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501 Cards in this Set
- Front
- Back
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National Institute of Health Stroke Scale -
- what is it - when is it used - broad categories it assesses |
clinical assessment tool used to evaluate acuity of stroke patient, guide treatment and predict treatment response
1.Level of conciousness 2. best gaze 3. visual 4. facial palsy 5. motor arm 6. motor leg 7. limb ataxia 8 sensory 9. best language 10. dysarthria 11. extinction/inattention (neglect) |
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Acute Limb Ischaemia:
1) the 6 P's! |
Painful, Pulseless, Perishingly Cold, Pallor, Paralysis, Paraesthesiae,
Look for rapid onset, features of pre-existing chronic arterial disease, pedal pulse in contralateral leg, potential source of embolus |
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Initial MGMT of Acute Limb Ischaemia
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1) Heparin/Low Molecular Weight Heparin
2) Analgesia 3) treat associated cardiac disease if present 4) If embolic disease - EMBOLECTOMY or INTRA-ARTERIAL THROMBOLYSIS 5) Thrombosis - Intra-arterial thrombolysis, angioplasty |
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Tumour Lysis Syndrome - what is it?
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complication of cancer treatment, particularly those with high cell turnovers such as ALL, AML and lymphoma.
break down products of dying tumor cells. Dying tumor cells cause endocrine dysfunction through release of products and contents; hyperkalaemia hypocalcaemia hyperphosphotaemia hyperuricaemia lactic acidosis |
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Post-Operative Pyrexia:
7 C's as potential causes what temperature constitutes p.o.p |
Chest - chest infection
cannula - cannula site infection calves - DVT Central line - central line infection Cut - wound infection Collection - subphrenic/pelvic abscesses Catheter - UTI 38 degrees |
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Post operative Poor Urine Outpu
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1) Prenal
2) Renal 3) Post renal - most common |
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Urinary Retention
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Once the bladder reaches a certain volume of distension it fails to function
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Causes of Prerenal failure
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renal hypoperfusion - Heart failure, Hypovolaemia
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Renal causes of poor urine output
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ACUTE RENAL Failure
- most often caused by Acute Tubular Necrosis - raised serum creatinine and urea - urine osmolality:plasma osmolality - <1 seek renal team input - STOP potassium loads - STOP drugs such as NSAID's, ACE inhibitors |
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Causes of Post Renal failure
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- most common
- Obstruction - blocked catheter, large prostate - can lead to retention - anticholinergic drugs - or those with anti-alpha adrenergic effects. - pain, inhibition due to lack of privacy, - Opiates |
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Management of Post Renal Failure
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Catheterisation;
a large residual volume of 500mls should drain if catheter already in situ, flush to ensure it is not blocked. look at color of urine - dark and concentrated? think prerenal cause. dipstick urine |
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Assessing Fluid balance
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Examination: Standing and lying blood pressure, skin turgor, dry mucous membranes, peripheral oedema, chest exam - pulmonary oedema?, ascites, distended bladder, tachycardia, signs of heart failure - raised JVP, S.O.B., Weight, temperature, NG tube? Stoma? wound?
Fluid balance chart: <30mls/hour (adult) = oliguria - input should = output - normally 0.5-1ml/kg/hour Blood results - U&E' ambient temperature - fluid replacement should increase 10% for each degree increase in temperature aim for >50mls urine per hour Liver and heart failure patients - R-A system conserves much soidum and water- avoid giving patients fluids rich in sodium - give 5% dextrose instead |
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Fluid overload management
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stop fluids
consider Loop diuretics - Furosemide 40mg catheterise patient and monitor urine output |
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ECG - Interpretation order
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Rate (300/ or 1500/)
Rhythm - p wave precedes each QRS, or equidistant space between R-R Axis - Leads I and aVF P wave - flutter, number, mitrale, pulmonale P-R interval - heart block - primary, secondary - Mobitz type 1 (Wenckebach), type 2, complete - Q wave QRS ST segment T wave QT length |
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Heart Block
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Primary - slow conduction - PR prolonged without missed beats
Secondary - Mobitz I - Wenckebach, Mobitz 2 - P-R constant before missed beat Complete Heart block - dissocation between atrial firing and ventricular rhythm. |
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Primary Survey Of ATLS includes (i.. A,B,C,D,E
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Airway and C spine control
Breathing & ventilation Circulation & Haemorrhage control Disability Exposure and environment |
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Anaphlaxis MGMT
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Adrenaline - 500 micrograms 1:1000 IntraMuscularly
Chloramphenamine - 10mg IM or slow IV Hydrocortisone - 200mg IM or slow IV Fluid challenge 500-1000Ml |
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Define Flail Chest
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a segment of chest wall, that owing to multiple fractures, has no continuity with the rest of the thoracic cage. it moves paradoxically with the rest of the chest i.e. inwards on inspiration and vica verca. Underlying lung contusion lead to V/Q mismatch
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Trauma series X ray's include
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Taken as part of ATLS primary survery
lateral C Spine X ray Chest X ray Pelvic X ray |
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Contraindication to NG tube:
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Basal skull, skull fractures; fracture to cribiform plate can lead NG tube being inserted into cranial vault.
use orogastric tube instead |
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5 ways of establishing patent airway
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1: Jaw thrust, chin lift - lifts tongue forwards
2: OroPharyngeal Airway/ Guedel airway - measured from centre of patients mouth to angle of jaw 3: Nasopharyngeal tube - better tolerated by conscious patients than Guedel. still not well tolerated. 4:Intubation - definitive airway - cuffed (to prevent aspiration) endotracheal tube. secured with tape and connected to oxygen Surgical airway: in cases of severe facial trauma. initially needle crico-thyroidotomy, then expanded surgical cricothyroidotomy where ET tube connected. Tracheostomys take longer to construct as they require prior division of the thyroid gland in theatre. a hole made in between 2-3 rings of thyroid cartilage. |
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Indications for definitive airway
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patient unable to breathe of own volition
Guedel fails to establish patent airway impending airway compromise - anaphylaxis, smoke inhalation injury head injury requiring therapeutic hyperventilation |
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How to check for correct placement of ET tube
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1: Measure end tital CO2 concentration
2: listen for breath sounds bilaterally, i.e. ensure et tube not placed alone in right main bronchus |
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Tension pneumothorax
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when air enters the pleural space from either outside, or from the lung. The pleura form a one way valve allowing entry of air during inspiration, but failing to allow it to escape during expiration. Subsequent life threatening tension builds up in the thoracic cavity causing lung collapse, mediastinal shift and tamponade. The mediastinum is PUSHED AWAY from the affected side!!!
an emergency. Look for shortness of breath, raised JVP, hypotension, tachycardia, tracheal deviation, hyperesonance to percussion and absent breath sounds on affected side. needle thoracotomy in the 2nd intercostal space mid clavicular line IMMEDIATELY! DO NOT WAIT FOR X RAY. This converts a tension to a simple pnuemothorax, that can be treated with a chest drain |
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insertion of a chest drain
location |
aseptic technique
anterior to the mid axillary line in the 5th intercostal space Local anaesthetic used to infiltrate skin. 2cm transverse incision made, blunt dissection down to the pleura, use a pair of forceps to push throuth and pierce the pleura. French guage 24-28 catheter drain fixed with stitch chest drain is connected to an underwater seal - this allows air to escape during expiration ensure the underwater seal is below the patient otherwise the water will enter the chest |
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How to check the if a chest drain is blocked?
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ask patient to cough; if it is patent, there will be bubbles in the underwater seal. bubbles will be absent if the chest drain is blocked.
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management of open pneumothorax/sucking chest wound
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close wound with sterile chest dressing taped on 3 sides to form a flap valve.
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whilst awaiting X matched blood, universal donor blood is often ordered. which blood type is universal donor?
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Type O negative blood is the universal donor.
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diagnosis of query intraperitoneal bleeding in non critical patient
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diagnostic peritoneal lavage - catheter placed in peritoneum and fluid sent for analysis for red blood cells
ultrasound CT |
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secondary survery AMPLE survey
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From patient or collateral history
Allergies Medication Past Medical History Last ate or drank Events prior to the accident |
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Dementia screen
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Full mental state exam
collateral history Medication review |
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assessment of C Spine x ray
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Adequacy and alignment
- 4 lines anterior vertebral body, anteiror vertebral canal, posterior vertebral canal, spinous processes bones cartilage - intervertabral discs should be of equal heights. soft tissue |
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define shock
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inadequate perfusion and tissue oxygenation of the vital organs - brain heart kidney skin
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list the 3 Non haemorrhagic causes of shock
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cardiogenic
anaphylactic septic |
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Commonest cause of shock is
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haemorrhage after injury leading to HYPOVOLAEMIC SHOCK
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4 STAGES OF SHOCK + signs
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Stage I - 0-15 - anxiety but few compensatory signs
Stage II - 15-30 % blood loss tachycardia, tachypnoea, decreased pulse pressure due to RISE IN DIASTOLIC pressure Stage III - 30-40% tachypnoea, tachycardia, SYSTOLIC HYPOTENSION, CONFUSION Stage IV shock - >40% loss - life threatening cold clammy patient depressed conscioussness |
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Management of Shock
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2 large bore cannulae - Poiseuilles law - flow proportional to the fourth power of the internal radius of the tube and inversely proportional to length.
antecubital fossa, femoral vein, cut down to saphenous vein located 2cm above and anterior to medial malleolus. children < 6 have vascular marrow - interosseus delivery FBC, U&E, Glucose, GROUP SAVE AND X MATCH, Toxicology, pregnancy test in females. central line if cardiogenic shock suspected Colloid and Type O stat. |
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Central line insertion 2 approaches are...
plus name insertion technique |
firstly - Seldinger technique is used
Infraclavicular approach --> subclavian vein Internal jugular vein |
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when inserting Central line, at what angle do you position patients head
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head down 15 degrees
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Complications of Central line insertion
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Pneumothorax
haemopneumothorax arterial puncture haematoma formation INFECTION |
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ATLS fluid resuscitation recommendations
+ 3 types of response |
2 litres of crystalloid fluid - response best measured by urine output
1 - rapid response - patient respond rapidly to fluid resuscitation and maintains clinical improvement 2 - transient response - initial response with a rise in BP and fall in HR transient due to ONGOING BLEEDING 3 - no respose - exsanguinating haemorrhage occuring!! BLOOD NEEDED URGENTLY |
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what is the best clinical indicator of response to fluid resuscitation
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urine output
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Indication for central line insertion
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to help monitor fluid replacement if cardiogenic shock suspected.
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Main aim of blood transfusion;
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to correct oxygen carriage capacity
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5 layers of the scalp
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the SCALP is highly vascular and large amounts of blood can be lost here
Skin, connective tissue, aponeurosis, Loose connective tissue periosteum |
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normal value of intracranial pressure
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<10mmHg
the pressure in the subarachnoid space |
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Cerebral perfusion pressure equation
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CPP - amount of oxygenated blood reaching brain
Mean arterial BP - ICP large increases in ICP lead to falls in CPP maintenance of CPP is one of the main priorities of managing a patient with severe head injury |
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the sign of blood in the CSF when dropped onto filter paper is called
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the halo sign
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causes of secondary brain injury
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hypovolaemia
hypo glycaemia hypoxia causes of primary brain injury - trauma |
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Name 2 types of diffuse brain injury
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Concussion - temporary loss of neurological function. reversable changes. usually good to admit for observation
Diffuse axonal injury - severe. microscopic structural damage throughout brain tissue. prolonged coma from days to weeks. Autonomic dysfunction. high mortality |
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Name 2 types of focal brain injury
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Contusion - focal brain injuries - Coup and contre coup
Intracranial haemorrhage! extradural, sub dural, subarachnoid, brain haemorrhage |
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name 2 types of contusion brain injury
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Coup - brain damaged by skull directly at site of injury
Contre coup - brain squashed by skull at remote point from the site of impact |
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Acute extradural/epidural haemorrhage - clinical features and pathology
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bleed from arteries supplying skull and dura
typically Middle meningeal artery located under the pterion. fracture of parietal or temporal bone. can be fatal. L.O.C/concussion followed by LUCID INTERVAL EXPANDING HAEMATOMA IN EXTRADURAL SPACE strips dura off skull CONVEX APPEARANCE ON CT sudden rise in ICP, compromises CPP. as ICP rises - UNCUS may HERNIA through tentorium, often damaging the Cn3 - Hutchinsons pupil, FIXED DILATED PUPIL + Contralateral hemiparesis --> brainstem CONING through foramen magnum |
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initially constricted then fixed dilated pupil - Hutchinsons pupil - a sign of
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extra dural haematoma causing a rapidly rising ICP and uncal herniation through the tentorium cerebri damaging the third cranial nerve.
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Management of acute extradural haematoma
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Urgent CT
neurosurgical consult surgical evacuation of clot if treated early - prognosis can be excellent |
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acute subdural haemorrhage features
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30% severe head injuries
rupture of bridging veins between cerebral cortex and dura. shearing or rotational injuriy elderly more susceptible - shrunken brains exert stress on bridging veins + alcoholics expanding mass causes problems of herniation and raised ICP. slower in presentation then epidural haemorrhage but HIGHER MORTALITY |
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subarachnoid haemorrhage features
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Hypertensive patients, family history, congenital arterial malformations - berry aneurysm
THUNDERCLAP HEADACHE symptoms of meningeal irritation |
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Shape of extradural haematoma on CT
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CONVEX
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brain haemorrhage and laceration
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tears to brain substance and bleeding into them
deficit depends on site surgery cannot currently help the patient |
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Assessment of severe head injuries
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history or collateral from witnesses ambulance
ABCDE GCS- monitor vital signs |
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Glasgow coma scale - out of 15 - name criteria
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Best eye opening /4 - Spont, voic, pain, none
Best verbal /5 - orientated, confused, inapp, incomprehensible, none Best motor /6 - obeys commands, localises to pain, withdraws from pain, flexs to pain, extends to pain, none |
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GCS score of 8 implies
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coma
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GCS 9-12 Implies
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moderate head injury
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GCS 13-15 IMPLIES
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minor head injury
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can bleeding into the skull of itself cause hypotension
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no - the space is not great enough to cause significant enough blood loss
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Define the triad of the Cushing response
WHAT CAUSES IT |
Progressive HYPERTENSION
decreased resp rate BRADYCARDIA Lethal rise in ICP - usually intracranial bleed. |
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MGMT severe brain injuries
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ABCDE
Ensuring optimal cerebral metabolic supply prevent intracranial hypertension |
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MGMT raised ICP
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hyperventilation - keeps PCO2 low - INTUBATE + VENTILATE
Mannitol - reduces ICP (mannitol is an osmotic diuretic) DO NOT ADMINISTER HYPOSMOLAR FLUIDS SUCH AS DEXTROSE THEY MAY WORSEN CEREBRAL OEDEMA |
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Indications for skull X ray
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L.O.C lasting more than a few minutes
neurological symptoms or signs basal skull frx suspected penetrating injury common sense - significant injury difficulty in assessing patient |
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which are more painful, superficial or deep burns and why
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superficial burns are painful - nerve endings lie in the dermis and deep burns damage them to the point where sensory modalities are lost.
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which skin cell layer is essential for regrowth
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germinal cell layer - instead fibrotic contractures grow back
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Number one complication of significant deep burns -
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dehydration and hypovolaemic shock due to oedema and capillary damage.
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name 4 types of burn
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Thermal
chemical electrical friction |
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complications of electrical burns
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occult deep burns
acute renal failure due to rhabdomyolysis |
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electrolyte disturbance a potentially fatal complication of severe burns
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hyperkalaemia
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MGMT burns patient
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Secure AIRWAY - impending airway compromise
Prevent FLUID LOSS Prevent INFECTION |
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Depth of Burns
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superficial burns - first degree
deep dermal/partial thickness- second degree - associated swelling, red skin, oozing and blistering - may require grafts - depends on skin types, keloid regrowth a problem. excruciating full thickness burns - third degree- skin dry, painless, insensate - white or charred. scarring. |
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what rule determines extent of burn coverage in terms of body surface area
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rule of 9's
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commonest cause of painless rectal bleeding in young patients
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haemorrhoids
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chronic atrophic gastritis is associated with
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megaloblastic / pernicious anaemia
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Features of Irritable bowel syndrome
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increased neural sensitivity in the bowel
pain relieved by defaecation bloating occasional mucus per rectum more frequent and looser stools with onset of pain LOOK OUT FOR CONSTITUTIONAL CHANGES physical exam should be normal INVX - FBC U&E, TFT, esr, biochem, flexible sigmoidoscopy, rectal biopsy |
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Which Criteria aid the diagnosis of IBS
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Manning Criteria
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Treatment of IBS
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Constipation - fibre diet
Anxiety - BZD's pain - antispasmodics, Tricyclics diarrhoea - loperamide, cholestyramine |
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ACE inhibitors are contraindicated in all three trimesters of pregnancy because they cause
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Teratogens
fetotoxic oligohydramnios and renal tract malformation |
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Warfarin is teratogenic in the first trimester. it causes
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defective ossification, facial and cardiac abnormalities and saddle shaped nose
occasionall warfarin is used in second and third trimesters but is associated with fetal cerebral haemorrhage |
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bile acid sequestrant used to treat hypercholesterolaemia
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cholestyramine
binds bile and prevents its reabsorption in GIT used to treat hypercholesterolaemia |
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Anticonvulsants cause which type of defect in pregnancy
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valproate, carbemazepine and phenytoin cause Neural tube defects
phenytoin can cause the fetal hydantoin syndrome |
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out of the following anticonvulsants, which is the least teratogenic with a 0.5-1% rate of NTD's (albeit reduced with folate acid supplements prior to conception)
phenytoin, valproate, carbemazepine |
carbemazepine
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baceterium associated with PSEUDOMEMBRANOUS COLITIS
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Clostridium dificile
pseudomembranous colitis as a result of C diff infection occurs commonly following treatment with a broad spectrum antibiotic. the complications of dehydration, perforation and obstruction may follow. treatment is with oral metronidazole or vancomycin |
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antibiotic treatment for C DIFF
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oral metronidazole or vancomycin
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test for c diff
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faecal C diff toxin
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4 causes of erythema nodosum
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erythema nodosum is inflammation of subcutaneous adipocytes - panicculitis seen bilaterally on the shins
Inflammatory bowel disease sarcoidosis sulphanomides mycoplasma/tb |
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extra GIT manifestations of IBD
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sacroilitis, arthritis, ankylosing spondylitis
uveitis, iritis iron deficiency anaemia, b12 deficiency erythema nodosum pyoderma gangrenosum |
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name a condition that contraindicates the prescription of an ACE inhibitor
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renal artery stenosis
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renal impairment (creatinine raised over 150) necessitates withdrawal of patients taking which oral hypoglycaemic?
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Metformin - excreted unchanged in the urine
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lower limb vibration sense is transmitted by which neuronal pathway
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fasciculus gracilis
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pancreatic lipase inhibitor
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orlistat
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NICE recommends bariatric surgery in which categories of people
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those with BMI > 40
Candidates with a BMI >35 + a comorbidity such as hypertension or diabetes |
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a glutamate antagonist for treatment of moderate to severe alzheimers
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memantine
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a anticholinesterase inhibitor licensed for treatment of mild to moderate alzheimers
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donepazil
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this clinical examination sign differentiates between testicular torsion and epididymitis
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Prehns sign; Epididymitis - reduced pain on elevation of testis
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common opportunistic pathogen that infects when foreign bodies are introduced to a patient
hint; coagulase negative |
coagulase negative staphylococcus epidermidis
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name hand deformities associated with Osteoarthritis
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DIP - Heberdens nodes
PIP - Bouchards nodes nodes are small bone spurs that develop at the top of joints SQUARING OF THE BASE OF THE THUMB |
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nodes in OA are
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small bone spurs that develop at the top of joints
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common sites of OA
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Hands, knee, hip
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commonest cause of bacterial meningitis in children
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Meningococcus
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commonest cause of meningitis in neonates
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Group B streptococcus
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what is the main causative organism of epiglottisis in the first year of life?
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haemophilus influenzae
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name 2 cephalosporin antibiotics
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ceftriaxone
cefotaxime |
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non typeable Hib causes which 2 infections in young children
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sinusitis
Otitis media |
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Haemophilus influenza should be treated with
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cephalosporins - ceftriaxone, cefotaxime.
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LFT's questions;
a rise in this is the cause of jaundice levels of this enzyme rises with obstruction in the bile ducts levels of this enzyme rises with hepatocellular injury Synthesised in the liver, this protein may fall in levels in liver failure this enzyme is raised in both hepatocellular and obstructive pictures |
bilirubin
Alkaline phosphatase transaminase - ALT/AST albumin Gamma GT |
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list complications of endocscopic retrograde cholangiopancreatography
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acute pancreatitis
bleeding cholangitis perforation |
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list 2 therapeutic procedures that may be performed via ERCP
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Sphincterectomy and stone removal
pancreatic stenting biliary stenting |
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Complications of gall stones: subdivide to their presence in the gallbladder, common bile duct and gut
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Gallbladder - acute and chronic cholecystitis, empyema and abscess formation, peritonitis, mucocele, carcinoma of the gallbladder, biliary colic
common bile duct; cholangitis, obstructive jaundice, pancreatitis gut - gallstone ilesu |
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when fatty food is ingested, the release of which hormone causes gall bladder contraction?
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cholecystokinin
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In biliary colic, what is causing pain
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a gallbladder contracting against a stone stuck in the gallbladder neck (Hartmanns pouch) or cystic duct
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clinical difference between pain associated with biliary cholic, and acute cholecystitis and why
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biliary colic - patient normally writhes
acute cholecystitis - patient lies still! due to localised peritonitis |
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describe Murphy's sign
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with the patient lying. apply pressure in the RUQ. when patient inspires and gallbladder moves down, he or she winces and stops. this is not present on the LUQ
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what is a phlegmon
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a mass comprising omentum and bowel, overlying an area of inflammation i,e, gallbladder
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management of patient with acute cholecystitis
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initial resuscitation with
IV fluids antibiotics FBC,U&E, amylase, LFTs, glucose ultrasound/HIDA scan analgesia Keep NBM 80-90% recover with conservative treatment within 48 hours, sent home and booked in for elective laparoscopic cholecystectomy in 8 weeks |
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in cholecystectomy, name 2 structures that are identified, ligated and divided.
which structure must the surgeon be careful not to damage |
cystic duct and cystic artery
bile duct |
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list advantages of laparoscopic surgery
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less postoperative pain
less chance of wound infection reduced postoperative chest infections due to increased mobility earlier mobilisation and discharge all due to smaller wound sites. |
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2 disadvantages of laparoscopic surgery
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loss of tactile feedback
risk of tumour implantation if carcinoma present |
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contraindications for laparoscopic cholecystectomy
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patients with cancer
bleeding disorders portal hypertension contraindication - multiple adhesions reduced tolerance of pneumoperitoneum in patients with cardioresp problems!!!! |
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why do patients with cardiorespiratory problems not tolerate pneumoperitoneum
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icreased intrabdominal pressure leads to decreased venous return and therefore increased strain on the heart
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complications of laparoscopic cholecystectomy
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general: increased heart strain due to pneumoperitoneum and decreased venous return, CO2 embolism, infection, wound healing problems, anaesthetic related
Specific - bleeding from cystic or hepatic artery, common bile duct damage, istrumental injury |
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When to use ERCP in diagnosing and removie bile duct stones
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it is not suitable to remove a gallbladder leaving stones trapped in the bile duct
ERCP should not be a diagnostic procedure perform MRPC - MAGNETIC RESONANCE CHOLANGIOPANCREATOGRAPHY, or ultrasound to identify dilated bile ducts, then perform ERCP to remove stones located there, and if needs be, elective cholescystectomy: |
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what to do if during laparoscopy, bile ducts are found to have stones upon inspection
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laparoscopic bile duct exploration - an advanced technique
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what is a gallbladder mucocoele?
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distended gallbladder due to a stone in the Hartmann's pouch causes mucus secreted by the gallbladder wall to build up. can be asymptomatic
can be prone to abscess formation |
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explain cholangitis
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infection in the biliary tract
normally caused by obstruction e.g. bile duct stones needs prompt diagnosis and treatment otherwise can be fatal. |
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define rigors
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involuntary shaking in association with pyrexia
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define Charcot's triad - and when is it used
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pain
jaundice rigors cholangitis |
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explain gallstone ileus
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small bowel obstruction
a large gallstone usually >2.5cm - erodes through the gallbladder wall into the duodenum. it usually occurs over a long period of time. the area is sealed by surrounding inflammation such that rarely does local abscess or peritonitis occur. the stone moves down the small gut via peristalsis - it usually impacts at the narrowest (2nd after G-O J) part of the GIT - 2ft from the ileocaecal valve causes small bowel obstruction treatment - surgical removal |
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define ileus
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absence of intestinal peristalsis
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what is the narrowest part of the intestinal tract after the gastrooesophageal junction
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2ft from the ileocaecal valve
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what percentage of gallstones are radio-opaque
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around 10%
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name the types of gallstones
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75% cholesterol
pigment stones - more common in haemolytic anaemias such as sickle cell mixed |
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classical radiographic picture of gallstone ileus
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small bowel obstruction
air in the biliary tree due to fistula formation between bowel and gallbladder gallstone in the right lower quadrant |
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what is the main type of pancreatic cancer with a poor prognosis
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ductal adenocarcinoma of the pancreas
highly malignant; usually metastasied by time of diagnosis; disease occurs in the head of the pancreas in 80% |
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which pancreatic tumours comprise the 10-15% with a better prognosis
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ampullary carcinoma
islet cell tumours cystic tumors |
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main aetiological factor for ductal adenocarcinoma of the pancrease
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smoking
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presenting features of ductal adenocarcinoma of pancreas
|
obstructive jaundice - often painless
sometimes severe abdominal pain weight loss malaiase anoerxia thrombophlebitis migrans. cervical lymphadenopathy, hepatomegaly, ascities |
|
|
define Courvoisiers law
|
in the presence of jaundice and the gallbladder is palpable, it is unlikely to be gallstones
|
|
|
treatment of pancreatic adenocarcinoma
|
mostly palliative; biliary stenting or bypass surgery
15-20% candidates for surgical resection (greater in patients with ampullary, islet and cystic tumors) |
|
|
what is 5 year survival following resection for those with;
a) ampullary, cystic or islet cell pancreatic tumors b) ductal adenocarcinoma of pancreas |
a) 40%
b) 10-15% |
|
|
what is the operation of choice for tumors of the peri-ampullary region
|
Whipples operation
-pancreatic-duodenectomy. |
|
|
what processes auses acute pancreatitis
|
autodigestion due to release of destructive enzymes - vicious cycle
|
|
|
what are Grey-Turners and Cullen's sign?
|
tracking of blood stained fluids - retropertioneal bruising
Cullens - at the umbilicus Grey-Turners- the flanks they are indicators of a severe attack of pancreatitis infection of associated pancreatic necrosis carries a high mortality rate. |
|
|
main presenting features of acute pancreatitis
plus name a relevant serum marker |
severe central abdominal pain radiating to back
N&V shock generalised peritonitis with guarding raised serum amylase |
|
|
list causes of acute pancreatitis
|
Get smash'n
Gallstones EThanol Trauma Steroids and otehr drugs Azathioprine Mumps + viruses such as coxsackie B Autoimmune disease - SLE Scorpion bites |
|
|
what is the most common cause of acute pancreatitis in the UK (60%)
|
gallstones
|
|
|
what is the most useful test in identifying acute pancreatitis but what is an important caveat
|
serum amylase. however normal in 30%
measure serum lipase too! or urinary amylase early IV fluids, analgesia and ANTIBIOTICS ERCP and sphincterotomy if gallstones |
|
|
what scoring system is used to assess severity in Acute Pancreatitis?
|
Ranson's scoring criteria for acute pancreatitis
3 or more suggests severe Age, LDH, glucose, AST, WCC are the initial measures, 48 hours later, other factors - |
|
|
in treatment of severe pancreatitis, most units will prescribe one week of prophylactic broad spectrum antibiotics - such as
|
meropenum, imiopenum, cirpofloxacin, cefuroxime.
if positive cultures after one week, more perscribed |
|
|
what is an early cause of mortality in patients with acute pancreatitis
|
multi organ failure - resp and renal
|
|
|
latent complication of acute pancreatitis
|
infected pancreatic necrosis - look for positive blood cultures
CT guided aspiration can be used to confirm infected necrosis |
|
|
what might be used to assist patient nutrition early on during acute pancreatitis
|
enteral feeding via feeding tube in the jejenum
earlier on N-J tube |
|
|
outline basic subdivisions of jaundice and give example
|
pre-hepatic - haemolytic anaemia
hepatic - hepatitis post-hepatic - obstructive jaundice cholestatic jaundice - caused by chlorpromazine |
|
|
features of obstructive jaundice
|
yellow skin and mucous membranes
dark urine - conjugated bilirubin pale stools - no bilirubin is entering the bowel pruritis pain is variable |
|
|
causes of obstructive jaundice
|
gallstones
carcinoma of the head of the pancreas cholangiocarcinoma chronic pancreatitis enlarged lymph nodes in the porta hepatis |
|
|
at what levels in the blood does bilirubin usually cause jaundice
|
>50umol.l (17 is the top end of normal range)
|
|
|
stigmata of chronic liver disease
|
spider naevia, dupuytrens, liver flap, liver palms, gynaecomastia, testicular atrophy, ascites, xanthalasma etc
|
|
|
in a patient presenting with obstructive jaundice, why is ultrasound a good tool
|
cheap
identify dilatation of bile dcut and biliary tree gall stones tumor of head of pancreas n.b lower end of the cbd and head of the pancreas are often poorly seen on ultrasound |
|
|
which diameter is always abnormal in the common bile duct
|
>1.1cm- look for presence of gallstones
|
|
|
a patient with obstructive jaundice (raised alk phos) and an ultrasound showing dilated cbd down to the head of the pancreas
|
carcinoma of the head of the pancreas or ampulla of vater
|
|
|
list complications of surgery in jaundiced patients
|
coagulopathy - vitamin K deficiency due to absense of bile salts in guts - vit k dependent clotting factors mya be in short supply
ALWAYS CHECK INR!!!!! renal failure - hepatorenal syndrome Nutrition Infection Cholangitis |
|
|
at what levels do you suspect/treat for toxic paracetamol ingestion
|
For patients over 6 years of age
Acute single ingestion: - >200mg/kg or 10g over a period of less than 8 hours. Repeated supratherapeutic ingestion: - >200mg/kg or 10g over 24 hrs - >150mg/kg or 6g per 24 hrs for the preceding 48 hrs - >100mg/kg or 4g/ day in pt with predisposing facto |
|
|
Glucocorticoids are used for the treatment of which disease processes
|
inflammation
autoimmunity hypersensitivity |
|
|
Prophylactic treatment for osteoporosis in patients taking long term glucocoritcosteroids
|
alendronate - weekly - bisphosphonate
calcium and vitamin D tablets interval consultations at bone clinic |
|
|
How to glucocorticoids predispose to osteoporosis
|
reduce osteoblast activity
|
|
|
Anal skin tags + iritis + erythema nodosum in a young patient presenting with bloody diarrhoea
ddx initial investigation (not bloods etc) |
IBD, most likely crohns
colonoscopy |
|
|
features of POLYMYALGIA RHEUMATICA
features on serum invx |
elderly patient
normochromic normocytic anamemia/anaemia of chronic disease shoulder and pelvic girdle muscle stiffness sub acute onset systemic inflammatory response - malaise, fever, fatigue, weight loss 30% have giant cell arteritis raised ESR & CRP |
|
|
treatment of Polymyalgia rheumatica
|
course of oral steroids
inflammatory markers should fall after a month of treatment |
|
|
Polymyositis - name features
|
proximal muscle weakness
pain raised creatine kinase |
|
|
a small vessel vasculitis that often presents with CNS and PNS signs
|
Polyarteritis nodosa
|
|
|
clinical features of Giant Cell arteritis
|
thickened tender temporal arteries
headache visual disturbance jaw claudication |
|
|
Pyoderma gangrenosum -
briefly define list 3 conditions it is associated with |
uncommon serious ULCERATIVE skin disease
necrotic skin expands into large ulcers often on legs inflammatory bowel disease rheumatoid arthritis paraproteinaemia |
|
|
What is paraproteinaemia
|
presence of a large amount of a particular clade of gamma globulin/ monoclonal gammaglobulin
sign of immunoproliferative disease |
|
|
Triad that classifies REITER'S SYNDROME
|
a REACTIVE ARTHRITIS
ARTHRITIS URETHRITIS CONJUNCTIVITIS |
|
|
Which organisms are known to precipitate reactive arthritis/Reiters syndrome
|
reiters - arthritis, conjunctivitis, urethritis
chlamydia yersinia salmonella shigella campylobacter |
|
|
What is Whipples disease
|
a systemic infectious disease caused by the bacterium tropheryma whipplei
diarrhoea abdominal pain fever arthritis lymphadenopathy and weight loss |
|
|
Fixed flexion at the proximal interphalangeal joint and fixed extension at the distal interphalangeal joint is termed....
a deformity associated with which rheumatological condition |
Boutonierre's deformity
Rheumatoid arthritis |
|
|
a patient with nicotine staining on the hands
clubbing of the fingers/loss of the angle of the nailbed pains in the wrist |
hypertrophic pulmonary osteodystrophy
|
|
|
stroke patient managmenet after acute mgmt prior to discharge
|
Help current problems
Prevent stroke happening again - i,e, look at risk factors Give patient stroke Care package Occupational therapy input physio input + manage risk factors diet and lifestyle changes medications - clopidogrel or aspirin - anticoagulation control hypertension + diabetes |
|
|
a patient with an acutely swollen tender, 1st red metatarsalphalangeal joint
what class of drug commonly precipitate such eruptions |
gout
diuretics negatively bifringent crystals on joint aspiration |
|
|
common seronegative spondylitis affecting spine and sarcoiliac joints
90% of caucasians with this condition have which HLA? |
ankylosing spondylitis
HLAB27 MALES 2:1 EYE SIGNS - uveitis and iritis systemic signs: achilles tendonitis, aortitis, apical lung fibrosis Rheumatoid factor negative - i.e. seronegative |
|
|
systemic causes of avascular necrosis i.e not direct trauma
|
sickle cell
SLE diabetes scleroderma steroid therapy extensive burns |
|
|
what is osteochondritis dissecans and what commonly causes it?
|
cracks form in articular cartilage and underlying subchondral bone, commonly due to compromised blood supply i.e. avascular necrosis
|
|
|
define amyloidosis
|
pathological process; accumulation of extracellular fibrils
amyloid P = the non fibrillar component - derived from the acute phase protein serum amyloid p H&E histology - deposits of homogenous eosinophilic material found in interstitium and walls of blood vessels canc cause renal failure due to renal depostion |
|
|
what is Azathioprine
when is it used list some side effects |
immunosuppressive drug
organ transplantation and autoimmune disease myelosuppresion - neutropenia + thrombocytopenia azoospermia hepatotoxicity N&V basal cell carcinoma |
|
|
pseudogout/pyrophosphate arthropathy most commonly affects which joint?
if you were to aspirate fluid from the joint and look at it what might you see? |
knee
positively bifringent crystals |
|
|
define dysphagia and odynophagia
|
dyshphagia is difficulty swallowing
odynophagia is pain on swallowing |
|
|
causes of dysphagia
|
intraluminal
- foreign body - polypoid tumors - oesophageal inflammation - oesophageal infection intramural - benign strictures - caustic substances, GORD - Malignant strictures - oesophageal web - Plummer Vinson sydrome - diffuse oesophageal vaspospasm - achalasia - scleroderma extra luminal - pharyngeal pouch - rolling hiatus hernia - bronchial carcinoma - retrosternal goitre - thoracic aortic aneurysm and other vascular structure systemic causes of dysphagia - neurological - pseudobulbar palsy, myaesthenia gravis, multiple sclerosis, strokes |
|
|
middle age female with dysphagia, iron deficency anaema,
|
Plummer Vinson syndrome
oesophageal webb - desquamated squamous epithelium |
|
|
3 mainstays of investigating dysphagia
|
endoscopy - allows visual assessment, biopsy and histology
barium swallow - assessment of motility manometry - lower oesophageal sphincter assessment |
|
|
2 principal risk factors for squamous cell carcinoma of the oesophagus
|
alcohol
tobacco |
|
|
Barretts oesophagus increases risk of which type of oesophageal cancer
|
adenocarcinoma
|
|
|
Define Barretts oesophagus
|
metaplasia = normal squamous epithelium in the distal oesophagus is replaced by columnar glandular epithelium
GERD is the main risk factor |
|
|
2 places with the highest prevalance of gastric cancer include
|
East asia & south america
|
|
|
in the Uk, the commonest site of gastric adenocarcinoma is;
|
proximal - the cardia
|
|
|
what is the most common form of gastric cancer
|
adenocarcinoma
|
|
|
list risk factors for developing gastric adenocarcinoma
|
helicobacter pylori
blood group A family History smoking diet - high in nitrosamines and salts containing food vitamin C consumption is thought to be protective |
|
|
Name different types of gastric cancers;
|
gastric adenocarcinoma
gastric lymphoma gastric stroma neuroendocrine tumors |
|
|
What is Linitus plastica?
|
diffuse gastric cancer affecting the entire stomach wall
- non distending stomach on endo linitus plastica means leather bottle stomach |
|
|
histologically gastric cancer can be subdivided into 2 groups; what are they
|
intestinal
diffuse - worse prognosis, linitus plastica |
|
|
What grading system is used for oesophageal cancer
|
TMN
|
|
|
What is the Krukenberg Tumor?
|
Transcoelomic spread of gastric cancer to the ovaries
|
|
|
succussion splash - what is it
|
splashing of residual gastric fluid caused by an obstructing antral cancer
|
|
|
Virchow's node - left supraclavicular lymphadenopathy is a sign of which cancer
|
gastric adenocarcinoma - Trosier's sign
|
|
|
cutaneous manifestation of gastric cancer
|
acanthosis nigricans
|
|
|
list basic surgical approaches to gastric cancer
|
early gastric cancer- endoscopic resection of tumour
most cases - total gastrectomy + Roux en Y anastomosis to prevent bile reflux |
|
|
a method of relieving obstruction in patients with gastric cancer (palliative measure)
|
pyloric stenting
|
|
|
from which cells do Gastrointestinal stromal tumors originate?
|
cajal cells- cajal cells are the pacemaker cells of the gastrointestinal tract
75% or around of GIST tumors are benign |
|
|
this kind of tumor will give positive results for c-Kit protein, CD34 and CD117
|
Gastrointestinal stromal tumors
|
|
|
where would you find a pharyngeal pouch/Zenckers diverticulum?
what is it? |
outpouching of the pharynx - usually found at between the upper border of the cricopharyngeus muscle and the lower border of the inferior constrictor muscle of the pharynx - a weak point called Killians dehiscence.
|
|
|
which side of the neck are pharyngeal pouches usually found?
|
left side
|
|
|
3 symptoms of pharyngeal pouch/Zenkers diverticulum
|
hallitosis
dysphagia regurgitation |
|
|
treatments for pharyngeal pouch
|
open surgical removal
endoscopic stapling of the bridge between the pouch and oesophagus |
|
|
spontaneous rupture of the oesophagus due to forceful prolonged vomiting is called -
|
Boerhaaves syndrome
|
|
|
list 2 types of hiatus hernia;
|
sliding - 85% - O-G junction is in the thorax
rolling - 10% -OG junction below diaphragm but part of stomach in thorax mixed - 5% |
|
|
symptoms of hiatus hernia
|
retrosternal burning pain worse on bending, stooping, lying flat
water brash - regurgitation of acid into mouth postprandial pain antacid efficacy |
|
|
list treatment for hiatus hernia
|
Divide into lifestyle, medical and surgical
lifestyle - weight loss, stopping smoking, eating smaller meals earlier in the evening Medical - H2 antagonists, PPI surgical - laparoscopic Nissen fundoplication |
|
|
what test can definitively confirm Gastrooesophageal reflux disease
|
24 hour ambulatory oesophageal pH assessment
|
|
|
Define achalasia
list presenting symptoms investigations |
failure of relaxation of smooth muscle at the lower oesophageal junction.
intermittent progressive dysphagia fluid regurgitation Dx --> barium swallow trtx: endoscopic dilatation, Botox, Hellers procedure |
|
|
Chagas disease/trypanosomiasis
|
caused by the parasite a protozoa called trypanosoma cruzi
|
|
|
on barium swallow a smooth tapering birds beak appearance was noted, in line with which condition?
|
Achalasia - failure of relaxation of smooth muscle at the lower oesophageal junction.
|
|
|
List sites of peptic ulceration;
where is the most common site? |
duodenal ulceration is the most common form of peptic ulcer disease
stomach, oesophagus, Meckels, Jejenum and sometimes at the site of a previous gastrectomy |
|
|
Peptic ulceration at the Jejenum is associated with which condition?
|
zollinger ellison syndrome - ectopic gastrin secreting tumor
|
|
|
list 2 symptoms of peptic ulcer disease
list 3 major complications of peptic ulcer disease |
dyspepsia/indigestion, bleeding/haematemesis
penetration into adjacent structures - fistula, obstruction - pyrloic scarring, perforation + anaemia |
|
|
most common sites of perforation in peptic ulcer disease
|
anterior duodenum
gastric ulcers |
|
|
the most important aetiological factor in peptic ulcer disease =
|
H pylori colonisation
10% of those colonised with H pylori will get peptic ulcer disease H pylori increases gastrin production. antral gastritis reduces the amount of D cells that produce somatostatin, an inhibitory peptide to stomach acid production |
|
|
Risk factors for peptic ulcer disease
|
H pylori infection
NSAID use smoking coffee consumption liver and renal failure hyperparathyroidism |
|
|
what clinical score can be used to assess patient risk of P.E/probability of presenting with P.E?
|
Wells score
|
|
|
describe typical presenting symptoms of duodenal ulcer
|
duodenal ulcers have a peak incidence between the ages of 45 and 55
95% occur in the 1st part of the duodenum food EASES pain. pain is worse at night and radiates through to the back |
|
|
describe typical presenting symptoms of gastric ulcers
|
gastric ulcers have a peak incidence between the ages of 55 to 65
Eating WORSENS pain |
|
|
Investigations for patients with dyspepsia should include
|
endoscopic assessment
urea breath test or stool sample for H pylroi |
|
|
what is an essential investigation for patients presenting with gastric ulcers?
|
biopsy to avoid missing cancers
|
|
|
management of peptic ulcer disease
|
lifestyle - smoking cessation
medical - STOP aspirin and NSAID TRIPLE THERAPY FOR H pylori eradication - PPI + 2 antibiotics (clarithromycin + one of amoxicillin or metronidazole Surgical fomerly - therapeutic vagotomy ( vagal innervation stimulates gastrin secretioN) |
|
|
H pylori epidemiology
|
30-40 % in adult population
higher prevalence in poorer populations |
|
|
outline triple therapy for H pylori eradication
|
PPI
CLARITHROMYCIN AMOXICILLIN OR METRONIDAZOLE for 1 week |
|
|
Testing for H pylori
|
Urea breath test (h pylori produces urea)
stool test serum antibodies to h pylori to confirm cure - endoscopy and biopsy to perform RAPID UREASE TEST!!! urea breath test and stool test is good enough for diagnosis but not to confirm eradication. |
|
|
What test is performed to confirm eradication of H pylori?
|
endoscopy and biopsy, with rapid urease test
|
|
|
what score is used to assess severity of community acquired pneumonia
|
CRB-65
0-1 - TREAT AT HOME 2 - admit for short stay 3-5 severe pneumonia Confusion, Resp Rate, BP, AGE 65 or over |
|
|
what stimulates gastric acid secretion?
|
1) Gastrin hormone
2) vagal nerve stimulation |
|
|
zollinger ellison syndrome
|
hyper secretion of gastric acid due to gastrinoma
|
|
|
Multiple endocrine neoplasia type 1
|
Hyperparathyroidism
insulinoma Zollinger Ellison syndrome Pituitary tumors |
|
|
M.E.N type 2
|
medullary carcinoma of thyroid
phaeocromocytoma |
|
|
causes of upper Gi bleeds
|
duodenal ulcer
gastric ulcer acute erosions of gastritis mallory weiss tear due to vomiting oesophageal varices oseophagitis malignancy |
|
|
symptoms of upper GI bleeds
|
haematemesis
- frank blood coffee ground vomiting - gastric bleed melaena - black tarry stools. haematoschezia- fresh blood per rectum ALWAYS LOOK FOR SIGNS OF SHOCK on exam always look for signs of liver disease |
|
|
score to identify patients most at risk of an adverse outcome post acute upper GI bleed
|
rockall score
|
|
|
Main treatment for upper gi bleed
|
endoscopy + injections (1:10000) adrenaline, thermal coagulation, clipping of the bleeds or varices.
surgery if failure to control bleeding via endoscopic intervention. Laparotomy is usually performed |
|
|
treatment of bleeding oesophageal varices
|
resusictation and correction of coagulopathies
endoscopic band ligation or injection sclerotherapy. if these fail to control bleeding a SENGSTAKEN tube can be inserted and inflated to tamponade bleeding. transfer to specialist centre |
|
|
posterior perforation of the duodenum is likely to damage which to local structures?
|
pancreas
gastroduodenal artery |
|
|
perforated peptic ulcer symptoms
|
may be mere mild dyspepsia
haematemesis severe epigastric pain vomiting tenderness over the epigastrium. rigid abdomen with rebound and percussion tenderness and absent bowel sounds --> peritonism always order an erect chest x ray looking for pneumoperitoneum |
|
|
treatment for duodenal perforation
|
resuscitation
repair with omental patch peritoneal washout send specimen for histological analysis - malignancy 90% of peptic perforations are associated with H pylori so TRIPLE THERAPY |
|
|
A Ramstedt pyloromyotomy is performed for which condition?
|
hypertrophic pyloric stenosis
|
|
|
name 3 special tests that may be performed as part of a shoulder examination
|
impingement test
apprehension test - looking for anterior dislocation of the gleno-humeral joint scarf test |
|
|
Clinical signs of parkinsons disease
|
Resting tremor
Bradykinesia shuffling/festinating gait cogwheel rigidity difficulty turning and initiating movement |
|
|
Explain myaesthenia Gravis
|
an acquired autoimmune disease; post synaptic ach receptors blocked by IgG autoantibodies at the NMJ
muscles are EASILY FATIGUED Weakness typically occurs at the periocular, facial, bulbar and girdle muscles. Can affect diaphragm causing breathing difficulties + swallowing --> dysphagia and aspiration |
|
|
Red flags - clinical signs of bacterial meningitis
|
meningism; neck stiffness and photophobia
Rash + headache Give IV Penicillin en route to hospital |
|
|
Retinal detachment symptoms
|
Floaters, grey curtain/veil moving across field of vision with sudden loss of vision
retinal detachment occurs when the retina's sensory and pigment layers separate. it is a time critical ophthalmic emergency |
|
|
a chronic non-progressive disorder of posture and movement
|
cerebral palsy
CNS injury acquired during the perinatal period i.e. birth asphyxia |
|
|
Clinical features of osteomalacia
|
bone pain
partial, undisplaced fractures PSEUDOFRACTURES- = Looser's zones on X ray Waddling gait due to proximal myopathy renal osteodystrophy lumbar lordosis |
|
|
Disorder of defective bone mineralisation
main cause |
Osteomalacia
vitamin D deficiency |
|
|
clinical signs of sensory ataxia
a cause |
wide based gait, patient will rely on vision to assist lack of proprioceptive feedback i.e. watches feet
unable to walk heel to toe positive Romberg's test i.e. more unsteady with eyes closed Subacute combined degeneration of the cord |
|
|
clinical signs of cerebellar ataxia
a cause |
wide based gait
Rombergs negative unable to walk heel to toe alcohol Multiple sclerosis - optic neuritis, sensory, cerebellar or brainstem symtpoms look for urinary incontinence and pale optic discs |
|
|
Investigation of choice for young male presenting with acute onset headache and drowsiness and low GCS - query subarachnoid haemorrhage
|
CT head will confirm diagnosis of SAH in 95% patients
|
|
|
sequelae of herpes zoster infection of CnV
|
trigeminal neuralgia
corneal ulceration postherpetic neuralgia look for a vesicular rash in the dermatomal distribution of the trigeminal nerve |
|
|
lower motor neurone signs
|
flaccid paralysis
decreased tone loss of stretch reflex fasciculations atrophy of muscle |
|
|
upper motor neurone lesions cause
|
weakness
increased tone spastic paralysis hyperreflexia |
|
|
the shoulders integrity is maintained by
|
glenohumeral joint capsule
cartilaginous glenoid labrum rotator cuff muscles anterior shoulder dislocations account for 95% of shoulder dislocations axillary nerve C5 is the most commonly injured nerve in such cases. |
|
|
complications of Subarachnoid haemorrhage
|
immediate
|
|
|
How many ml's of fluid must be present before a pleural effusion is evident on chest x ray?
|
300mls
|
|
|
When aspirating fluid, which parameters help distingusih between a transudate and an exudate?
|
Lights criteria may be used.
looks at serum vs fluid protein and Lactade dehydrogenase ratio raised protein and or LDH is indicative of exudate >30g.l protein indicative of exudate |
|
|
When might you use Ziehl-Nielson stain and culture?
|
to diagnose TB
|
|
|
list causes of a transudate pleural effusion
|
Heart failure
liver failure renal failure e.g. caused by NSAID hypoalbuminaemia - nutrional failure hypothyroidism |
|
|
causes of an exudative pleural effusion
|
Bronchial carcinoma
mesothelioma parapneumonic effusion secondary to bacterial pneumonia acute pancretitis - look for serum amylase RA TB P.E |
|
|
2 reaons why poisoning occurs
|
1) deliberate
2) accidental - accumulation of long term medications to toxic levels, use of potent drugs. |
|
|
outline general management of poisoning
|
1) supporitve care
2) antidotes or methods to try and help clear the toxin from the body |
|
|
What drug is used as an antidote to paracetamol overdose
list one risk of administering this drug |
N-acetylcysteine
anaphylaxis |
|
|
outline paracetamol hepatotoxcitiy and the role of N-acetylcysteine
|
in overdose paracetamol depletes antioxidant stores in liver cells.the p450 system metabolise a portion of paracetamol to a highly reactive intermediary metabolite - N-acetyl-p-benzoquinoneimine. NAPQI is normally conjugated to glutathione to from cysteine and mercapturic acid conjugates . In paracetamol overdose liver glutathione supplies become depleteed and a build up of NAPQI occurs causing hepatotoxic damage
|
|
|
what types of paracetamol overdose are most difficult to treat?
|
single dose paracetamol overdoses are relatively straightforward to treat.
staggered doses, late presenting patients and those at high risk are more difficult to reat always check the normogram - drug dose to hours taken |
|
|
what in cases of paracetamol overdose, information is imediately important to ascertain?
|
WHEN the paracetamol was taken
- always measure the blood level at least 4 hours after this time How much was taken |
|
|
On the dose to time taken normogram in the BNF, it has a line for high risk patients. list some patients at high risk for paracetamol overdose
|
those on prescribed enzyme inducing drugs - phenytoin, rifampicin, carbamazepine
alcoholics malnutrition patients with AIDS |
|
|
WHEN DO YOU GIVE presumtive doses i.e. before drug levels, of NAC
|
in patients with suspected major oversdoses >12g
|
|
|
list drugs with narrow therapeutic ratios
|
Digoxin
theophylline Lithium Phenytoin Antibiotics - gentamicin, vancomycin, tobramycin |
|
|
Define a primary endocrine disorder
define a secondary endocrine disorder |
primary disorders are disorders of the gland that produces the hormone abnormality
secondary endocrine disorders are disorders of the hormones supplying the target gland |
|
|
outline the Thyroid hormone endocrine pathway
|
hypothalamus produces TRH - which acts on the Anterior Pituitary --> which releases TSH --> which stimulates the thyroid to produce T4 [Thyroxine] & T3 - Triiodothyronine.
T4 + T3 feedback onto both hypothalamus and AP to suppress TSH & TRH release |
|
|
Outline the TFT picture of
Primary hyperthyroidism Secondary Hyperthyroidism give examples of diseases |
primary hyperthyroidism: Graves disease
High T4, Low TSH - due to negative feedback mechanism Secondary Hyperthyroidism - Pituitary tumour High T4 Normal- high TSH |
|
|
What is the physiological active hormone produced by the thyroid
|
T4 - THyroxine
t4 & t3 are mostly bound by thyorid binding globulin - raised and lowered in certain states ie. rasied in high oestrgoen states and low in low protein states |
|
|
outline TFT's changes in hypothyroid disease
|
primary hypothyroid - Hashimotos
T3,T4 low, TSH high 2ndary hypothyroidism - T34 low, tsh low |
|
|
explain sick euthyroid syndrome
|
careful when interpreting TFT's in acutely unwell patients because a transient decrease in both TSH and T4 can occur
|
|
|
outline the adrenal hormone pathway
|
hypothalamus releases CRH --> Pituitary releases ACTH --> adrenals --> glucocoritocoids --> negative feedback on hypothalamus and pituitary
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what is Cushing's syndrome?
when does it most often occur what is Cushings disease |
cushings syndrome is a condition of glucocortiocid excess. most commonly caused by iatrogenic steroid release e.g. chronic severe asthma
Cushing disease - ACTH excess from the pituitary gland - secondary hyperadrenalism |
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give a cause of primary adrenalism
give a cause of secondary adrenalism |
adrenal gland tumour --> primary
cushings disease or AP tumour --> secondary |
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Adrenal hormone picture in primary and secondary hyperadrenalism
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primary - High glucocorticoids, low ACTH
Secondary - high glucocorticoids, normal-high acth |
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Give 2 tests that diagnose Cushing's syndrome
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1) 24 hour urinary free cortisol level - an elevated level of steroid in the urine - Cushings
2) Dexamethasone suppression tests - a healthy person given a dose of dexmatheasone should experince a negative feedback effect on their adrenal axis resulting ina lower cortisol reading later. 2 types of dexamethasone tests a) overnight dexamethasone suppression test - patient given 1mg of dex at 11pm; blood taken at 9 am. >100nmol.l cortisol is abnormal b) low-dose dexamethasone suppression test - patient given 8 doses of 0.5mg dex at 6 hourly periods, starting at 9 am. cortisol levels >50nmol.l at 48hours abnormal |
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what is Addison's disease
what test can be used in its diagnosis |
primary hypoadrenalism
Short synacthen test (synacthen is synthetic ACTH) - a low or minimal response is diagnostic of primary hypoadrenalism |
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what is the short synacthen test?
what is synacthen? |
synacthen is synthetic ACTH
short synacthen test is performed in order to test for primary hypoadrenalism or addisons disease. ACTH should normally lead to an increase in circulating cortisol - but in patients with addison's it has has no effect due to glandular pathology |
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when is the insulin tolerance test performed
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at specialist centres to assess adrenal function and growth hormone deficiency
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a patient with excess metanephrines in the urine; what diagnosis must be ruled out?
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phaeochromocytoma.
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outline categories in the Bamford/Oxford stroke classifciation
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Total anterior circulation syndrome TACS
Partial anterior circulation syndrome - PACS posterior circulation syndrome - POCS Lacunar circulation syndrome - LACS |
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outline Total anterior circulation syndrome
part of the oxford stroke classification/Bamford stroke classification |
TACS - large cortical stroke in the MCA/ACA areas
all three of; 1 unilateral weakness +/- sensory deficit of face, arm leg 2 - homonymous hemianopia 3 higher cerebral dysfunction - dysphasia, visuospatial disorder |
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damage to the right optic tract will likely lead to which kind of vidual disturbance?
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left homonymous heminaopia
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Outline Partial anterior circulation syndrome
part of the oxford stroke classification/bamford |
PACS- cortical stroke in MCA and ACA areas
Dx - 2/3 of TACS criteria 1- unilateral weakness/motor deficit to face, arm leg +/- sensory deficit 2 - homonymous heminaopia 3 - higher cerebral dysfunction - dysphasia, visuospatial disorder |
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outline posterior ciruclation disorder
part of tte oxford stroke classification |
POCS - posterior circulation infarct - basilar/vertebral arteries
one of 1) cerebellar or brainstem syndromes 2) isolated honomymous hemianopia 3) loss of conscioussness |
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Outline 2 scales/classification useful in stroke diagnosis
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National Institute of health stroke scale - assess acuity of patient, guide treatment and predict treatment response
Oxford stroke classification/bamford stroke classification - delineate different patterns of stroke/syndromes |
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outline LACS - lacunar syndrome
part of the Bamford/oxford stroke classification |
lacunar syndrome - lacunar infarcts
subcortical strokes!!!! usually due to small vessel disease. no evidence of higher cerebral dysfunction e.g. dysphasia or visuospatial loss one of 1. unilateral weakness of face, arm or leg +/- sensory deficit 2. pure sensory stroke 3. ataxis hemiparesis |
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What is the new WHO 2011 criteria for the diagnosis of diabetes?
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an HbA1C 48mmol.l or 6.5% or above
previous diagnostic criteria for diabetes included: diabetic symptoms - symptoms - polyuria, polydipsia, weight loss + fasting plasma glucose >7.0mmol or random plasma glucose >11.1mmol [perform confirmatory tests! |
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outline methods & values of diabetes diagnosis
give the WHO 2011 guidelines first |
WHO 2011 guidelines - single HbA1C of 48mmol.mol or 6.5% or more
or fasting plasma glucose >70.mmol or random plasma glucose of 11.1mmol for both these modalities repeat the reading there is also a 2hour fasting glucosealways check for diabetic symptoms |
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give 3 main symptoms of diabetes
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polyuria, polydipsia, unexplained weight loss
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which test acn you perform to differentiate between psychogenic polydipsia and diabetes insipidus?
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the water deprivation test
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diabetes insipidus is related to the dysfunction of which hormone?
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anti-diuretic hormone/vasopressin
prodcued in the posterior pituitary promotes water reabsorption inthe collecting tubules in Diabetes insipidus there are problems with ADH release |
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explain diabetes insipidus -
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a problem with ADH release
2 types 1 Cranial - insufficient hypothalamic release of ADH 2 Nephrogenic - sufficient circulating ADH but poor renal response |
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water deprivation test - effect on a patient with DI?
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Worsening dehydration. patient still fails to concentrate urine - they pass dilute urine and have a rising serum osmolality
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how to differentiate between cranial and nephrogenic diabetes insipidus ?
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give synthetic ADH - Desmopressin - should reverse cranial DI, but have no effect on nephrogenic DI
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what is SIADH
LIST CAUSES |
SYNDROME OF INAPPROPRIATE ADH SECRETION
excess ADH secreted Retention of water --> DILUTE SERUM, CONCENTRATED URINE causes: pneumonia, lung cancer, head injury, brain tumours, CARBEMAZEPINE, NEUROLEPTICS |
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SIADH diagnostic criteria - list
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Normal - renal, adrenal & thyroid function
HYPONATRAEMIA - diluted LOW SERUM OSMOLALITY urine osmolality>serum osmolality ABSENSE FOR DEHYDRATION AND FLUID OVERLOAD |
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What 2 things must be ruled out in cases of query SIADH
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Fluid overload
dehydration |
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causes of hyperprolactinaemia
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physiological: pregnancy and lactation
Pathological: prolactine secreting pituitary tumour, PCOS Iatrogenic: phenothiazine antipsychotics, antiemetics |
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Acromegaly is associated with elevated levels of which hormone?
what can be used as a marker for measuring the average level of this hormone |
Growth hormone
measuring GH levels is not relable method of diagnosis of acromegaly, instead Insulin-Like growth factor levels are used. If IGF-l levels are raised, it is suggestive of acromegaly GH has anti insulin properties acromegaly is diagnosed if theGH level is >1m U/l during a glucose tolerance test |
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what test is used to diagnose acromegaly
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glucose tolerance test is performed and GH levels measured.
glucose doses given and blood testing taken to check time taken for its clearnce from the blood i.e. watching for persistent hyperglycaemia |
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Glycaemic status can fall under at least 5 categories; list them
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Normal
impaired fasting glucose impaired glucose tolerance diabetes mellitus gestational diabetes mellitus |
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common symptoms of hyperglycaemia
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polydipsia
polyuria weight loss fatigue blurring of vision cutaneous complications of diabetes |
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describe oral glucose tolerance test
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OGTT - patient given 75g glucose dose orally after a period of fasting. plasma glucose measured at baseline and after 2 hours of fasting
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Do women who experience gestational diabetes have an increased risk of developing diabetes in later life?
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yes
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explain glycated haemoglobin
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product of reaction between glucose and HbA. Gives estimation of blood glucose levels over 3 month period/60days
For most diabetic patients a target HbA1c of between 6.5-7.5% is desired. |
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give example of when HbA1c might not be a reliable indicator of 3 monthly glucose levels
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patients with haemoglobinopathies - HbA HAS A REDUCED LIFESPAN
USE FRUCTOSAMINE LEVELS INSTEAD TO MEASURE GLYCAEMIC CONTROL. |
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Explain fructosamine as a measure of glycaemic control
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fructosamine can be used as an alternative measure of long term glycaemic contro,"", especially in patients where HbA1c cannot be used due to for instance, a haemoglobinopathy.
fructosamine is a glycated plasma protein that provides information of glucose levels for the past 1-3 weeks |
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Which is the anti-epileptic currently advised by NICE for use in pregnancy to treat epilepsy?
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Carbemazepine
- an hepatic p450 enzyme inducer! |
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Define hypoglycaemia
commonest cause |
plasma glucose <3.5mmol.l
imbalance betwen glucose intake and insulin doses in patient with diabetes |
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How to distinguish hypoglycaemic attacks caused by endogenous and exogenous insulin?
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C-peptide levels
C-peptide is a waste chain of Pro-insulin, cleaved off when insulin is formed from endogenosu proinsulin. Exogenous insulin does not contain C peptide |
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list causes of hypoglycaemia
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Imbalance between glucose/calorie intake and insulin administration in a person with type 1 diabetes
Excess exogenous insulin administration side effect of oral antihyperglycaemic medication e.g. sulphonylureas such as gliclazide INSULINOMA Liver failure - depleted glycogen stores excess alcohol intake |
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Remnant of the vitello intestinal duct that normally dissapears during embryological development
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meckels diverticulum
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explain meckels diverticulum
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rule of 2's
2% population, 2ft from the iliocaecal valve in the ileum. usually asymptomaitc however can --> pain similar to appendicitis if inflammed bleed volvulus, intussusseption can contain gastric mucosa --> bleeding treatment of inflammed Meckels diverticulum is excision |
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what is a raspberry tumour
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mucosa protruding through the umbilicus - a far reaching meckels diverticulum forming vitello-intestinal fistula.
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commonest cause of major gastrointestinal bleeding in teenagers?
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meckel's diverticulum with ectopic gastric mucosa
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discuss small bowel tumours;
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rare - <5% all GIT tumors
primary, secondary, benign or malignant benign; go through layers of bowel wall - lipoma, leiomyoma, neurofibroma, adenoma pre-malignant - adenomatous polyps - Polyposis syndromes - Peutz-Jeghers benign tumours tend to be found incidentally or due to bleeding malignant: adenocarcinoma of the small intestine - arise from polyps, lymphoma, carcinoid (low grade malignacny arise rfom neuroectoderm cells) |
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commonest site for carcinoid tumours?
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appendix + tricuspid and pulmonary vavlves as tumor embolus
release 5-HT and kinins - can cause symptoms |
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Pupil tests; name 3 pupillary reflex tests, & what they test for
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1) pupillary light reflex test; direct & consensual - tests for integrity of the pupillary light pathway
- shine light onto pupil and test for direct and conensual pupillary constriction/miosis in response - normal test -there should be BRISK, EQUAL, SIMULTANEOUS pupillary responses to light shone on either side 2) Swinging light test: compares the direct and consensual responses of each eye rather than detecting if they are there or not normal test: pupils should constrict or stay the same size; if the pupil dilates when light is shone on it it means that the direct light reflex in that eye IS WEAKER THAN THE CONSENSUAL REFLEX [produced by taking away the light stimulus from the other eye] implying an OPTIC NERVE PATHOLOGY. THIS IS A RELATIVE AFFERENT PUPILLARY DEFECT. note - that you cannot have a RAPD if both eyes have optic nerve damage 3: accomodation/near reflex test assesses the miosis component of near fixation patients pupils should constrict when focusing on an object in their near visua field i.e. arms distance away |
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What 2 main parameters of the pupil should you note on initial obseration;
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size and shape
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what is Holmes Adie pupil
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tonic mydriasis of a pupil (usually unilateral) in an otherwise healthy patient
Slow reaction to light thought to be caused by viral or bacterial damage to the post ganglionic PNS (to sphincter pupillae) |
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Topical drugs that cause pupillary mydriasis
systemic drugs that cause pupillary mydriasis |
tropicamide [antimuscarinic] sympathomimetics e.g. phenylephrine, adrenaline, atropine
sympathomimeitcs - adrenaline, atropine, TCA's, amphetamines, ecstacy |
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drugs causing pupillary miosis
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topical - pilocarpine (muscarinic agonist)
systemic - morphine, organophosphates |
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What is pathology of the gram negative spirochete treponema pallidum often referred to as?
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Syphillis
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Which infection/bacteria most often causes Argyll Robertson pupils. describe what might be seen
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Treponema Pallidum infection/Syphillis
Small, Irregular pupils that DO NOT REACT TO LIGHT, but DO accomodate other causes include diabetes and pinealoma |
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Describe a prostitutes pupil
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Argull Robertson pupil
accomodates but doesnt react (i.e. to light and near fixation) small, irregular non reactive pupils a sign of tertiary neurosyphillis or - infection by treponema pallidum |
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what is tabes dorsalis
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syphillitic myelopathy
slow degeneration of afferent sensory fibres treponema pallidum neurosyphillitic disease Dorsal column loss - joint position, vibration sense, broad based sensory ataxia, high stepping gait, charcot's joints, bladder insensitivity, lightning pains |
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outline pupillary light reflex pathway
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cranial nerve2 --> optic chiasm [pretectal nucleus] --> EDINGER WESTPHAL NUCLEUS --> CILIARY GANGLION --> SHORT CILIARY NERVES OF PUPIL.
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Nystagmus is caused normally by pathology in one of 2 regions;
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ear and posterior fossa
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Nystagmus in one eye with greater amplitude ipsilaterally i.e. nystagmus in the right eye most MARKED on looking right. list causes
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1) Ipsilateral Cerebellar or Brainstem lesion - vascular, neoplasm, demyelinating/MS
2)contralateral vestibular lesion - fast to contralateral side 3) peripheral - cochlear dysfunction - labrynthitis, menieres, CnVIII disease, viral neuronitis - acute vertigo vertical nystagmus implies central brainstem pathology |
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what might be the cause of vertical nystagmus
|
central brainstem pathology
upgaze - superior colliculus level downgaze - level of the foramen magnum |
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What causes Benign Paroxysmal Vertigo?
what does benign paroxysmal vertigo present with |
dislodged otoliths in the semilunar canals
vertigo and nystagmus on movement. treatment is symptomatic and repositioning of the otoliths - Epleys manoevre |
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for which condition might Epleys maneouvre be performed?
what does it do? |
In benign paroxysmal vertigo
to reposition dislodged otoliths causing vertigo and nystagmus on movement |
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explain intussusseption
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where a segment or portion of intestine, via peristalsis, becomes invaginated into its own lumen, or 'telescoped' into its own lumen. the invaginated portion is termed the intussusceptum and can be pushed further down the bowel
most commonly seen in children p/c; colciky abdominal pain and obstruction; Red currant jelly stools (mucus and blood) complications: strangulation + infarction aetiology: thought a focus such as a hypertrophied Peyer's patch (GIT mucosal lymphoid tissue), Meckels diverticulum (rule of 2's). MGMT: hydrostatic reduction with an enema or surgical. RECURRENCE IS UNCOMMON IF REDUCED. sometime resection needed. |
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Causes of intussusseption in adults and children
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most cases are seen in children
Meckel's and hypertrophied Peyer's patches act as a focus for peristaltic action to begin telescoping. In adults, a tumour, benign or malignant, must be ruled out. |
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what is the commonest emergency presentation requiring surgery in the UK?
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acute appendicitis
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explain the pathology of acute appendicitis
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obstruction leading to subsequent infection and inflammation ( similar conceptually to cholangitis and pyelonephritis)
faecoliths or hypertrophied lymphoid tissue are the most common cause of the obstruction. caecum carcinoma is another rare causes of appendiceal obstruction |
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outline typical clinical presentation of acute appendicitis
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Early stage - inflammation confined to appendix wall and therefore visceral poorly localised pain. progressive inflammation leads to localised peritonitis
typically = patient presents with a central colicky pain (reflecting midgut visceral innervation), within a few hours progresses to a Right iliac fossa pain, worse on movement with tenderness and guarding. |
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What findings might there be on clinical examination of a patient with acute appendicitis?
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mild fever, anorexia, nausea and vomiting
Rovsings sign - pain worse in RIF compared to LIF Guarding, localised RIF tenderness rebound tenderness always order pregnancy test in woman of childbearing age. |
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outline appendicectomy
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incision made in the RIF. Conventionally (but not quite in reality) over McBurneys point - 2/3rds away along from the umbilicus to the ASIS.
incision made through SKIN and SUBCUTANEOUS TISSUE. External Oblique, Internal Oblique and Transverse abdominis are divided/opened without cutting muscle fibres. incision made in the peritoneum, appendix and caecum identified. blood vessels and mesentary of appendix are divided and appendix ligated. fluid and pus swabbed out. if severe contamination or infection, a drain can be left in. absorbable sutures used to close muscle layers. Metronidazole or other antibiotics are given at induction |
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What is McBurneys point?
where is it? |
the site of the base of the appendix
2/3rds of the way along a line drawn from the umbilicus to the ASIS. |
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what is the most common site of the appendix?
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retrocaecal - 74%
pelvic - 7% - can be felt on rectal exam ~2cm below the ileocaecal valve caecum - beginning of large bowel |
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why do some patients with acute appendicitis experience rectal tenderness?
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tracking down of fluid and pus to the most dependent part of the abdominal cavity, the Pouch of Douglas/recto uterine pouch
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What should be the main differential diagnosis for acute appendicitis?
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mesenteric adenitis
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explain mesenteric adenitis
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enlargement of the mesenteric lymph nodes, pain, fever and localised tenderness
most commonly seen in children & adolescents associated with LRTI and URTI |
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commonest causes of small bowel obstruction
list other causes |
1) adhesions secondary to surgery
2) hernias luminal: impacted faeces, Foreign body, tumours, large polyps, intussusseption extramural;adhesions, strangulated hernia, volvulus, extrinsic compression intramural; tumours infarction, crohns, fissures, strictures |
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list the cardinal features of small bowel obstruction
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pain - colicky, severe - central abdomen common location due to representation there of embryological midgut visceral innervation
abdominal distension - variable nausea and vomiting - early with high, late with low intestinal obstruction absolute constipation - no passage of flatus look for signs of strangulation - focal tenderness, tinkling bowel sounds |
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define strangulation
list 2 clinical signs |
compromise of part of the intestinal blood supply due to twisting and kinking of its mesentary
focal tenderness and bowel sound tinkling order plain abdo x ray - look for small bowel loops - small bowel should be no >3cm diameter, have valvulae conniventes and be centrally located |
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what to do in an obstructed patient with a hernia
|
operate to release the herniated bowel, which is likely strangulated. if nonviable on inspetion - resection required.
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Conservative management (or early management prior to surgery) of small bowel obstruction due to adhesions
|
NBM
NG tube placement on free drainage - suck IV fluids drip resolution of obstruction reflected by - lessening of pain, decrease in NGT aspirate volumes, passage of flatus, resolution of X Ray signs if the patient doesnt settle within 24h or signs of strangulation, surgery indicated. laparotomy to divide adhesions |
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pseudo-obstruction - define it!
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an obstruction that has occurred in the absence of a mechanical cause;
medications - opiates, anticholinergics/muscarinics trauma - bowel handling electrolyte abnormalities |
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List major risk factors for a cerebrovascular accident/stroke
|
Smoking
Hyperlipidaemia Hypertension Diabetes + congential venous malforamtions, malignancy, AF |
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List stroke investigations
use NIH stroke scale to assess need for CT |
Blood capillary glucose - exclude hypoglycaemia
ECG - AF CT - If urgently considering thrombolysis + GCS<13, progressive symptoms, possible bleed [WARFARIN, MENINGISM (SAH)], othewise CT within 24h |
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2 factors or signs that might make you suspect a person to be suffering from a haemorrhagic stroke
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Meningism - Subarachnoid haemorrhage
Warfarinised patients |
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MGMT CVA
|
Acute: early diagnosis and imaging to confirm [NIH, OSC,CT]
Thrombolysis if: haemorrhage excluded, within 2h symptom onset, blood pressure <185/110, no C/I i.e. recent major bleed, warfarin. T-pA Aspirin [unless C/I] for 2/52 DO NOT TREAT BP unless HYPERTENSIVE EMERGENCY REVERSE ANTICOAGULATION i.e warfarin IF HAEMORRHAGIC ADMIT - SPECIALIST ACUTE STROKE UNIT assess swallowing, nutrition early mobilisation (sit up, sit out, get up, get out) On discharge: consider anticoagulation after 2/52 treat Risk factors - antihypertensives, statins IF TIA aspirin 300mg +/- dipyridamole risk stratification - lipids, glucose, smoking, bp look for site of embolus; carotid doppler, ECG, Echocardiography |
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when do you consider carotid endarterectomy in patients with TIA?
|
If >70% stenosis on side related to TIA symptoms.
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outline causes of stroke
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Ischaemic - 85% - thrombotic, embolic - heart/carotids, unknown
Haemorrhagic - 15%, SAH 5%, intracerebral 10% |
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outline Stroke classification
|
strokes may arise from the INTERNAL CAROTIDS - anterior circulation or the VERTEBROBASILAR - Posterior circulations
Bamford/Oxford stroke classification - used to divide CVA's according to their territory, extent and cause TACS, PACS, LACS, POCS |
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intrinsic factor and parietal cell antibodies are associated with which autoimmune condition?
|
Pernicious anaemia
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Thyroid stimulating antibodies are associated with which autoimmune condition>
Anti-Thyroglobulin and Anti-thyroperoxidase antibodies are associated with which autoimmune condition? |
Graves disease
Hashimoto's thyroiditis; |
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c-ANCA /Anti-Protease 3 antibodies are associated with which condition?
|
Wegener's granulomatosis
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Explain Wegener's Granulomatosis
|
A vasculitis of unknown aetiology, primarily affecting the Upper respiratory tract, lungs and kidney.
rhinorrhoea, nasal mucosal ulcers, cough, haemoptysis, pleuritic chest pain. C-XR - nodular masses + cavitation 90% cases C-ANCA/anti neutrophil cystoplasmic antibodies Treatment: cyclophosphamide |
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Which condition is associated with honeycomb lung on C-XR?
|
widespread PULMONARY FIBROSIS
honeycomb lung - dilated thickened terminal and respiratory bronchioles produce cyst like air spaces giving a honeycomb impression on X Ray |
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Anti-Smooth muscle antibodies are found in which autoimmune condition?
|
autoimmune hepatitis
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Anti-Mitochondrial antibodies are found in which autoimmune condition?
|
Primary Biliary Sclerosis
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Describe Trendelenberg's gait
|
Pelvis drops on weakened side during weight bearing stance phase and body leans to unaffected side.
due to ineffective hip abduction |
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Describe Antalgic gait
|
shortening of stance phase and leaning of body to unaffected side
sign of osteoarthritis |
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Describe a positive Trendelenberg's test and list causes.
|
Pelvis drops on the unsupported side when leg is raised due to weak abductors/hip instability.
Dislocation of hip, weak abductor muscles, hip pain and shortening of the femoral neck. |
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What might be the cause of discrepencies between apparent limb length, but not true limb length?
what are the points from which you measure true and apparent limb length |
Apparent limb length - Xiphisternum to medial malleolus
True limb length - ASIS to medial malleolus A feixed adduction deformity will cause discrepencies between apparent limb length, but not true limb length |
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Causes of true limb shortening - list
|
Perthe's disease
Slipped upper femoral epiphysis Osteoarthritis Fracture of neck of femur avascular necrosis dislocation of hip |
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Explain Perthes disease
|
ischaemia to the femoral epiphyses in young children, normally boys, leads to avascular necrosis of the femoral head and joint and growth dysfunction. self limiting, occurs in stages.
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|
Thomas test looks for?
|
fixed flexion deformity. patient unable to fully straighten leg withlumbar lordosis eliminated.
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|
list 3 secondary causes of osteoarthritis
|
Paget's
Perthes RA trauma |
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Pain characteristics of OA
|
progresses over a long period of time
stiffness after periods of rest pain after periods of use may radiate from hip to knee |
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Clinical picture of OA of the hip
|
trendelenberg or antalgic gait
trendelenbergs test may be positive limb may be held in external rotation and adducted there may be apparent shortening limited or restricted movements in all planes fixed flexion deformity may be present |
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explain trochanteric bursitis
|
the trochanteric bursa overlies the greater trochanter of the femur. inflammation can occur acutely through traume or through repetitive cumulative injury.
there is pain over the greater trochanter. worsened when lying onteh side and can wake patientat night. walking makes pain worse movement is not restricted, tender on palpation |
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What is Schobers test and why is it used
|
an assessment of lumbar spine mobility / flexion
the modified schobers test is commonly performed as part of a back examination in clinic Identify PSIS/dimples of venus. mark them. measure 5cm below and 10cm above. keep knees straight, bend forward to touch toes as far as they can go. then measure distance between top and bottom marker; 15cm should grow to at least 20cm, <5cm is a concern <5cm = reduced lumbar flexion |
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what is the straight leg test for
|
tests for sciatic nerve impingment
pain at less than 60 degrees of hip flexion check for pain in the lower back and buttocks at 45 degrees adn dorsiflex the foot |
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|
define
kyphos kyphosis spondylolisthesis |
kyphos - sharp bend of the spine
kyphosis -undue bending of the spine spondylolisthesis - loss of lumbar lordosis |
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Explain Homan's sign
|
a sign of deep venous thrombosis. pain in the calf is elicited or exacerbated by passive dorsiflexion of the foot
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Outline emergency treatment within 6hours in order to rescue acute ischaemic limb
|
Urgent surgical consult
--> ANGIOGRAPHY Angioplasty - if urgent symptoms thrombolytic - tPA if local thrombosis Anticoagulate patient with heparin post procedure cardiac echo or ultrasound can find source of emboli later look out for reperfusion injury or compartment syndrome |
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Jam ThreadS
|
Jaundice
Anaemia/haematology Myocardial infarction TB hypertension rheumatic fever Epilepsy Asthma and COPD Diabetes Stroke |
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Discuss embolectomy
|
surgical removal of emboli or thromboses blocking a circulation. Blocking of major vessels can lead to severe ischaemic damage and organ necrosis. Embolectomy is often a last resort intervention [thrombolytic thereapy preferred in PE for example]
Fogarty balloon catheters often used - has an inflatable tip which is inflated after passing through artery PAST the point of clot, then drags out the thrombus. |
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Outline DVT prophylaxis in surgical patients
|
stop oral contraceptive pill 4 weeks prior to op
LMWH 40mg - enoxaparin TEDS stockings - not in ischaemic leg |
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Treatment for DVT
|
LMWH 40mg in the evening. Use APTT to guide dosing. stop when INR 2-3
start them simultaneously on Warfarin - will need heparin cover for first week treat 3 months if post op dvt treat for 6 months if no cause found treat for lifetime if thrombophiliac or recurrent DVT |
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why place a urinary catheter, a cvp line and a ng tube in an acute surgical patient
|
urinary catheter - to measure urinary output and monitor for shock
CVP line - to guide fluid replacement - assess intravascular bp NG - to prevent aspiration |
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outline immediate general management for patient presenting with acute ischaemic limb
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ABC
Antiemetics, analgesia and O2 as required place 2 large bore cannulae start the patient on IV fluids - 1L bag of Hartmanns solution FBC,U&E, CK, Clotting screen -INR, APTT, PT, Glucose, CRP, ESR, ABG, Urinalysis, crossmatch 4-6 L blood Place NBM Run fluids if not already consider urinary catheter, CVP to guide fluid replacement and NG tube order urgent ECG, CXR, abdominal USS + cardiac USS looking for thrombosis, angiography infrom seniors alert theatres |
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Patients on a Calcium channel blocker should not be coprescribed which medication?
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Beta Blocker
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List 2 medications given in the acute management of hyperkalaemia
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Calcium gluconate 10mls IV- give over 2 minutes and may repeat until 50mls, every 15minutes
Actrapid insulin 10mls in 50mls of 50% Dextrose IV over 10 minutes |
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A man with known past history of Etoh and peptic ulcer disease presents with epigastric pain, rebound tenderness and rigidity. what is the most important next investigation
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erect chest x ray checking for pneumoperitoneum and plain abdominal film
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give some clinical signs of class 3-4 haemorrhage
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heart rate >120
rr >30 bp low patient confused |
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2 tests you might order to rule out acute pancreatitis
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amylase
lipase |
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imaging for query renal colic patient
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KUB xray
erect chest xray IV urogram ECG ct abdomen abdominal ultrasound - gallstones/cholecystitis |
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abdominal ultrasound findings in gallstones/cholecystitis
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thick walled and shrunken gallbladder
pericholecystic fluid dilated cbd>6mm |
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explain in general terms the pathology caused to local structure by a prolapsed disc
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the prolapsed nucleus propulsus can compress on an adjacent nerve root, causing pain and symptoms in the anatomy it supplies
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common complaints of patients presenting with prolapsed disc
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pain on lifting objects
inability to straighten leg sciatic leg pain/sciatica - severe pain localised in the lumbar region or that radiates down the back of the leg coughing, sneezing and straining reproduces the back pain and sciatica tender lower vertebrae and paraverterbral muscles, listing tendency, limited forward flexion. SLR positive on affected side |
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what are the most common sites of disc prolapse?
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L4/L5
L5/S1 |
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Weakness of big toe extension and loss of sensation on out aspect of lower leg and dorsum of foot suggests
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prolapse disc at L4/5
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pain in calf, weakness to plantar flexion and eversion of the foot, loss of sensation over lateral aspect of the foot and depressed ankle reflex suggest
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prolapse of disc at L5/S1
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Explain Scoliosis
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abnormal lateral curvature of the spine
EARLY - < occurs before 7 years Late - after 7 years 80% of those with late scoliosis are girls By Location: Thoracic, Lumbar, Thoraco-lumbar S - shape - 2 curvatures |
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Outline clinical symptoms of Wernicke's encephalopathy
What supplement must be part of her treatment |
Ophthalmoplegia
ataxia nystagmus confusion impairment of short term memory Thiamine/B1 - Pabrinex |
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an ototoxic antbiotic
a drug also with a narrow therapeutic range |
gentamicin
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in acute renal failure, which tests might you order to monitor the condition?
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ARF - decline in renal function enough to produce Uraemia and oliguira [<30mls/hr or <400mls/day)
often occurs over a period of days or a week. often reversible. Dx based on serum creatinine (>500umol.l) or urea levels. Blood tests: U&E - Cr, urea, K+, Hb myoglobin Creatinine clearance monitoring is more precise indication of kidney function than eGFR or serum urea alone always check for nephrotoxic drugs |
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Indications for renal replacement therapy
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failure to control: fluid overload, hyperkalaemia, hypocalcaemia, metabolic acidosis
hyperuraemia, GFR<15ml.min, poisoning e.g. salicylates. |
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3 types of renal replacement therapy
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peritoneal dialysis
haemofiltration renal transplant |
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List causes of chronic renal failure
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Diabetic nephropathy
Hypertensive nephropathy Renal artery stenosis congenital - PKD, Alport's syndrome, tuberous sclerosis Glomerular diseae - IgA neprhopathy, Wegeners, amyloidosis Systemic inflammatory disease- SLE, |
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ultrasound sign of chronic renal failure
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bilateral small kidneys
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at what levels of serum urea do symptoms of chronic renal failure often become apparent?
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40mmol.l - though many have symptoms at levels belowq
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Symptoms and signs of chronic renal failure
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malaise, anorexia, nausea & vomiting, diarrhoea
nocturia, polyuria, pruritis - high levels of urea anaemia symptoms peripheral oedema, pulmonary oedema bruising bone pain hypoalcaemia hyperkalaemia hyperpigmentation severe- mental slowing, seizures |
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Outline staging of chronic kidney disease
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5 stages; symptoms usually experienced at stage 4.
stage 1. eGFR >90mls.min stage 2-3 p GFR-30-89. treat with RENOPROTECTION Stage 4 - GFR 15-30 mls.min - renal replacement therapy stage 5 - <15mls.min = kidney failure |
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outline renoprotection therapy
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Hypertensive control
low protein diet for patients with stage 2 and 3 renal failure i.e. >30ml.min |
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Blood investigations and probable findings in chronic renal failure
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FBC - normocytic, normochromic anaemia
U&E's - raised Urea and Creatinine PO4+ - raised PTH --> raised Glucose - diabetic nephropathy? ESR - raised in vasculitic causes of CRF |
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Outline common findings on urinalysis of a patient with Chronic renal failure
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haematuria and casts --> GLOMERULONEPHRITIS
Proteinuria - glomerular disease white cells - infection - UTI, pyelonephritis 24 hour creatinine clearance - determining precise renal function and hence level of renal failure urinary electrolytes Osmolality - low in kidney failure as kidney unable to concentrate urine |
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why must you be extra vigilant for acute renal failure in elderly patient?
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low muscle mass and low dietary intake can lead to decievingly low creatinine, masking ARF.
weigh high risk patients daily and serum electrolytes monitoring |
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initial investigations in suspected acute renal failure
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U&E's - creatinine, urea, hyperkalaemia
FBC Dipstick urine - glucose , osmalality, casts, wcc urine microscopy - red cell casts or microscopic haematruria (glomerulonephritis) always check for nephrotoxic drugs |
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Causes of Acute Tubular Necrosis
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ischaemic damage
nephrotoxins cholestatic jaundice gram-negative septicaemia pre-eclampsia heroin use - due to formation of myoglobin and haemoglobin casts myoglobin or haemoglobinaemia due to muscle injury ACE inhibitors - dilate efferent arteriole --> lowering glomerular pressure exacerbating renal failure in patients with renal disease NSAID's - reduce prostaglandin production, which are vasodialtors, this leads to vasoconstriction of the afferent arteriole reducing GFR |
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Which 2 drugs which when prescribed in conjunction can cause acute on chronic renal failure in a patient with renal artery stenosis?
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Nsaid's and Ace inhibitors
causing afferent vasoconstriction and efferent vasodilation |
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complications of acute renal failure
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fluid retention --> overload and oedema
electrolyte imbalance - hyperkalaemia accumulation of toxins |
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what is BUN an indicator of?
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Blood urea nitrogen - accumulation of toxins such as nitrogen and urea in the blood
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In an oliguric patient, after obstruction has been ruled out, what should be considered next? give indicators of pre-renal failure
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pre-renal failure
hypovolaemia, heart failure, vascular disease [renal artery stenosis], NSAID's or ACEi's, peripheral vasodilation, anaphylaxis |
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first step in trtx of pre-renal injury.
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correct volume status -
in a patient with acute pre-renal failure, correction of volume status should reverse the renal failure. |
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indicators of pre-renal injury/hypovolaemia
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orthostatic hypotension
decreased skin turgor, dry mucous membranes prolonged cap refill 10% weight loss |
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Briefly explain hepatorenal syndrome
what is the management |
systemic vessel vasodilatation but renal vessel vasoconstricted (decreased GFR)
give systemic vasoconstricter, correct liver failure patient will present hypovolaemia --> correct fluid status |
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How do NSAID'S effect renal function?
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NSAID's inhibit prostaglandin (vasodilator) production and thereby increase systemic vasoconstriction, causing constriction of the afferent renal arteriole and exascerbating renal renal failure by decreasing renal perfusion
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outline how NSAID's might lead to oedema and hypertension
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vasoconstriction of the renal artery due to decreased prostaglandin action leading to reduced renal perfusion and an increase in Na+ reabsorption and hence a decrease in water excretion [water follows salt]
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what is the function of Angiotensin 2
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vasoconstrictor of the efferent arteriole, activated during episodes of hypovolaemia or where reduced blood flow decreases GFR. The Renal-angiotensin system is activated to cause A2 action
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How do ACE inhibitors and Angiotensin 2 blockers cause acute kidney injury?
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by decreasing GFR through inhibiting vasoconstriction of the efferent arteriole.
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3 causes of ATN
what is seen on urinalysis |
Cellular debris
nephrotoxins ischaemia mild proteinuria/albuminuria granular cell casts red cell casts myoglobinaemia |
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which part of the kidney is most sensitive to ischaemia?
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the renal medulla - highest oxygen demand
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how can contrast agents induce acute kidney injury
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cause vasoconstriction of the renal artery
avoid by ensuring adequate hydration and keeping patient off NSAID's |
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Main causes of acute interstitial necrosis?
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iatrogenic
penicillin, cephalosporin, NSAID look for eosinophils in the urine |
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name an ototoxic, nephrotoxic aminoglycoside with a narrow therapeutic range
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gentamicin
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Give the antidote for the following medications in combatting their overdose;
Amitriptyline B-Blockers BZD's Cyanide Digoxin Heparin Iron Methanol Methaemoglobin organophosphates opiates paracetamol sulphonylureas verapamil warfarin |
Amitriptyline - sodium bicarbonate
B-Blockers - glucagon BZD'S - flumazenil cyanide - hydroxocobalamin/nitrites digoxin - digoxin antibodies heparin - protamine Iron - desferrioxamine methanol - ethanol methaemoglobin - methylene blue organoophosphates - atropine opiates - naloxone paracetamol - n acetyl cysteine sulphonylureas - octreotide verapamil - calcium warfarin - vitamin k, octiplex |
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a weak mu receptor agonist similar to codeine used to treat long term moderate pain i.e RA
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Tramadol
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explain methaemoglobin and methaemoglobinaemia
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methaemoglobin is a form of haemoglobin that contains ferric acid. it has an increased affinity for bound oxygen and is less inclined to release it to surrounding cells. a reduecd ability of an rbc to release o2 to surrounding tissues causes a leftward shito f the oxy haemoglobin dissocation curve.
methaemoglobinaemia leads to hypoxia certain drugs can cause this methylene blue is the treatment |
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somatostatin inhibits which hormone
what is its synthetic analogue |
growth hormone, glucagon, insulin
octreotide |
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explain how a spacer device works;
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allows for better coordination and effective inhalation of a dispensed aerosol drug. it also filters larger drug molecules that might otherwise lead to hoarse throat, and candida infections. permits entry of smaller drug molecules
reduces risk of candidasis to use: put one end in mouth, activate drug, take 5 normal sized breahts in and out. do it twice 9i.e. ten breaths) |
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what percentage of drug inhaled through an inhaler with good technique (without spacer) reaches the lungs)
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15%
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when should i take my reliever inhaler?
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when experiencing shortness of breath or other symptoms.
before an event that you know often causes symptoms e.g. exercise |
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a long acting b2 agonist available as an inhaler
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salmeterol
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a short acting b2 agonist
a fast acting b2 agonist a short acting anticholinergic used in obstructive lung disease |
salbutamol
terbutaline ipratropium (atrovent) |
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what is seretide?
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salmeterol + fluticasone
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list examples of typical/1st gen and atypical 2nd gen anti-psychotics/neuroleptics
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1st generation typical: chlorpromazine, haloperidol
2nd gen atypical: clozapine, risperidone, olanzipine, quietiapine most block dopamine receptors but also have affects on other pathways |
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what are the main class of side effects associated with anti-psychotic drugs
what pathway are the implicated in |
extrapyramidal effects - akathesia, acute dystonia, parkinsonism.
these effects do not occur with clozapine and are far less likely with atypical drugs due to D2 blockade of the nigrastriatal pathjways other s/e - weight gain, drowsiness, agranulocytosis - chlorpromazine |
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main side effect of atpical antipsychotics
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weight gain
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When is the Schilling test performed
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investigation for vitamin B12 deficiency to determine diagnosis of pernicious anaemia.
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Explain Glaucoma
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high intraocular pressure due to imbalance in production and drainage of aqueous humour causes Cn2 damage.
There are 2 types -open and closed angled |
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what is aqueous humour and outline the aqueous pathway
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aqeuous humor is a fluid produced by the ciliary body helping to shape the eye as well as nourish the avascular lens and cornea. Fills both anterior and posterior chambesr.
the fluid is drained out of the eye via the Irido-corneal angle in the anterior chamber. The fluid filters back into the circulation via the trabecular meshwork into the canal of schlemm. |
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explain Open Angle Glaucoma
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most common type
presents in patients >40 Risk F: FH, age, african-americans, thin corneas, large verticle nerve cupping, high eye pressure. pathphys: degeneration of trabecular meshwork results in aqueous build up and chronic elevated eye pressure leading to Cn2 atrophy and gradual visual loss exam: elevated eye pressure. highest in the morning, Optic disc changes [increased cupping and ratio, vertical thinning, haemorrhage at disc, visual loss trtx: trabeculectomy, lasor proceudre with argon laser, plastic tube |
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explain Acute closed angle glaucoma
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a medical emergency
caused by PUPILLARY BLOCK - lens pushes up against posterior iris blocking flow of aqueous humor through the pupil. iris and lens move anteriorly, closes the irido-corneal angle and blocks the trabecular meshwork. this causes a rapid rise in eye pressure which damages retina risk f: hyperopic eyes with shallow anterior chambers, pupil dilatation, medications causing pupil dilatation presenting: PAINFUL RED EYE, halo aroudn lights, swelling of the cornea cause the halo exam: sluggish dilated pupil, high pressure, rock hard eye trtx - decrease pressure quickly: Timolol, iv mannitol and pilocarpine (miotic) then surgery! |
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what is the characteristic visual loss associated with open angle glaucoma
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central vision spared - peripoheral visual loss
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how might acute closed angle glaucoma present
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Acute RED painful eye - N&V
halo - corneal oedema rock hard eye sluggish dilated pupil increased fluid pushed iris against cornea, closing canal of schlemm blocking humor drainage and leading to a RAPID rise in bp |
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Treatment for acute close angle glaucoma
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many treatments at once
Timolol _ carbonic anhydrase inhibitors to decrease humor production IV mannitol and pilocarpine (pilocarpine causes local miosis) then surgical treatment - burn hole in iris to communicate ant and post chambers to relieve pressuer gradient allowing iris to revert back to normal position, opening trabeular meshwork. |
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Haemophilia A is a congenital deficiency of which clotting factor
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Factor 8/VIII
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a syndrome caused by a microdeletion on chromosome 22q11.
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DiGeorge syndrome
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name a congenital syndrome diagnosed on nuchal translucency
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trisomy 21
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What is the ABCD2 score used for?
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ABCD2 score is used after a TIA to predict the risk of stroke.
Age>60years Blood pressure - 140/90 Clinical features - unilateral weakness, Duration Diabetes |
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environmental risk factors for hypertension
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obesity, alcohol, salt, stress, diabetes,
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Cardiac complications of hypertension
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systemic left sided heart disease - cardiac dilation, heart failure and sudden death,
LVH |
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WHO criteria for hypertension
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<50 - 140/90
>50 - 160/95 though risk CV events increases within normal limits |
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NICE guidelines on hypertension: when to offer treatment
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Blood pressure 160/100 on 1 occasion
blood pressure >140/90 on 2 occasions systolic >160 blood pressure >140/90 and cvd risk |
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Treatment of hypertension
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<55 years and not black:
step 1: ACE/ARB step2: ACE +CCB or ACE + thiazide step 3: ACE + CCB + Thiazide step 4: further diuretic, alpha blocker, or beta blocker SPECIALIST ADVICE NEEDED. >55 or black at any age Step 1: CCB or thiazide step 2: ACE + thiazide or CCB step 3: ace, thiaz, ccb step 4 - bblocker and specialist |
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What is the Apgar score
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apgar sc ore is the birth prognosis score
activity, pulse, grimace, apperance of skin, respiration 7-10 normal 0-3 critically low |
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What is the CHADS2 score
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CHADS2 Score assesses risk of stroke in AF
Congestive heart failure Hypertension Age >75 Diabetes mellitus Stroke or TIA in past - 2 points warfarin iven to those with a score >2 - aim to raise INR to 2-3 |
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Which scale can be used to assess breathlessness in COPD
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MRC Dyspnoea scale
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talk about the NYHA classification
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The NYHA classification for heart failure
Class I - Mild - no undue dyspnoea from ordinary activity Class II - Mild - at rest ok, Dyspnoea on ordinary activity Class III - Moderate - <ordnary activity causes dyspnoea - limiting Class IV - Severe - dyspnoea present at rest, all activity causes discomfort |
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What is the difference between the Wells score and the Adapted Wells score
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Wells score - pretest clinical probability scoring for DVT: score > 3 treat as high probability DVT
Adapted Well'sscore for pulmonary embolism 7 or over points = high probability maignancy,haemoptysis, prev hx of dvt, hx of pe, immobilisation or surgery recent, tachycardia, |
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Heart failure on x ray
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prominent upper lobe vessels due to oedema
cardiomegaly pleural efffsion kerley b lines - interstitial oedema bat wings |
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Where does pain emanating from the small bowel usually radiate to?
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umbilicus
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How are adhesions treated surgically?
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laparotomy and division.
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4 cardinal signs of small bowel obstruction
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pain
vomiting distension absolute constipation |
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defintion and 3 causes of pseudoobstruction
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obstrcution without mechanical cause
electroylte imbalance, drugs (ach inhibitors), trauama |
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3 main causes of large bowel obstruction
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carcinoma of the colon, diverticulitis and volvulus of sigmoid or caecum
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difference in vomiting symptom associated with small and large bowel obstruction?
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vomiting takes longer to present in large than small bowel obstruction
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20% of people have a competent ileocaecal valve, why is this dangerous in large bowel obstrcution?
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retrograde decompression of large bowel into small cannot occur in these patients allowing for greater pressure rises and icnreaseing hter isk of perforation of the large bowel
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most common site of perforation in large bowel obstruction.
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caecum, the thinnest walled part.
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Investigations of large bowel obstruction
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FBC, U&E, amylase and group ans save
X rays emergency contrast enema to distinguish between true and pseeudo obstrcution sigmoidoscopy |
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Management of peritonism in a patient with suspected large bowel obstruction
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the othe peritonism indicates perforation; perforation needs emergency laparotomy,
another indication for emergecny laparotomy is a caecum >10cm as this means imminent perforation. |
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what can be done for large bowel obstrcution in patients unfit form ajor surgery
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the insertion of self expanding metallic stents under endoscopic or radiological guidance are useful in the decompression acutely obstructive cancers
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