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.
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.
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)
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
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.
Neurological side effects of opioid toxicity?
Describe the lesions of discoid lupus.
- Scaly, hyperpigmented erythematous plaques the heal with scarring.
- Occur in sun-exposed areas.
Treatments for discoid lupus?
- Topical or intralesional potent steorids
- Topical Calcineurin inhibitors
- Oral steroids
When do you stop all meds in Alzheimers?
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
When do you consider memantine in AD?
- Moderate AD with C/I to ACHe inhibs
- Severe AD.
milky/fatty looking serum sample?
Lipoprotein lipase deficiency
What is your study of choice to find ectopic gastric mucosa, such as a Meckel's diverticulum?
Technitium-99M pertechnetate scintigraphy
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
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.
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
If you have carcinomatous meningitis, which primaries should you be looking for?
- lung cancer,
- lymphomas and leukaemia
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
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.
What would you give an asthmatic who came in with a narrow complex VT?
What therapies are available for hepatorenal syndrome?
Terlipressin - causes spalnchnic vasoconstriction.
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
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
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
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.
Which malignancies is dermatomyositis assoc with?
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
Treatment for schistosomaiasis?
Praziquanil + steroids if its gone neuro
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.
Herald patch followed by multiple erythematous plaques on the trunk parallel to rib lines?
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
Management of HSP?
- If proteinuria and HTN - ACEi
- If worsening - renal biopsy to look for crescentic Glomerulonephritis and consideration of immunosuppresion
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
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.
- Rheumatic fever
- Hypocomplementaric urticarial vasculitis
Intractable seizures with metabolic acidosis and large anion gap
- Vit B6 - pyridoxine IV is the Rx of choice
- Use bicard for the acidosis
Which organism has a predilection for A diabetic with ascending cellulitis tracking along venous path?
Group B Strep
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
Differential for autonomic neuropathy?
- Chronic renal failure
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.
How long do you need to discontinue PPIs for before Urea breath testing?
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.
Whats the other term for hypophosphatemic vitamin-D resistant rickets?
X-linked dominant vitamin D resistant rickets.
Causes of a metabolic Alkalosis?
- Prolonged hypokalemia - body preferentially loses H+ to maintain K+
- Ingestion of base
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
Contraidications to NIV?
- Haemodynamically unstable
- Unable to protect airway
- Facial injuries/burns
- Undrained pneumothorax
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
What treatment is best in a patient complaining of bone pain with a raised ALP and normal calcium?
- Theyve got pagets
- Give them Bisphosphonates
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%
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