathy? |
|
Definition
Proliferative diabetic retinopathy (PDR) is the more advanced form of the disease. New blood vessels start to grow in the eye (neovascularisation), which are fragile and can haemorrhage. This may cause blurred vision and scarring of the retina.
In most cases, it will leave just a few specks of blood, or spots, floating in a person's visual field, though the spots often go away after a few hours
On funduscopic exam, a doctor will see cotton wool spots, flame hemorrhages, and dot-blot hemorrhages. |
|
|
Term
|
Definition
Mononeuropathy is a type of neuropathy that only affects a single nerve.
The most common cause of mononeuropathy is by physical compression of the nerve, known as compression neuropathy. Carpal tunnel syndrome and axillary nerve palsy are examples of this. |
|
|
Term
|
Definition
ANTERIOR UVEITIS
Redness of the eye
Blurred vision
Photophobia or Sensitivity to light
Eye pain
Floaters which are dark, floating spots along the visual field
Headaches
INTERMEDIATE UVEITIS
Most common:
Floaters
Blurred vision
POSTERIOR UVEITIS
Inflammation in the back of the eye is commonly characterized by:
Floaters
Blurred Vision
Photopsia or seeing flashing lights |
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|
Term
| What are the features of a vitreous haemorrhage? |
|
Definition
- sudden onset of floaters followed by diffuse vision loss
- monocular
- usually painless
- strong association with retinal neovascularisation
- associated with diabetes and sickle cell disease
- may occur after trauma
On examination:
severe vision loss; no afferent papillary defect; possible cells in anterior chamber; blood in vitreous humour with poor view of fundus |
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|
Term
| How does Creutzfeldt-Jacob disease present? |
|
Definition
The first symptom of CJD is rapidly progressive dementia, leading to memory loss, personality changes and hallucinations.
This is accompanied by physical problems such as:
- speech impairment
- jerky movements (myoclonus)
- balance and coordination dysfunction (ataxia)
- changes in gait
- rigid posture
- seizures |
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Term
| How does cushings syndrome present? |
|
Definition
extreme weight gain (buffalo hump, moon face)
muscle and bone weakness
osteoporosis
diabetes mellitus
hypertension
Immune suppression
moodiness, irritability, or depression
sleep disturbances
menstrual disorders such as amenorrhea in women and decreased fertility in men
Hirsutism |
|
|
Term
| What are the symptoms of depression? |
|
Definition
depressed mood
weight change
libido changes
sleep disturbance
psychomotor problems
low energy
excessive guilt
poor concentration
suicidal ideation
no mixed symptoms of depression and mania
functional impairment |
|
|
Term
| What are the symptoms of a frontal lobe tumour? |
|
Definition
sudden personality change
uncoordinated walking or weakness of one side of the body
loss of smell
occasional speech difficulties |
|
|
Term
| What are the symptoms of an occipital lobe tumour? |
|
Definition
| loss of vision to one eye |
|
|
Term
| What are the symptoms of a temporal lobe tumour? |
|
Definition
| seizures, which may cause strange sensations: a feeling of fear or intense familiarity (déjà vu), strange smells or blackouts; speech difficulties; memory problems |
|
|
Term
| What are the symptoms of a parietal lobe tumour? |
|
Definition
| difficulty speaking or understanding words; problems with writing, reading or doing simple calculations; difficulty coordinating certain movements, and finding your way around; numbness or weakness on one side of the body |
|
|
Term
| What are the symptoms of a cerebellar tumour? |
|
Definition
| lack of coordination; slurred speech (dysarthia); unsteadiness; flickering involuntary movement of the eyes (nystagmus); vomiting and neck stiffness |
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|
Term
| What are the symptoms of hypothyroidism? |
|
Definition
weakness
lethargy
cold sensitivity
constipation
weight gain
depression
menstrual irregularity
myalgia
dry or coarse skin
course hair
bradycardia |
|
|
Term
| What are the symptoms of hypomania? |
|
Definition
mood state characterized by persistent and pervasive elevated (euphoric) or irritable mood
extremely energetic, talkative, confident, and assertive. They may have a flight of ideas and feel creative. Many people also experience signature hypersexuality |
|
|
Term
| What are the symptoms of psychotic depression? |
|
Definition
delusions (beliefs or feelings that are untrue or unsupported)
hallucinations
agitation
difficulty falling asleep and frequent waking during the night
+ depressive symptoms |
|
|
Term
| What are the symptoms of a subdural haematoma? |
|
Definition
Gradually increasing headache and confusion
fluctuating levels of consciousness
Irritability
Seizures
Pain
Numbness
Headache (either constant or fluctuating)
Dizziness
Disorientation
Amnesia
Personality changes |
|
|
Term
| What are the symptoms of temporal lobe epilepsy? |
|
Definition
Symptoms:
deja vu
memories flooding into consciousness
amnesia during attack
olfactory or gustatory hallucinations
sensations rising up the body
Signs:
cut off from the outside world during an attack - feeling detached from surroundings
slow and confused
repetitive vocalisations
automatisms (repetitive movements)
lip-smacking
sniffing |
|
|
Term
| What does astrovirus cause? |
|
Definition
| gastroenteritis in children and adults. The main symptoms are diarrhea, followed by nausea, vomiting, fever, malaise and abdominal pain. |
|
|
Term
| What are the features of Hepatitis A? |
|
Definition
RNA virus usually spread by the fecal-oral route; transmitted person-to-person by ingestion of contaminated food or water or through direct contact with an infectious person
HAV infection produces a self-limited disease that does not result in chronic infection or chronic liver disease
Symptoms usually last less than 2 months, although some people can be ill for as long as 6 months:
Fatigue
Fever
Abdominal pain
Nausea
Appetite loss
Jaundice |
|
|
Term
| What are the features of Hepatitis C? |
|
Definition
chronic infection can lead to scarring of the liver and ultimately to cirrhosis
HCV is spread primarily by blood-to-blood contact associated with intravenous drug use
Liver cirrhosis may lead to portal hypertension, ascites (accumulation of fluid in the abdomen), easy bruising or bleeding, varices (enlarged veins, especially in the stomach and esophagus), jaundice, and a syndrome of cognitive impairment known as hepatic encephalopathy |
|
|
Term
| What are the different types of HPV associated with? |
|
Definition
Genital warts are caused by different strains of human papilloma virus - especially HPV types 6 and 11
infection with HPV type 16 or 18 has been associated with a higher rate of progression of cervical squamous intraepithelial lesions and cancer |
|
|
Term
|
Definition
|
|
Term
| What does herpes simplex type 1 cause? |
|
Definition
Type I Herpes virus
HSV I is spread by infected saliva and is therefore spread by close personal contact.
it is most commonly associated with oral-facial lesions
Type 2 herpes virus
- is a genital infection and is usually spread by genital contact
it is marked by groups of vesicles on the genitalia - genital herpes |
|
|
Term
| What virus causes measles? |
|
Definition
Measles is one of the most highly communicable infectious illnesses caused by an RNA paramyxovirus
prodromal stage is characterised by the onset of fever, malaise, coryza, conjunctivitis and cough
rash is erythematous and maculopapular, starting at the head and spreading to the trunk and limbs over three to four days
Koplik spots (small red spots with blueish-white centres) may appear on the mucous membranes of the mouth one to two days before the rash appears and may be seen for a further one to two days afterwards
Individuals are infectious from the beginning of the prodromal period (when the first symptom appears) to four days after the appearance of the rash |
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|
Term
|
Definition
chest pain (pleuritic)
dyspnoea
tachypnoea
pleural rub
haemoptysis |
|
|
Term
| How does broncial carcinoma present? |
|
Definition
Most common in older adult smokers and ex-smokers. Small tumours in the lung are often asymptomatic, so the majority of patients either have locally advanced or metastatic disease at diagnosis.
Most common presenting symptoms are:
- cough
- chest pain
- haemoptysis
- dyspnoea
- weight loss
Auscultation of the lungs may demonstrate wheeze, crackles, decreased breath sounds, and dullness to percussion. |
|
|
Term
| What are the features of bronchiectasis? |
|
Definition
cough
sputum production
crackles, high-pitched inspiratory squeaks and rhonchi
dyspnoea
fever
pleuritic chest pain
clubbing |
|
|
Term
| What are the features of chronic bronchitis? |
|
Definition
- Hx of smoking may be present
- Presents with progressive shortness of breath, wheeze, cough, and sputum production, including haemoptysis.
O/E:
may show quiet breath sounds, prolonged expiratory phase, rhonchi, or wheezes; advanced cases: cyanosis, barrel chest, use of accessory muscles of inspiration, increased S2 over left sternal border, or peripheral oedema |
|
|
Term
| What are the features of acute exacerbation of congestive cardiac failure? |
|
Definition
dyspnoea
pulmonary crepitations
peripheral oedema
cool peripheries
chest pain
third heart sound (S3)
fatigue and weakness
hypotension
tachycardia
elevated jugular venous pressure
displaced apex beat (point of maximal impulse)
dullness to percussion and decreased air entry in lung bases
wheezing |
|
|
Term
| What are the features of mitral stenosis? |
|
Definition
In general, features of mitral stenosis on examination include:
small pulse, which may be irregularly irregular
jugular venous pressure is only raised if there is heart failure
right ventricular hypertrophy, tapping apex beat
loud S1, loud P2 if pulmonary hypertension
opening snap
mid-diastolic murmur heard at the apex only
pre-systolic accentuation murmur if no atrial fibrillation |
|
|
Term
| What are the features of Goodpasture's syndrome? |
|
Definition
reduced urine output
haemoptysis
oedema
recent URTI
shortness of breath
cough
fever
nausea
crackles on lung examination |
|
|
Term
| What is idiopathic pulmonary haemosiderosis? |
|
Definition
A rare condition presenting in childhood or young adulthood with either anaemia or haemoptysis.
It presents with:
- recurrent intrapulmonary haemorrhage
- recurrent haemoptysis
- pyrexia
- secondary iron deficiency anaemia |
|
|
Term
| How would lobar pneumonia present? |
|
Definition
Common symptoms and signs of pneumonia include:
cough
fever
pleuritic chest pain
The classical physical signs of pneumonic lung consolidation are:
reduced percussion note
bronchial breathing
crackles
whispering pectoriloquy
pleural friction rub |
|
|
Term
| What iatrogenic factor can cause acute close-angle glaucoma? |
|
Definition
| Dilating drops (eg anticholinergics) to help examine retina |
|
|
Term
| How would you treat alcohol withdrawal syndrome? |
|
Definition
1. Nutritional - Pabrinex (vit B and C).
2. chlordiazepoxide for withdrawal symptoms. |
|
|
Term
| Who can give consent for an unconscious adult and under what act? |
|
Definition
Adults with Incapacity (Scotland) Act 2000 - Part 5.
If a welfare attorney or guardian is appointed to make medical decisions then seek consent from them if practicable and reasonable to do so.
If not then doctor is authorised to treat if appropriate. Section 47 certificates must be filled in. |
|
|
Term
| What are upper motor neurone signs? |
|
Definition
Upper motor neurone signs are the result of an interruption in the neural pathway above the anterior horn cell.
Characteristic of an upper motor neurone disease are:
- weakness - the extensors are weaker than the flexors in the arms, but the reverse is true in the legs
- muscle wasting is absent or slight - muscle wasting is prominent in a lower motor neurone lesion
- hyper-reflexia and clonus - reflexes are absent or reduced in a lower motor neurone lesion
- spasticity
- no fasciculations - fasciculations occur in a lower motor neurone lesion
- extensor plantar responses |
|
|
Term
| What are lower motor neurone signs? |
|
Definition
STORM BABY:
Strength
Tone
Other
Reflexes
Muscle mass
Babinski's sign
· In Lower all things go down: strength, tone, reflexes, muscle mass, and the big toe down in plantar reflex (Babinski's sign is big toe up: toe up = UMNL).
- Muscle paresis or paralysis
- fibrillations
- fasciculations
- hypotonia or atonia- Tone is not velocity dependent
- Areflexia or hyporeflexia -Along with deep reflexes even cutaneous reflexes are also decreased or absent
- Strength -weakness is limited to segmental or focal pattern, Root innervated pattern |
|
|
Term
| A patient with alcohol withdrawal becomes increasingly agitated and unresponsive. His left pupil is enlarged and he has UMN signs in the L arm and leg. Blood glucose is normal. What are the most likely causes of his acute deterioration? |
|
Definition
1. Intracranial haemorrhage
2. Subdural haemorrhage |
|
|
Term
| What are the other possible causes of reduced GCS in a patient with alcohol withdrawal? |
|
Definition
- hypoglycaemia
- hypoxia
- seizure
- infection
- sedation with drugs
- stroke |
|
|
Term
| Your patient with acute alcohol withdrawal's GCS deteriorates. What is your next investigation? |
|
Definition
|
|
Term
| What 2 drugs can terminate status epilepticus? |
|
Definition
PR diazepam.
IV lorazepam.
Phenytoin infusion |
|
|
Term
| You think that atopic eczema (atopic dermatitis) is a likely diagnosis. What 2 further points in the history would you seek to support your diagnosis? |
|
Definition
1. Atopy: Personal or family Hx of atopy (hay fever, asthma...)
2. Exacerbating factors: Pets at home? Irritant soaps? Wool clothes? Stress? |
|
|
Term
List 2 clinical signs which you would seek on examination of the skin to support your
diagnosis of atopic eczema. |
|
Definition
1. Erythematous, dry scaly patches.
2. Scratch marks (excoriation when epidermis breached).
3. Flexural areas.
4. Acute lesions: erythematous, vesicular, weepy lesions. |
|
|
Term
| What are the 2 main approaches to the topical treatment of eczema? |
|
Definition
MEDICAL:
1. Emollients - E45.
2. Corticosteroids for flare ups - Hydrocortisone, Betamethasone.
3. Topical Tacrolimus (immunosuppresant) for flare ups. |
|
|
Term
| What is the natural history of atopic eczema? |
|
Definition
1. Can be exacerbated by stress, irritant soaps, dog and cat fur.
2. Disease usually gets better going into adult life but there are relapses. |
|
|
Term
What advice would you give to the patient about her potential occupation? List 2
facts you would wish to discuss. |
|
Definition
1. Irritant chemicals in:
- Hairdressing (shampoo).
- Catering (wet work, detergent).
- Production engineering (soluble oil).
2. Lesions of eczema can be colonised by e.g. staph aureus. This has implications for working in health care and catering.
3. Working with animals. |
|
|
Term
| What are the symptoms of aortic stenosis? |
|
Definition
1. Syncope/presyncope.
2. Shortness of breath.
3. Chest pain on exertion.
4. Sudden death |
|
|
Term
Please describe 3 features of the murmur that you would expect to elicit in a case of
aortic stenosis. |
|
Definition
Ejection systolic
Best heard at the right 2nd intercostal space at border of sternum
Radiates to carotids
May hear an ejection click
Heaving apex beat
Slow rising pulse |
|
|
Term
| Why do patients with aortic stenosis experience chest pain? |
|
Definition
LV hypertrophy therefore increased myocardial oxygen demand.
Stenosed aortic valve therefore not enough blood reaching the coronary vessels. |
|
|
Term
| What is the most useful investigation to identify the cause of aortic stenosis and what abnormalities would you expect to find on this investigation? |
|
Definition
1. Thickened, calcified aortic valve cusps.
2. Left ventricular hypertrophy.
3. High pressure gradient across aortic valve.
LV ejection fraction not always changed. |
|
|
Term
The cardiologist recommends cardiac catheterisation for your patient with possible aortic stenosis. Why is this invasive test
indicated? |
|
Definition
| To determine whether he has coexisting coronary artery disease. If so, it can be treated at the same time as the valve procedure. |
|
|
Term
| You suspect a patient has carpal tunnel syndrome. In addition to pain, what other symptoms would you enquire about? |
|
Definition
Weakness of grip
Paraesthesia (numbness, tingling) |
|
|
Term
List 4 features on physical examination or testing that would help to confirm your
diagnosis of carpal tunnel syndrome. |
|
Definition
1. Positive Tinel's sign (Percussion of median nerve over flexor retinaculum causes worsening of symptoms in the median nerve distribution).
2. Positive Phalen's test positive (Flexion of wrist for 60s. causes worsening of symptoms in the median distribution).
3. Wasting of thenar eminence.
4. Weakness of thumb opposition.
5. Positive carpal tunnel compression test (pressure over proximal edge of carpal ligament causes worsening of symptoms in median nerve distribution)
6. Pain and paraesthesia is in the median nerve distribution (radial 3 and 1/2 digits). |
|
|
Term
| Name 6 conditions that may be associated with carpal tunnel syndrome |
|
Definition
Acromegaly.
Pregnancy.
Rheumatoid arthritis.
Diabetes mellitus.
Renal haemodialysis/amyloidisis.
Myxoedema. |
|
|
Term
| Name 2 possible treatments of carpal tunnel syndrome. |
|
Definition
Conservative: Wrist splint to be worn at night.
Surgical: Carpal tunnel release (division of the flexor retinaculum. |
|
|
Term
| Name 2 symptoms and signs that differentiate ulnar nerve entrapment from carpal tunnel syndrome. |
|
Definition
1. Ulnar nerve entrapment causes pain and paraesthesia in the ulnar distribution (ulnar 1 and 1/2 digits).
2. Ulnar nerve entrapment causes a partial claw hand (pinky and ring finger clawed).
3. Ulnar nerve entrapment causes positive Froment's sign (weakness of thumb adduction/loss of pincer grip/flexion of thumb on attempted pincer grip. |
|
|
Term
List 3 symptoms that you would enquire about, on further questioning, which would
support a diagnosis of claudication? |
|
Definition
1. Pain of calves or buttocks on walking a certain distance.
2. Pain relieved at rest.
3. Pain comes on more rapidly when walking uphill. |
|
|
Term
List 3 signs or tests that you would look for on local examination of the leg to support
your hypothesis of chronic arterial vascular disease. |
|
Definition
Buerger's test positive.
Hair loss, thin skin - atrophic skin changes.
Pale legs.
Cold legs.
Prolonged capillary refill. |
|
|
Term
She asks you about her condition of arterial vascular disease. In <50 words describe the likely cause of this
presentation as you would outline it to her. |
|
Definition
| Smoking, being overweight and increasing in age all predispose the arteries to form fatty deposits inside their walls. The arteries in your legs have narrowed because of this, causing less blood to reach your muscles. When you exercise, your legs are not getting enough oxygen due to the decreased blood flow and so become painful. |
|
|
Term
You suspect critical ischaemia. List 4 features which, on examination of the leg,
would support your assessment and suggest that the ischaemia is critical. |
|
Definition
Presence of gangrene.
Absent pedal pulses.
Foot pain at rest, relieved by dangling legs over side of bed.
(Presence of ulceration.)
Low Buerger's angle (< 20 degrees).
ABPI < 0.5. |
|
|
Term
| Name 3 organs that may cause food related pain. |
|
Definition
Gallbladder
Stomach
Pancreas |
|
|
Term
| What is the significance of a positive Murphy's sign? |
|
Definition
A positive Murphy's sign is seen in acute cholecystitis.
It is elicited by firmly placing a hand at the costal margin in the right upper abdominal quadrant and asking the patient to breathe deeply. If the gallbladder is inflamed, the patient will experience pain and catch their breath as the gallbladder descends and contacts the palpating hand. |
|
|
Term
| You suspect the patient may have a peptic ulcer. Name 1 investigation which could be performed to confirm the presence of H. Pylori. |
|
Definition
Urease breath test
(or if in A&E = oesophagogastroduodenoscopy + CLO test and biopsy) |
|
|
Term
| Briefly outline the action of lansoprazole in reducing acid secretion. |
|
Definition
Lansoprazole is a PPI. This irreversibly blocks hydrogen/potassium ATPase in parietal cells of the stomach,
The result is reduced H+ secretion. Reducing stomach acid formed. |
|
|
Term
| What are the complications of peptic ulceration? |
|
Definition
Acute upper GI bleed
Gastric outlet obstruction
Iron deficiency anaemia due to chronic blood loss |
|
|
Term
| What important initial investigation should you perform if you suspect perforation and what would it show? |
|
Definition
| Erect chest X-ray = pneumoperitoneum (air under the diaphragm) |
|
|
Term
| What is the most likely procedural reason for an acute haemolytic reaction to occur? |
|
Definition
Human error:
- Labelling.
- Collecting wrong blood from fridge.
- Failure to carry out required checks. |
|
|
Term
| What would you do if someone had an acute transfusion reaction? |
|
Definition
0. Stop transfusion.
1. O2 therapy.
2. IV fluids.
3. Adrenaline (if swollen lips, shock or breathing difficulty - like now, in case anaphyliaxis).
4. Consider inoptrope support if hypotension prolonged.
INVESTIGATIONS
1. Take blood cultures and samples for culture from component pack.
2. Inform blood bank.
3. Seek urgent critical care and haematology advice.
4. Admit to ICU if possible. |
|
|
Term
| List three further short term complications of blood transfusions. |
|
Definition
1. Infective shock (contaminated blood pack).
2. Severe anaphylaxis.
3. Febrile non-haemolytic tranfusion reactions
4. TRALI: Transfusion-related acute lung injury is a form of ARDS. Happens within 6 hours of transfusion. |
|
|
Term
Apart from investigations for haemolysis, list 2 other investigations, explaining your
reason for doing the test, to help elucidate the cause of the increased MCV. |
|
Definition
B12 - deficiency can cause macrocytic megaloblastic anaemia
Folate - deficiency can cause macrocytic megaloblastic anaemia
TFTs - hypothyroidism can cause macrocytic anaemia |
|
|
Term
| List 2 biochemical or haematological abnormalities that may occur in haemolysis. |
|
Definition
Biochemistry
- high LDH
- high unconjugated serum bilirubin
- haemoglobinuria
- haemosiderinuria
Haematology
- increased reticulocyte count
- methaemoglobinaemia |
|
|
Term
| Explain why in haemolysis increased serum bilirubin may not lead to increased renal excretion of bilirubin. |
|
Definition
| Haemolysis is a prehepatic cause of jaundice. This causes unconjugated hyperbilirubinaemia. Unconjugated bilirubin is not water soluble and so is not excreted by the kidney. |
|
|
Term
| What 2 defects in the red cells can cause haemolysis and give one example of each. |
|
Definition
1. Haemoglobinopathy (abnormal Hb)
- Sickle-cell disease.
- Thalassaemia.
2. Abnormal cell membrane
- Spherocytosis
- Elliptocytosis
3. Enzyme defect (abnormal enzymes)
- G6PD deficiency. |
|
|
Term
| List 2 organisms you would wish to vaccinate someone with a splenectomy against? |
|
Definition
1. Streptococcus pneumoniae.
2. Haemophilus influenzae B.
3. Meningitis C.
4. Flu. |
|
|
Term
| What pieces of advice would you give someone following a splenectomy? |
|
Definition
1. Stand-by amoxicillin to be started immediately if any symptoms of infection noticed.
2. Warn of risk of malaria and other tropical infections if going overeas.
3. Wear medic-alert identification.
4. Lifelong prophylactic Abx.
5. Annual flu vaccine and pneumococcal every 5 years |
|
|
Term
A 27 year old man has recently been admitted to hospital with an alcohol problem and is now seeking help for it. List 3 features from different aspects of the patient’s social history which would
indicate the severity of his alcohol problem. |
|
Definition
1. Quantity - how much is he drinking each week?
2. Occupation - is his drinking affecting his job?
3. Family/friends - is he still in contact with them? do his family/friends drink similarly to him? |
|
|
Term
| Give 4 long-term neurological sequelae of alcohol abuse. |
|
Definition
1. Peripheral neuropathy.
2. Cortical atrophy. Cerebellar degeneration.
3. Seizures.
4. Wernickes encephalopathy
5. Korsakoffs psychosis |
|
|
Term
| Give 4 long term psychiatric complications of alcohol abuse. |
|
Definition
1. Alcoholic hallucinosis.
2. Depression.
3. Increased suicide risk.
4. Morbid jealousy.
5. Anxiety disorder.
6. Sexual dysfunction. |
|
|
Term
| What parameters predict lung function in a normal, non-smoking subject? |
|
Definition
|
|
Term
| What is the difference between an obstructive and restrictive pattern in spirometry? |
|
Definition
Obstructive pattern
- FEV1 reduced more than FVC.
- FEV1/FVC ratio <0.7.
Restrictive pattern
- FVC reduced.
- FEV1/FVC ratio is normal or raised. |
|
|
Term
List 2 further noteworthy features indicated by the results:
Predicted Observed Post-dilator
FVC (L) 4.79 2.06 2.13
FEV1 (L) 3.67 0.56 0.60
TLC (L) 7.02 8.64
RV/TLC (%) 32 69
DLCO (mL/min/mm Hg) 27 21 |
|
Definition
1. No significant improvement after bronchodilator Rx.
2. Total lung capacity is increased due to hyperinflation.
3. Residual volume is increased due to loss of alveolar capacitance.
4. Impaired DLCO. |
|
|
Term
| You also arrange for some baseline blood tests, which show a raised haemoglobin of 19.8g/dl. What is the physiological explanation for the raised haemoglobin? |
|
Definition
| Chronic hypoxia stimulates kidney release of erythropoietin, which stimulates bone marrow production of red blood cells. |
|
|
Term
| What methods of smoking cessation are available? |
|
Definition
1. NRT - gum, patch.
2. Smoking cessation clinic.
3. Bupoprion (atypical antidepressant) - Reduces nicotine cravings and withdrawal symptoms.
4. Varenicline (Champix) - Nictonic receptor partial agonist. |
|
|
Term
| Patient brought in with a paracetamol overdose. What is the most important urgent investigation to undertake at this stage and why? |
|
Definition
Plasma paracetamol level
This will guide management |
|
|
Term
| What would you administer orally to reduce absorption of a paracetamol overdose? |
|
Definition
|
|
Term
| What investigations should be done and why in someone with a paracetamol overdose (other than paracetamol level)? |
|
Definition
LFTs - paracetamol is hepatotoxic
Coagulation screen - paracetamol is hepatotoxic and can impair liver synthesis of clotting factors
U&Es - assess renal damage and electrolyte levels for baseline measures
ABG - paracetamol OD can cause acidosis |
|
|
Term
| What is the most important treatment of paracetamol overdose and how does it work? |
|
Definition
N-acetylcysteine
When paracetamol is taken in large quantities, a minor metabolite called N-acetyl-p-benzoquinone imine (NAPQI) accumulates within the body. It is normally conjugated by glutathione, but when taken in excess, the body's glutathione reserves are not sufficient to inactivate the toxic NAPQI. This metabolite is then free to react with key hepatic enzymes, therefore damaging hepatocytes. This may lead to severe liver damage and even death by fulminant liver failure.
For this indication, acetylcysteine acts to augment the glutathione reserves in the body and, together with glutathione, directly bind to toxic metabolites. These actions serve to protect hepatocytes in the liver from NAPQI toxicity. |
|
|
Term
| Over the next 3 days a patient with paracetamol overdose becomes mildly jaundiced, agitated and confused. What is the likely diagnosis and what action can be taken? |
|
Definition
Hepatic encephalopathy due to liver failure
Refer to tertiary centre for liver transplant |
|
|
Term
| What symptoms would you enquire about to support a diagnosis of claudication? |
|
Definition
Leg pain relieved by rest
Pain exacerbated by exercise and impairs walking
Pain is located in the thigh/buttock/calf |
|
|
Term
| What signs or tests would you look for on examination of the leg to support a diagnosis of chronic arterial vascular disease? |
|
Definition
Diminished peripheral pulses
Cold/shiny skin
Pale peripheries
Peripheral hair loss
Ulceration/gangrene
Thickened toenails
Muscle atrophy |
|
|
Term
| Describe the likely cause of arterial vascular disease to the patient. |
|
Definition
- As we get older, the blood vessels that supply oxygen to our muscles may get narrower
- Smoking and being overweight are known to exacerbate this problem
- Once severe enough, narrowing prevents the muscles getting enough oxygen which is felt as pain |
|
|
Term
| What are the features of critical ischaemia? What would you find on examination? |
|
Definition
rest pain
arterial ulceration
gangrene
O/E - beurger's angle <20
- capillary refill <15secs
- diminished/absent pulses
- evidence of gangrene/ulceration |
|
|
Term
| What are the features of acute ichaemia? |
|
Definition
Pale
Pulseless
Painful
Paraesthetic
Perishing cold
Paralysis |
|
|
Term
| How do you treat acute HF? |
|
Definition
Oxygen
Morphine
Furosemide
GTN
Sit patient up |
|
|
Term
| 74 yr old lady has collapsed at home. She is cyanosed, producing green sputum, restless and vague about recent events has has an abbreviated mental test score of 6/10. What is the diagnosis for her acute deterioration in mental dysfunction? |
|
Definition
|
|
Term
| What are possible causes of delirium? |
|
Definition
HIDEMAP:
H - hypoxia
I - infection (eg pneumonia)
D - drugs
E - endocrine, e.g. diabetes
M - metabolic, e.g. hyper/hypocalcaemia
A - alcohol
P - psychosis |
|
|
Term
| What 2 gas abnormalities would you expect on an ABG in someone with pneumonia and delirium? |
|
Definition
|
|
Term
| How would you try to correct hypoxia and acidosis? What precautions should you take? |
|
Definition
| Oxygen with a 24% (low-flow) venturi mask due to risk of COPD in this patient |
|
|
Term
| What antibiotics would you use to treat pneumonia? |
|
Definition
|
|
Term
| 12hrs following admission a patient has not passed urine. What is the most appropriate investigation and how would you correct this abnormality? |
|
Definition
Pelvic ultrasound/U&Es
Urinary catheter |
|
|
Term
| A patient presents with a 10cm ulcer about her left medial malleolus. What in the history would suggest that the ulcer is venous? |
|
Definition
History of venous disease, DVTs or trauma (surgery/fractures to leg)
Pain less on elevation
Hx of immobility |
|
|
Term
| What examination findings would support a diagnosis of a leg ulcer being venous in origin? |
|
Definition
Located in the "gaiter" area
Characteristics - shallow/wet/irregular borders
Signs of venous hypertension
- oedema
- extravasation
- death of erythrocytes (skin pigmentation)
- scarring of the skin (atrophie blanche) and underlying tissue (lipodermatosclerosis) |
|
|
Term
| List 2 investigations which should be performed in someone with a venous ulcer. |
|
Definition
Ankle-brachial pressure index
- exclude arterial disease as the cause
Capillary glucose
- to check for undiagnosed diabetes mellitus (this influences management as it affects healing)
Bloods
- FBC (? infection)
- CRP (? vasculitis)
- albumin (hypoalbuminaemia can impair healing) |
|
|
Term
| Suggest 2 curative treatments you might consider for a venous ulcer. |
|
Definition
Multilayer decompression bandages
- to reduce blood pooling in lower limb
Cleansing and debridement |
|
|
Term
| Give 2 pieces of advice to a patient to prevent further venous ulcers once the ulcer has healed. |
|
Definition
Lifestyle modification
- encouraging patients to mobilize to encourage blood flow to the legs
- weight loss
- smoking cessation
Graduated class 1 or 2 elastic stockings can help prevent recurrence
Keep legs elevated at rest to reduce BP in lower limb |
|
|
Term
| What abnormalities on a FBC would suggest infectious mononucleosis? |
|
Definition
Leucocytosis
Lymphocytosis |
|
|
Term
| List 4 clinical signs you may find on examination of someone with EBV. |
|
Definition
Fever
Enlarged tonsils
Splenomegaly
Lymphadenopathy |
|
|
Term
| What is the causative organism for infectious mononucleosis? |
|
Definition
|
|
Term
| What is the mode of transmission for infectious mononucleosis? |
|
Definition
| The virus is excreted for some months in nasopharyngeal secretions (primarily by saliva) so can be spread by kissing, coughing, sneezing, or sharing a glass or food utensil |
|
|
Term
| What test confirms a diagnosis of infectious mononucleosis? |
|
Definition
| Paul-Bunnell (monospot) test |
|
|
Term
| What are 4 complications of EBV? |
|
Definition
Ruptured spleen
Meningitis
Chronic fatigue syndrome
Hepatitis
Guillian-barre syndrome |
|
|
Term
| What is the management of EBV? |
|
Definition
Symptomatic treatment from analgesics and throat lozenges
Adequate hydration
Avoiding contact sports |
|
|
Term
| How would you determine whether renal failure was acute or chronic? |
|
Definition
USS - look at the size of the kidney (both small = chronic)
FBC - look for normochromic anaemia (anaemia = chronic)
Parathyroid hormone - seen in real osteodystrophy
X-Ray - chondrocalcinosis at knees/pubic symphysis, osteopenia and bone fractures - look for renal osteodystrophy |
|
|
Term
| What 4 clinical features and/or laboratory findings that would guide your decision as to whether someone needs dialysis or not? |
|
Definition
- diuretic-resistant pulmonary oedema
- hyperkalaemia (refractory to medical treatment)
- metabolic acidosis (refractory to medical therapy)
- uraemic complications (pericarditis, encephalopathy, bleeding)
- dialysable intoxications (lithium, toxic alcohols, salicylates) |
|
|
Term
| What 3 forms of renal replacement therapy are available for someone with chronic renal failure? |
|
Definition
Haemodialysis
Peritoneal dialysis
Transplant |
|
|
Term
| What is the best form of renal replacement therapy in the long term? |
|
Definition
|
|
Term
What is the name given to this blood picture:
low Hb, low MCV, low MCH |
|
Definition
| Hypochromic microcytic anaemia |
|
|
Term
| What is the most likely haematological disorder in this lady with hypochromic microcytic anaemia? |
|
Definition
|
|
Term
| Name 2 possible factors underlying iron deficiency anaemia. |
|
Definition
Low dietary intake of iron
Multiple pregnancies
Female sex |
|
|
Term
| What arterial pO2 would you expect in someone with iron deficiency anaemia? |
|
Definition
| Normal because O2 content decreases in proportion to the haemoglobin |
|
|
Term
|
Definition
| Immature RBCs with no nucleus that contain RNA |
|
|
Term
| The reticulocyte count is normal. What does this mean? |
|
Definition
| This indicates the anaemia is due to dysfunctional erythropoeisis and not due to haemolysis or bleeding (eg menorrhagia) |
|
|
Term
A patient witth anaemia is found to be from South Asia. What co-existing blood condition may this patient have?
What is the test for this? |
|
Definition
Thalassaemia trait
Test - haemoglobin electrophoresis |
|
|
Term
| What is an accessory nipple? |
|
Definition
| They occur along the milk lines running from each axilla to the groin. Accessory nipples most commonly occur below the normal breast, whilst accessory breast tissue most commonly occurs in the lower axilla. |
|
|
Term
| What is a phyllodes tumour? |
|
Definition
Phyllodes tumors are typically large, fast growing masses that form from the periductal stromal cells of the breast.
Patients typically present with a firm, palpable mass. These tumors are very fast growing, and can increase in size in just a few weeks. Occurrence is most common between the ages of 40 and 50, prior to menopause. |
|
|
Term
|
Definition
Duct ectasia of the breast is a condition in which the lactiferous duct becomes blocked or clogged.
Signs of duct ectasia can include nipple retraction, inversion, pain, and sometimes bloody discharge. |
|
|
Term
| What are the symptoms of ductal carcinoma in situ? |
|
Definition
DCIS almost never produces symptoms or a lump that can be felt, so it is almost always found through screening mammography
DCIS is usually seen on a mammogram as very small specks of calcium known as microcalcifications |
|
|
Term
|
Definition
| The typical case is the presence of a painless, firm, solitary, mobile, slowly growing lump in the breast of a woman of childbearing years |
|
|
Term
| What is an intraductal papilloma? |
|
Definition
They are the most common cause of bloody nipple discharge in women age 20-40 and generally do not show up on mammography due to their small size, so the next step in treatment would be a galactogram to guide the subsequent biopsy.
The masses are often too small to be palpated or felt. A galactogram is therefore necessary to rule out the lesion. |
|
|
Term
| What is a mammary fistula? |
|
Definition
This is a communication between the skin and a major subareolar breast duct.
It may occur following incision and drainage of a non-lactating abscess, spontaneous discharge of a periareolar mass or following biopsy of a periductal inflammatory mass. |
|
|
Term
|
Definition
A breast cyst is a fluid-filled sac within the breast.
They're often described as round or oval lumps with distinct edges. In texture, a breast cyst usually feels like a soft grape or a water-filled balloon, but sometimes a breast cyst feels firm
Breast cysts can be painful and may be worrisome but are generally benign. They are most common in pre-menopausal women in their 30s or 40s. They usually disappear after menopause, but may persist or reappear when using hormone therapy. |
|
|
Term
| What is acute tubular necrosis? |
|
Definition
The death of tubular cells that form the tubule that transports urine to the ureters while reabsorbing 99% of the water (and highly concentrating the salts and metabolic byproducts).
Tubular cells continually replace themselves and if the cause of ATN is removed then recovery is likely. ATN presents with acute kidney injury (AKI) and is one of the most common causes of AKI. The presence of "muddy brown casts" of epithelial cells found in the urine during urinalysis is pathognomonic for ATN |
|
|
Term
| What are the symptoms of IgA nephropathy? |
|
Definition
The classic presentation is episodic frank hematuria which usually starts within a day or two of a non-specific upper respiratory tract infection.
Loin pain can also occur. The gross hematuria resolves after a few days, though microscopic hematuria may persist. These episodes occur on an irregular basis every few months and in most patients eventually subsides
Renal function usually remains normal, though rarely, acute renal failure may occur (see below). This presentation is more common in younger adults |
|
|
Term
| What is interstitial nephritis? |
|
Definition
A form of nephritis affecting the interstitium of the kidneys surrounding the tubules. This disease can be either acute, meaning it occurs suddenly, or chronic, meaning it is ongoing and eventually ends in kidney failure.
When caused by an allergic reaction, the symptoms of acute tubulointerstitial nephritis are fever, rash, and enlarged kidneys. Some people experience dysuria, and lower back pain. In chronic tubulointerstitial nephritis the patient can experience symptoms such as nausea, vomiting, fatigue, and weight loss. Other conditions that may develop include hyperkalemia, metabolic acidosis, and kidney failure. |
|
|
Term
| What is membranous nephropathy? |
|
Definition
Slowly progressive disease of the kidney affecting mostly patients between ages of 30 and 50 years, usually Caucasian.
Some patients may present as nephrotic syndrome with proteinuria, edema with or without renal failure. Others may be asymptomatic and may be picked up on screening or urinalysis as having proteinuria. |
|
|
Term
| What is minimal change disease? |
|
Definition
Disease of the kidney that causes nephrotic syndrome and usually affects children (peak incidence at 2–3 years of age).
The symptoms are proteinuria (leakage of protein into the urine) and edema (water retention). Nephrotic syndrome (NS) is a general term that refers to the loss of protein in the urine, hypoalbuminemia, and edema. Many conditions are categorized as nephrotic syndromes—minimal change disease is unique, because it is the only one lacking any evidence of pathology on light microscopy (hence the name).
When protein is lost in the urine, the concentration of protein in the blood decreases, thereby reducing the intravascular Oncotic pressure relative to the interstitial tissue. The subsequent movement of fluid from the vascular compartment to the interstitial compartment manifests as the swelling known as edema. Edema is commonly observed in the feet and legs, particularly in individuals with poorly functioning venous valves, and in the belly or abdomen (ascites), and around the eyes, but can occur anywhere, especially in response to gravity. Additionally, because of this extra fluid that stays in the body, individuals often gain weight and experience fatigue—in many patients, for example, clothes and shoes no longer fit. Some people notice that their urine becomes more frothy or foamy from the excess protein in the urine, and may find that they urinate less often. |
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Term
| What is nephrocalcinosis? |
|
Definition
Diffuse, fine, renal parenchymal calcification on radiology
It is most commonly seen as an incidental finding with medullary sponge kidney on an abdominal x-ray.
Though this condition is usually asymptomatic, if symptoms are present they are usually related to the causative process, (e.g. hypercalcemia). These include renal colic, polyuria and polydipsia |
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Term
| What are the symptoms of renal artery stenosis? |
|
Definition
Symptoms of renovascular hypertension include:
High blood pressure at a young age
High blood pressure that suddenly gets worse or is difficult to control
Kidneys that are not working well, which often occurs suddenly
Narrowing of other arteries in the body, such as to the legs, the brain, the eyes and elsewhere
Sudden buildup of fluid in the air sacs of the lungs (pulmonary edema) |
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Term
| What are the symptoms of urinary tract obstruction? |
|
Definition
Obstruction in the urethra causes bladder dilation, secondary hypertrophy and diverticulae formation.
Obstruction in a ureter causes dilation of the ureter (megaureter) and renal pelvicalyceal system (hydronephrosis).
Pain, particularly when the urinary obstruction is acute.
Decreased renal function due to back pressure causing renal tubular atrophy, glomerular hyalinisation and fibrosis.
Increased risk of urinary tract infection (UTI), sepsis and stone formation due to urinary stasis. |
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Term
| What is Wegener's granulomatosis? |
|
Definition
Kidney: rapidly progressive glomerulonephritis (75%), leading to chronic renal failure
Characterized by severe and rapid loss of kidney function featuring severe hematuria (blood in the urine), red blood cell casts in the urine, and proteinuria (protein in the urine), sometimes exceeding 3 g protein/24 h, a range associated with nephrotic syndrome. Some patients also experience hypertension (high blood pressure) and edema. Severe disease is characterized by pronounced oliguria or anuria, which portends a poor prognosis |
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Term
| What are the 4 different varieties of malignant lung tumours? |
|
Definition
Small cell lung cancer
Non-small cell lung cancer
- squamous cell carcinoma
- adenocarcinoma
- large cell carcinoma |
|
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Term
| What are the 4 common presenting symptoms of lung carcinoma? |
|
Definition
Dyspnoea
Haemoptysis
Weight loss
Cough
Chest pain |
|
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Term
| What is the first-line treatment for pneumonia? |
|
Definition
| Amoxycillin (500mg 3x daily) |
|
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Term
| Name 2 measures that can be used to increase sputum production. |
|
Definition
Physiotherapy
Nebulised saline
Postural drainage |
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Term
| As part of your investigation of a patient with pneumonia and previous lung cancer you find his platelet count is 75. List 3 possible causes. |
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Definition
Side effect of chemotherapy
Side effect of radiotherapy
Platelet clumping
Metastatic spread to bone marrow or spleen |
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Term
| What is the initial management of pyelonephritis? |
|
Definition
| Antibiotics and IV fluids |
|
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Term
| What 2 investigations would help elucidate the cause of a renal mass? |
|
Definition
Ultrasound - ?hydronephrosis
Non-contrast CT pyelogram - method of choice for suspected calculi (IV/contrast not recommended in renal insufficiency) |
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Term
| What consequence action should be taken if these tests reveal hydronephrosis? |
|
Definition
Removal of the obstruction and drainage of the urine
If higher obstruction:
- nephrostomy tube (acute)
- ureteric stent or pyeloplasty (chronic)
If lower obstruction:
- urinary/suprapubic catheter |
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Term
| What are the possible consequences of delaying treatment for hydronephrosis? |
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Definition
Stagnant urine increases the risk of infection and sepsis
Obstruction builds pressure, feedback pressure to kidney, causes chronic kidney damage |
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Term
| Give 2 methods by which kidney stones may be managed. |
|
Definition
CONSERVATIVE:
analgesia (NSAIDs/morphine), fluids, tamsulosin, nifedipine
SURGICAL:
shock wave lithotripsy, laser probes, ureteroscopic lithotripsy, open lithotomy |
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Term
| List 2 other differential diagnoses of painful/painless testicular swelling. (not cancer) |
|
Definition
Hydrocoele
Torsion
Orchitis
Epidiymo-orchitis |
|
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Term
| Name 2 causes of painless scrotal swelling. |
|
Definition
Epidymal cyst
Acute epididymitis
Varicocele
Inguinalscrotal hernia |
|
|
Term
| What radiological investigation would you use for a scrotal mass? |
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Definition
|
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Term
| Name the 2 common histological types of testicular tumour. |
|
Definition
|
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Term
| List 2 tumour markers that may be raised in testicular cancer. |
|
Definition
Alpha-fetoprotein (teratomas)
Beta-human chorionic gonadotrophin (teratomas and seminomas) |
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Term
| Name 3 treatment options for treating testicular tumour. |
|
Definition
- Surgical → orchidectomy
- Radiotherapy (local irradiation)
- Chemotherapy (e.g. Combination therapy with bleomycin, etoposide and cisplatin is now the standard regime) |
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Term
| What 2 features would you look for in the history to check for Parkinson's disease? |
|
Definition
Resting tremor
Rigidity
Bradykinesia |
|
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Term
| What 6 features do you look for on examination in someone you suspect has Parkinson's? |
|
Definition
Loss of arm swing
Difficulties with fine movements
Micrographia (small handwriting)
Facial hypomimia
Shuffling gait
Slurred monotonous speech
"Pill-rolling" resting tremor
Orthostatic hypotension
Cogwheel rigidity |
|
|
Term
| What pathological change underlies Parkinson's disease? |
|
Definition
The core pathology in Parkinson's disease is:
- degeneration of the dopaminergic nigrostriatal pathway
- decrease in the striatal concentration of dopamine
- presence of laminated inclusions - Lewy bodies - in neurons of the substantia nigra |
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Term
| What are the 2 drugs given as a single preparation in Parkinson's disease? Why should they be combined? |
|
Definition
L-Dopa with an inhibitor of peripheral dopa decarboxylase (carbidopa)
Carbidopa is used in augmentation of L-DOPA (Levodopa) in the treatment of Parkinson's disease (PD) to block the peripheral conversion of L-DOPA into dopamine for the purpose of reducing adverse side effects.
Combined therapy potentiates the central effects of l-dopa by decreasing the dose-dependency 4-5 fold, therein allowing for effective Parkinson's Disease treatment without cardiovascular risk associated with high peripheral dopamine. |
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Term
| What drugs can cause tremors? |
|
Definition
REST TREMORS can be caused by dopamine receptor blockers such as neuroleptics, atypical antipsychotics, anti-nausea agents (metoclopramide, prochlorperazine, promethazine), and calcium-channel blockers (flunarizine, cinnarizine) or dopamine depletors (reserpine, tetrabenazine
ACTION TREMORS are common following treatment with antidepressants (serotonin-reuptake inhibitors, tricyclics, monoamine oxidase inhibitors), mood stabilisers (lithium), antiepileptic drugs (valproic acid), cardiac drugs (amiodarone), immunosuppressants (ciclosporin, corticosteroids), asthma drugs (salbutamol, theophylline), and stimulants (amphetamines) |
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Term
| Give 2 classes of drugs and one example of each that can cause Parkinsonism. |
|
Definition
Neuroleptics (haloperidol)
Atypical antipsychotics (clozapine, rispiradone)
SSRIS (fluoxetine)
Anti-emetic (metaclopromide) |
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Term
| A patient comes into A&E with diarrhoea, a low potassium and high urea and creatinine. Why are these results relevant? |
|
Definition
Raised Urea/Creatinine → indicates dehydration and need for fluid resuscitation
Hypokalaemia → indicates significant diarrhoea and may cause arrhythmias/altered nerve conduction |
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Term
| What advice do you give nurses when admitting someone infectious? |
|
Definition
- Salmonella can spread directly from person to person so barrier nursing is needed
- Following Salmonella infection a patient continues to carry and secrete organisms for several weeks |
|
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Term
| What type of IV fluid would you give a patient with hypokalemia? How fast would you give the first 500ml? |
|
Definition
| Hartmanns solution over 30mins to 1 hour |
|
|
Term
| What is the first line antibiotic therapy for salmonella? |
|
Definition
| Ciprofloxacin for 3-7 days until fevers resolve |
|
|
Term
| What observations do you use to confirm death? |
|
Definition
Pupils fixed and dilated
No heart sounds for > 5 mins
No respiratory effort for one minute
All major pulses absent |
|
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Term
| What circumstances is it mandatory to inform the procurator fiscal about an adult death? |
|
Definition
- Sudden death
- Deaths related to neglect or complaint
- Drug-related death
- any death due to a disease, infectious disease or syndrome which poses an acute, serious public health risk including:
● any form of food poisoning, Hep A/B/C/E
- Death during administration of GA
- Legionnaire’s disease |
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Term
| What 2 features would you look for on inspection of the legs to confirm a fractured neck of femur? |
|
Definition
Shortened in comparison to other leg
Externally rotated |
|
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Term
| Hopelessness is the biggest predictor of a single behaviour in depression. What is that behaviour? |
|
Definition
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Term
| A patient complains of depression, her pulse is slowed and she has evidence of goitre. What blood test would you undertake and why? |
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Definition
| Thyroid function tests - to exclude or confirm hypothyroidism as the cause of her symptoms |
|
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Term
| How long does it take fluoxetine to work? |
|
Definition
| SSRIs take 2-6 weeks before their effects can be felt. |
|
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Term
| A patient put on fluoxetine for depression responds well. How long should she continue to take it once she feels better? |
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Definition
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Term
| After 3 months on fluoxetine for depression the patient's symptoms worsen. Suggest 2 medication strategies that can be offered to boost the effectiveness of her tablet. |
|
Definition
- Increase the dosage and check compliance
- Add a mood stabiliser e.g. Lithium
- Add a dopamine re-uptake inhibitor e.g. Bupropion (rarely done in clinical practice)
- Add a 5-HT2 receptor antagonist e.g. Mirtazapine (beware serotonin syndrome) |
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Term
| You decide to change a patient's antidepressant from fluoxetine to venlafaxine. What course of action is recommended before this can be done? |
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Definition
| Withdrawal of fluoxetine before cautious introduction of venlafaxine at low dose |
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Term
| A patient is acutely suicidal. Is it necessary to complete a section of the MHA to prevent her from leaving and could you legally detain her in the surgery if this was not completed in time? |
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Definition
Yes: under common law nurses in NHS properties may detain someone for 2 hours without completing a form with a further 1 hour given for a doctor to examine the patient.
If necessary, an Emergency Detention Certificate (72hrs detention) form can then be completed |
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Term
| Why are reflexes brisk in someone with a sudden onset of weakness on the R side with increased muscle tone? |
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Definition
Loss of descending inhibitory input to the reflex arc resulting in an uninhibited reflex response
Globally, brisk reflexes suggest an abnormality of the UMN or pyramidal tract |
|
|
Term
| Which cranial nerve is likely to be affected in a stroke with loss of sensation to the right side? |
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Definition
|
|
Term
| What visual field abnormality would you expect to find on examination of someone with right sided weakness, increased tone and decreased sensation? |
|
Definition
| Right homonymous hemianopia |
|
|
Term
| What 2 articles of the human rights act are most applicable when considering a DNR order? |
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Definition
Act 2 - right to life
Act 3 - protection from inhuman treatment |
|
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Term
| What 3 issues do you need to take into consideration before writing a DNR order? |
|
Definition
- Has the DNR order been discussed with the patient and family
- Does the patient have capacity to make the decision
- Would resuscitation likely to be successful and beneficial for the patient |
|
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Term
| Other than rectal carcinoma, what is likely to cause intermittent rectal bleeding? |
|
Definition
Haemorrhoids
IBS (crohn's disease, ulcerative colitis)
Diverticular disease
Anal fissure
Coagulopathies |
|
|
Term
| What features in the history (other than rectal bleeding) would you ask about to support a diagosis of rectal carcinoma? |
|
Definition
Weight loss
Change in bowel habit - increased freq/changed consistency/mucus passed
Sense of incomplete evacuation of bowels (tenesmus)
family history of colo-rectal cancer |
|
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Term
| What factors do you need to take into account in order to determine a patient with rectal carcinoma's prognosis? |
|
Definition
- Local Spread i.e. whether it has penetrated the bowel wall or not (yes → ~66% 5-yr survival)
- Lymphatic Spread i.e. whether there is lymph node involvement (yes → ~33% 5-yr survival)
- Distant Metastases i.e. whether other structures are involved (yes → ~5% 5-yr survival) |
|
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Term
| Name 2 medical conditions which may predispose patients to rectal carcinoma. |
|
Definition
Inflammatory bowel disease (esp ulcerative colitis, but also crohns)
Colorectal polyps
Familial adenomatous polypsosis (FAP) |
|
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Term
| What can cause dysphagia other than oesophageal cancer? |
|
Definition
Gastric reflux disease
Stroke
Parkinson's disease
Myasthenia gravis
Multiple sclerosis
Achalasia
Foreign body
Retrosternal goitre |
|
|
Term
| Give 2 features in any patient's Hx which would suggest a malignant cause of dysphagia? |
|
Definition
Weight loss
Sudden onset of dysphagia
Progressive dysphagia |
|
|
Term
| What key investigations would you request in a patient with dysphagia? |
|
Definition
|
|
Term
| Name the 2 pathological types of oesophageal carcinoma. |
|
Definition
Adenocarcinoma
Squamous cell carinoma |
|
|
Term
| Your consultant is considering a surgical resection for your patients oesophageal carcinoma. What investigation is now important and why would you undertake it? |
|
Definition
| Spiral CT abdo/chest - principle modality for staging the tumour. If the scan reveals inoperable or metastatic disease then there may be no advantage in further assessment of the primary. |
|
|
Term
| How would you palliate someones symptoms with oesophageal cancer? |
|
Definition
Radiotherapy - to relieve dysphagia
Intubation with a rigid silastic endoprothesis or expandable metal stent
Ablation with laser or argon beam plasma coagulation
Opiates for pain relief
Psychological and social support |
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Term
| 54yr old man with inflammatory bowel disease presents with an increase in bowel frequency, passage of mucus and blood PR and 2 month Hx of 4kg weight loss. Give 3 possible explanations for the patients change in symptoms. |
|
Definition
Exacerbation of inflammatory bowel disease
Stopping medication
Neoplastic change
Bacterial infection |
|
|
Term
| Name 4 non-invasive routine investigations you would undertake in someone with increased bowel freq and passage of mucus and blood with weight loss. |
|
Definition
FBC - check if patient is anaemic due to chronic blood loss
Clotting screen - patient may have a bleeding tendency
ESR - may be elevated in patients with inflammatory bowel disease
Stool culture - test for bacteria
Urea - rise in urea is consistent with a recent upper GI bleed
Group and save - in case the patient needs blood replacement or goes to theatre |
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Term
| What urgent investigations would you consider to obtain a biopsy sample for rectal bleeding? |
|
Definition
| Proctoscopy +/- rigid sigmoidoscopy |
|
|
Term
| Name the characteristic features seen on pathological examination of the biopsy material in ulcerative colitis (rectal) |
|
Definition
1. Ulceration confined to mucosa and submucosa.
2. Infiltration of leucocytes and plasma cells during active disease.
3. Crypt abscesses.
4. Loss of haustrations leading to smooth bowel - drain pipe appearance.
5. Pseudopolyps (in both type of IBD).
6. Decreased goblet cell mucin |
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Term
| Biopsies confirm chronic ulcerative colitis with areas of severe dysplasia. Give 2 treatment options. |
|
Definition
Surgical: Panproctocolectomy with ileostomy or ileo-anal pouch
Medical: IV corticosteroids (eg hydrocortisone sodium succinate) |
|
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Term
| What does low back pain, ocular inflammation and prolonged morning stiffness suggest? |
|
Definition
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|
Term
| What does back pain associated with numbess in the lateral border of the foot and increased pain on coughing suggest? |
|
Definition
|
|
Term
| What does 2 week Hx of low back pain, sensation of numbness in the perineal region and loss of bladder control suggest? |
|
Definition
|
|
Term
| What does persistent back pain, worse at night, previous breast cancer and recent weight loss suggest? |
|
Definition
|
|
Term
| What are anticholinergic side effects? |
|
Definition
Ataxia; loss of coordination
Decreased mucus production in the nose and throat; consequent dry, sore throat
Xerostomia or dry-mouth with possible acceleration of dental caries
Cessation of perspiration; consequent decreased epidermal thermal dissipation leading to warm, blotchy, or red skin
Increased body temperature
Pupil dilation (mydriasis); consequent sensitivity to bright light (photophobia)
Loss of accommodation (loss of focusing ability, blurred vision — cycloplegia)
Double-vision (diplopia)
Increased heart rate (tachycardia)
Tendency to be easily startled
Urinary retention
Diminished bowel movement, sometimes ileus - (decreases motility via the vagus nerve)
Increased intraocular pressure; dangerous for people with narrow-angle glaucoma
Shaking |
|
|
Term
| What is aortic incompetence? |
|
Definition
Aortic insufficiency (AI), also known as aortic regurgitation (AR), is the leaking of the aortic valve of the heart that causes blood to flow in the reverse direction during ventricular diastole, from the aorta into the left ventricle.
Symptoms of aortic insufficiency are similar to those of heart failure and include dyspnea on exertion, orthopnea and paroxysmal nocturnal dyspnea. Palpitations, collapsing pulse and angina pectoris may also be felt. In acute cases there may be cyanosis and circulatory shock.
The murmur of chronic aortic insufficiency is typically described as early diastolic and decrescendo, high pitched, which is best heard in the third left intercostal space and may radiate along the left sternal border. |
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Term
|
Definition
Ejection systolic murmur, best heard at the 2nd intercostal space left sternal edge. Radiates to the carotids.
Hypotension, cold peripheries, left ventricular enlargement, dyspnoea, slow rising carotid pulse.
May hear an ejection click, heaving apex beat or slow rising JVP with plateau.
Caused by congenital bicuspid valve or calcification of a normal 3 cusp valve or rheumatic fever. |
|
|
Term
| What is mitral regurgitation? |
|
Definition
Pan systolic murmur best heard over the apex, radiating to axilla.
Apex beat is displaced due to left ventricular dilatation and you may get signs of heart failure and AF.
Second heart sound may be absent. Murmur lasts the whole of systole. Low-pitched and easier to hear if the patient rolls onto their left side.
Caused by rheumatic heart disease, infective endocarditis, AF, cardiomyopathy, MI. |
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Term
|
Definition
Late systolic murmur best heard at the apex.
Similar to mitral regurg except the murmur will first be audible half way through systole and be preceded by the characteristic click of a prolapsing valve.
Caused by hypertrophic cardiomyopathy. |
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Term
|
Definition
Mid-diastolic murmur rarely heard anywhere other than the mitral area.
Often associated with AF. |
|
|
Term
| What is acute pericarditis? |
|
Definition
Best heard in the left sternal edge with the patient sat upright on full expiration.
Symptoms of pericarditis: sharp retrosternal pain, may radiate to shoulders and neck, fever
May hear a pericardial friction rub. |
|
|
Term
| What is an atrial septal defect? |
|
Definition
Wide splitting of the second heart sound, not altered by respiration.
Splitting of S2 can be normal during inspiration, because the diaphragm contracts and the venous return to the heart is increased. Therefore the R side of the heart takes longer to fill so the sound is split. |
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|
Term
| What is pulmonary artery hypertension? |
|
Definition
Common symptoms are shortness of breath, fatigue, non-productive cough, angina pectoris, fainting or syncope, peripheral edema (swelling around the ankles and feet), and rarely hemoptysis (coughing up blood).
Pulmonary venous hypertension typically presents with shortness of breath while lying flat or sleeping.
Signs include a loud S2 (pulmonic valve closure sound), (para)sternal heave, jugular venous distension, pedal edema, ascites, hepatojugular reflux, clubbing etc. |
|
|
Term
| What is pulmonary stenosis? |
|
Definition
Dynamic or fixed obstruction to flow from the right ventricle of the heart to the pulmonary artery.
Resistance to blood flow causes right ventricular hypertrophy. If right ventricular failure develops, right atrial pressure will increase, and this may result in reopening of the foramen ovale, shunting of unoxygenated blood into the left atrium, and systemic cyanosis. If PS is not severe, congestive heart failure occurs, and systemic venous engorgement will be noted. |
|
|
Term
| What is tricuspid stenosis? |
|
Definition
Valvular heart disease which results in narrowing of the tricuspid valve of the heart.
It is caused by rheumatic fever and accompanied by mitral stenosis.
Mid-diastolic murmur best heard over left sternal border with rumbling character and tricuspid snap opening with wide splitting S2.
May increase in intensity with inspiration. |
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|
Term
| Name the causative drug. An 80yr old man with Parkinson's whose rigidity increases on starting a new drug. |
|
Definition
|
|
Term
| Name the causative drug. A 70yr old woman with hypertension becomes short of breath and wheezy with a new tablet. |
|
Definition
|
|
Term
| Name the causative drug. A 53yr old man with hypertension, previously treated with atenolol develops bradycardia and pulmonary oedema on a new drug. |
|
Definition
|
|
Term
| Name the causative drug. A 21yr old man with status epilepticus develops hypoxia after IV therapy. |
|
Definition
|
|
Term
| Name the causative drug. A 65 yr old man develops urinary retention, constipation and a dry mouth as a side effect of a new drug. |
|
Definition
|
|
Term
| What is acrodermatitis enteropathica? |
|
Definition
Acrodermatitis enteropathica (AE) is a disorder of zinc absorption.
Typically presents when child is weaned.
Features:
- irritability and emotional disturbances are evident in the acute due to atrophy of the brain cortex
- skin lesions include a periorificial and acral vesiculobullous eruption leading to scaley, sharply demarcated crusted plaques |
|
|
Term
| What are the symptoms of atopic eczema? |
|
Definition
a chronic, relapsing course
pruritus
redness
swelling - either papules or oedema
blisters
lichenification - from continued scratching
dry skin
visible flexural dermatitis involving the skin creases, such as the bends of the elbows or behind the knees |
|
|
Term
| What are the symptoms of urticaria? |
|
Definition
| Commonly referred to as hives, is a kind of skin rash notable for pale red, raised, itchy wheals |
|
|
Term
| What are the signs of allergic dermatitis? |
|
Definition
Allergic dermatitis often causes a red, streaky, or patchy rash where the substance touched the skin. The allergic reaction is often delayed, with the rash appearing 24 - 48 hours after exposure. The rash may:
Have red bumps that may form moist, weeping blisters
Feel warm and tender
Ooze, drain, or crust
Become scaly, raw, or thickened |
|
|
Term
| What is dermatitis herpetiformis? |
|
Definition
Is a chronic blistering skin condition, characterised by blisters filled with a watery fluid.
Intensely itchy, chronic papulovesicular eruptions, usually distributed symmetrically on extensor surfaces (buttocks, back of neck, scalp, elbows, knees, back, hairline, groin, or face). |
|
|
Term
| What are the signs of scabies? |
|
Definition
The characteristic symptoms of a scabies infection include intense itching and superficial burrows. The burrow tracks are often linear, to the point that a neat "line" of four or more closely placed and equally developed mosquito-like "bites" is almost diagnostic of the disease.
In the classic scenario, the itch is made worse by warmth and is usually experienced as being worse at night, possibly because there are fewer distractions.
The superficial burrows of scabies usually occur in the area of the hands, feet, wrists, elbows, back, buttocks, and external genitals. |
|
|
Term
| What is addison's disease? |
|
Definition
Addison’s disease is a rare, chronic endocrine disorder in which the adrenal glands do not produce sufficient steroid hormones (glucocorticoids and often mineralocorticoids).
It is characterised by a number of relatively nonspecific symptoms, such as abdominal pain and weakness, but under certain circumstances, these may progress to Addisonian crisis, a severe illness which may include very low blood pressure and coma.
Hyponatremia (low sodium level in the blood)
Hyperkalemia (elevated potassium level in the blood)
Hypercalcemia (elevated calcium level in the blood) |
|
|
Term
| What are the symptoms of acute L4/5 disc protrusion? |
|
Definition
| In the acute presentation, symptoms often follow trauma or an injury to the disc produced by a sudden spinal strain, such as lifting heavy weights. There is acute low back pain, and, in the event of nerve root compression, radiating pain, paresthesias, and motor weakness. Severe bilateral root dysfunction may produce bowel and bladder incontinence and sexual dysfunction. |
|
|
Term
| What are the symptoms of developmental dysplasia of the hip? |
|
Definition
There may be no symptoms. Symptoms that may occur can include:
Leg with hip problem may appear to turn out more
Reduced movement on the side of the body with the dislocation
Shorter leg on the side with the hip dislocation
Uneven skin folds of thigh or buttocks
After 3 months of age, the affected leg may turn outward or be shorter than the other leg. |
|
|
Term
|
Definition
Self-limiting condition in which there is an inflammation of the inner lining (the synovium) of the capsule of the hip joint.
It is the most common cause of sudden hip pain and limp in young children
A recent viral infection (most commonly an upper respiratory tract infection) or a trauma have been postulated as precipitating events |
|
|
Term
|
Definition
Characterized by idiopathic avascular osteonecrosis of the capital femoral epiphysis of the femoral head leading to an interruption of the blood supply of the head of the femur close to the hip joint.
Common symptoms include hip, knee, or groin pain, exacerbated by hip/leg movement. The pain is moderate to severe, at times rendering the patient unable to stand. There is a reduced range of motion at the hip joint and a painful or antalgic gait. There may be atrophy of thigh muscles from disuse and an inequality of leg length.
The first signs are complaints of soreness from the child, which are often dismissed as growing pains, and limping or other guarding of the joint, particularly when tired |
|
|
Term
| What are the symptoms of juvenile idiopathic arthritis? |
|
Definition
Lethargy, reduced physical activity, and poor appetite. The first manifestation, particularly in young children, may be limping. Children may also become quite ill, presenting with flu-like symptoms that persist. The cardinal clinical feature is persistent swelling of the affected joint(s), which commonly include the knee, ankle, wrist and small joints of the hands and feet. Swelling may be difficult to detect clinically, especially for joints such as those of the spine, sacroiliac joints, shoulder, hip and jaw, where imaging techniques such as ultrasound or MRI are very useful.
Associated with inflammation of the eye |
|
|
Term
| What are the symptoms of SLE? |
|
Definition
Almost everyone with SLE has joint pain and swelling.
Common symptoms include:
Chest pain when taking a deep breath
Fatigue
Fever with no other cause
General discomfort, uneasiness, or ill feeling (malaise)
Hair loss
Mouth sores
Sensitivity to sunlight
Skin rash -- a "butterfly" rash over the cheeks and bridge of the nose affects about half of people with SLE. The rash gets worse in sunlight. The rash may also be widespread. |
|
|
Term
| What are the symptoms of a slipped capital femoral epiphysis? |
|
Definition
Difficulty walking, walking with a limp
Knee pain
Hip pain
Hip stiffness
Outward-turning leg
Restricted hip movements |
|
|
Term
| What are the symptoms of renal cell carcinoma of kidney? |
|
Definition
| The classic triad is hematuria (blood in the urine), flank pain and an abdominal mass. |
|
|
Term
| What are the symptoms of transitional cell carcinoma of the bladder? |
|
Definition
Bladder cancer characteristically causes blood in the urine. This blood in the urine may be visible to the naked eye (gross/macroscopic hematuria) or detectable only by microscope (microscopic hematuria). Hematuria is the most common symptom in bladder cancer.
Other possible symptoms include pain during urination, frequent urination, or feeling the need to urinate without being able to do so. |
|
|
Term
| What are the symptoms of testicular torsion? |
|
Definition
Sudden onset of severe pain in one testicle, with or without a previous predisposing event
Swelling within one side of the scrotum (scrotal swelling)
Nausea or vomiting
Lightheadedness
Testicle lump
Blood in the semen |
|
|
Term
| What are the symptoms of pyelonephritis? |
|
Definition
| Presents with fever, accelerated heart rate, painful urination, abdominal pain radiating to the back, nausea, and tenderness at the costovertebral angle on the affected side. |
|
|
Term
| What are the symptoms of anterior cerebral artery infarct? |
|
Definition
Paralysis or weakness of the contralateral foot and leg due to involvement of Motor leg area
Cortical Sensory loss in the contralateral foot and leg
Gait apraxia Impairtment of gait and stance
Abulia akinetic mutism, slowness and lack of spontaneity
Urinary incontinence which usually occurs with bilateral damage in the acute phase
Frontal Cortical release reflexes: Contralateral grasp reflex, sucking reflex, gegenhalten(paratonic rigidity) |
|
|
Term
| What are the symptoms of internal carotid artery occlusion? |
|
Definition
Typical symptoms are contralateral weakness or sensory disturbance, ipsilateral blindness, and (if the dominant hemisphere is involved) dysphasia, aphasia or speech apraxia.
Cognitive impairment and decline are associated with asymptomatic high-grade stenosis of the left internal carotid artery.[3]
Asymptomatic patients are most often identified when a cervical bruit is heard on physical examination. |
|
|
Term
| What are the symptoms of lacunar stroke? |
|
Definition
Pure motor stroke/hemiparesis (most common lacunar syndrome: 33-50%)
It is marked by hemiparesis or hemiplegia that typically affects the face, arm, or leg of one side. Dysarthria, dysphagia, and transient sensory symptoms may also be present. |
|
|
Term
| What is lateral medullary syndrome? |
|
Definition
Characterized by sensory deficits affecting the trunk (torso) and extremities on the opposite side of the infarction and sensory deficits affecting the face and cranial nerves on the same side with the infarct. Specifically, there is a loss of pain and temperature sensation on the contralateral (opposite) side of the body and ipsilateral (same) side of the face. This crossed finding is diagnostic for the syndrome.
Clinical symptoms include swallowing difficulty, or dysphagia,slurred speech, ataxia, facial pain, vertigo, nystagmus, Horner syndrome, diplopia, and possibly palatal myoclonus. |
|
|
Term
| What are the symptoms of a posterior cerebral artery infarct? |
|
Definition
Acute vision loss
Confusion
New onset posterior cranium headache
Paresthesias
Limb weakness
Dizziness
Nausea
Memory loss
Language dysfunction |
|
|
Term
| What are the symptoms of a subdural haematoma? |
|
Definition
Gradually increasing headache and confusion. Crescent shaped on CT.
Other signs and symptoms of subdural hematoma can include any combination of the following:
A history of recent head injury
Loss of consciousness or fluctuating levels of consciousness
Irritability
Seizures
Pain
Numbness
Headache (either constant or fluctuating) |
|
|
Term
| What is Claude's syndrome? |
|
Definition
Claude's Syndrome is clinically characterised by:
ipsilateral Horner's syndrome
contralateral hemiplegia
contralateral sensory loss - face and limbs
if lower midbrain involved - ipsilateral cerebellar deficit |
|
|
Term
| WHat is Benedikt's syndrome? |
|
Definition
Benedikt's Syndrome describes an ipsilateral III nerve palsy accompanied by contralateral 'cerebellar' tremor - a slow rhythmic tremor of the contralateral hand and foot, increased by excitement and voluntary movement, absent in sleep. It is a consequence of damage to the red nucleus - the outflow from the opposite cerebellar hemisphere. There may also be contralateral hyperaesthesia.
The syndrome may result from occlusion of the penetrating branches of the basilar artery in the midbrain. |
|
|
Term
| What is Weber's syndrome? |
|
Definition
Weber's Syndrome constitutes an ipsilateral third nerve paralysis with a contralateral hemiplegia. It is due to a lesion in one half of the midbrain e.g. as a result of occlusion of the paramedian branches of the basilar artery.
If there is a localised lesion in the region of the red nucleus, then there is paralysis of upward gaze. |
|
|
Term
| What are the symptoms of Burkitt's lymphoma? |
|
Definition
In the African Burkitt's lymphoma there is a strong association with Epstein-Barr virus infection. Other associations include malarial infection and translocation involving chromosome 8 and 14.
Found largely in children or young adults. In both forms, the disease rarely arises in the lymph nodes. In African cases, involvement of the maxilla or mandible is the common mode of presentation, whereas abdominal tumours - bowel, retroperitoneum, ovaries - are common in cases seen elsewhere. Leukaemic transformation of Burkitt's lymphoma is uncommon. |
|
|
Term
| What is chronic myeloid leukaemia? |
|
Definition
It occurs mainly in middle aged and elderly people and is characterised by marked leucocytosis, a left shifted myeloid series and in 95% of patients, the Philadelphia chromosome.
CML develops insidiously. Initial symptoms are often nonspecific and due to anaemia or hypermetabolism. Weakness, weight loss and fatigue are common. Massive splenomegaly is characteristic and may cause left hypochondral pain. |
|
|
Term
| What is chronic lymphoid leukaemia? |
|
Definition
Typical clinical features of CLL include:
non-specific symptoms -
“B” symptoms (lethargy, weight loss, fever and night sweats) and infections
of anaemia and thrombocytopenia - which may be autoimmune.
lymphadenopathy occurs in 80% of cases.
typically, moderate enlargement, affecting nodes in the neck, axilla and groin.
classically, symmetrical with non-tender, rubbery nodes
may have developed over a period of months or years.
splenomegaly in 50% of cases
heaptomegaly
skin lesions - pruritus, Herpes zoster, generalised infiltration (l'homme rouge, usually associated with pruritus), vesibullous lesions |
|
|
Term
| What are the symptoms of Hodgkin's lymphoma? |
|
Definition
The majority of patients present with lymphadenopathy.
Other features include:
generalised pruritus
anaemia
immune dysfunction
B symptoms:
- fever
- night sweats
- weight loss
In advanced disease there may be infiltration of any organ often presenting with hepatosplenomegaly. Other sites for tumour localisation include bone, bone marrow, lung, kidneys. |
|
|
Term
| What is pernicious anaemia? |
|
Definition
Pernicious anaemia (PA) is a disease of the stomach that is characterised by megaloblastic anaemia due to vitamin B12 deficiency, itself, secondary to intrinsic factor deficiency and gastric atrophy. It usually has an autoimmune basis.
Prominent clinical features include:
low grade pyrexia
weight loss
diarrhoea
lemon yellow colour:
jaundice, due to haemolysis
pallor, due to anaemia
degenerative features e.g. subacute combined degeneration of the spinal cord
premature greying of the hair |
|
|
Term
| What is polycythaemia vera? |
|
Definition
The clinical features of polycythaemia vera comprise:
most frequently over the age of 50, insidious onset
males more than female, Caucasian more than Afro-Carribean
pruritus is very common - exacerbated by a warm bath
splenomegaly
suffused reddish to red-blue tinge of nose, ears, lips and buccal mucosa |
|
|
Term
| What are the symptoms of sickle cell anaemia? |
|
Definition
Almost all patients with sickle cell anemia have painful episodes (called crises), which can last from hours to days. These crises can cause pain in the bones of the back, the long bones, and the chest.
Fatigue
Paleness
Rapid heart rate
Shortness of breath
Yellowing of the eyes and skin (jaundice)
Painful and prolonged erection (priapism)
Poor eyesight or blindness
Problems thinking or confusion caused by small storkes
Ulcers on the lower legs (in adolescents and adults) |
|
|
Term
| What is sideroblastic anaemia? |
|
Definition
This is characterised by:
dyserythropoesis
iron overload
ring sideroblasts
Symptoms of sideroblastic anemia include skin paleness, fatigue, dizziness, and enlarged spleen and liver. Heart disease, liver damage, and kidney failure can result from iron buildup in these organs |
|
|
Term
|
Definition
Alpha thalassemia silent carriers generally have no signs or symptoms of the disorder. This is because the lack of alpha globin protein is so minor that the body's hemoglobin works normally.
People who have alpha or beta thalassemia trait can have mild anemia. However, many people who have these types of thalassemia have no signs or symptoms.
People who have hemoglobin H disease or beta thalassemia major (also called Cooley's anemia) have severe thalassemia. Signs and symptoms occur within the first 2 years of life. They may include severe anemia and other health problems, such as:
A pale and listless appearance
Poor appetite
Dark urine (a sign that red blood cells are breaking down)
Slowed growth and delayed puberty
Jaundice (a yellowish color of the skin or whites of the eyes)
An enlarged spleen, liver, and heart
Bone problems (especially bones in the face) |
|
|
Term
| 83yr old woman with 2 week Hx of obstructive jaundice. Diabetic for 2 months and lost 7kg. Pale stools and dark urine. What 2 investigations would you order? |
|
Definition
- Blood tests (FBC, U&Es, LFTs)
- Abdominal USS
- Pancreatic CT |
|
|
Term
| 83yr old woman with 2 week Hx of obstructive jaundice. Diabetic for 2 months and lost 7kg. Pale stools and dark urine. What are the 2 main diagnoses to consider? |
|
Definition
- pancreatic cancer
- gallstones |
|
|
Term
| What are 3 complications of an ERCP? |
|
Definition
- pancreatitis
- haemorrhage from sphincterotomy
- ascending cholangitis
GENERAL
- Bleeding
- Perforation
- Infection e.g. Acute Cholangitis
- Aspiration Pneumonia |
|
|
Term
83yr old woman with 2 week Hx of obstructive jaundice. Diabetic for 2 months and lost 7kg. Pale stools and dark urine.
Cytology reveals malignant cells. What 3 management options would you like to discuss with your patient? |
|
Definition
1. RESECTION
Not appropriate for most patients because of disease stage and co-morbidity
For the patient in this question, as they have obstructive jaundice the neoplasm is going to be in the pancreatic head or ampulla so pancreaticoduodenectomy (Whipple’s) or pylorus preserving pancreaticoduodenectomy are the likely procedures
2. ONCOLOGY
Neoadjuvant or Palliative Chemotherapy (Gemcitabine)
Radiotherapy is not commonly used for the primary tumour but possibly for metastases
3. PALLIATIVE
Symptom control i.e. decompression of biliary tree (stent via ERCP or PTC), analgesia, anti-emetics and nutritional supplementation |
|
|
Term
| What side-effect of haloperidol would cause neck pain and face twisting to one side? |
|
Definition
|
|
Term
| What is the underlying action of Haloperidol that causes dystonia and in which brain region does it occur? |
|
Definition
- D2 receptor antagonism
- The Nigrostriatal dopamine pathway in the brain |
|
|
Term
| What are 3 side effects of by D2 receptor antagonism? |
|
Definition
- Tardive Dyskinesia
- Akathisia (restlessness)
- Parkinsonism |
|
|
Term
| Name 2 management strategies to counteract the side-effects of D2 receptor antagonism. |
|
Definition
Stop Haloperidol and switch to an atypical antipsychotic e.g. Aripiprazole
Lower the dose of Haloperidol |
|
|
Term
| Name 2 antipsychotic drugs least likely to cause D2 receptor antagonist side-effects. |
|
Definition
- Aripiprazole
- Clozapine |
|
|
Term
| What are the 3 main symptoms of parkinson's disease? |
|
Definition
- Tremor
- Rigidity
- Bradykinesia |
|
|
Term
| What 2 drugs can be used in combination with L-dopa to enhance it's activity? |
|
Definition
COMT-inhibitor: e.g. entacapone, tolcapone:
used as an adjunct to L-dopa (increases half life of the drug)
monoamine oxidase (MAO) inhibitors. These drugs slow the breakdown of dopamine that occurs naturally in the brain and dopamine produced from levodopa. |
|
|
Term
| How do drugs used in combination with L-dopa enhance it's activity? |
|
Definition
A COMT inhibitor is a drug that inhibits the action of catechol-O-methyl transferase. This enzyme is involved in degrading neurotransmitters. => reduces half life of L-DOPA
Monoamine oxidase (MAO) inhibitors. These drugs slow the breakdown of dopamine that occurs naturally in the brain and dopamine produced from levodopa |
|
|
Term
| Give 2 major adverse effects of chronic L-dopa administration. |
|
Definition
- On-Off Phenomenon
- End-of-Dose Dyskinesia
- Cardiovascular Effects i.e. Arrhythmia, Palpitations, Postural Hypotension, Syncope
- Hallucinosis |
|
|
Term
| Suggest 2 drugs that can be used as alternatives to L-dopa therapy. |
|
Definition
- Dopamine Receptor Agonists e.g. Ropinirole
- MAO-B Inhibitor e.g. Selegiline
- Anticholinergics e.g. Amantadine
- Catechol-O-MethylTransferase (COMT) Inhibitor e.g. Entacapone |
|
|
Term
| A 2 month old baby comes in with a boggy swelling on the right side of his scalp after a fall. What is the most likely cause of the skull swelling? |
|
Definition
| Haematoma or subdural haemorrhage |
|
|
Term
| What is the most likely underlying mechanism for a 2 month old baby to have a head haematoma? |
|
Definition
| Trauma (non-accidental injury ie shaken baby syndrome) |
|
|
Term
| What medical investigations should you do for a baby with a possible head injury? |
|
Definition
- Bloods → FBC (subdural bleed → ↓ Hct/↑WCC), Coag Screen (may be underlying bleeding disorder)
- LFTs → for assessment of NAI
- Imaging → Cranial CT, Cranial US, Cranial MRI, Skeletal Survey (NAI) |
|
|
Term
| As the FY1 in A&E, what would you do when the parents want to take home their baby with a possible NAI? |
|
Definition
- Seek senior advice immediately
- Inform parents that due to the nature of the injury you need to ask a senior colleague to review child
- When speaking to senior colleague you would inform them of your suspicion and ask them to review |
|
|
Term
| What features would you look for on opthalmic examination of a baby with a possible NAI of the head? |
|
Definition
|
|
Term
Name 3 other professionals or resources outside the hospital that might provide important
information to elucidate the diagnosis in a child with a possible NAI |
|
Definition
- Social Workers
- Health Visitor
- GP |
|
|
Term
| List 2 complications of preterm rupture of membranes. |
|
Definition
1. Chorioamnionitis (infection).
2. Preterm labour.
3. Congenital pneumonia (of newborn).
Fetal distress/death.
Placental abruption. |
|
|
Term
| A lady has had a pre-term rupture of membranes and you perform a speculum examination. What should you look for and what investigations would you perform during the examination? |
|
Definition
1. High vaginal swab for culture (e.g. chlamydia trachomatis).
2. Cervical effacement and dilatation.
3. Look at colour of and smell amniotic fluid (draining through cervix) |
|
|
Term
List 3 variables that you would wish to monitor to try and identify the
onset of complications of premature rupture of membranes? |
|
Definition
Chorioamnionitis:
1. WCC and CRP.
2. Maternal temperature.
Preterm labour:
3. CTG to monitor fetal heart rate and uterine contractions.
4. Dilatation of cervix. |
|
|
Term
| In the first 4 hours after delivery, what respiratory signs would sugest RDS? |
|
Definition
Nasal flaring
Intercostal drawing |
|
|
Term
| A patient has suspected meningococcal septicaemia. Give 2 examples of appropriate antibiotics which should be administered immediately by the GP and which route? |
|
Definition
Intramuscular benzylpenicillin
Intravenous ceftriaxone |
|
|
Term
| What 4 microbiological tests can identify meningitis? |
|
Definition
- Blood culture + PCR
- Blood gram stain + microscopy
- CSF culture + PCR
- CSF gram stain + microscopy |
|
|
Term
| What are the 2 public health implications of a suspected case of meningococcal sepsis? |
|
Definition
- Bacterial meningitis is a notifiable disease
- There is a legal requirement to notify public health
- The patient’s close contacts need to be traced and offered prophylaxis |
|
|
Term
| What is the main limitation of the currently available vaccine for bacterial meningitis? |
|
Definition
| The vaccine is only for meningococcal group C and not the other serotypes |
|
|
Term
| Patient has a TSH that is undetectable (<0.05mU/L). What diagnosis does this indicate? |
|
Definition
| Thyrotoxicosis most likely due to primary hyperthyroidism |
|
|
Term
| Why is TSH low in hyperthyroidism? |
|
Definition
- TSH is produced by the anterior pituitary, and stimulates production of thyroid hormones (T3 & T4)
- Increased thyroxine inhibits the hypothalamic-pituitary-thyroid axis as part of a -ve feedback loop
- The above results is ↓ production of TSH |
|
|
Term
| Outline the pathogenesis of Graves Disease. |
|
Definition
- Autoantibodies to the TSH receptor thyroid follicular epithelial cells are created
- These autoantibodies stimulate inappropriate activation of thyroid hormone production |
|
|
Term
Outline 3 treatment options for a patient with Graves disease (½ mark each), and provide one specific side
effect that you would warn the patient about for each treatment option. |
|
Definition
- Anti-thyroid Drugs e.g. Carbimazole or Propylthiouracil → can cause agranulocytosis
- Radioactive Iodine → may cause initial worsening in hyperthyroid symptoms
- Thyroidectomy → likely hypothyroidism needing lifelong thyroxine treatment
- Propranolol → exercise intolerance |
|
|
Term
| List 5 factors for coronary artery disease. |
|
Definition
- Asian Ethnicity
- Smoker
- Hypercholesterolaemia
- Hypertension
- Male |
|
|
Term
| List 4 drugs for unstable angina and a reason for prescribing each. |
|
Definition
- Atenolol (beta blocker) → ↓ BP, HR and controls angina
- Simvastatin → ↓ cholesterol and ↓ mortality
- Amlodipine (Ca channel blocker) → ↓ BP by vasodilation and controls angina
- Ramipril (ACE inhibitor) → ↓ BP and ↓ mortality
- Morphine → controls pain and helps patient feel at ease
- Aspirin → anti-platelet and ↓mortality
- Nitrates →↓ BP by vasodilation and controls angina
- Clopidogrel → anti-platelet and ↓ mortality |
|
|
Term
| List the 2 cardinal ECG features of an acute full thickness anterior myocardial infarction and outline their electrophyiological cause. |
|
Definition
1. ST Elevation:
- Normal muscle is polarised (normal-potential) during diastole and only depolarised during the
action potential
- However, MI triggers depolarisation of the muscle with resetting of the baseline of the affected leads causing abnormal currents to flow between adjacent depolarised and polarised tissues i.e. “current of injury”
2. Pathological Q Waves:
- An initial downward movement of the QRS is a Q wave
- Pathological Q waves occur after an MI and have a width of ≥1 small box and a depth >25% of the total QRS height
- They occur due to the “myocardial window” i.e. the area of old myocardial infarction is
electrically silent and acts as a window meaning that the lead recording from that site sees
activity from the opposite side of the heart, which is moving away from the lead causing a downward deflection (the q wave). |
|
|
Term
|
Definition
Leukaemia is a progressive, malignant disease of the blood-forming organs, characterised by distorted proliferation and development of leukocytes and their precursors in the blood and bone marrow.
- Haematological Malignancy
- Presence of neoplastic haemopoietic cells in the bone marrow +/- peripheral circulation |
|
|
Term
| What is the most common type of leukaemia in children? |
|
Definition
| Acute lymphoblastic leukaemia |
|
|
Term
| What is the philadelphia chromosome? |
|
Definition
| a specific chromosomal abnormality that is associated with chronic myelogenous leukemia (CML). It is the result of a reciprocal translocation between chromosome 9 and 22 |
|
|
Term
| Which type of adult leukaemia is the philadelphia chromosome most commonly associated with? |
|
Definition
| Chronic myeloid leukaemia |
|
|
Term
| Apart from the Philadelphia chromosome, which other chromosomal abnormality predisposes children to leukaemia? |
|
Definition
|
|
Term
| What 3 investigations should be done to confirm leukaemia? |
|
Definition
Bone marrow aspirate
FBC
Peripheral blood film |
|
|
Term
A girl with leukeamia is prescribed allopurinol, why is this?
What electrolyte abnormality is the oncologist trying to avoid by prescribing allopurinol? |
|
Definition
To prevent Tumour Lysis Syndrome.
Hyperuricaemia. |
|
|
Term
| What is the definition of a stroke? |
|
Definition
A rapidly developing focal neurological deficit of vascular origin lasting over 24 hours or resulting
in death. |
|
|
Term
| Suggest 4 risk factors for stroke |
|
Definition
- Hypertension
- Atrial fibrillation
- Diabetes mellitus
- Smoking
- Previous TIA/stroke
- male
- high cholesterol |
|
|
Term
| A CT scan reveals an area of ischaemia. Explain the pathogenesis of this type of stroke. |
|
Definition
- Narrowing of the supplying blood vessels (thrombus or embolus) causes reduced blood flow (and thus oxygen and glucose) to an area of the brain
- There is a central area of necrosis surrounded by a penumbra that may be salvageable if blood supply is re-established
- The ischaemic cascade is initiated causing inflammation and oedema that results in tissue damage
- This leads to glutamate toxicity and cell membrane permeability changes thus activating destructive enzymes |
|
|
Term
Symptoms: weakness on right side of body, confusion, slurred speech.
What artery is likely to have been affected by this stroke? |
|
Definition
| Left middle cerebral artery |
|
|
Term
| List 4 significant non-neurological complications of stroke. |
|
Definition
- Aspiration pneumonia
- DVT/PE due to immobility
- Communication difficulties due to dysphasia and dysarthria
- Depression
- Bed sores due to immobility |
|
|
Term
| Outline 2 management options for a patient with a stroke that the Occupational Therapist would be able to help with. |
|
Definition
- Home assessment and adaptations where appropriate
- Physical and cognitive deficit screen and provision of aids where needed |
|
|
Term
| What are the features of biliary colic? |
|
Definition
Pain is steady, starts rapidly, becomes intense and lasts at least 30 minutes and up to several hours.
Many patients complain of right upper quadrant pain, right flank pain, or even mid chest pain with cholelithiasis. There may be radiation to the back and shoulders and other concomitant symptoms such as vomiting and diarrhea. Fatty foods can provoke biliary pain |
|
|
Term
| What are the features of acute cholecystitis? |
|
Definition
Pain in the right upper quadrant or epigastric region. Symptomatically it differs from biliary colic by the presence of an inflammatory component (fever)
This pain is initially intermittent, but later usually presents as constant and severe
Referred pain may occur in the right scapula region
This may also present with the above mentioned pain after eating greasy or fatty foods such as pastries, pies, and fried foods.
This is usually accompanied by diarrhea, vomiting and nausea. The gallbladder may be tender and distended. |
|
|
Term
| Symptoms of acute pancreatitis? |
|
Definition
severe epigastric pain (upper abdominal pain) radiating to the back
nausea
vomiting
diarrhoea
loss of appetite
high temperature (Fever)
chills (shivering)
hemodynamic instability, which include shock
tachycardia (rapid heartbeat)
respiratory distress
peritonitis |
|
|
Term
| What are the symptoms of acute renal colic? |
|
Definition
The pain typically begins in the abdomen and often radiates to the hypochondrium or the groin. The pain is often colicky (comes in waves) due to ureteric peristalsis, but may be constant.
Described as the worst pain ever. |
|
|
Term
| Symptoms of carcinoma of stomach? |
|
Definition
Stage 1 (Early)
Indigestion or a burning sensation (heartburn)
Loss of appetite, especially for meat
Abdominal discomfort or irritation
Stage 2 (Middle)
Weakness and fatigue
Bloating of the stomach, usually after meals
Stage 3 (Late)
Abdominal pain in the upper abdomen
Nausea and occasional vomiting
Diarrhea or constipation
Weight loss
Bleeding (vomiting blood or having blood in the stool) which will appear as black. This can lead to anemia.
Dysphagia; this feature suggests a tumor in the cardia or extension of the gastric tumor in to the esophagus. |
|
|
Term
| Symptoms of crohns disease? |
|
Definition
It primarily causes abdominal pain, diarrhea (which may be bloody if inflammation is at its worst), vomiting (can be continuous), or weight loss.
Growth failure in children
Uveitis
Can lead to obstruction, fistulae, or abscesses |
|
|
Term
| What are the symptoms of gallstone ileus? |
|
Definition
Symptoms of ileus include, but are not limited to:
moderate, diffuse abdominal discomfort
constipation
abdominal distension
nausea/vomiting, especially after meals
lack of bowel movement and/or flatulence
excessive belching |
|
|
Term
| What are the symptoms of a hiatus hernia? |
|
Definition
Protrusion (or herniation) of the upper part of the stomach into the thorax through a tear or weakness in the diaphragm.
Causes:
dull pains in the chest, shortness of breath (caused by the hernia's effect on the diaphragm), heart palpitations (due to irritation of the vagus nerve), and swallowed food "balling up" and causing discomfort in lower esophagus until it passes on to stomach |
|
|
Term
| Symptoms of pancreatic cancer? |
|
Definition
Pain in the upper abdomen that typically radiates to the back(seen in carcinoma of the body or tail of the pancreas)
Loss of appetite (anorexia) or nausea and vomiting
Significant weight loss (cachexia)
Painless jaundice
diabetes
depression
symptoms of metastases |
|
|
Term
| Symptoms of a perforated peptic ulcer? |
|
Definition
A perforated peptic ulcer causes sudden, intense and steady pain
An ulcer severe enough to cause a perforation can also cause noticeable bleeding. Vomit that looks bright red or contains reddish-brown clumps or dark contents that resemble coffee grounds indicates bleeding caused by an ulcer. Other signs of bleeding include the presence of blood in the stool or passing black, tarry stools.
Fever
Abdominal swelling
Septic shock |
|
|
Term
|
Definition
| dult-onset Still's disease is a systemic inflammatory disease. The classic presentation is the triad of persistent high spiking fever, joint pain and a distinctive salmon-colored rash |
|
|
Term
| What are the symptoms of polymyalgia rheumatica? |
|
Definition
The classic symptoms include:
Pain and stiffness (moderate to severe) in the neck, shoulders, and hips, which inhibits activity, especially in the morning/after sleeping.
Fatigue and lack of appetite (possibly leading to weight loss) are also indicative of polymyalgia rheumatica.
Anaemia
An overall feeling of illness
Low-grade (mild) fever |
|
|
Term
| What is reactive arthritis? |
|
Definition
Reactive arthritis is classified as an autoimmune condition that develops in response to an infection in another part of the body.
Because common systems involved include the eye, the urinary system, and the hands and feet, one clinical mnemonic for Reiter's syndrome is "Can't see, can't pee, can't climb a tree."
The arthritis that follows usually affects the large joints such as the knees causing pain and swelling with relative sparing of small joints such as the wrist and hand |
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Term
| What are the symptoms of psoriatic arthritis? |
|
Definition
Common symptoms of psoriatic arthritis include:
Pain, swelling, or stiffness in one or more joints.
Joints that are red or warm to the touch.
Sausage-like swelling in the fingers or toes, known as dactylitis.
Pain in and around the feet and ankles, especially tendinitis in the Achilles tendon or Plantar fasciitis in the sole of the foot.
Changes to the nails, such as pitting or separation from the nail bed.
Pain in the area of the Sacrum (the lower back, above the tailbone) |
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Term
| What are the signs of adrenal insufficiency? |
|
Definition
severe abdominal pains
vomiting
profound muscle weakness and fatigue
depression
extremely low blood pressure (hypotension)
weight loss
kidney failure
changes in mood and personality
shock
Hyponatremia
Hyperkalemia
Hypercalcemia
Addison's can present with tanning of the skin that may be patchy or even all over the body. Characteristic sites of tanning are skin creases (e.g. of the hands) and the inside of the cheek |
|
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Term
| What are the symptoms of Paget's disease? |
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Definition
| An elevated level of alkaline phosphatase in the blood in combination with normal calcium, phosphate, and aminotransferase levels in an elderly patient are suggestive of Paget's disease. |
|
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Term
|
Definition
Conn's syndrome is an aldosterone-producing adenoma characterized by the overproduction of the mineralocorticoid hormone aldosterone by the adrenal glands
Aldosterone causes increase in sodium and water retention and potassium excretion in the kidneys, leading to arterial hypertension (high blood pressure)
Increased aldosteronism will lead to hypernatremia and hypokalemia
The hydrogen ions that are exchanged for sodium are generated by carbonic anhydrase in the renal tubule epithelium causing increased production of bicarbonate. The increased bicarbonate and the excreted hydrogen combine to generate a metabolic alkalosis. |
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Term
| What are the symptoms of Graves disease? |
|
Definition
Graves' disease is characterised by:
hyperthyroidism
diffuse goitre:
usually only moderately enlarged
thrill or bruit may be detected on account of increased vascularity
extrathyroid features:
Graves' ophthalmology - 40% of cases
pretibial myxoedema - 5% of cases
thyroid acropachy - rare
onycholysis - rare |
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Term
| What are the symptoms of a branchial cyst? |
|
Definition
| usually presents as a smooth, slowly enlarging lateral neck mass that may increase in size after an upper respiratory tract infection |
|
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Term
| What are the symptoms of horners sydrome? |
|
Definition
Signs that are found in patients on the affected side of the face include:
- partial ptosis (drooping of the upper eyelid from loss of sympathetic innervation to the superior tarsal muscle, also known as Müller's muscle
- upside-down ptosis (slight elevation of the lower lid)
- anhidrosis (decreased sweating on the affected side of the face)
- miosis (small pupils)
- enophthalmos (the impression that the eye is sunk in)
- loss of ciliospinal reflex
- bloodshot conjunctiva, depending on the site of lesion. |
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Term
| What are the symptoms of myasthenia gravis? |
|
Definition
| Muscles become progressively weaker during periods of activity and improve after periods of rest. Muscles that control eye and eyelid movement, facial expressions, chewing, talking, and swallowing are especially susceptible. The muscles that control breathing and neck and limb movements can also be affected. |
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Term
| Symptoms of neurosyphilis? |
|
Definition
Abnormal gait
Blindness
Confusion
Dementia
Depression
Headache
Incontinence
Irritability
Numbness in the toes, feet, or legs
O/E:
Abnormal reflexes
Muscle atrophy
Muscle contractions |
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Term
| What causes bitemporal hemianopia? |
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Definition
Bitemporal hemianopia most commonly occurs as a result of tumors located at the mid-optic chiasm. Since the adjacent structure is the pituitary gland, some common tumors causing compression are pituitary adenomas and craniopharyngiomas.
Also another relatively common neoplastic etiology is meningiomas. An etiology of vascular origin is an aneurysm of the anterior communicating artery which arise superior to the chiasm, enlarge, and compress it from above. |
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Term
|
Definition
secretes excessive amounts of the free (not protein bound, and circulating in the blood, thyroid hormones, triiodothyronine (T3) and/or thyroxine (T4)
increased heat production - warm, moist skin, heat intolerance
telangiectasia, palmar erythema, pretibial myxoedema, onycholysis
weight loss, increased appetite, increased frequency of bowel movement but frank diarrhoea is uncommon; steatorrhoea may occur; dyspepsia; like juvenile-onset diabetes mellitus, may cause a decrease in weight despite an increased appetite
oligomenorrhoea
tachycardia, exertional dyspnoea, hyperdynamic circulation; systolic hypertension is common and diastolic hypertension can occur in up to 30% of patients
tiredness, irritability, nervousness
fine tremor, hyperkinesia
there are eye signs in Graves' disease |
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Term
| What symptoms would an occipital lobe infarct cause? |
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Definition
The most common presentation of an occipital lobe lesion is of a visual field defect:
cortical blindness
Anton's syndrome (form of cortical blindness in which the patient denies the visual impairment)
prosopagnosia (inability to recognise familiar faces despite having normal visual acuity and visual fields)
visual agnosia
homonymous hemianopia with or without involvement of the macula
visual hallucinations may accompany migraine and epilepsy - these are elementary, appearing as patterns such as zig-zags and flashes and filling the hemianopic field; in comparison, temporal lobe visual hallucinations are formed, complex, and fill the entire visual field.
visual illusions - micropsia - objects appear smaller - and macropsia - objects appear larger |
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Term
| What are they symptoms of a 3rd nerve (oculomotor) palsy? |
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Definition
The eye is incapable of movement upwards, downwards or inwards, and at rest the eye looks laterally and downwards owing to the overriding influence of the lateral rectus and superior oblique muscles respectively. The reduced response of levator palpebrae superioris results in ptosis - a drooping of the upper eyelid.
pupil may be fixed and dilated, and accommodation lost |
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Term
|
Definition
Optic atrophy is the result of progressive optic nerve disease.
Loss of vision, either central or peripheral, is the only symptom.
The optic disc is pale and white. |
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Term
| 25 year old is seen in A&E with a Hx of right iliac fossa pain and slight vaginal bleeding after 7 weeks amenorrhoea. What is the differential diagnosis? |
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Definition
Ectopic pregnancy
Incomplete miscarraige
Pelvic inflammatory disease |
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Term
| 25 year old is seen in A&E with a Hx of right iliac fossa pain and slight vaginal bleeding after 7 weeks amenorrhoea. Give 2 important points in the history which you wish to elicit. |
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Definition
- dyspareunia recently? (suggests ectopic)
- Hx of ectopic/miscarraige
- does she know if she is pregnant?
- is she sexually active?
- does she use contraception? |
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Term
| 25 year old is seen in A&E with a Hx of right iliac fossa pain and slight vaginal bleeding after 7 weeks amenorrhoea. What investigations should you do? |
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Definition
- urinary pregnancy test
- transvaginal ultrasound
- bloods - FBC, clotting, hCG |
|
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Term
| Name a treatment option for incomplete miscarraige, ectopic pregnancy and PID. |
|
Definition
Incomplete miscarraige
- prostaglandins for evacuation of retained products of conception
Ectopic pregnancy
- methotrexate direct injection w/laparoscopy
PID - broad-spectrum antibiotics |
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Term
| What injection must be administered to a Rh negative pregnant woman who bleeds during pregnancy? |
|
Definition
Anti D immunoglobulins
(28-32 weeks and 72hrs after birth) |
|
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Term
| What is the pathophysiological significance of raised JVP and crackles at lung bases? |
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Definition
Biventricular failure.
Raised JVP = increased systemic venous congestion (right HF)
Crackles = pulmonary congestion (left HF) |
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Term
| What class of diuretic would you choose in someone with acute heart failure? Why? |
|
Definition
Loop diuretic.
It provides rapid symptomatic relief, improves cardiac function, relieves pulmonary and peripheral oedema |
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Term
| Spironolactone can be used as an effective way of preventing hypokalemia. Name another drug that has a similar effect. |
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Definition
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Term
| What additional benefits can a patient get from using spironolactone? (other than preventing diuretic induced hypokalemia) |
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Definition
| Reduces mortality and improves symptoms |
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Term
| Dogoxin, beta blockers and dobutamine were all considered for initial treatment of acute heart failure. Why were they rejected? |
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Definition
Dogoxin - he is in sinus rhythm, therefore not indicated, doesn't decrease mortality
Beta-blockers - negatively chronotropic and inotropic, contraindicated in acute HF
Dobutamine - (sympathomimetic) not indicated as this patient is not in shock, associated with increased mortality |
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Term
| What precautionary measures would you warn a patient about and that should be taken before starting a patient on ACE inhibitors? |
|
Definition
Warn them about 1st dose hypertension, cough, hyperkalemia, renal impairment.
Start at lose dose, titrate up.
Check U&Es before for renal impairment, hyperkalemia.
Check for drug interactions w/pts current meds (eg ciclosporin) |
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Term
| What would you expect to see on a chest X ray showing a pleural effusion? |
|
Definition
- blunting of costophrenic angle
- meniscus sign (concave surface at top of opacified area) |
|
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Term
| You consider performing a diagnostic aspiration of a pleural effusion. What additional imaging would be of use prior to aspiration? |
|
Definition
|
|
Term
| What position should the patient be in for pleural aspiration? |
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Definition
| Sit the patient as upright as possible. A pillow can be used to support arms and head on an adjustable table or couch. If the patient leans forward too much it increases the risk of liver/spleen injury. |
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Term
| What are the three main causes of pleural effusion? |
|
Definition
- malignancy
- pneumonia
- TB
- left ventricular failure
- PE |
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Term
| Following a pleural aspiration, the fluid withdrawn is clear and yellow in colour. What 3 important investigations would you order and why? |
|
Definition
BIOCHEMISTRY
- protein/albumin (exudate/transudate)
CYTOLOGY
- microscopy for bronchial carcinoma/mesothelioma
BACTERIOLOGY
- microscopy + culture (bacterial infection/TB) |
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Term
| A patient with a pleural effusion's husband comes to see you. He says he has worked on the shipyards. Why is this relevant? |
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Definition
The patient may have been exposed to asbestos through her husband.
This increases the risk of pleural mesothelioma. |
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Term
| 7 year old boy with 6 month history of nasal blockage, recurrent ear pain and difficulty hearing. Treated unsuccessfully with antibiotics and decongestants. What 2 diagnoses would you consider? |
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Definition
- acute otitis media with effusion (glue ear)
- foreign body
- allergic rhinitis |
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Term
| In the boy with possible otitis media, what 4 further features in the Hx would help clarify the diagnosis and/or evaluate symptoms? |
|
Definition
- discharge from the ear?
- uni or bilateral nasal obstruction (uni - foreign body)
- how severe is hearing loss: affecting speech/school?
- PMH of otitis media?
- FHx of deafness? |
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Term
| A pure tone audiogram demonstrates bilateral, low frequency conductive hearing loss. What surgical treatments may be offered for hearing loss in a child? |
|
Definition
- grommets
- adenoidectomy |
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Term
| How can surgical therapy help a child with hearing loss? |
|
Definition
Grommets allow aeriation of middle ear. Improves infection and hearing via increased conduction of sound.
Adenoidectomy prevents blockage of eustachian tubes by the adenoids and removes source of infection. Improves nasal obstruction. |
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Term
| List 4 features on the history which suggest pain is pericardial in origin. |
|
Definition
- sharp, pleuritic pain
- radiates to trapezius
- exertion does not alter pain
- worse in supine position
- worse on inspiration
- better on sitting up/bending forward |
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Term
| What signs would you expect to find if someone had pericarditis? |
|
Definition
- low grade fever
- pericardial friction rub on auscultation |
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|
Term
| What abnormalities would you see on an ECG in someone with pericarditis? |
|
Definition
- PR depression
- concave upwards ST segment elevation in all leads bar aVR/V1 |
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Term
| What is the firstline treatment of choice for a patient in pain with pericarditis? What side effects would you warn him about? |
|
Definition
NSAIDs (eg ibuprofen)
- GI disturbance eg nausea, diarrhoea
- hypersensitivity eg rash, bronchospasm |
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Term
| What are possible causes of pericarditis? |
|
Definition
- neoplasm
- MI
- autoimmune (SLE, RA, rheumatic fever)
- trauma to heart
- uremia
- aortic dissection
- side effect of medication |
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Term
| List 2 likely diagnoses in patients with heartburn. |
|
Definition
|
|
Term
| What lifestyle advice should you give to someone with heartburn? |
|
Definition
- don't go to bed with a full stomach
- don't overeat
- avoid alcohol
- stop smoking
- avoid trigger foods
- decrease weight |
|
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Term
| What 2 drugs can you give someone with heartburn? |
|
Definition
PPI (eg omeprazole)
H2 receptor antagonist (eg ranitidine) |
|
|
Term
| What investigations would you do for heartburn that did not resolve? |
|
Definition
- urea breath test
- manometry
- oesophogastroduodenoscopy +/- biopsy |
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|
Term
| Biopsies from the distal oesophagus demonstrate extensive intestinal metaplasia. What is the diagnosis? What is its significance? |
|
Definition
Barrett's oesophagus - columnar metaplasia of squamous cells in distal oesophagus.
Can progress to oesophageal carcinoma. |
|
|
Term
| What clinical signs would you look for on examination of someone who you suspected had cervical cancer? |
|
Definition
- pelvic mass
- bloody/purulent discharge
- friable, red, raised area of cervix
- enlarged cervix on bimanual
- cervical ulceration
- irregular cervix surface |
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|
Term
| What are the 2 most common types of malignant tumour of the cervix? |
|
Definition
- squamous cell carcinoma
- adenocarcinoma |
|
|
Term
| What are the 3 stages of premalignant cervical cancer? |
|
Definition
CIN1 - mild
CIN2 - moderate
CIN3 - severe dysplasia (carcinoma in situ) |
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|
Term
| What agent can cause cervical intraepithelial neoplasia? |
|
Definition
|
|
Term
| What 2 ways can HPV cause abnormal cell proliferation? |
|
Definition
- integration of viral DNA into epithelial cell DNA
- viral antigens/proteins bind to host cell tumour suppressor genes |
|
|
Term
| What are the 2 most common identifiable causes of acute pancreatitis? |
|
Definition
- alcohol
- gallstones
Less common
- pancreatic cancer
- trauma
- ERCP
- mumps |
|
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Term
| What investigations using contrast can you use to image the bile duct? |
|
Definition
ERCP (endoscopic retrograde cholangiopancreatography)
Precutaneous transhepatic cholangiography
Operative cholangiography
Hepatobiliary iminodiacetic acid (HIDA) |
|
|
Term
| What are the definitive surgical management options for gallstones? |
|
Definition
ERCP + sphincterotomy
Laparoscopic cholecystectomy
Extracorporeal shockwave lithotripsy |
|
|
Term
| What would you expect on clinical examination of someone with an L5 or S1 compression? |
|
Definition
L5 impairment causes
- weakness of big toe extension
- weakness of knee flexion
- sensory loss on the outer side of the foot
- sensory loss on the dorsum of the foot
S1 impairment causes
- weak plantarflexion
- weak eversion of the foot
- a depressed ankle jerk reflex
- sensory loss along the lateral border of the foot |
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Term
| Why is surgical decompression required in cauda equina syndrome? |
|
Definition
| It is a medical emergency - surgical decompression will reduce the chance of long-term neurological damage |
|
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Term
| What 2 investigations would you like to carry out to investigate the degree of metastasis of a prostate cancer? |
|
Definition
Staging
- CT abdo/chest/pelvis
Bone scan
- look for bony mets |
|
|
Term
| What is the most common type of malignant tumour occuring in the prostate gland? |
|
Definition
|
|
Term
| A patient with prostate cancer is deemed unsuitable for surgery. What other treatment options are available? |
|
Definition
- palliative radiotherapy to bony mets, external beam
- palliative chemotherapy
- medical management with GnRH receptor antagonists (eg leuprorelin) |
|
|
Term
| Explain the difference between stage and grade in the pathological assessment of malignant tumours. |
|
Definition
STAGE
- measure of spread (higher stage -> spread to other parts)
GRADE
- measure of histological differentiation (lower grade is slower-growing and resemble normal cells) |
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Term
| A ex-smoker lady with back pain in the upper lumbar area and normal neurological examination comes in. What are your top 2 differentials other than osteoporosis? |
|
Definition
- spinal neoplasia
- pathological lumbar fracture |
|
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Term
| List 4 risk factors you would enquire about in someone you suspect has osteoporosis. |
|
Definition
- Hx of steroid use
- age of menopause +/- HRT
- family Hx
- excess alcohol take
- smoking |
|
|
Term
| What would you tell a patient about the risks of HRT? |
|
Definition
Increased risk for
- breast cancer
- stroke
- DVT/PE
- but risk still low
Decreased risk for
- colon cancer
- hip fracture |
|
|
Term
| What advice and treatment would you give to a patient with osteoporosis and a crush fracture at L1 on discharge? |
|
Definition
- alendronic acid 70mg/week (biphosphonate)
- cholecalciferol 600U OD
- regular exercise - strength + balance
- ensure no trip hazards in the house |
|
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Term
| Suggest 3 psychiatric symptoms you would look for on a patient you suspect has delirium. |
|
Definition
- visual/auditory hallucinations
- delusions
- lack of insight
- disturbance of cognition |
|
|
Term
| What can predispose someone to delirium? |
|
Definition
- infection
- vascular event
- metabolic/electrolyte imbalance
- post-op opioids
- drug withdrawal (eg alcohol)
- hypoglycaemia
- hypoxia |
|
|
Term
| LIst 3 cognitive functions you would test and an example of one question for each function. |
|
Definition
ORIENTATION
(time, person, place)
RECALL
- list 3 objects and ask to repeat immediately then later
LANGUAGE
- name an object eg pen |
|
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Term
| List 2 methods for obtaining an uncontaminated urine sample from a 4 month old boy. |
|
Definition
Clean-catch MSSU
Suprapubic aspiration |
|
|
Term
| Name 2 other parts of the septic screen you would perform to identify the source of infection in a 4 month old boy. |
|
Definition
CULTURE
- blood, urine, CSF (if not contraindicated) for culture and sensitivity
MICROSCOPY
- urine + CSF
Bloods
- WCC, ESR, CRP
Imaging
- chest Xray |
|
|
Term
| What 2 standard criteria are used to define a lab culture diagnosis of UTI? |
|
Definition
|
|
Term
| What is the usual organism which is obtained from a positive urine culture? |
|
Definition
|
|
Term
| What treatment should a 4 month old boy recieve on discharge following a UTI? |
|
Definition
|
|
Term
| What initial radiological investigation would you request for a 4 month old boy folllowing a UTI? |
|
Definition
| Ultrasound of the urinary tract to identify any structural abnormalities |
|
|
Term
| What is meant by phase 5 with regards to BP measurement? |
|
Definition
| Point at which all sounds disappear. It correlates with diastolic BP. |
|
|
Term
| What would your approach be to someone with a moderately raised BP? |
|
Definition
- repeat the measurement
- lifestyle advice
- stop smoking
- lose weight
- reduce salt intake |
|
|
Term
| What are the long-term advantages of reducing BP with medication? |
|
Definition
- decreased risk of stroke
- decreased risk of MI
- decreased mortality |
|
|
Term
| What drug treatments are most helpful for hypertension? |
|
Definition
ACE inhibitors (eg ramipril)
Calcium channel blockers (eg amlodipine)
Thiazide diuretic (eg bendroflumethiazide)
Beta blockers (eg atenolol) |
|
|
Term
| What are the side effects of ACE inhibitors, beta blockers, calcium channel blockers and thiazide diuretics? |
|
Definition
ACE inhibitors
- cough/hyperkalemia
B-blockers
- bronchospasm
Calcium channel blockers
- ankle oedema
Thiazide
- gout |
|
|
Term
| List 4 symptoms/signs which may indicate an airway problem in a fireman with burns. |
|
Definition
- stridor
- dyspnoea
- soot in mouth/nares/sputum
- hoarseness
- tongue-swelling |
|
|
Term
| What are the admission criteria for a burns patient? |
|
Definition
- burns on face and hands
- IV treatment required
- smoke inhalation injury
- circumferential burns |
|
|
Term
| How do you assess the depth of burns to the skin? |
|
Definition
PARTIAL THICKNESS
- painful/red/blistered
FULL THICKNESS
- painless/white/not perfused
- sensation
- appearance
- capillary refill |
|
|
Term
| What is an escharotomy and why would you do one? |
|
Definition
- removal of burnt skin (eschar)
- necessary for full thickness circumferential burns of neck/thorax/extremities
- done to prevent compartment syndrome restricting blood flow |
|
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Term
| A 68yr old man presents with back pain, weakness and numbness in the legs following treatment for lung cancer. You suspect a 2ndry deposit in the spine. What other functional disturbance is likely to be present on inquiry? |
|
Definition
Saddle anaesthesia
Bowel/urinary incontinence |
|
|
Term
| What features on examination would suggest an upper motor neurone lesion? |
|
Definition
- upgoing plantars
- brisk reflexes
- increased tone
- clonus |
|
|
Term
| What 3 urgent treatments can be considered to help symptoms of leg weakness following a secondary deposit on the body of the 11th dorsal vertebrae? |
|
Definition
- IV dexamethasone
- local radiotherapy
- surgical decompression laminectomy |
|
|
Term
| What are 2 possible explanations for a raised serum calcium level in someone with bony metastases from lung cancer? |
|
Definition
- lung cancers can secrete PTHrP which increases calcium uptake from the gut and increase bone turnover
- bony metastases cause bone lysis and osteoclast activation which increases calcium release |
|
|
Term
| What features of sarcoidosis would you look for on a clinical examination? |
|
Definition
- erythema nodosum
- arthlargia
- uveitis (red painful eye)
- lymphadenopathy |
|
|
Term
| What investigations other than biopsy might help confirm a diagnosis of sarcoidosis? |
|
Definition
- FBC (lymphopemia, thrombocytopenia, raised ESR)
- serum calcium (hypercalcemia)
- CT scan (mediastinal node disease) |
|
|
Term
| What is the characteristic microscopic finding in sarcoidosis? |
|
Definition
|
|
Term
| List 3 cardiovascular or respiratory complications of sarcoidosis that might explain a dry non-productive cough and breathlessness on exertion. |
|
Definition
- pulmonary fibrosis
- pulmonary hypertension
- cardiomyopathy |
|
|
Term
| What 2 differentials of sarcoidosis are important to exclude? |
|
Definition
- TB
- bronchial carcinoma |
|
|
Term
| What features from the history would suggest that a patient has rest pain secondary to arterial disease? |
|
Definition
- pain relieved by dangling legs off bed
- pt suffers from intermittent claudication
- Hx of ischaemic heart disease |
|
|
Term
| Give 4 features on examination that support a diagnosis of rest pain secondary to arterial disease? |
|
Definition
- diminished/absent distal lower limb pulses
- pale legs
- cold legs
- hair loss on legs
- ulceration |
|
|
Term
| What investigations would you consider for peripheral arterial disease? |
|
Definition
- ABPI
- duplex ultrasonography
- arteriography
- lipids |
|
|
Term
| What are the symptoms of endometriosis? |
|
Definition
- dysmenorrhoea
- dyspareunia
- menorrhagia
- chronic pelvic pain |
|
|
Term
| What are the signs of endometriosis? |
|
Definition
- chocolate cysts may be seen on laparoscopy
- enlarged ovaries
- visible lesions in the vagina or on the cervix
- tender nodules along the uterosacral ligaments, or in the pouch of Douglas
- a fixed, retroverted uterus on bimanual examination |
|
|
Term
| What is a treatment for mild/moderate endometriosis which will increase the chance of conception? |
|
Definition
- controlled hyperstimulation of ovaries
- surgical coagulation/diathery/laser ablation and removal of endometriomas |
|
|
Term
| What 2 features would you find on a biopsy of endometriosis? |
|
Definition
- endometrial epithelium
- haemosiderin-laden macrophages |
|
|
Term
| List 2 other causes of blockage to the fallopian tubes other than endometriosis. |
|
Definition
|
|
Term
| What issues need to be discussed with a patient before they start IVF? |
|
Definition
- success rate
- other options (eg adoption)
- limited attempts on NHS - up to 3 cycles
- decision subject to suitability (psych assessment and age) |
|
|
Term
| What features of the skin suggest a diagnosis of psoriasis? |
|
Definition
- well-defined, raised, erythematous and scaly lesions
- surface silvery scale which may be easily removed often leading to pin - point capillary bleeding (Auspitz sign)
- occurs on the extensor surfaces, scalp, torso
- nail changes - onchylosis, pitting |
|
|
Term
| Under what conditions can psoriasis make patients systemically unwell? |
|
Definition
- erythrodermic psoriasis
- generalised pustular psoriasis |
|
|
Term
| Why are topical corticosteroids not used as firstline therapy for psoriasis? |
|
Definition
Side effects
- skin thinning
- easy bruising
- Cushings syndrome
Risk of developing unstable psoriasis when corticosteroids stopped. |
|
|
Term
| What topically applied treatments are firstline for psoriasis? |
|
Definition
- emollients (eg aqueous cream)
- Vit D analogues (eg calcitriol)
- coal tar (eg psoriderm) |
|
|
Term
| Apart from UV phototherapy, name a secondline oral drug for psoriasis. What is a side effect of this? |
|
Definition
Methotrexate/ciclosporin.
SE - pancytopenia, liver cirrhosis |
|
|
Term
| What symptoms would support a diagnosis of a panic attack? |
|
Definition
- globus pharyngis
- fear of dying
- collapse
- chest tightness despite no cardiac abnormality
(light-headedness, SOB, tingling in fingers, hyperventilation but this is mentioned in the Q) |
|
|
Term
| What is the most likely underlying diagnosis in someone having a panic attack? |
|
Definition
| Panic disorder with agoraphobia |
|
|
Term
| Why do people having panic attacks get tingling in their fingers? |
|
Definition
| Hyperventilation -> resp alkalosis -> paraesthesia |
|
|
Term
| What simple non-pharmalogical measure might you take immediately in casualty to treat the acute problem? |
|
Definition
- encourage deep breaths (7 secs in, 11 out)
- challenge their -ve thoughts |
|
|
Term
| What drugs are appropriate for short-term management of a panic attack? |
|
Definition
- B blockers (eg propanolol)
- SSRI (eg citalopram/fluoxetine) |
|
|
Term
| What psychological treatment is appropriate for long term management of panic attacks? |
|
Definition
|
|
Term
| What test on clinical examination would you do for sciatica? |
|
Definition
| Straight leg raise test. Limitation of straight leg raise with sciatica pain radiating down buttocks and lower limb |
|
|
Term
| How many people with a prolapsed disc are likely to require surgery? |
|
Definition
90% resolve at 8wks with analgesia.
By 1 year outcomes for those with and without surgery are the same. |
|
|
Term
| What symptoms would you expect if a patient has obstructive jaundice? |
|
Definition
- dark urine
- pale stools |
|
|
Term
| Name 3 mechanisms by which antibiotics may cause jaundice and give an example of a drug that may be responsible. |
|
Definition
PREHEPATIC (eg rifampicin)
- impaired bilirubin uptake
- increased unconjugated bilirubin
= jaundice
INTRAHEPATIC (eg rifampicin)
- induces liver failure
- decreased excretion of bilirubin
= jaundice
POSTHEPATIC (eg flucloxacillin)
- increased risk of gallstones
- blocks duct
- decreased excretion
= jaundice
Allergic haemolytic anaemia (eg cephalosporins)
- increased RBC breakdown
- increased bilirubin
= jaundice |
|
|
Term
| An abdominal ultrasound is performed. What finding would lead you to conclude that he has extrahepatic biliary obstruction? |
|
Definition
| Dilatation of the common bile duct/common hepatic duct |
|
|
Term
| What are the 2 main causes of extrahepatic biliary obstruction? |
|
Definition
Neoplastic disease
(of pancreatic head, ampulla or bile duct)
Common bile duct stone (choledocolithiasis) |
|
|
Term
| Name 3 conditions which patients commonly recieve TPN. |
|
Definition
- bowel obstruction
- short bowel syndrome
- gastroschisis |
|
|
Term
| What is the initial management of a patient recieving parenteral nutrition who you suspect has developed sepsis? |
|
Definition
- line and peripheral culture
- remove the line if central venous line is suspected as the cause of sepsis
- prescribe antibiotics after organisms have been identified |
|
|
Term
| What 4 steps are taken to minimise the risks of developing infections with organisms like MRSA? |
|
Definition
- hand washing before and after patients
- isolation of patients with known/suspected MRSA
- use disposable gloves when handling open wounds
- keep hospital environment clean |
|
|
Term
| A patient with TPN has developed sepsis. They then develop a painful right swollen arm. What complication do you suspect and how should it be managed? |
|
Definition
Axillary vein thrombosis.
Give heparin. |
|
|
Term
| What drugs are commonly responsible for bleeding duodenal ulcers in the elderly? |
|
Definition
NSAIDS (ibuprofen)
Antiplatelets/anticoagulants (warfarin) |
|
|
Term
| What tests can be used to diagnose H. Pylori in peptic ulcer disease? |
|
Definition
Urea breath test.
H. Pylori stool antigen test. |
|
|
Term
| What is the correct management of someone with a bleeding duodenal ulcer? (apart from blood transfusion) |
|
Definition
- fluid resusitation
- endoscopic haemostasis (eg thermal coagulation)
- PPI |
|
|
Term
| What is the mechanism of action of omeprazole? |
|
Definition
Proton pump inhibitor
- irreversibly blocks H/K+ ATPase in parietal cells
- decreases H+ secretion
- decreases HCl
- increases gastric pH |
|
|
Term
| What hormone is secreted by the gastric mucosa? What cell type is responsible? |
|
Definition
|
|
Term
| Name 3 conditions associated with increased plasma levels of gastrin. |
|
Definition
- atrophic gastritis
- Zollinger-ellison syndrome
- peptic ulcer disease |
|
|
Term
| What non-invasive investigations would you perform in someone with cough, night sweats and weight loss? |
|
Definition
Sputum culture/microscopy
- might show organisms confirming TB, pneumonia, bronchitis
Sputum cytology
- may show malignant cells confirming a tumour
Mantoux test
- if strongly +ve suggests TB
- if no reaction in an immunized individual might indicate overwhelming infection
CT/MRI chest
- might show scarring and calcification suggestive of previous TB |
|
|
Term
| What are your differentials for someone with a cough, weight loss and night sweats? |
|
Definition
- bronchial carcinoma
- TB
- sarcoidosis
- pneumonia |
|
|
Term
| What are the symptoms of left ventricular failure? |
|
Definition
- exertional dyspnoea
- orthopnoea
- paroxysmal nocturnal dyspnoea
- fatigue
- cough with pink frothy sputum
- cold peripheries
- nocturia |
|
|
Term
| What neurohumoral mechanisms can be activated in heart failure? |
|
Definition
- renin-angiotensin-aldosterone system
- hypothalamic-pituitary-adrenal axis
- natriuretic peptides |
|
|
Term
| What are the symptoms of carcinoid syndrome? |
|
Definition
- flushing
- palpitations
- oedema
- wheezing |
|
|
Term
| What biochemical investigation is performed to test and screen for and monitor treatment of carcinoid syndrome? |
|
Definition
| 24 hr urine collection for 5-HIAA (serotonin metabolite) |
|
|
Term
| Why does carcinoid syndrome present later in patients with small bowel carcinoid than those with pulmonary carcinoid? |
|
Definition
Carcinoid is due to excess serotonin entering the systemic circulation.
The liver metabolises the break down of bowel carcinoid tumour products and so effects are not seen until the carcinoid has spread and is no longer confined to the small bowel or mesentery. |
|
|
Term
| What features of a carcinoid tumour at presentation would make it more likely to follow a malignant course? |
|
Definition
- tumour size
- depth of local invasion
- presence of metastases
- peripheral location |
|
|
Term
| List 2 malignant tumours that are relatively common in the small bowel. |
|
Definition
Adenocarcinoma
GI stromal tumour
Lymphoma |
|
|
Term
| Apart from foetal heart monitoring, give 2 methods by which foetal wellbeing might be assessed. |
|
Definition
1. USS measurement of head circumference and abdominal circumference.
2. USS quantification of amniotic fluid volume.
3. USS detection of fetal movements, tone, breathing movements.
4. Doppler ultrasonography of umbilical artery. |
|
|
Term
| Give 2 examples of abnormalities of the foetal heart monitor trace which you would look for, which would indicate a foetal problem. |
|
Definition
- loss of accelerations
- baseline tachycardia (>160bpm)
- reduced variability |
|
|
Term
| What short-term consequences (pregnancy and peri-natal period) are there of intra-uterine growth restriction? |
|
Definition
- respiratory distress syndrome
- low birth weight - increased risk of perinatal mortality/still birth
- hypoglycaemia
- necrotising enterocolitis |
|
|
Term
| What 2 potential long-term medical complications may a baby with intra-uterine growth restriction have when it becomes an adult? |
|
Definition
- diabetes mellitus type 2
- coronary artery disease
- cerebral palsy
- mental retardation |
|
|
Term
| An elderly lady has been feeling tired and unmotivated. She hasn't been looking after herself and feeling generally unwell. She is a smoker and hypertensive. What are possible differentials? |
|
Definition
- depression
- hypothyroidism
- dementia
- grief reaction |
|
|
Term
| What mental state findings do you require for a diagnosis of clinical depression? |
|
Definition
- persistently low mood
- poor concentration
- lack of motivation
- suicidal ideation
- poor eye contact
- not taking care of appearance |
|
|
Term
| You decide to prescribe an antidepressant drug. What factors would contribute to your choice of drug? |
|
Definition
- does patient have suicide risk? If so, prescribe SSRI, not TCA as worse to OD
- interactions with current medications
- does pt have insomnia? - use amitriptyline due to sedative action |
|
|
Term
| What is the most common type of testicular tumour in the 20-30 age group? |
|
Definition
|
|
Term
| What is the most common type of tumour in the testis in men >60? |
|
Definition
Lymphoma
Interstitial tumour |
|
|
Term
| What blood tests would you do in a man with a testicular tumour? |
|
Definition
Alpha fetoprotein
Beta HCG
LDH |
|
|
Term
| What 2 lab results confirm the clinical diagnosis of nephrotic syndrome? |
|
Definition
- proteinuria >4.5g/day
- hypoalbuminaemia (serum albumin <25g/L) |
|
|
Term
| What 3 investigations are essential before performing a renal biopsy? |
|
Definition
Ultrasound
FBC
Coagulation screen |
|
|
Term
| What 2 complications should you discuss with the patient when obtaining patient consent for renal biopsy? |
|
Definition
- bleeding (haematuria and perirenal haematoma in 70% of cases)
- pain in flank radiating to shoulder
- risk of infection |
|
|
Term
| What is the most likely histological diagnosis on renal biopsy in a patient with SLE and nephrotic syndrome? |
|
Definition
| Membranous nephritis and in situ immune complex deposition |
|
|
Term
| Name 2 autoantibodies most commonly detected in SLE. |
|
Definition
- anti-nuclear antibodies (ANA)
- anti double stranded DNA antibodies (dsDNA) |
|
|
Term
| 72 year old obese lady with 6 month history of increasing right knee pain. What is the most likely diagnosis? |
|
Definition
| Osteoarthritis of right knee |
|
|
Term
| What features of the history would be important to take into consideration when assessing the severity of her symptoms? |
|
Definition
- loss of function - how far can she walk?
- does the pain keep her awake? |
|
|
Term
| What features O/E would you look for in osteoarthritis? |
|
Definition
- Heberden's and bouchard's nodes
- joint crepitus
- decreased ROM
- Baker's cyst
- Joint effusion
- joint instability |
|
|
Term
| What are the 3 broad types of non-surgical management of osteoarthritis? |
|
Definition
- analgesia
- lifestyle changes eg weight loss
- physiotherapy - exercises and walking aids |
|
|
Term
|
Definition
Systemic inflammatory response syndrome (SIRS) is the presence of two or more of the following:
- abnormal body temperature
- heart rate
- respiratory rate
- blood gas
- white blood cell count |
|
|
Term
|
Definition
| Sepsis is defined as SIRS in response to an infectious process. |
|
|
Term
|
Definition
| Severe sepsis is defined as organ dysfunction due to an infection. |
|
|
Term
|
Definition
| Septic shock is severe sepsis plus persistently low blood pressure following the administration of intravenous fluids |
|
|
Term
| What are possible causes of left iliac fossa pain with fever, tachycardia and raised WCC? |
|
Definition
- acute diverticulitis
- leaking aortic abdominal aneurysm
- pyelonephritis
- locally perforated sigmoid carcinoma |
|
|
Term
| What would be your initial management for a patient with LIF pain, febrile, tachycardia and raised WCC? |
|
Definition
- analgesia (morphine)
- antipyretics (paracetamol)
- antibiotics (cover gram -ve bacteria and anaerobes eg co-amoxiclav)
- monitor vitals |
|
|
Term
| At laparotomy, the sigmoid colon is found to be the cause of the patient's peritonitis. What operative procedure is indicated? |
|
Definition
|
|
Term
| Describe 3 features of sigmoid diverticular disease. |
|
Definition
- out pouching of bowel mucose through muscle wall of bowel
- lack normal muscle coats
- lie alongside taenia coli |
|
|
Term
| In one sentence, describe the abnormality that occurs in intussusception? |
|
Definition
| A length of bowel telescopes into itself, proximal to distal. |
|
|
Term
| What physical signs may be present in intussusception? |
|
Definition
- tachycardia
- abdominal distension
- sausage-shaped abdo mass (usually RUQ)
- constipation |
|
|
Term
| What 2 investigations can help diagnose intussusception? |
|
Definition
- abdominal US
- air contrast enema |
|
|
Term
| What are the complications of intussusception? |
|
Definition
- perforation and generalised peritonitis
- ischaemia and gangrene
- shock |
|
|
Term
| How can intussusception treated? |
|
Definition
| Air or barium contrast enema |
|
|
Term
| Other than pancreatic insufficiency, what is the main symptom of chronic pancreatitis? |
|
Definition
| Recurrent severe abdominal pain |
|
|
Term
| What are the 3 main cell types in the islets of langerhands and what hormones do they secrete? |
|
Definition
Alpha cells - glucagon
Beta cells - insulin
Delta cells - somatostatin |
|
|
Term
| What are the 2 main symptoms of pancreatic exocrine insufficiency? |
|
Definition
|
|
Term
| Name 3 digestive enzymes secreted by acinar cells. |
|
Definition
|
|
Term
| What treatment is available for exocrine insufficiency? |
|
Definition
| Pancreatic enzyme replacement - creon |
|
|
Term
| A patient had a major abdo operation and his BP has now fallen to 90/70, O2 sats 98% and he has not passed urine. What 4 clinical signs would you use to assess the patient and why are these valuable? |
|
Definition
HR - increased in SIRS
RR - increased in SIRS
Temp - high or low in SIRS
GCS - cerebral perfusion and need for intubation |
|
|
Term
| What is a central venous line used to assess the patient's status? |
|
Definition
CVP measures the right ventricular preload.
Used to determine if a fluid challenge is sustained and to monitor fluid status. |
|
|
Term
| What is the volume of urine needed to be passed per hour to ensure that oliguric renal failure is less likely to occur? |
|
Definition
|
|
Term
| How can you assess how much urine is being passed per hour? |
|
Definition
| Catheterise patient and monitor urine output |
|
|
Term
| If urine output is low, what course of action should be taken? |
|
Definition
- IV fluids
- ultrasound kidneys to look for obstruction
- treat complications of ARF
- consider dialysis |
|
|
Term
| How do you assess competence? |
|
Definition
- Identify whether Gemma fully appreciates the impact this decision will have
- Ensure that Gemma is able to use, retain and weigh-up the information necessary to make an informed decision by asking her to summarise what you have told her in her own words
- Check that Gemma does not have an underlying disturbance or impairment of mental functioning that may impair her ability to make informed decisions e.g. an intellectual disability or mental illness |
|
|
Term
| Under what circumstances would you break confidentiality? |
|
Definition
1. If it is required by law e.g. notifiable diseases or connected with litigation
2. If the patient consents ␣ either directly or implicitly for the sake of their own care e.g. sharing information with other healthcare professionals or for use of audit or to their family
3. It is justified in terms of public interest i.e. to protect the patient or to protect others |
|
|
Term
| Under what circumstances would you break confidentiality? |
|
Definition
1. If it is required by law e.g. notifiable diseases or connected with litigation
2. If the patient consents ␣ either directly or implicitly for the sake of their own care e.g. sharing information with other healthcare professionals or for use of audit or to their family
3. It is justified in terms of public interest i.e. to protect the patient or to protect others |
|
|
Term
| What are the implications of the rise in obesity and diabetic hospitalisations on the prevalence of other diseases? |
|
Definition
Obesity is a major risk factor for numerous diseases and, in particular, vascular diseases such as coronary artery disease (CAD), stroke and peripheral vascular disease. As such, it is a reasonable assumption to make that if the prevalence of obesity is rising, so too is the prevalence of conditions such as Angina.
Moreover, diabetes is also associated with many other diseases and has a strong correlation with vascular disease. In particular, poor diabetic control (such as that demonstrated by those undergoing hospitalisation) is associated with an even greater risk of developing complications of diabetes such as CAD, diabetic retinopathy and diabetic nephropathy. That there has been an increase in diabetes-related hospitalisations suggests that the above may also be on the rise. |
|
|
Term
| What are the implications of the rise of obesity and diabetic hospitalisations on the levels of disability? |
|
Definition
Though obesity itself is not a disability, it can lead to severe physical disability through the various conditions associated with it. For example, the increased loading on joints is associated with the development of Osteoarthritis, which can result in progressive limitation of movement and loss of independence.
Moreover, the rise in diabetes-related hospitalisations may reflect a rise in the prevalence of disabling complications of diabetes, such as diabetic retinopathy. As a result, these trends may be representative of an overall increase in the levels of disability. |
|
|
Term
| What are the implications of these trends for health service planning? |
|
Definition
It shows that current methods of intervention are inadequate, and that a greater effort must be made in order to minimise any further rise ␣ in particular in the early stages of life through education
- That a larger proportion of the NHS budget will need to be invested in treating conditions associated
with obesity and diabetes
- That there will need to be renewed research efforts into how best to combat obesity and diabetes
- That there should be greater resources allocated to monitoring those who are obese or diabetic, and in encouraging them to help themselves through weight loss, dietary control and increased exercise. |
|
|
Term
| What are the physical consequences of the rise in alcohol consumption? |
|
Definition
Physical:
- Increase in the prevalence of vascular disease i.e. CAD, CVD, PVD
- Increase in the prevalence of alcoholic liver disease
- Increase in the prevalence of hepatocellular carcinoma
- Increase in the prevalence of oesophageal cancer |
|
|
Term
| What are the mental consequences of the rise in alcohol consumption? |
|
Definition
- Increase in the prevalence of alcohol-related dementia
- Increase in the prevalence of alcoholic-hallucinosis
- increase in the prevalence of Wernicke's encephalopathy and Korsakoff's psychosis |
|
|
Term
| What are the social consequences of the rise in alcohol consumption? |
|
Definition
- Increase in preventative healthcare costs in order to combat the rise
- Increase in healthcare costs to combat alcoholism and the numerous co-morbidities associated with it
- Decrease in available funding for other areas of healthcare |
|
|
Term
| What can be done to decrease the numbers of alcohol-related deaths in Glasgow? Consider the individual, healthcare professional, drinks industry and government. |
|
Definition
Individuals:
- Attempt to cut down drinking
- Be more open to seeking help
- Be vigilant where friends/family are concerned and encourage them to talk/seek help if their drinking is
believed to be a problem
Healthcare Professionals:
- Enquire about the alcohol intake of all patients and, where applicable, encourage them to cut down
- Offer concise and beneficial advice on how best to cut down to those requiring or seeking it
Drinks Industry:
- Encourage all companies to take part in the responsible drinking campaign
- Prevent companies from targeted marketing at younger and more susceptible individuals
- cease production of cheap super-strength drinks
Government:
- Introduce minimum pricing per unit for alcohol
- School Curriculum ␣ ␣ emphasis on the health-risks and problems associated with binge-drinking
- Raise the legal drinking age
- Do not allow alcohol to be advertised until after the watershed to minimise its visual prominence
- Ban any alcohol advert within a specific distance of schools |
|
|
Term
| What should you ascertain when you are going to see Mrs Davies, a patient who has not consented for an operation and is due in surgery? |
|
Definition
- Is this woman Mrs Davies?
- Has the procedure been explained to Mrs Davies?
- Is there another reason she has not signed the consent form?
- What is Mrs Davies pre-medication?
- Has Mrs Davies taken this pre-medication? |
|
|
Term
| What are the main elements of informed consent? |
|
Definition
- Autonomy
- Capacity
- Disclosure |
|
|
Term
| What are the factors about this case that worry you about having to consent Mrs Davies? |
|
Definition
- You are an FY1 who is not in the theatre team and, as such, are not qualified to consent her
- Mrs Davies daughter is present and clearly distressed |
|
|
Term
| What information should be given to a patient in obtaining consent for a surgical procedure? |
|
Definition
- Details of the diagnosis and associated prognosis both with and without treatment
- Any uncertainties about the diagnosis and potential avenues of further investigation prior to treatment
- All the available options for treatment or management of the condition including the option not to treat
- Purpose of the proposed procedure including details of subsidiary treatment methods such as pain
relief; how the patient should prepare for the procedure and details of what the patient might
experience during or after the procedure including both common and serious side effects
- For each alternative option an explanation of the likely benefits and probabilities of success with
discussion of any serious or frequently occurring risk or lifestyle changes that may occur
- Advice about whether the proposed treatment is experimental
- how the patient's condition and any side-effects will be monitored or re-assessed
- The name of the doctor who will have overall responsibility for the treatment and, where appropriate,
names of the senior members of their team
- Whether doctors in training will be involved and the extent to which students may be involved
- A reminder that patients can change their minds about a decision at any time
- A reminder that patients have a right to seek a second opinion
- Where applicable, details of costs or charger which the patient may have to meet |
|
|
Term
| Following a seizure, what advice would you give the patient regarding driving? |
|
Definition
- Explain he is not allowed to drive for at least one year
- Explain why ␣ because he is at risk of another seizure, which could cause harm to himself and others
- Explain it is his responsibility to report this to the DVLA
- Explain that he should try to make other arrangements at work - If he agrees, you should speak to his wife and impress on her how important this is |
|
|
Term
| Three months after a seizure you see the patient driving his family to the local amusement park. What further action would you take in response to this situation? |
|
Definition
- Ask to see him in a consultation or make a phone call in order to discuss this
- If he does not agree with the diagnosis, you can suggest an appointment with another doctor for a second opinion
- Make every reasonable effort to get him to stop driving ␣ this may include writing to the patient stating
that you will be forced to declare the information and why
- If he does not take action, you should contact the DVLA medical adviser with the relevant medical information before writing to the patient and informing him that you have contacted the DVLA |
|
|
Term
| Why is confidentiality important? |
|
Definition
- Confidentiality is important as it:
- Shows an ethical and moral respect to the patient
- Shows respect for the patient's privacy
- Ensures the patient is in control of their health information
- Is central to the patient trusting the doctor not only in terms of keeping things private, but also in trusting their recommendations and trusting them with their health
- Recognises that the doctor is in a position of power and is an assurance that the doctor will not abuse this
- Maintains confidence in the health service
Without confidentiality:
- Patients may be reluctant to seek care
- Patients may withhold important information that may make diagnosis and treatment difficult
- Population control of communicable disease would be difficult because people would fear the social stigma of an illness |
|
|
Term
|
Definition
| The average number of years a person born in an given country would live if mortality at each age remains constant in the future. |
|
|
Term
| How is life expectancy calculated? |
|
Definition
- Life expectancy is calculated using a mathematical tool called a 'life table'.
- These are constructed by taking death rates from the population in question and applying them to a hypothetical cohort of persons.
- The life table is then able to provide probabilities concerning the likelihood of someone in this hypothetical population dying or surviving before their next birthday
- Life expectancy can be provided for any age in the life table, by summing the number of person years (the total number of years lived by all persons in the life table) and dividing this by the number of persons still alive in the life table |
|
|
Term
| If inequalities in health are to be combated, at what stage in the life cycle will it be necessary to intervene? |
|
Definition
- Prebirth ␣ Barker hypothesis i.e. focus on maternal health and nutrition. Seen as a very important factor causing health inequality correlating to a social gradient in maternal nutrition.
- Early Years ␣ many behaviours are learnt early on. Attachment Theory and parenting styles are important for later emotional and neurological development.
- Adolescence ␣ peer pressure which may lead to the acquisition of new behaviours for good or ill
- Middle Life ␣ social position important with most behaviours established
- Late Life ␣ chronic disease emerging, use of services important as well as social networks.
It is necessary to intervene at all the stages of the life cycle. It is known that risk factors track throughout life (social class will likely be the same when an adult) so it is important to act early.
Public Health interventions to target inequalities are most effective when at all stages |
|
|
Term
| What areas should the GP explore when communicating with Ms Scott, who doesn't want her child to have the MMR vaccine? |
|
Definition
1. Identify Knowledge Base:
- Where do these concerns come from?
- What exactly does she know about the supposed risks?
- Has she seen the evidence herself?
- Is there any reason (other than the media) that she is particularly worried?
- Is there anything else aside from autism that she is worried about with regards the MMR vaccine?
- Is she aware of the risks of not getting Jordan immunised i.e. measles and associated complications?
2. The Evidence:
1. That most of the information in the media stems from papers by Andrew Wakefield
2␣The data showing a link between the MMR and autism is believed to have been misconstrued
3. That no study since has been able to reproduce his findings or confirm his hypothesis of a link
4. That Wakefield himself was paid £400,000 by lawyers engaged in an anti-MMR lawsuit, bringing his ability to remain objective into question
5. That 10 of the 12 co-authors on the paper have retracted their support of his findings
6. That Wakefield had applied for a patent on a single-jab measles vaccine prior to his anti-MMR campaign, which raised further questions about his motives and possible bias
7. That in 2010 Wakefield was struck off the Medical Register (meaning he could no longer legally practice as a doctor in the UK) following an investigation by the General Medical Council into the manner in which one particular trial of his was conducted
3, The Risks of not Being Immunised:
- Explain clearly to Ms Scott that without this vaccine Jordan is at an increased risk of contracting Measles owing to the highly contagious nature of the virus and lack of a single measles vaccine
- Explain to her that should Jordon contracted measles, it will be an entirely unpleasant experience
- Explain that while mortality is very rare in the UK and most children recover with no long term consequences, there is still a risk, however small, of Jordan developing complications such as pneumonia (1-6%) or Encephalitis (~1 in 1500)
-Should Jorden contract measles, he may infect others, more vulnerable than he.
4. Autonomy:
- Explain to Ms Scott that, ultimately, the decision is hers and all the GP can do is explain the facts then respect her decision |
|
|
Term
| What conflicting issues arise when speaking to a patient who doesn't want her child getting the MMR vaccine, and how could you apply ethical terms to these? |
|
Definition
1. Beneficence:
The key conflicting issue here is a difference in opinion with regards what is best for Jordan. Naturally, Ms Scott only wants what is best her child and believes that stopping him from receiving the MMR is in his best interests given the supposed risk of autism. However, as a well-informed medical professional, the GP believes that giving him the vaccine would be the most appropriate course of action and must explain their reasoning for this in order to try and resolve the conflict.
2. Non-Maleficence:
This is a key issue in the above scenario as both parties believe that opposing courses of action are seen to result in harm to Jordan. Should he receive the vaccine, Ms Scott is worried he may eventually develop autism and so believes that by not getting him vaccinated she is preventing him from being harmed. In stark contrast to this, the GP believes that not getting Jordan vaccinated will cause him (and potentially the wider community) greater harm through an increased risk of contracting measles.
3. Autonomy:
Whenever possible the wishes of the patient should be respected. Given that Ms Scott speaks on behalf of Jordan, should the above conflict fail to be resolved then ultimately the GP must respect her decision even if they do not necessarily agree with it. This raises further ethical concerns for the GP since they will then be forced to follow a course of action that they believe conflicts with the principles of beneficence and non-maleficence, while raising the issue of what is more important: respect for autonomy, or doing what they believe to be right for Jordan.
4. Informed Consent:
Prior to this consultation Ms Scott could be seen as lacking all the necessary information to make an informed decision and, as such, her ability to judge the appropriateness of Jordan receiving the MMR vaccine could be seen as compromised. Assuming this was the case, it could be seen as unethical for the GP to accept her decision without first exploring her fears and attempting to give her all the relevant information.
5. Double Effect:
The dynamics of the relationship between Ms Scott and her GP are unknown to us in this scenario. As a result, it may be the case that although she disagrees with the MMR vaccine, Ms Scott may accept it as the correct course of action following a recommendation from the GP. Though this would be a positive outcome for Jordan, it may also cause Ms Scott undue stress as she could still be worried about the risks of the vaccine. |
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Term
| In the situation of a 15yr old pregnant girl wanting a termination, what ethical issues arise? |
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Definition
Beneficence:
The primary concern here is what is best for Gemma. Clearly, she is of the belief that terminating this pregnancy is in her best interests. However, her reasoning and the potential consequences of a termination should be fully explored before any decision is made.
Non-maleficence:
Although she may believe this to be the best course of action in the short-term, she may not have considered the potential psychological harm such an action may have on her.
Autonomy:
Ultimately, once all the facts have been explained to her, if she is deemed to have capacity, her choice must be respected.
Confidentiality:
Legally, if Gemma has capacity,you are unable to inform anyone about the situation without her consent. However, you should encourage Gemma to speak to both parties about this, as it is a difficult decision to make, and she will need all the support she can get whether she chooses to terminate or not.
Double Effect:
Though this termination may be seen as a positive outcome for Gemma since it allows her to continue with her life as though nothing had happened, as previously explained it may also have a detrimental effect on Gemma's well-being owing to the consequences of her decision (i.e. the death of the foetus). |
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Term
| What would you do in the course of your encounter with Gemma, the 15 year old pregnant girl requesting a termination? |
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Definition
- Assess whether or not she has capacity
- Explore the certainty of her pregnancy i.e. amenorrhoea, home-test results, GP-test results
- Explore her reasons for requesting a termination
- Explore whether or not this was planned
- Try to identify if this is her decision, or if she feels pressured into it
- Explore with her the impact of a termination on both her physical and psychological well-being
- Try to establish whether she has confided in anyone and, if not, encourage her to do so
- Encourage her to speak to her parents about the matter
- Establish whether the father knows/his opinion
- If the father does not know, then encourage her to speak to him about the matter
- Explore with her the impact of not proceeding with a termination on her current life as well as the lives of the father and her parents
- Explore whether she is currently taking or using any form of contraception and, if not, whether she would consider doing so in the future |
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Term
| What information does the doctor need to obtain from the daughter before responding to her regarding her asking to be allowed to die in peace? |
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Definition
- proof that she is Mrs Bradley's daughter (this is a very important matter to discuss)
- severity of mother's condition
- Whether or not her mother has capacity
- Whether or not her mother gave any indication as to her wishes should a situation such as this arise
- Whether the described arrangement is registered with the Public Guardian
- Precisely what the daughter knows about the mothers condition
- Whether or not the daughter fully appreciates the consequences of such a decision
- Whether there is anyone else she feels should be brought into this discussion e.g. husband/ other children |
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Term
| What ethical issues will need to be considered when speaking to a Mrs Bradley's daughter about whether she should be given treatment or allowed to die in peace? |
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Definition
Autonomy:
- What, if any, wishes Mrs Bradley had regarding such a decision
Beneficence:
- What is best for Mrs Bradley i.e. whether this course of action would minimise her suffering, or if it would simply cut her life short
- the primary concern is Mrs Bradelys well- being, the effect her condition is having on her family should not be entirely overlooked
Non-maleficence:
- The potential harm to Mrs Bradley from a decision made either way. For example, whether another treated episode might result in a similarly negative outcome for her psychological well-being (with or without physical consequences), or if it would be of benefit to her by improving her physical health.
Futility and Utility:
- Whether subjecting Mrs Bradley to further potentially invasive and distressing procedures/treatments will be of justifiable benefit to her well-being
Competing Rights:
- Mrs Bradley has the right to receive treatment. However, should she now lack capacity it will become her daughter's right to make medical decisions on behalf of her mother meaning that she may choose to overrule this right |
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Term
| Evidence that smoking was harmful began to emerge in the 1950s ␣ why did it take so long for smoking prevalence to fall? |
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Definition
- Opposition from tobacco companies was powerful
- Other statisticians claiming artefact and bias in previous research linking tobacco and poor health
- Powerful media force that promoted smoking in films and associated smoking with class, female
emancipation and glamour
- Many people still believed tobacco was beneficial to health. |
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Term
| Name at least 6 factors that were responsible for the decline in smoking prevalence. |
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Definition
- Price regulation
- Reducing force of advertising
- Restricting point of sale
- Stricter prosecution
- Increasing educational in schools
- Anti-smoking campaigns
- Increased support to quit
- Clear epidemiological research showing causality between disease and smoking
- Smoking ban |
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Term
| Which main categories of diseases have declined along with smoking? Is this coincident decline or evidence of a causative link? |
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Definition
- Mainly infectious diseases e.g. Respiratory diseases (e.g. TB, influenza or whooping cough) Non-respiratory (e.g. measles, scarlet fever)
- Declines are not evidence of a causal link. To establish causality you need to meet the Bradford Hill criteria. The links may be causal, but you cannot establish that just by looking at morbidity trends, especially because there will be a time lag between smoking exposure and disease onset. In addition, there were a great deal of other improvements (e.g. better housing, nutrition, safer employment) that would count as confounding factors. |
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Term
| Briefly outline the impacts of obesity on individuals (4 marks) and on society (4 marks). |
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Definition
Individuals:
- Increased risk of vascular disease including CAD, CVA and PVD
- Increased risk of developing Type II Diabetes Mellitus
- Increased risk of developing non-alcoholic liver disease
- Increased risk of oesophageal cancer
Society:
- Increased burden on healthcare through obesity-related co-morbidities
- Increased proportion of budget will be funnelled into combating obesity and co-morbidities
- Decrease in available funding elsewhere
- detrimental global perception of the UK as a fat nation |
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Term
| What needs to be done at the level of the individual (5 marks) and society (5 marks) to combat obesity? |
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Definition
| Individuals: - Increase energy expenditure whenever possible (e.g. use stairs not escalator) - Meet minimum recommendations for weekly exercise (at least 150mins of moderate intensity aerobic exercise each week along with 2 sessions of muscle strengthening activities) - Alter diet i.e. increased fruit/vegetables and decreased high-fat foods - Decreases overall energy intake if living a sedate lifestyle - Where applicable decrease weekly alcohol intake (one pint of 5% beer = 250 calories) Society: - Ensure to mention that you␣re ␣the Obesogenic environment␣ and how these would help combat it - Place equal emphasis on exercise as currently exists with smoking/drinking in the primary healthcare setting - Raise awareness of benefits and recommendations for exercise through major public health campaign (similar to current milk promotion) focussed in areas recognised of being of poorer health - Promote community exercise/activity groups from the primary healthcare setting Increase the distance between bus stops - Do not provide disabled parking stickers to individuals if their condition would benefit from exercise and any discomfort/pain experienced is not severe - Increase funding opportunities for voluntary sport and activity clubs - Run educational classes for parent on healthy eating/cooking - Remove escalators and replace with lifts only accessible to those who met the above criteria for disabled parking stickers - Introduce legislation governing the amount of processing food is allowed to undergo in order to minimise the detrimental effects of high-fat ready meals, processed meats etc. |
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