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What is a Permanent vegetative state?
PVS is 'wakefulness without awareness:
- Breathe spontaneously
- Move limbs and laugh spontaneously
- Open and close eyes in time with day and night
- Haemodynamically stable
- Respond to pain stimuli
Represents irreversible damage to cerebral hemispheres whilst leaving the stem intact.
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What is a Akinetic mutism?
- 'The promise of speech'
- They look like they are about to speak
- They track you round the room and are aware of you.
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What is Locked-in syndrome?
Complete awareness but inability to respond (almost)
- Caused by a lesion of the descending corticospinal tract in the pons below the level of the occulomotor nerve nucleus.
- Or it can be caused by widespread LMN loss (e.g. severe GBS)
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Cavernous sinus thrombosis?
- Unilateral Chemosis, proptosis and opthalmoplegia.
- Also presents with blindness, unilateral facial/head pain.
- Usually caused by an infection spreading from the face, sinuses or orbits.
- Untreated it can cause subdural empyemas and blindness
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Chronic paroxysmal hemicrania?
- Severe unilateral temporal pain lasting 2-45 mins.
- Occur 4-5 times a day.
- happen to mainly women in their 20s
- Very responisive to indomethacin.
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Neurological side effects of opioid toxicity?
- Myoclonus
- Hallucinations
- Delerium
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Describe the lesions of discoid lupus.
- Scaly, hyperpigmented erythematous plaques the heal with scarring.
- Occur in sun-exposed areas.
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Treatments for discoid lupus?
- Topical or intralesional potent steorids
- Topical Calcineurin inhibitors
- Anti-malarials
- Oral steroids
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When do you stop all meds in Alzheimers?
MMSE<10
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When would you consider AcHE inhibitors in Alzheimer's? Hoe do you monitor?
- Mild or moderate alzheimers.
- Assess every 6 months to monitor response. If not responding, Stop them
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When do you consider memantine in AD?
- Moderate AD with C/I to ACHe inhibs
- Severe AD.
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milky/fatty looking serum sample?
Lipoprotein lipase deficiency
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What is your study of choice to find ectopic gastric mucosa, such as a Meckel's diverticulum?
Technitium-99M pertechnetate scintigraphy
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If a patient is Antiendomysial negative, why does this not rule out coeliacs?
- Because coeliacs patients are IgA deficient.
- Anti-endomysial antibodies are IgA.
- You need to check their Immunoglob levels first
- and THEN do a TTG cus thats IgG
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A patient with behcet's comes in with a DVT...what do you do?
DO NOT ANTICOAG them.
Their clots dont embolise. and putting them on anticoag could pop an underlying pulmonary arterial aneurysm.
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How do you treat isolated hypercalciuria thats causing recurrent renal stones?
- Increase the amount they pee out with diuretics.
- Thiazides do this, whilst also reducing urinary calcium excretion.
- Loops increase urinary calcium excretion
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If you have carcinomatous meningitis, which primaries should you be looking for?
- breast
- lung cancer,
- melanoma,
- lymphomas and leukaemia
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What nerve's run in the jugular foramen and are therefore damaged when an otitis externa starts chewing through the skull base?
- 9, 10, 11, 12
- Its also called villaret's syndrome
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If a patient with CKD on dialysis is not responding to EPO and IV iron what could be the underlying cause?
Severe hyperparathyroidism causing marrow fibrosis.
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What would you give an asthmatic who came in with a narrow complex VT?
Verapamil
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What therapies are available for hepatorenal syndrome?
Terlipressin - causes spalnchnic vasoconstriction.
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If gout has needle shaped crystals that are strongly negatively birefringent, what do other crystals look like?
- Calcium pyrophosphate - Rhomboid, weakly positive
- Calcium oxalate - Bipyramidal, strongly positive
- Calcium hydroxyapatite - Small, non-birefringent - only visible under electron microscopy
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what is the only agent that shows any benefit if used in patients with impaired glucose tolerance?
Acarbose - improved cardiovasc morality and decreases time to insulin dependence
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What is neuralgic amyotrophy?
- Its usually proceeded by an upper respiratory tract infection.
- Pain around the shoulder is the presenting symptom that is usually very severe.
- As the pain starts resolving, weakness begins and usually affects the muscles innervated by the upper brachial plexus (C5-6).
- Treatment is conservative. It is usually a self-limiting condition (improvement over weeks to months).
- CSF protein can be elevated, dont let this put you off the diagnosis
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If youve got low vit D and phosphate but your PTH is high...what does it suggest?
- PTH insensitivity - pseudohypoparathyroidism
- Short, stock, slipped fem heads, bracky metacarpals and tarsals.
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Which malignancies is dermatomyositis assoc with?
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What drugs can you use in a patient who is dig toxic and having broad complex arrythmias?
Electric, amiodarone and quinidine will all make things a lot worse
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Treatment for schistosomaiasis?
Praziquanil + steroids if its gone neuro
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If you have an obese diabetic with hypertension and a creatinine of 150, whats the best thing you can do to help them with their cardiovascular risk?
- Attack the hypertension first - Ramipril.
- You tolerate a 30% deterioratuon of renal function.
Weight loss and tight glycaemic control are just not as good according to UKPDS and HOPE.
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Herald patch followed by multiple erythematous plaques on the trunk parallel to rib lines?
Pityriasis rosea
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What is HSP?
- An IgA mediated vasculitis.
- Presents 1-3 days following the infection of an IgA secreting mucous membrane. (usually pharynigitis)
- Vasculitis occurs in the kidneys, skin, joints and gut.
- Results in abdo pain, joint pain, renal dysfunc and classic rash
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Management of HSP?
- If proteinuria and HTN - ACEi
- If worsening - renal biopsy to look for crescentic Glomerulonephritis and consideration of immunosuppresion
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Grossly elevated calcium and PTH?
- Most probably parathyroid carcinoma.
- It wont be a PTHrp cancer because the related peptide does not cross react with the PTH assay.
- Parathyroid adenomas tend to have lower values of PTH
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What is Jaccoud's arthropaythy?
What are the 4 main causes?
Joint subluxations and swan neck deformities, caused by recurrent episodes of synovitis that damage tendon sheath.
- SLE
- Rheumatic fever
- Hypocomplementaric urticarial vasculitis
- Parkinsons
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Isoniazid overdose?
Intractable seizures with metabolic acidosis and large anion gap
- Vit B6 - pyridoxine IV is the Rx of choice
- Use bicard for the acidosis
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Which organism has a predilection for A diabetic with ascending cellulitis tracking along venous path?
Group B Strep
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Can you DC cardiovert a patient with a pacemaker?
- Yes. Just check it afterwards.
- Also consider the patient for an antiarrythmic as theyve probably got tachy brady syndrome if they have a pacemaker and now have AF
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Differential for autonomic neuropathy?
- Diabetes
- Chronic renal failure
- Porphyria
- Amyloidosis
- Aids
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If a patients thyroid FNA shows Medullary thyroid cancer whats the next management step?
- Screen for RET oncogene
- They may well have MEN2A
- Also screen them for a phaeo and hyperparathyroid.
- If RET positive, need to scan the rest of the family.
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How long do you need to discontinue PPIs for before Urea breath testing?
14days
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You see a baby with charachteristic racoon eyes rash...whats the underlying disease and whats the most common long term complication?
Neonatal lupus - mum probably has Antiro/la antibodies but no overt lupus.
Complication = complete heart block.
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Whats the other term for hypophosphatemic vitamin-D resistant rickets?
X-linked dominant vitamin D resistant rickets.
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Causes of a metabolic Alkalosis?
- Vomiting
- Prolonged hypokalemia - body preferentially loses H+ to maintain K+
- Ingestion of base
- Burns
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What can you use if a patient in status epilepticus does not respond after 30mins of seizure activity?
- IV fosphenytoin
- Phenytoin prodrug
- Gets to therapeutic levels quicker,
- you can infuse it quicker
- Less incidence of adverse effects
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Contraidications to NIV?
- Haemodynamically unstable
- Vomiting
- Unable to protect airway
- Facial injuries/burns
- Undrained pneumothorax
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Which tests would you do if someone wanted to know their risk of developing T1DM?
- Loss of first phase insulin response - 100% of people with this develop diabetes within 5 years. Its a sign of impending Bcell destruction
- Loss of second phase insulin response- intermediate risk between antibody and loss of first phase
- Either Anti-IA2 or ZNT8 antibodies= 50% chance of developing diabetes in next 5 years
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What treatment is best in a patient complaining of bone pain with a raised ALP and normal calcium?
- Theyve got pagets
- Give them Bisphosphonates
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What mortality rates relate to CURB scores?
- Low severity: CURB-65 0-1, mortality <3%
- Moderate severity: CURB-65 2, mortality 9%
- High severity: CURB-65 3-5, mortality 15-40%
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Which patients should have VTE prophylaxis before travelling and what form should it take?
- Active cancer
- Recent surgery
- Previous unprovoked VTE
- More than 1 risk factor
Give them below knee stockings. NEVER give LMWH
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