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115 Cards in this Set
- Front
- Back
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Describe some 'positive' symptoms in schizophrenia? |
Delusions, hallucinations, disorganisation |
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Describe some 'negative' symptoms in schizophrenia? |
Affective blunting, anhedonia, amotivation/avolition, poor self care, social withdrawal, alogia |
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Describe the different types of delerium? |
Hyperactive (30%- includes wandering, hallucinations, repetitive behaviours or aggression. Hypoactive (25%) is easily missed, patients may be quiet and withdrawn. 45% of delerious patients show a mixed pattern. |
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Name some precipitating factors for delerium? |
Medications, infection/sepsis, metabolic encephalopathy, dehydration, electrolyte imbalance, fever, substance withdrawal, disturbed sleep, urinary catherisation, pain, unfamiliar surroundings... |
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Name some factors that predispose patients to delerium? |
increased age, pre-existing cognitive deficits, dementia, polypharmacy, sensory impairment or deprivation, multiple medical conditions. |
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What are the four criteria in the Confusion Assessment Method (CAM)? |
1. Acute onset and fluctuating course 2. Inattention 3. Disorganised thinking 4. Altered conscious state |
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What are the behavioural and psychological symptoms of dementia (BPSD)? |
The non-cognitive deficits eg mood changes, behavioural symptoms, disturbed perception, altered thought content etc. |
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Define dementia? |
Dementia = Memory impairment plus one or more of: aphasia, apraxia, agnosia, disturbed executive function, with a significant decline in function over time, unrelated to delerium or other neurological or psychiatric disorder. |
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Describe the interpretation of results of the MMSE? |
25-30 = normal 21-14 = mild cognitive impairment 14-20 = moderate cognitive impairment <13 = severe cognitive impairment |
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Name some differential diagnoses in dementia? |
Alzheimers disease, vascular dementia, dementia with Lewy bodies (Parkinsons disease), frontal lobe dementia. |
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Contrast the features of delerium and dementia. |
Delerium = sudden onset, days to weeks, other illness usually present, worse at night, impaired attention, consciousness fluctuates, variable orientation to surroundings, slow, often incoherent speech. Dementia = slow onset, months to years, possibly no other illness, worse at night (sundowning), attention maintained, consciousness normal, forgetting wors. |
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Describe some causes of increased drive for ventilation? |
Exercise, metabolic acidosis, hypoxia, anxiety |
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Where are wheezes and crackles heard in the lung? |
Wheeze = airways Crackles = terminal lung units |
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What do these blood gases indicate: pH 7.5, CO2 30, O2 70, HCO3 23 |
Respiratory alkalosis with a widened A-a gradient |
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What is a normal A-a gradient? |
Young adult non smoker = 5-10 mm Hg on RA Elderly people = 14 mm Hg on RA |
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How do you calculate the A-a gradient? |
A-a gradient = PA02- PaO2 To figure this out you need to first calculate PA02 = PiO2 - (pCO2/0.8) Note that Pi02 on room air is 150 |
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Where is visceral vs parietal abdominal pain felt? |
Visceral pain = central (referred, embryological origin) Parietal pain = localised |
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How can you distinguish the location of a bowel obstruction based on the frequency of vomiting? |
-Frequent early vomiting with not much pain = foregut eg pyloric stenosis. -Vomiting every few minutes to half hourly = midgut eg SBO -Vomiting rarely = LBO |
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What cause of upper abdominal pain radiates to the shoulder tip? |
Perforated peptic ulcer Note that the shoulder also shares a nerve supply with the diaphragm- C3/4) |
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What does a positive Murphy's sign indicate? |
Acute cholecystitis (hand below costal margin, ask the patient to breathe in or cough) |
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What are Cullens and Grey Turners signs? |
Both indicate retroperitonal bleeding eg from acute pancreatitis |
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Where does pain from diverticulitis most commonly present? |
LIF |
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List some differentials for appendicitis? |
Mesenteric adenitis Terminal ileitis Meckels diverticulum Caecal diverticulitis |
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List the Fried's criteria for frailty |
1. Unintentional weight loss 2. Weakness 3. Exhaustion 4. Slow walking speed 5. Low physical activity (Frail = 3+ criteria) |
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Name some features of mechanical joint pain? |
Chronic pain (months to years) Progressive Worse with movement Relieved by rest Not much swelling Little stiffness |
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Name some features of inflammatory joint pain? |
Acute or subacute (days to weeks) May change quickly Better with movement Worse with rest Swelling may be prominent Stiffness prolonged (worst in mornings) |
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List four features of OA on Xray |
Reduced joint space Osteophytes Sclerosis Subchondral cysts |
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Differentials for a single inflamed joint? |
Septic arthritis, gout, pseudo-gout, inflammatory arthritis |
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What sort of crystals are found in gout and pseudo-gout? |
Gout = Monosodium urate crystals Pseudo gout = Pyrophosphate crystals |
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What joints in the hands are typically affected in RA? |
MCP and PIP joints |
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How sensitive/specific for RA are rheumatoid factor and CCP antibodies? |
Rheumatoid factors = 70% sensitive and 80% specific CCP antibodies = 70% sensitive and 90% specific |
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What might you see on an MRI brain taken during a migraine? |
A spreading wave of cortical depression, which is probably glial rather than neuronal and is often occipital in origin. |
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List some features of a visual aura in migraine? |
Scintillating scotoma and monochromatic patterns including wavy lines, fortification spectra and water effects. May be creeping hemi or quadrantanopia. |
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What are you worried about in a sudden onset "thunderclap" headache? |
SAH |
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Describe some signs and symptoms of raised ICP |
Headache, worse in the morning and on straining. Nausea. Papilloedema (leading to peripheral vision loss or transient blindness). Diplopia (6th nerve palsy). Altered conscious state. |
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What are the initial investigations if you suspect SAH? |
Plain CT brain and an LP (do not do LP if signs if raised ICP) |
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Name some causes of secondary hypertension? |
Renal disease, renal artery stenosis, OSA, or adrenal tumours eg secreting aldosterone, cortisol or catecholamines. |
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How do you diagnose hypertension? |
BP needs to be over 140/90 after 5 minutes of seated rest, on two readings 2 minutes apart. Should be confirmed on additional visit or home readings. |
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Describe the treatment algorithm for primary hypertension? |
Step 1: ACE inhibitor, dihydropyridine calcium channel blocker or low dose thiazide diuretic. Step 2: Dual therapy with an ACE inhibitor plus a calcium channel blocker, or ACE plus diuretic. Step 3: Triple therapy Step 4: Consider adding spironolactone, a beta blocker or vasodilator. |
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When should you treat hypertension? |
When systolic over 180 or diastolic over 110 in isolation, or when over 140 or 90 in presence of other CVD risk factors |
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How should you manage a patient for surgery whose HbA1c is 9.2%? |
If HbA1c is over 9%, surgery should be deferred and the patient referred to an endocrinologist. |
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What is the difference between nociceptive and neuropathic pain? |
Nociceptive = physiological pain, caused by tissue injury or illness. Neuropathic pain = pathological, caused by nervous system damage or abnormality. |
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How does paracetamol and what is the maximum safe dose in adults? |
Paracetamol inhibits peripheral prostaglandin synthesis. Safe dose is up to 4g per day. |
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What is the mechanism of action of NSAIDs? |
Non-selective inhibition of COX-I and II, thereby inhibits prostaglandin synthesis. |
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List some adverse effects of NSAIDs? |
Peptic ulceration Renal impairment Anti-platelet action Bronchospasm in asthmatics Exacerbation of CCF |
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List some adverse effects of opioids? |
Sedation Respiratory depression Nausea Euphoria Miosis Bradycardia Postural hypotension Urinary retention |
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What is an advantage of Tramadol over other opioids? And a disadvantage? |
Less respiratory depression More nausea and vomiting |
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What is Amitryptilline used for? |
Neuropathic pain |
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Name some anti-epileptic drugs used in neuropathic pain? |
Carbemazepine Sodium Valproate Gabapentin/Pregabalin All 'membrane stabilisers' which reduce abnormal firing of nerves |
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What is normal urine output? |
Above 30ml per hour or 0.5 ml/kg/hour |
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Describe some ways of preventing post-surgical complications? |
Analgesia review Mobilisation Chest physio VTE prophylaxis Prevention of pressure sores Adequate nutrition and fluids |
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What might cause a fever on day 3 post surgery? |
Pulmonary infection |
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What might cause a fever on day 5 post surgery? |
UTI, surgical site infection, DVT or PE |
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What is a normal level for plasma potassium? |
3.5-5 mmol/l |
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What drugs or metabolic states shift potassium into cells? |
Insulin Beta agonists Aldosterone Alkalosis |
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What causes potassium to leave cells? |
Lack of insulin, acidosis, aldosterone antagonists eg ARBs |
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What classes of bacteria are sensitive to penicillin? |
Most Gram positive cocci (eg Staphs and Streps) All Gram positive bacilli (Clostridium, Listeria) Most Gram negative cocci (Neisseria, HiB) No Gram negative bacilli |
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What bacteria are resistant to penicillin and why? |
Gram negative bacilli, because they have a beta lactamase or other resistance mechanisms. Examples = E.coli, Klebsiella, PA |
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What is Flucloxacillin used for? |
Fluclox is an anti-staphylococcal penicillin, which has replaced Methicillin. Used for Staph. |
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What coverage do Ampicillin and Amoxycillin have? |
Broad spectrum, extending penicillin coverage to the 'easier' Gram negatives. |
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Name two anti-pseudomonal penicillins? |
Ticarcillin and Piperacillin |
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What drug would you use in a patient who was allergic to penicillin? |
A Cephalosporin eg Cefazolin |
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What antibiotic would you choose for Gram negative sepsis? |
Gentamycin (nephrotoxic and ototoxic) |
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What is Ciprofloxacin used for? |
Prostatitis, Typhoid and for Gram negatives eg Salmonella, Campylobacter, Shigella, E.Coli |
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Name one adverse effect of Ciprofloxacin? |
Achilles Tendonitis |
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How is Vancomycin given? |
IM or IV, not orally (not absorbed) |
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What drug would you use to treat MRSA? |
Vancomycin |
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What drug causes 'red man' syndrome and what is this? |
Vancomycin, if given too fast it causes massive histamine release and sense of impending doom |
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What joints are typically affected in OA? |
PIPs and DIPs Thumb and MCPs Cervical and lumbar spine Knees Hip |
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What joints are typically spared in OA? |
Wrists, elbows and shoulders |
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What are nodules on the fingers called in OA? |
DIP = Heberdens nodes PIP = Bouchards nodes |
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Roughly describe the pathophysiology of OA? |
1. Chondrocyte injury 2. Chondrocyte proliferation and secretion of inflammatory emdiators, collagens, proteoglycans and proteases --> remodelling of cartilage matrix 3. Repetitive injury and chronic inflammation leads to extensive cartilage loss and sub chondral bone changes. |
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Name some causes of acute kidney injury |
1. Pre renal = Fall in BP, or interruption to blood flow to the kidneys. 2. Intra renal = Direct damage to the kidneys from inflammation, toxins, drugs, infection or prolongued ischaemia. 3. Post renal = obstruction eg due to enlarged prostate, stones, tumour or injury |
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Name some intrinsic (ie renal) causes of acute kidney injury? |
ATN (most common) Interstitial nephritis Glomerulonephritis Vasculitis Thrombosis/embolism |
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How would you assess AKI? |
Volume studies Urine studies Renal ultrasound |
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Treatment for AKI? |
Loop diuretics and renal replacement therapy (dialysis) |
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How can you prevent AKI? |
Careful fluid management- maintain euvolaemia. Minimise kidney insults eg drugs, contrast, infection etc. Manage any acute illness. |
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How can you recognise AKI? |
1.5 x increase from most recent baseline creatinine, OR 6 hours of oliguria |
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When would you see Bence Jones protein (BJP) in the urine? |
Multiple myeloma |
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Define oliguria |
Urine output less than 400ml/24 hours |
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What are some investigations for an arrhythmia? |
ECG Holter monitor, Event recorder, Loop monitor Echocardiogram Electrophysiology study Stress testing Coronary angiography |
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Describe the key functions of the liver? |
Synthesis of clotting factors (except VIII) Gluconeogenesis and glycogen storage Albumin synthesis Drug metabolism and clearance The urea cycle Immune activity (gut derived bacteria) |
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Elevation of which liver enzymes suggests hepatocellular injury or necrosis? |
AST and ALT |
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Elevation of which liver enzymes suggests intra or extra-hepatic cholestasis? |
ALP and GGT |
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What does ALT> AST suggest? |
Possible cirrhosis |
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Describe the pathogenesis of COPD? |
Noxious agents eg cigarette smoke -> inflammation -> small airway disease (inflammation and remodelling) + parenchymal destruction (loss of alveolar astachments and loss of elastic recoil) -> airflow limitation |
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What changes occur in the lung parenchyma in COPD? |
-Alveolar wall destruction -Loss of elasticity -Destruction of pulmonary capillary bed -Increased inflammatory cells |
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List some risk factors for COPD? |
Smoking and passive smoking Indoor air pollution eg biomass fuels Occupational exposure to irritants Alpha-1 anti-trypsin deficiency Bronchial hyperresponsiveness Recurrent RTIs in childhood |
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What FEV1/FVC ratio indicates airflow obstruction? |
<0.7 |
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Describe the pathophysiology of emphysema? |
Protease/anti-protease imbalance (proteases digest elastin and other structural proteins in the alveolar wall, antiproteases protect). Macrophages and T cells are prominent. |
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Outline the features of COPD that distinguish it from asthma |
Progressive course Late onset of symptoms Moderate to heavy smoking history usually Not reversible Neutrophilic inflammation Changes in the peripheral airways Fibrosis -> obliterative bronchiolitis Mucus hypersecretion prominent |
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Outline the features of asthma that distinguish it from COPD |
Variable/episodic course Onset at a young age No association with smoking Reversible airflow limitation INflammation largely eosinophilic All airways affected Doesnt involve lung parenchyma Fibrosis is NOT a feature |
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Name one side effect of anti-cholinergic drugs for COPD such as Tiotropium and Ipratropium? |
Dry mouth |
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Why do you need higher doses of inhaled corticosteroids in COPD that in asthma? |
Because neutrophilic inflammation is 'steroid resistant' |
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What are some causes of acute exacerbation of COPD? |
Respiratory infections eg URTI, bronchitis, pneumonia Heart failure and arrythmia Systemic infection or fever Anaemia Anxiety |
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What are the DSM-IV criteria for a Major Depressive Episode? |
1. Depressed mood 2. Diminished interest or pleasure in activities 3. Weight/appetite loss or gain 4. Insomnia or hypersomnia 5. Psychomotor agitation or retardation 6. Fatigue or loss of energy 7. Feeling worthless or excessively guilty 8. Diminished concentration 9. Thoughts of death or suicidal plans |
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What somatic symptoms are associated with anxiety disorders? |
Dizziness/light headedness, tachycardia, sweating, hyperreflexia, hypertension, palpitations, pupil mydriasis, restlessness, tingling in extremities, tremors, upset stomach, diarrhoea, urinary frequency, hesitancy or urgency. |
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What are some possible complications of AMI? |
-Angina, re-infarction. -Heart failure, cardiogenic shock, valve dysfunction, aneurism, cardiac rupture. -Arrythmias. -Emoboli. -Pericarditis. |
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What are the elements of the Cincinatti 'Pre Hospital Stroke Scale'? |
1. Have the patient smile to assess facial droop 2. Pronator drift with eyes closed 3. Abnormal speech |
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Define T.I.A? |
A brief neurological episode lasting less than 24 hours without damage on imaging |
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What are some conditions that mimic stroke? |
Seizure, sepsis, space occupying lesions, syncope, delerium, vestibular dysfunction, dementia, migraine, acute mononeuropathy, spinal cord lesions. |
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What features suggest a true stroke rather than a mimic? |
Exact time of onset Patient well in recent weeks but now has definite focal signs and symptoms. |
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What features suggest a mimic rather than a true stroke? |
-Known cognitive impairment -Loss of consciousness or seizure at onset -Patient able to walk -No lateralizing symptoms -Confusion -No neurological signs |
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What are some modifiable risk factors for stroke? |
-Hypertension -Diabetes -Smoking -AF/heart disease -Cholesterol -Alcohol -Prothrombotic factors -Prior stroke or TIA |
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What are the components of the CHADS-VAS score? |
Congestive Heart FAilure 1 point Hypertension 1 point Age > 75 2 points Diabetes 1 point Stroke or TIA previously 2 points VAscular disease Age 65-74 Sex (female) 1 point |
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Describe the key elements in secondary stroke prevention |
Blood pressure control Cholesterol lowering and statins Antiplatelet therapy Anticoagulation in AF Carotid revascularisation (stenting or endarterectomy) |
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What is the normal range for bicarbonate on an ABG? |
22-30 |
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What is the normal range for CO2 on an ABG? |
35-45 mm Hg |
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What is the difference between type 1 and type 2 respiratory failure? |
Type 1 = Impaired gas exchange -> hypoxia (low oxygen), PaO2 <60 mm Hg Type 2 = Hypoventilation -> hypercapnia (high carbon dioxide), PaCO2 > 50 mm Hg |
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What can cause Type 1 respiratory failure (hypoxia)? |
-Reduced inspired O2 eg at altitude -Ventilation/perfusion mismatch eg pneumonia or PE -Impaired diffusion eg fibrosis or COPD -Shunts |
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What are some conditions that cause Type 2 respiratory failure? |
-Central depression eg narcotic overdose -Blocked upper airway -Pump failure eg NMD, Guillain Barre -Muscle fatigue -Intrinsic lung disease eg severe COPD -Chest wall abnormalities |
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What happens to the lungs in ARDS? |
Increased pulmonary capillary permeability causes gas exchange defects (low VQ units, shunts) and a mechanical defect (increased elastic work of breathing). |
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How would you manage a patient with ARDS? |
-High flow humidified oxygen -Careful monitoring of sats and ABGs -CPAP or BiPAP -Invasive ventilation if necessary |
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What muscles involved in respiration might be impaired by motor neurone disease? |
-Diaphragm -Intercostals -Sternocleidomastoid -Scalenes |
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List some causes of immunosuppression |
Post-chemotherapy neutropaenia Lymphocyte dysfunction eg HIV Immunoglobulin deficit eg myeloma Splenectomy Pregnancy Malnutrition Corticosteroids |
