Aims and objectives Recap some of the most challenging questions from - - PowerPoint PPT Presentation

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Aims and objectives

• Recap some of the most challenging questions from yesterday’s quiz
• Not every question will be addressed for the purpose of time
• All answers and explanations are in the slides
• Duration: 60 mins
• Slides and recordings: app.bitemedicine.com

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Explanations

app.bitemedicine.com IV chlorphenamine In anaphylaxis, antihistamine should be given after adrenaline and fluids Oral prednisolone IV steroids are given in anaphylaxis IV hydrocortisone Given after antihistamine as steroids take time to work Salbutamol nebuliser May be given as an adjunct for bronchodilation IV noradrenaline Not involved in anaphylaxis management A young lady presents with stridor after eating a peanut. You have given IM adrenaline and started 500ml IV fluids. What is your next step?

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app.bitemedicine.com Monitor The potassium is raised and so action must be taken Calcium gluconate Only given in the presence of ECG changes (UK renal association) Calcium resonium Reduces potassium absorption in the gut but takes time to work Nebulised salbutamol Causes intracellular shift of potassium Haemodialysis Only used in refractory cases A patient with known CKD has a potassium of 6.9mmol/L. The ECG is shown. What is your next step?

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Adapted from the UK renal association guidelines

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(2)

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app.bitemedicine.com Rise in creatinine 1.25x baseline AKI: 1.5x baseline Cr in the past 7 days Urine output < 40ml/hour AKI: fall in urine output to less than 0.5ml/kg/h for more than 6 hours Urine output < 35ml/hour AKI: fall in urine output to less than 0.5ml/kg/h for more than 6 hours Rise in creatinine of 30umol/L AKI: rise in Cr of 26 umol/L in 48h eGFR 45 A stand-alone measurement is not useful. We need to know the patient’s baseline A 67-year-old female is admitted with a UTI. She weighs 60kg. Which of the following suggests she has an AKI?

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Explanations

app.bitemedicine.com Adrenaline therapy alone Never used alone, only as an adjunct, as per NICE Fibrin sclerotherapy Sclerotherapy and thermal coagulation require adrenaline as well Thrombin sclerotherapy Sclerotherapy and thermal coagulation require adrenaline as well Thermal coagulation Sclerotherapy and thermal coagulation require adrenaline as well Clipping Can be done with or without adrenaline A patient presents with haematemesis and is diagnosed with a bleeding peptic ulcer

• n endoscopy. What is the most appropriate management option?

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app.bitemedicine.com Lactate 3 mmol/L Treatment has not yet started so septic shock cannot be diagnosed Systolic BP 85 mmHg Treatment has not yet started so septic shock cannot be diagnosed Diastolic BP 60 mmHg Treatment has not yet started so septic shock cannot be diagnosed HR 110 Treatment has not yet started so septic shock cannot be diagnosed None of the above Septic shock is defined as fluid refractory hypotension with a raised lactate. This patient has not yet commenced treatment so shock cannot be diagnosed A 60-year-old male with a UTI presents with a HR 110 and BP 85/60. You have not started treatment. Which option suggests septic shock in this patient?

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After fluid resuscitation

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app.bitemedicine.com Coxsackie Viruses are the most common cause of meningitis, of which enteroviruses (e.g. Coxsackie) are the commonest Mumps Rare cause S.pneumoniae (pneumococcus) Most common bacterial cause in the US N.meningitides (meningococcal) Most common bacterial cause in the UK (NICE) E.coli A rare cause and typically affects neonates Which of the following is the most common cause of meningitis?

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app.bitemedicine.com Platelet factor 4 Heparin induced thrombocytopaenia involves antibodies against heparin-PF4 complex ADAMTS 13 Enzyme responsible for cleaving vWF. Reduced activity in TTP Factor VIII Incorrect GpIIb/IIIa Involved in platelet adhesion. Deficiency results in Glanzmann disease IgG Incorrect A patient on Dalteparin (LMWH) develops thrombocytopaenia. Which of the following antigens is involved?

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app.bitemedicine.com CML Lymphadenopathy not common CLL Most common adult leukaemia. Suspect in elderly with massive splenomegaly and lymphadenopathy AML May also present similarly but less common and median age of presentation is younger ALL Typically seen in children Marginal zone lymphoma Rare and associated with underlying condition such as H.pylori gastritis A 70-year-old male presents with fatigue. His spleen is palpable at his umbilicus and he has cervical lymphadenopathy. What is the likely diagnosis?

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app.bitemedicine.com Urgent colonoscopy Fe deficient anaemia in the elderly is colon cancer until proven otherwise Urgent OGD OGD may also be done if colonoscopy does not reveal bleeding point Urgent OGD and colonoscopy OGD may also be done if colonoscopy does not reveal bleeding point Faecal occult blood OGD may also be done if colonoscopy does not reveal bleeding point Commence IV iron The patient should be started on oral iron A 65-year-old lady presents to the GP with fatigue. She is noted to have an iron deficient anaemia. She is otherwise well. What is your next step?

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app.bitemedicine.com Aspirate with a 16G cannula Aspiration suitable for a primary pneumothorax (>2cm) or a secondary pneumothorax (1-2cm) Aspirate with an 18G cannula Sclerotherapy and thermal coagulation require adrenaline as well Insert 8-14Fr chest drain Secondary pneumothorax (as COPD history) and over 2cm requires 8-14Fr chest drain as per BTS Insert 20-28Fr chest drain Too big Discharge and review in outpatient clinic Not appropriate A 50-year-old male with a history of COPD presents with pleuritic chest pain. He is diagnosed with a 3cm pneumothorax. What is your management?

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app.bitemedicine.com Percutaneous nephrolithotomy Renal stone larger than 20 mm in adult, including staghorn stones, offer PCNL Shockwave lithotripsy Used for small renal and ureteric stones Tamsulosin expulsive therapy Only suitable for small ureteric stones Watchful waiting Too big Ureteroscopy Can be used second-line A 20-year-old male presents with loin-to-groin pain. He is apyrexial and passing

• urine. CT KUB: 22mm renal pelvis stone. What is your management?

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app.bitemedicine.com CT of hip/pelvis Only if MRI is unavailable within 24 hours or contraindicated MRI of hip/pelvis Offer MRI if hip fracture is suspected despite negative X-rays. If MRI is not available within 24 hours or is contraindicated, consider CT Ultrasound of hip/pelvis Not sensitive Discharge with analgesia and reassurance Clinical suspicion warrants further imaging Prepare the patient for theatre Imaging required before theatre An elderly female has a fall and AP pelvis and lateral hip x-rays demonstrate no clear

• fracture. A hip fracture is strongly suspected. What do you do?

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app.bitemedicine.com Adhesional small bowel obstruction Adhesional SBO will not present so soon post-op Large bowel obstruction Vomiting is a late feature of LBO and more suggest SBO Hospital acquired pneumonia The patient is breathless due to abdominal splinting. There are no other features of pneumonia Paralytic ileus Features of SBO post abdominal surgery = ileus. The patient is breathless due to abdominal splinting Community acquired pneumonia The patient is breathless due to abdominal splinting. There are no other features of pneumonia A 60-year-old is 2 days post-op following an open cholecystectomy. He develops breathlessness, vomiting and abdominal distension. What is the cause?

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app.bitemedicine.com Spironolactone Only start if K < 4.5 Bisoprolol Quadruple therapy with K > 4.5 requires an alpha or beta blocker Verapamil Not used in HTN Finasteride Not used in HTN Losartan Already on an ACEi. ARB may be used instead of an ACEi but not in addition A 60-year-old Caucasian needs optimisation of his hypertension. He is on ramipril, amlodipine, indapamide. Which agent should be added? Na 140, K 4.9.

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app.bitemedicine.com Increase the dose of metformin 1g BD is max dose Commence gliclazide Causes weight gain Commence liraglutide Only indicated if BMI 35 or over and the patient has failed triple therapy Commence pioglitazone Causes weight gain Commence dapaglifozin Does not cause weight gain A type 2 diabetic is on 1g BD metformin and her HbA1c is 59 mmol/mol. She has a BMI of 33 and an eGFR of 62 ml/min. What is your next step?

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Drug class Side effects Biguanides GI upset AKI Sulfonylureas Hypoglycaemia Weight gain SGLT-2 inhibitor UTI Thiazolidinediones Weight gain Fluid retention DPP-4 inhibitor GI upset GLP-1 inhibitor GI upset Loss of appetite

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app.bitemedicine.com Reduced appetite Classic feature of appendicitis Nausea Classic feature of appendicitis Tachycardia Often present Temperature 38.9°C Classic appendicitis. Low grade fever is usually expected. High fever is not usually seen in appendicitis and suggests alternative pathology e.g. mesenteric adenines Rosving’s sign Classic sign in appendicitis. Palpation of the LIF elicits pain in the RIF A young male presents with 2 days of peri-umbilical pain, now localised to the RIF. WBC 18, CRP 190. Which of these features would not be expected?

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app.bitemedicine.com Urinary catecholamines Less sensitive Urinary vanillylmandelic acid Less sensitive Urinary metanephrines Serum and urinary metanephrines are most sensitive (endocrine society) Chromogranin A May be used in follow-up CT abdomen Not first-line and only done if there is biochemical evidence of a phaeochromocytoma A 43-year-old male presents with palpitations. His BP is 171/99 and HR is 110. What is your first line investigation?

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app.bitemedicine.com Trans-sphenoidal resection of the pituitary Medical therapy is first-line in prolactinoma. Surgical management is first-line in acromegaly Pegvisamont Used in acromegaly. A GH antagonist Radiotherapy May be used if medical and surgical therapy not appropriate or has failed Cabergoline Dopamine agonist is first-line Apomorphine Dopamine agonist used in Parkinson’s disease A 26-year-old presents with amenorrhoea. She has bilateral galactorrhoea. Given the likely diagnosis, what is your management?

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app.bitemedicine.com Systolic blood pressure <100mmHg SBP <90mmHg (NOT 100mmHg) Hepatomegaly Alone, this is not an adverse feature Burning epigastric pain Typical cardiac chest pain, e.g. central crushing chest pain, is an adverse feature Raised JVP Heart failure is an adverse feature – pulmonary oedema and/or raised jugular venous pressure (with

• r without peripheral oedema and liver enlargement)

Peripheral oedema Alone, this is not an adverse feature Which of the following is an adverse feature in a patient with atrial fibrillation, as per Resus Council Guidelines?

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app.bitemedicine.com Pain relieved by lifting the ipsilateral testicle Prehn’s positive suggest epididymitis Cremasteric reflex present Absent Blue-dot sign Suggests torsion of the testicular appendage (Hydatid of Morgagni) Low-riding testicle Usually high-riding testicle Prehn's sign negative Lifting the testicle should not relieve the pain in testicular torsion Which of the following is likely to be seen in a patient with testicular torsion?

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app.bitemedicine.com Left marginal Branch of the left circumflex Lateral circumflex Lateral, anterolateral, or posterior MI Posterior descending Posterior MI Right coronary Inferior MI is most likely to involve the right coronary artery Left anterior descending Anterior or anterolateral MI A 60-year-old male presents with central chest pain. Serial ECGs show ST elevation in leads II, III, aVF. Which artery is most likely to be occluded?

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(3)

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app.bitemedicine.com Harvard Incorrect DeSnakey DeBakey! Stanford Stanford and DeBakey classifications can be used Pennsylvania Incorrect Glasgow Incorrect Which of the following is a classification system used for aortic dissection?

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app.bitemedicine.com Offered to all males aged 55 and over Males only, who are 65 years and over Offered to everyone aged 55 and over Males only, who are 65 years and over Offered to all males aged 65 and over All males aged 65 years and over as a one-off ultrasound Offered to everyone aged 75 and over Males only, who are 65 years and over Offered to all males aged 75 and over Males only, who are 65 years and over Which of the following best describes the abdominal aortic aneurysm screening guidelines in England?

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• H. Influenzae

H.Influezae and M.Catarrhalis are also common causes

• S. Pneumoniae

Most common bacterial cause

• M. Catarrhalis

H.Influezae and M.Catarrhalis are also common causes

• S. Pyogenes

Not a common cause Respiratory syncytial virus Not a bacteria What is the most common bacterial cause of otitis media?

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app.bitemedicine.com ↑ TSH, ↑ T4 Secondary hyperthyroidism is extremely rare ↓ TSH, ↓ T4 This suggests secondary hypothyroidism ↑ TSH, ↓ T4 This suggests primary hypothyroidism ↓ TSH, ↑ T4 Grave’s disease is the most likely cause ↑TSH, ↔ T4 This suggests subclinical hypothyroidism A 30-year-old female presents with weight loss, diarrhoea and sweating. Thyroid function tests are requested. What are the most likely findings?

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app.bitemedicine.com Ampulla of the fallopian tube Most common site (75%) Isthmus of the fallopian tube Second most common (~11%) Fimbria of the fallopian tube Rare Ovary Rare Cervix Rare What is the most common site of implantation in an ectopic pregnancy?

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app.bitemedicine.com FBC Not diagnostic Urinalysis Not diagnostic Echocardiogram Allows for visualisation of the bacterial vegetation. Transoesophageal echo has a higher sensitivity 12-lead ECG Not diagnostic Chest X-ray Not diagnostic A 50-year-old intravenous drug user presents with a fever, breathlessness, and a pansystolic murmur. What is the diagnostic investigation of choice?

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app.bitemedicine.com Hypermetropia Acute angle closure glaucoma (hypermetropia is risk factor) Male sex Female sex is a risk factor Caucasian ethnicity East Asian ethnicity is a risk factor Young age Increasing age is a risk factor Opiate use Opiates are a mitotic. Mydriatic drugs are a risk factor e.g. phenylephrine A 64-year-old has a unilateral red, painful eye with blurred vision and vomiting. The pupil is fixed and dilated. Which is an underlying risk factor?

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app.bitemedicine.com Acute closed angle glaucoma Tends to be really painful with nausea and vomiting. Seen in elderly Open angle glaucoma Painless visual loss in the elderly Bacterial keratitis Contact lens wearer with a red, painful eye and reduced acuity = keratitis Anterior uveitis Tends to be associated with autoimmune conditions. Contact lens points toward keratitis Episcleritis Red eye which usually is not painful A 30-year-old woman presents with a watery, red, and painful right eye. O/E there is a hypopyon. She is a contact lens wearer. What is the diagnosis?

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app.bitemedicine.com Patients are at increased risk of primary spontaneous pneumothorax Increased risk of secondary pneumothorax PEFR is a useful investigation to diagnose COPD PEFR is not useful as it often underestimates the severity of airflow obstruction Offer patients one-off pneumococcal and annual influenza vaccinations This is the correct answer regarding vaccinations in COPD GOLD Stage 4 is an FEV1 of 50-79% predicted GOLD stage 4 is FEV1 <30% predicted Long term oxygen therapy is indicated in non-smokers with PO2 <8.3 kPa Long term oxygen therapy is indicated in non-smokers with PO2 <7.3 kPa alone Which of the following is true regarding COPD?

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app.bitemedicine.com Mixed insulin regimen Second-line Basal bolus insulin regimen First-line in T1DM Continuous insulin infusion Only if the patient has disabling hypoglycaemia or persistent hyperglycaemia Metformin Used in T2DM Insulin standard therapy regimen Fictitious A young female is diagnosed with type 1 diabetes mellitus. What is the first-line management option?

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app.bitemedicine.com t(12;21) ALL t(15;17) AML (APML subtype) t(14;18) Follicular lymphoma t(11;14) Mantle cell lymphoma t(9;22) CML Which of the following translocations is most common in mantle cell lymphoma?

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Translocation Disease t(12;21) ALL t(15;17) AML (acute promyelocytic leukaemia subtype) t(9;22) CML t(14;18) Follicular lymphoma t(8;14) Burkitt lymphoma t(11;14) Mantle cell lymphoma

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app.bitemedicine.com Cancer 2 years ago Active cancer as per NICE is a risk factor. Well’s criteria defines it as malignancy with treatment within last 6 months or palliative Nephrotic syndrome Urinary loss of anticoagulants such as antithrombin III put patients in a hypercoagulable state BMI 28 Obesity (BMI 30 or over) is a risk factor Haemophilia A A bleeding disorder, not a hypercoagulability disorder Age 50 As per NICE, Age > 60 is a risk factor Which of the following is a risk factor for developing a pulmonary embolus?

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app.bitemedicine.com Prolonged PT The APTT is prolonged as factor VIII is affected (intrinsic pathway) Prolonged APTT The patient likely has Von Willebrand disease. Lack of vWF causes a reduced half-life of factor VIII causing prolongation of the APTT Reduced PT Incorrect Reduced APTT Incorrect Thrombocytopaenia Von Willebrand disease is not associated with thrombocytopaenia A 25-year old lady has a history of menorrhagia and epistaxis. She has a family history of a bleeding disorder. Which of the following is expected?

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Von Willebrand disease

Genetic Haemophilia Von Willebrand disease

Pathophysiology

• Autosomal dominant condition
• Multiple different types
• Type 1 (80%): reduced vWF
• Type 2 (20%): qualitative defect
• Type 3 (~1%): complete absence of vWF (autosomal recessive)

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Von Willebrand disease

Pathophysiology

• Autosomal dominant condition
• Multiple different types
• vWF stabilises factor VIII → deficiency results in reduced VIII half-life

Clinical presentation

• Most common hereditary coagulation disorder
• Increased bleeding time
• APTT prolonged
• Reduced factor VIII levels
• Ristocetin assay: failure of agglutination

Management

• Desmopressin
• Factor VIII concentrate
• vWF concentrate

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app.bitemedicine.com Folate deficiency Causes a macrocytic anaemia Vitamin B12 deficiency Causes a macrocytic anaemia Chronic liver disease Causes a macrocytic anaemia. (Liver is involved in RBC membrane synthesis) Hypothyroidism Causes a macrocytic anaemia. (Multifactorial. Interferes with EPO production) Anaemia of chronic disease Causes a microcytic or normocytic anaemia Which of the following is the least likely cause of a macrocytic anaemia?

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app.bitemedicine.com Nebulised adrenaline Can be used if airway obstruction is imminent Oral dexamethasone Child presents with mild croup which can be treated with oral dexamethasone. Stridor on exertion is not a concerning feature unlike stridor at rest Insert oropharyngeal airway No evidence of stridor at rest which would warrant airway management. In croup, intubation should be carried out if evidence of airway obstruction Nebulised budesonide Used in moderate-severe cases where the child cannot tolerate oral dexamethasone Examine the throat Avoid where possible as this may cause agitation and exacerbate airway obstruction A 2-year-old presents with a barking cough. He is comfortable at rest but develops stridor on running around. SpO2: 94%. What is your management?

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app.bitemedicine.com Monitor Only commence anti-epileptics if the seizure is > 5mins. Before this time, it may self-terminate Insert an oropharyngeal airway The airway is patent. Oropharyngeal airway should be avoided whilst the patient is seizing Buccal midazolam This can be given if the seizure lasts > 5 mins. Typically used pre-hospital IV lorazepam This can be given if the seizure lasts > 5 mins. Used if there is IV access PR diazepam This can be given if the seizure lasts > 5 mins. Typically used pre-hospital A 20-year-old is having a tonic-clonic seizure on the ward. It has been 3 minutes 15

• seconds. His airway is patent. What is your next step?

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app.bitemedicine.com Visuospatial neglect This is more likely if the non-dominant hemisphere was affected i.e. a R MCA infarct Broca's aphasia The patient has had a L MCA infarct (arm weakness > leg). In a right-handed individual, the Broca’s area is found in the dominant (left) hemisphere Ipsilateral homonymous hemianopia Contralateral homonymous hemianopia would be expected Contralateral hemianopia with macular sparing This is found in a PCA infarct as the occipital pole which is responsible for macular vision has a dual blood supply (MCA and PCA) Intention tremor This is a cerebellar symptom A right-handed 60-year old presents with right sided weakness. The right arm is weaker than the right leg. What else may you expect?

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app.bitemedicine.com IgA nephropathy Nephritic syndrome occurring a few days post mucosal infection e.g. URTI Rapidly progressive glomerulonephritis Nephritic syndrome with rapid decline in renal function. Can be caused by PSGN Buerger's disease Vasculitis seen in smokers. Not a cause of nephritis syndrome Focal segmental glomerulosclerosis A cause of nephrotic syndrome (proteinuria > haematuria) Post-streptococcal glomerulonephritis Nephritic syndrome occurring 1-2 weeks after streptococcal infection A 20-year-old presents with frank haematuria. He had tonsillitis 2 weeks ago which

• resolved. Urine dip: blood ++++; protein +. What is the diagnosis?

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References

1. CardioNetworks: Drj / CC BY-SA (https://creativecommons.org/licenses/by-sa/3.0) 2. Mikael Häggström / Public domain 3. Glenlarson [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0/)] All other images were made by BiteMedicine and not suitable for redistribution.

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