RB 4th set Flashcards

Question

Systolic murmur causes

Answer 1

Pansystolic - MR, TR, VSD Ejection systolic - AS, PS, HCM, ASD Late systolic - MVP

Answer 2

Takotsubo CM Vasospasm Myocarditis/pericarditis LV aneurysm LVH/cardiomyopathy BBB Paced rhyhtm BER Brugada Hyperkalaemia ICH

Answer 3

Admit under cardiology with monitored bed

Answer 4

Pansystolic + Left 5th ICS + radiates to axilla

Answer 5

ACUTE AV block Hypotension with IV administration QT prolongation but low risk TdP due to antiarrhythmic actions CHRONIC Pulmonary fibrosis LFT derangement Thyroid dysfunction Skin deposits

Answer 6

STE V1 (highly specific if concurrent STD in V2) Isoelectric ST segment V1 and marked ST depression V2 STE III > II Confirmed by STE In V3R-V6R

Answer 7

Onset while standing Prodrome of presyncopal symptoms Tonic mvmt only, < 30 seconds No tongue biting / incontinence Post-event confusion < 5mins Post event bradycardia

Answer 8

RV infarction Posterior infarction Bradyarrhythmias - 2nd / 3rd deg AV block

Answer 9

Lower dose venodilation - reduces preload Higher dose also arterial dilation - reduces afterload Also decreases myocardial O2 demand

Answer 10

Age < 40 Atypical Sx Symptom free No known IHD Normal troponin Normal ECG No further objective testing

Answer 11

* Rate/rhythm - maintain SR (cardiovert AF), aim rate 80-100 bpm * Preload/afterload - noradrenaline/vasopressing to maintain MAP > 65 for coronary and end organ perfusion * Contractility - dobutamine 2-20mcg/kg/min, or milrinone * NIV * IABP/VA-ECMO/LVAD

Answer 12

* Ongoing/recurrent chest pain * Elevated troponin * New ischaemic ECG changes - STD/STE/TWI, or Wellen's syndrome * Diaphoresis * SBP < 90 * Syncope * Known LVEF < 40% * Prior AMI/CABG = inpatient work up

Answer 13

Decreased partial pressure of oxygen Gas expansion -> barotrauma risk Hypothermia Noise/vibration/space

Answer 14

Isoprenaline aim HR > 100 OR Temporary transvenous pacing (recurrent pause dependent) OR Lignocaine 1-1.5mg/kg load then infusion 4mg/kg/hr if successful

Answer 15

**Arrhythmias** ACS Myocarditis Drug toxicity - CCB/BB, Na channel blockers causing VT Contusion Free wall / IVS / PM rupture Critical AS/MS Aortic dissection

Answer 16

CHESS CCF Haematocrit < 30% ECG abnormal (changed, or any non SR on ECG/monitoring) SOB Systolic < 90mmHg at triage Predicts 7 day risk of adverse outcomes in patients with syncope or near-syncope Low risk if nil criteria (< 1%)

Answer 17

White cantered retinal haemorrhages

Answer 18

U/A for infection + UEC (check renal function)

Answer 19

Constant abdominal pain worse on inflow - abrupt or gradual onset Cloudy dialysate Generalised peritonism (not focal) Inflamed Tenckhoff site Fever

Answer 20

Haemolysis in G6PD deficiency Serotonin syndrome if concurrent serotonergic drugs Paradoxical Methaemoglobinaemia in large doses > 7mg/kg Interferes with SpO2 readings -> SpO2 may worsen initially despite resolution of Meth-Hb Extravasation causes necrosis

Answer 21

Gentamicin 7mg/kg + flucloxacillin 2g q4h + vancomycin 30mg/kg +/- ceftriaxone 2g if Neisseria meningitis suspected Meropenem + vancomycin if risk multidrug-resistant GN

Answer 22

Conservative if grade 1-3 and stable Angio if pseudoaneurysm/AVF or blush Surgical if: - grade 5 - unstable - ongoing bleeding not controlled by embolisation - urinary extravasation (stenting/percutaneous drainage)

Answer 23

PRE-RENAL Hypoperfusion = Hypovolaemia, Cardiogenic shock, Hepatorenal syndrome Renovascular = Renal artery stenosis, Renal vein thrombosis, Malignant HTN INTRINSIC Ischaemic ATN = progression of pre-renal damage Nephrotoxic ATN = myoglobin, tumour lysis syndrome, meds (aminoglycosides, mannitol, cisplatin)), radiocontrast dye Acute GN = post-strep, Goodpasture's, HSP AIN = meds (beta lactams, NSAIDs), infection (PN/abscess) POSTRENAL = obstruction Instrinic = calculi, malignancy, posterior urethral valves, clot Extrinsic = malignancy, retroperitoneal fibrosis, BPH

Answer 24

Clinical features - GI upset, cloudy dialysate Biochem - WCC > 100/mm3, > 50% PMN Culture - positive (2 or more of above)

Answer 25

UTI Trauma Nephritic syndrome - Post strep GN, IgA nephropathy, HSP, HUS, Nephrotic syndrome - MCD, HSP Bleeding disorder = ITP, Haemophilia Structural = Wilm’s, PCKD

Answer 26

17-hydroxyprogesterone level - raised Cortisol level - low ACTH stimulation test Renin

Answer 27

- Atherosclerosis - HTN, DM - Glaucoma - Vasculitis - Hypercoagulable state - compression from thyroid / orbital tumours

Answer 28

Typically, elderly female in winter Environmental = hypothermia / cold exposure Meds = GA / Sedatives / Amiodarone Infection MI / CVA SIRS = surgery / trauma GIT bleed

Answer 29

* Seek and treat cause * Fluids/dextrose/correct electrolytes * DCCV for arrhythmias - likely drug resistant * Benzos/dexmedetomidine for agitation * Cooling * ICU

Answer 30

* Facial congestion/plethora * Neck vein distension * Resp distress Whilst holding arms elevated Causes: 1. Malignancy - lung Ca/lymphoma/mets 2. Thrombosis 3. Thyroid multinodular goitre 4. Thoracic aneurysm 5. TB 6. Irradiation

Answer 31

Dilutional due to raised osmolality

Answer 32

Inhibits thyroid synthesis Inhibits peripheral conversion of T4 to T3 Lugol -> blocks release of thyroid hormone

Answer 33

Unreasonable behaviour that creates a risk to health and safety Has to be repeated over time or occurs as part of a pattern of behaviour DIRECT BULLYING = direct behaviour to belittle or demean person Aggressive/intimidating behaviour Humiliating comments Spreading misinformation or malicious rumours INDIRECT BULLYING = excludes/removes benefits from person Assigning meaningless tasks unrelated to job Setting unreasonable tasks beyond/below skill level Deliberating changing work rosters to inconvenience employee

Answer 34

As effective as IV in moderate dehydration Reduced LOS Fewer adverse events

Answer 35

Allergy Delayed presentation > 3hrs Current DVT / PE

Answer 36

GCS 7-12 - WFNS IV GCS 3-6 - WFNS V Stupor, moderate-severe hemiparesis - Hunt and Hess 4 Deep coma, decerebrate posturing - Hunt and Hess 5 Cushing's response - bradycardia/HTN

Answer 37

Hypotension - fluids +/- noradrenaline Seizures - benzos +/- phenobarbitone SVT - adenosine, esmolol infusion Ventricular arrhythmias - often treatment resistance; lignocaine, beta blockers, amiodarone HypoK/Mg - replace

Answer 38

EBV / CMV SLE Hodgkin’s lymphoma Haemolytic anaemia - Hereditary spherocytosis, Thalassaemia, Sickle cell disease

Answer 39

White cottage cheese PV discharge Itch / pain, superficial dyspareunia White adherent plaques on exam Clotrimazole 500ng intravaginal pessary, once at bedtime

Answer 40

1. Supine, rolled towel under shoulder to retract shoulder 2. Place middle finger in sternal notch = aiming point 3. Place thumb in deltopectoral groove = entry point - insertion point 1.5cm (thumb width) from clavicle 4. Keep needle horizontal at all times 5. Insert to touch clavicle 6. Then depress under clavicle and advance fowards towards sternal notch 7. Dilate etc.

Answer 41

Air enema reduction Laparotomy for manual reduction

Answer 42

1. Head/neck position 2. External laryngeal manipulation 3. Adjuncts 4. Size/type of device - laryngoscope and ETT 5. Suction 6. Adequate sedation/paralysis

Answer 43

Irreversible = Phenelzine/tranylcypromine > 2mg/kg causes severe serotonin/sympathomimetic toxicity May be delayed onset Reversible = Moclobemide Mild serotonin syndrome in isolation, > 3g causes QT prolongation but TdP is rare Severe serotonin syndrome if on other serotonergic agents MANAGEMENT As per serotonin syndrome AC if intubated and irreversible Labetalol or vasodilator infusion for refractory HTN Phentolamine IV 1-5mg for irreversible MAOI No beta blockers - cause unopposed alpha stimulation

Answer 44

CT PROS 95% sensitivity/specificity Reduces negative laparotomy rate to < 10% Alternative diagnosis e.g. colitis, Crohn’s, renal calculus Surgical planning CT CONS Radiation Delay to surgical management Specialist interpretation Prolongs ED LOS

Answer 45

Onset of regular contractions until full cervical dilatation (10cm) Latent 0-4cm Active 4-10cm Stage 2: Full dilatation of cervix to delivery of baby Stage 3: Birth until placenta delivery

Answer 46

MDAC IHD if: - serum level > 100mg/L - MDAC ineffective / not feasible due to ileus

Answer 47

Treat cause - stop nephrotoxic/myotoxic meds, fasciotomy for compartment syndrome Correct life threats - shock, hyperkalaemia Aim UO 3-4ml/kg/hr with 4ml/kg/hr IVF +/- mannitol Urinary alkalinisation with isotonic bicarb (1L D5W with 150mmol NaHCO3) RRT if resistant AEIOU

Answer 48

EARLY Unexplained ETCO2 rise Tachycardia/arrhythmias + tachypnoea + hypoxia Generalised rigidity + jaw rigidity persisting after sux has worn off Diaphoresis Hyperthermia = body temp rises 1 degree every 10 mins post induction Hyperkalaemia LATE/WITH PROGRESSION DIC Rhabdomyolysis Hypotension Lactic/respiratory acidosis

Answer 49

* Aortic regurgitation * Aortic rupture * Tamponade * MI * Branch vessel dissection -> pseudohypotension (dissection flap has cut off limb perfusion) * Iatrogenic from treatment

Answer 50

Critical - VTE is a major cause for M&M

Answer 51

1. Stop trigger e.g. volatiles 2. 100% FiO2 + hyperventilate 3. Deep sedation + paralyse with rocuronium 4. Active cooling 5. Dantrolene 2.5mg/kg q10min to max 10mg/kg 6. Treat Cx - hyperkalaemia, arrhythmias, myoglobinuria (alkaline diuresis), DIC (FFP/cryo/platelets), monitor for compartment syndrome 7. ICU

Answer 52

Demyelination e.g. tumefactive MS Radiation necrosis OR resolving haematoma Mets Abscess GBM Infarct (subacute) OR inflammatory (neurocysticercosis, tuberculoma) Contusion AIDS-related CNS disease = toxoplasmosis, cryptococcosis Lymphoma DR MAGICAL

Answer 53

CK > 15,000 Hyperkalaemia/HyperPO4 AKI AST rise DIC

Answer 54

4.5% reduction in 28 day mortality – supports CRASH-2 No difference at 6 months More survivors with poor neurological outcome in TXA group

Answer 55

= ROAST Rigidity Opisthotonos - dramatic severe backwards arching Autonomic dysfunction Spasms Trismus

Answer 56

1. Pericarditis / myocarditis 2. LV aneurysm 3. Takotsubo CM 4. Coronary Vasospasm 5. BBB / ventricular pacing 6. BER 7. Brugada 8. Hyperkalaemia 9. Raised ICP

Answer 57

Soft systolic murmur Wide + fixed split S2 (delayed emptying of RV)

Answer 58

Harsh pansystolic murmur -> at LSE

Answer 59

* Pulled elbow * Upper limb # * Septic arthritis - fever / hot swollen immobile joint * Leukaemia - a/w hepatosplenomegaly, bruising * NAI - mechanism not compatible with age

Answer 60

PAMI = Primary Angioplasty in MI, 1993 Primary PCI superior to fibrinolysis   death + re-infarction

Answer 61

Acute MR = MI with papillary muscle rupture, Infective Endocarditis Chronic MR = MVP, RHD, HCM

Answer 62

Acute AR = IE, aortic dissection, traumatic rupture Chronic AR = HTN, Bicuspid valve, RHD

Answer 63

>3 hrs / day >3 days / week For at least 3 weeks 20% infants < 3months

Answer 64

1. Giant bullous emphysema - will be clinically stable + interstitial vascular markings within bullae 2. Lung bullae 3. Normal structures can be FP - from medial border of scapula, overlapping breast margins 4. Artifacts - monitoring leads, skin folds

Answer 65

* Persistent fluid leak -> use Z-track technique (5%) * Bowel perforation * Local bleeding * Major bleeding * Infection = localised/peritonitis * Hypovolaemia/hyponatraemia/hepatorenal syndrome --> if > 5L removed give albumin 100ml 20% per 3L drained --> cease drainage when less than 100ml/h for two hours (max 6 hours)

Answer 66

Evidence of tension: - incise sternal notch - insert finger into pretracheal space to decompress

Answer 67

Chromic gut 4-0 - for slower absorption, lasts 2 weeks - good for highly mobile + moist + vascular environment of tongue + less tissue reaction

Answer 68

* Low tension: 6-0 Ethilon * High tension: 5-0 Ethilon, or try to reduce tension with deep suture layers and use 6-0 on skin = better cosmetic outcome * Eyebrow/beard = Prolene 6-0/5-0 (blue) * Avoid need for removal = fast absorbing plain gut 6-0/5-0 -> absorbs over 7 days instead of ~10 days for Vicryl rapide * Deep layer repair or Intraoral mucosa = Vicryl or Monocryl 5-0 (Ethilon = nylon, Vicryl/monocryl = absorbable) Intraoral mucosa suture type -> Vicryl 5-0 (absorbable) Nail bed -> use chromic gut 6-0

Answer 69

Binds to plasminogen  inhibits fibrinolysis

Answer 70

PBI Atropine for respiratory secretions Antivenom - 4 ampoules for severe

Answer 71

1. Deterioration of clinical status 2. Unclear Dx 3. Concern for complications

Answer 72

- young children  Rifampicin 10mg/kg (600mg) PO BD for 2 days - adults / on OCP  Ciprofloxacin 500mg PO single dose - pregnant - IM Ceftriaxone 250mg single dose + vaccine for household contacts

Answer 73

Consider not right IJ due to subcut emphysema

Answer 74

Fill ETT cuff with saline

Answer 75

Airway injury / aspiration: * Stridor/dysphonia/throat pain/SOB = airway threatening GI injury * Vomiting, dysphagia, drooling, abdominal pain, oropharyngeal lesions * Oesophageal perforation -> mediastinitis with chest pain/fever/subcut emphysema * Gastric/intestinal perforation -> peritonitis * Risk of strictures at 6-12 weeks and oesophageal carcinoma decades later Shock * Due to mediastinitis/peritonitis +/- metabolic acidosis

Answer 76

- Resp depression - Loss of airway reflexes - Hypotension - Paradoxical agitation

Answer 77

EARLY * GI upset * Tachycardia/HTN * Bronchoconstriction * Agitation, twitching * Seizures LATE (1-4 hours) *** Bradycardia * Hypotension** * Arrhythmias * Lethargy/paralysis -> coma * Apnoea

Answer 78

Appears well Reluctant to divulge in non-private area Knowledge of agent out of scope of triage RN

Answer 79

1. Serum level > 80 mg/L 2. Prolonged coma / serum level > 40 mg/L after 48 hrs 3. Predicted long coma based on ingestion dose

Answer 80

- Na channel blockade - Anticholinergic effects

Answer 81

1. Mask size/seal 2. FiO2 based on hypoxia 3. EPAP based on FiO2 4. IPAP / pressure support based on WOB/Vt/CO2 clearance 5. Trigger flow rate to achieve synchrony 6. May start with lower settings for tolerance

Answer 82

1. Adrenaline infusion 2. HIET 3. IV Fluid resus 4. Intubation once stabilised + Art line + IJ CVC - leave femoral for ECMO - give AC < 4h 5. NaHCO3 for ventricular arrhythmias 6. ICU - consider ECMO if refractory shock

Answer 83

1. JIA 2. Acute rheumatic fever 3. Reactive arthritis 4. Viral arthritis - Parvovirus B19 etc. 5. HSP 6. Polyarticular septic arthritis (disseminated gonococcal, immunocompromised) 7. Leukaemia

Answer 84

Infectious period = 48 hrs before rash onset until all crusted Incubation period = 10-21 days

Answer 85

1. S3 gallop 2. Displaced apex beat 3. Raised JVP / creps / hepatosplenomegaly **4. Narrow pulse pressure 5. Cold peripheries**

Answer 86

MI/IHD with scarring Cardiomyopathy - DCM, HCM, ARVD Channelopathy - long QT, Brugada Electrolytes - HypoK/Mg/Ca Drug-induced - TCA etc. Hypothermia Electrical injury

Answer 87

Bowel perforation Local infection Transient microscopic haematuria (common) Bladder haemorrhage

Answer 88

Unresponsive coma Absence of brain stem reflexes Apnoea No reversible causes identified (i.e., not sedated / paralysed)

Answer 89

- sedatives (barbiturates, baclofen) - hypothermia - locked in syndrome - GBS

Answer 90

NON-CONTRAST CT = ideally interpreted by neuroradiologist PROS Sensitivity > 99% within 6 hours - haematocrit > 30% + isolated thunderclap + no seizure/LOC/neck pain + neuroradiologist report Identify alternate causes of headache CONS Reduced sensitivity: delayed scanning, small volume bleeds, haematocrit < 30%, motion artefact, Hb < 100 CT ANGIOGRAM = 95% sensitive/specific for aneurysm detection PROS With SAH: detect aneurysm, AVM No SAH: detect RCVS (reversible cerebral vasoconstriction syndrome), cervical artery dissection CONS FP: incidental finding -> 2% have asymptomatic unruptured aneurysms. May result in unnecessary interventions FN: Does not detect perimesencephalic; may miss small aneurysms Specialist interpretation, radiation/contrast

Answer 91

PROS Gold standard for aneurysm detection Coiling Treat vasospasm -> local vasodilators CONS Poor availability + complications

Answer 92

Unstable (= laparotomy) / Salpingotomy preferred if possible * Intraperitoneal bleeding/FF * FHR activity * Adnexal mass > 3.5cm or BHCG > 3500 * Severe pain * Contraindication to medical Mx

Answer 93

EXPECTANT = q48h B-HCG Compliant with follow up and red flags to attend ED No pain/tenderness Low/falling BHCG < 1000 IU/L Inconclusive US i.e. location of pregnancy uncertain

Answer 94

Compliant with follow up and red flags to return to ED * Stable * No FF/blood * No FHR activity * Adnexal mass < 3.5cm and BHCG < 3500 * No pain/tenderness * Normal FBE/UEC/LFT (no bone marrow/renal/liver impairment) * Not breastfeeding * Will use contraceptive for 3 months from last methotrexate dose

Answer 95

1. Irregular intervals, don't escalate 2. Variable length, don't progressively lengthen 3. Central abdomen or groin 4. May stop/slow with change of position 5. No cervical dilatation

Answer 96

Baclofen 25mg TDS Diazepam PRN aiming gentle sedation Barbiturate if refractory to above = oral phenobarbitone 30mg hourly aiming gentle sedation

Answer 97

Short time intervals between dosing < 4 hours Waking up during the night to dose High daily doses > 15ml

Answer 98

Determines risk of in hospital mortality from upper GI bleeding * Albumin < 30 * INR > 1.5 * Mental status altered * SBP < 90 * Age > 65

Answer 99

Sluggish pupils

Answer 100

Constipation

Answer 101

Ruptured membranes > 18 hrs before delivery Increases risk of maternal / neonatal infection

Answer 102

1. Previous baby with GBS sepsis 2. GBS bacteriuria during pregnancy 3. < 37/40 GA 4. Prolonged ROM > 18 hrs 5. Maternal fever > 38C 6. PV discharge

Answer 103

Salbutamol 6-12 puffs + ipratropium 4-8 puffs burst q20min for 1 hour Review 20 min post 3rd dose to decide timing of next dose Oral prednisolone 1mg/kg or dexamethasone 0.3mg/kg if > 6 years

Answer 104

Give one dose salbutamol via MDI/spacer, or Symbicort if > 12 and already using Symbicort Reassess after 20 mins: - if good response, no further salbutamol and reassess at 1 and 2 hours - discharge at 2 hours if well / no IWOB - otherwise treat as moderate

Answer 105

1. Skin - pyoderma gangrenosum 2. MSK - arthritis 3. Eyes - uveitis 4. Hepatobiliary - primary sclerosing cholangitis 5. Urinary - renal calculi 6. Haem - anaemia of chronic disease 7. Pulmonary - ILD

Answer 106

Percutaneous US-guided aspiration Breast surgeon for I&D if recurrent Otherwise, same as mastitis – continue breastfeeding

Answer 107

1. Maintain effective breastfeeding 2. Refer to lactational consultant 3. Check positioning/attachment 4. Gentle breast compression + warmth whilst feeding, cool packs after feeds 5. Avoid restrictive clothing/bra 6. Hydration 7. Monitor need for supplemental infant feeds

Answer 108

* Signs of PLF * CN7 palsy * Large/posterior perforation * Severe hearing loss * Not healing

Answer 109

Immunocompromised Pregnant < 6 months and mother non-immune Non-immune > 6 months and day 3-6 post exposure

Answer 110

100% FiO2 via NRB for 6 hours and until asymptomatic Cardiac monitoring

Answer 111

1. Honeycomb appearance in mid-forearm btw FDS and FDP, approx. mid-line of forearm 2. Radial artery lies lateral in this fascial plane 3. “Stay away” injection -> target fascial plane adjacent to nerve itself 4. 5ml into fascial sheath

Answer 112

Awake fibreoptic in OT with ENT back up for surgical airway RSI with surgical back up Surgical airway

Answer 113

1. Mid-forearm, linear probe in trans 2. Identify ulnar artery -> ulnar nerve runs closely at wrist and separates in mid-forearm 3. In plane approach 4. “Stay away” injection -> target fascial plane adjacent to nerve itself 5. 5ml into fascial sheath

Answer 114

1. Arm on lap 2. Probe 3cm above elbow crease 3. Identify nerve close to humerus in fascial plane btw brachialis & brachioradialis muscles 4. 5ml into fascial sheath

Answer 115

IV Midazolam 0.1 mg/kg

Answer 116

ADVERSE EFFECTS = serum level > 2 Hypotension Bradycardia Hyporeflexia Muscle weakness Confusion AV block + respiratory depression > 5 Evidence: Single dose reduces admission and improves lung function in severe asthma

Answer 117

Amethocaine 4% (ester) Not for < 1 month More rapid onset Longer duration action 6 hours v 4 hours No risk of Methaemoglobinaemia

Answer 118

Reason for intubation resolved A - airway grade 1-2, strong cough B - PaO2 > 60 mmHg on FiO2 <0.4, PEEP/PS < 5, spontaneous respiration with TV > 6ml/kg, RR < 30, minimal secretions C - stable haemodynamics (in ED, should not be on vasopressors) D - sedation / paralysis worn off, obeys commands, can life arms in air 15s, lift head off pillow E - department okay, approp time of day

Answer 119

* Time of day * Nursing staff = experienced staff available to nurse 1:1 * Medical staff = appropriately trained to re-intubate * Equipment available for reintubation/NIV * No other suitable disposition (ICU bed availability) * Departmental status – acuity of other patients, staffing

Answer 120

1. Call for help = ENT/anaesthetics + difficult airway kit + fibreoptic scope 2. 100% FiO2 to face and trache 3. Detach any external device and remove inner cannula 4. Attempt to pass suction catheter -> if passes = patent airway 5. If doesn’t pass, tube is displaced or obstructed. Deflate cuff and remove tube 6. If upper airway patent, attempt to ventilate using standard upper airway techniques - BVM + adjuncts, LMA or intubation - Will have to occlude stoma with gentle hand pressure 7. If unsuccessful: - Ventilate stoma using paediatric facemask or size 2 LMA OR - Replace tracheostomy tube OR - Intubate the stoma via a bougie and 6.0 ETT

Answer 121

Tetanus Ig 250 IU Cipro 500mg PO BD + Fluclox

Answer 122

PPV - reduces sensitivity + reverses dynamics Right heart failure / valvular disease Anatomical variability Patient supine No clear consensus on where to measure

Answer 123

Short acting - allows ongoing neurological assessment Can be given IM Rapid onset e.g. hypoxic patient

Answer 124

- High fever with relative bradycardia - Rose spots = 2-4 mm faint blanching maculopapular spots on anterior chest wall / abdo -> arises in cluster of ~10 - Splenomegaly - Altered mental state

Answer 125

1. History - ICH/CNS neoplasm 2. Exam - SBP > 185/110 despite antihypertensive therapy 3. Labs - INR > 1.7 4. Imaging - Extensive hypodensity on CT consistent with irreversible injury

Answer 126

PROS Gold standard for aneurysm detection Coiling Treat vasospasm -> local vasodilators CONS Poor availability + complication

Answer 127

Heparin / clexane + protamine Insulin Neuromuscular blockers

Answer 128

- Absent pulse - HR < 60 despite 30s of PPV

Answer 129

1. Auscultate 2. Feel for pulsations at base of umbilical cord 3. Pulse oximetry 4. ECG monitoring

Answer 130

1. Tone 2. Breathing 3. HR

Answer 131

1. Hypothermia 2. Pregnancy 3. PE - thrombolysis and prolonged CPR 4. Trauma - thoracotomy etc. 5. Witnessed pVT/VF - 3 stacked shocks 6. Post major cardiac surgery - re-sternotomy within 5 mins

Answer 132

PPV provided via T-piece at: * PEEP 5-8 * PIP 30 * Pressure release 50 * Rate 40-60 * Room air initially then titrate to SpO2

Answer 133

1. Reversible acute disease process + oxygenation index > 0.4 and ventilation index > 40 for 4 hours 2. Failure to respond to maximum inotropic Rx 3. Cardiac arrest 4. Cardiogenic shock 5. Sepsis

Answer 134

Measure O2 Sats of Hb by comparing visible red light + infrared light Measurement 50 times/second of pulsatile signal

Answer 135

* Non-arterial pulsation -> TR or high airway pressures can cause venous pulsations * Reduced plethysmographic volume = poor perfusion / peripheral vasoconstriction (shock/hypothermia) -> use ear/forehead probe * Abnormal Hb: - COHb causes overestimation (not distinguished from O2) - MethHb > 10% causes oximeter to read sats 85%, regardless of true sats - Profound anaemia -> insufficient Hb for accurate signal * Reduced light transmission = nail polish, pigmented skin (overestimates in black people) * Signal interference = high intensity external light, shivering

Answer 136

Breath delivery = volume v pressure Breath type = controlled, assisted, supported BREATH DELIVERY Volume: Preset Vt. Need to observe plateau pressure Pressure: Preset pressure. Observe Vt More physiological + comfortable BREATH TYPE Controlled = patient does no work, ventilator does not allow spontaneous breaths. Think paralysed patients Assisted = patient triggers ventilator (sucking on ETT and generating pressure/flow change), ventilator completely takes over and delivers full breath Supported (spontaneous) = patient triggers, ventilator supports

Answer 137

BSL, Handheld iStat, Blood cultures

Answer 138

Proximal ipsilateral fracture Ipsilateral vascular injury Bone pathology (osteoporosis/genesis imperfecta) Skin pathology (cellulitis or burn) Previous IO insertion at same site

Answer 139

Well placed IVC (if US at least >10mm in vessel -> use ultralong) Large superficial veins Regular assessment: observation protocol Q15 checks Dilute concentrations: 6mg in 1L

Answer 140

BSL, Hb Urea / Creatinine

Answer 141

Phentolamine 5mg in 10ml normal saline 5 small aliquots across injury site = alpha antagonist, counteracts vasoconstriction/ischaemia effects of vasopressor extravasation

Answer 142

1. Benefits of PS = maintain respiratory work effort, comfort, assess for extubation 2. But still maintain minimum number of mandatory breaths 3. Diaphragmatic training -> patient can breathe spontaneously between mandatory breaths

Answer 143

* SGLT-2 inhibitors = empagliflozin * Starvation / prolonged nausea/vomiting * ETOH intoxication * Sepsis * GI pathology - pancreatitis, gastroenteritis * Ketogenic diet

Answer 144

IV dextrose immediately 5% dextrose 250ml/h if hypovolaemic, 10% dextrose 125ml/h if euvolemic Withhold SGLT-2 inhibitors

Answer 145

Age > 12 Unilateral periorbital, severe Acute recurrent Restlessness/agitation -> pacing around department Autonomic features: ipsilateral conjunctival injection, lacrimation, rhinorrhoea, miosos/ptosis, facial flushing/sweating, fullness of ear Resolves within hours MANAGEMENT 100% FiO2 15L via NRB for 15 mins Rizatriptan 10mg PO or sumatriptan 6mg SC Low threshold for imaging

Answer 146

1% if no risk factors = population risk 10% if risk factors - FHx epilepsy - neurodevelopmental disorder - complex febrile seizure

Answer 147

All ages Bilateral, non-pulsatile, mild-moderate Chronic non-progressive Not exacerbated by activity No associated symptoms MANAGEMENT Simple analgesia Avoid triggers

Answer 148

* Balanced 1:1:1 transfusion * TXA * Calcium * Avoid hypothermia * Avoid acidosis * ROTEM/TEG guided replacement

Answer 149

UO ≥ 2 ml/kg/hr

Answer 150

IBD Haemorrhoids Meckel's diverticulum Anal fissure Infectious colitis

Answer 151

1. Notify blood blank - collect fresh group and hold / FBE and send back blood products 2. Open disclosure to patient/family 3. Document + Complete incident report form for quality review

Answer 152

Diverticular disease Angiodysplasia Ischaemic/infectious colitis Colorectal carcinoma Aortoenteric fistula Haemorrhoids

Answer 153

1. Intubate + ventilate right lung 2. Extend thoracostomy to midline and posteriorly towards bed -> 20cm incision in 5th ICS following superior contour of 6th rib 3. Incise/blunt dissect intercostal muscles 4. Breach parietal pleura using finger -> Mayo scissors into pleural space and swept along top of 6th rib medially and laterally 5. Insert and open Fincochietto retractor (rib spreaders) - handle towards axilla

Answer 154

1. SIADH 2. Cushing syndrome 3. Carcinoid -> flushing and diarrhoea 4. Lambert-Eaton syndrome 5. SVC syndrome

Answer 155

Normal vascular tissue within anal canal Disease occurs if bleeding, prolapse, pain, discharge, pruritic

Answer 156

1. HyperPTH -> hypercalcaemia 2. Horner's syndrome 3. Pancoast tumour -> ulnar neuropathic pain

Answer 157

Pulmonary Osteoarthropathy

Answer 158

Paraneoplastic -> Gynaecomastia

Answer 159

All GN coccobacilli H. influenzae Klebsiella Pseudomonas

Answer 160

1. Stop ventilation 2. Thoracostomy on each side -> divide intercostal muscles and parietal pleura 3. W shaped incision following 5th ICS 4. Cut through sternum with trauma shears or Gigli saw

Answer 161

* Mycoplasma pneumoniae * Moraxella catarrhalis - COPD * Legionella pneumophila * Chlamydia pneumoniae/psittaci * Coxiella burnetti

Answer 162

1. Pericarditis 2. SJS 3. AIHA 4. Hepatitis

Answer 163

Vancomycin 125 mg PO / NG q6h Metronidazole IV 500mg TDS or intracolonic

Answer 164

TRAP Tremor = resting and decreases with movement Rigidity (cogwheel or lead pipe) Akinesia/bradykinesia -> shuffling gait Postural instability

Answer 165

Initial bolus 500-1000ml to restore circulating volume * Calculate TBW deficit = 0.6 x pre-morbid weight x [(Na-140)/140] or assume 12-15% fluid deficit * Correct deficit + maintenance fluids over 48 hours * 0.45% normal saline for first 24 hours if corrected Na > 150, otherwise 0.9% saline if Na < 150 * Na should not be lowered more than 10mmol in 24 hour period

Answer 166

UA: - Leucocytes = sensitive - Nitrites = specific, not sensitive - Leucocytes + nitrites = almost 100% specific, 30% sensitive Note moderate pyuria present in half of infants with fever who do not have urinary sepsis – related to leucocyte excretion Urine MCS = E. coli, Enterococcus faecalis, Staph saprophyticus, proteus, klebsiella, pseudomonas Imaging if concern for obstruction, failure to respond to Rx, DM, shock

Answer 167

Urethritis = purulent discharge Cystitis = fever + suprapubic tenderness Prostatitis = tender enlarged prostate Epididymoorchitis = scrotal swelling/erythema Urolithiasis especially VUJ Appendicitis = tender RLQ

Answer 168

Distribution Crohn's = transmural, entire GIT, skip lesions UC = mucosal, continuous from rectum Symptoms Crohn's = RLQ pain, weight loss; extra-intestinal Cx more common UC = LLQ pain, blood/mucous diarrhoea, tenesmus Radiology Crohn's = string sign UC = lead pipe colon with loss of haustral markings Treatment Steroids for flare of both Proctocolectomy can be curative for UC

Answer 169

1. Clarify what can be used - some accept PCC and cryo 2. Minimise blood loss - bloods in paediatric tubes, only necessary tests; stress ulcer prophylaxis 3. Avoid coagulopathy - avoid aspirin/NSAIDs; use reversible agent if anticoagulation required 4. Promote blood synthesis - EPO, B12, folate, IV iron 5. Aggressive treatment of bleeding - early procedural control; TXA, DDAVP

Answer 170

Visual loss = methylprednisolone 1g IV daily for 3 days then oral pred as below No visual loss = prednisolone 60mg daily for minimum 4 weeks

Answer 171

Giant Cell Arteritis - Vasculitis of medium-large arteries, most commonly temporal artery Female smokers aged > 50 50% have PMR

Answer 172

Soft food bolus Normal lateral neck XR Protective airway reflexes No signs of esophageal perforation

Answer 173

* pH < 7.1 / Bicarb < 5 * Ketones > 6 * GCS < 12 * SBP < 90 * K < 3.5 on admission

Answer 174

1. Treat if CK > 5000 or McMahon score > 6 = risk AKI/dialysis 2. IVF 4ml/kg/hr aiming UO 3-4ml/kg/hr +/- mannitol to maintain 3. Isotonic bicarb - Urinary alkalinisation aiming urine pH > 7 4. Correct electrolytes + hyperkalaemia 5. Stop nephrotoxins 6. Fasciotomy if compartment syndrome 7. RRT if refractory to above

Answer 175

CSF - similar to viral meningitis - positive viral PCR EEG = periodic, asymmetric sharp waves seen in acute febrile setting of HSV Imaging to exclude SOL/abscess -> MRI is better as can show features suggestive of encephalitis e.g. temporal lobe abnormalities in HSV Wound swab PCR of any vesicular lesions EMPIRICAL MANAGEMENT Acyclovir 10mg/kg q8h / 500mg/m2 if < 12 years, 20mg/kg < 3 months Add benzylpenicillin 2.4g q4h if at risk group for Listeria

Answer 176

CK (> 15,000 is severe) Isolated AST rise Hyperkalaemia -> arrhythmias HyperPO4/Mg Hypocalcaemia early -> hypercalcaemia late DIC Renal failure due to myoglobin nephrotoxicity, hypoperfusion from hypovolaemia, precipitation of uric acid and phosphate crystals in tubules, low urine pH and renal vasoconstriction

Answer 177

Patients assessed in ED requiring admission Delayed from leaving ED > 8 hours due to Lack of inpatient bed capacity

Answer 178

PROS Occlusive microbial barrier Rapid + comfort CONS Low tensile strength (less than 5-0) - not effective for deep/irregular/increased wound tension Can't soak Not effective if hair

Answer 179

1. Facilitate hospital discharges - early morning consultant WR, MDT discharge planning, discharge lounge 2. Reduce inpatient demand - delay elective surgery, HITH, outpatient mental health/ETOH and drug services 3. Streamline flow - direct pull/admission to ward, early referrals 4. Streamline care - front loaded care - nurse initiated XR/bloods, rapid assessment at triage 5. Streamline disposition - early ED senior review / decision making

Answer 180

PROS Meticulous approximation Greatest tensile strength -> lowest dehiscence rate CONS Requires removal if non-absorbable LA Time consuming Greatest tissue reactivity Needlestick risk

Answer 181

Maternal... PHx/FHx pre-eclampsia Obesity HTN Renal disease DM Autoimmune disease Pregnancy... Multiple pregnancy New partner or > 10 years since last pregnancy with same partner Primigravida

Answer 182

1. Safe period of observation with no bleeding 2. General advice - no valsalva/straining, nose picking/blowing for one week; avoid aspirin/NSAIDs 3. Education RE: simple first aid for minor recurrent bleeding 4. Follow up arranged 5. Appropriate social circumstances 6. Return precautions a. recurrent bleed not responding to simple measures b. pack in situ that needs removal

Answer 183

1. AVN of lunate - Kienbock disease 2. Carpal instability 3. Osteoarthritis 4. Complex regional pain syndrome

Answer 184

Weakness of Thumb opposition / ABduction / Flexion

Answer 185

(Food protein-induced allergic proctocolitis) < 6 months Blood/mucous in stool Infant well and thriving Management Cow milk elimination (maternal if breast fed) - wait 2 weeks to see improvement or extensively hydrolysed formula

Answer 186

Dry mouth Blurred vision Urinary retention AACG

Answer 187

1. Infective enterocolitis esp bacterial 2. Meckel's diverticulum 3. Intussusception causing infarction/obstruction 4. Food protein-induced allergic proctocolitis (FPIAP) - from CMPI 5. Constipation with anal fissure 6. Swallowed blood from nipples 7. Hirschprung's enterocolitis IBD Food protein-induced enterocolitis syndrome (FPIES)

Answer 188

* Euvolaemic hypotonic hyponatraemia - Absence of hypotension/hypovolaemia/edema * Serum osmolality < 275 mmol/kg * Urine osmolality > 100 mmol/kg (inappropriately concentrated) - Urine osmolality often > plasma osmolality * Urine Na > 20mmol/L with normal dietary salt/water intake * Normal cardiac/liver/renal/thyroid/adrenal function * No diuretics Correctable with water restriction

Answer 189

Malignancy - small cell lung cancer CNS - stroke/TBI/infection/tumour Pulmonary - pneumonia Endocrine - hypothyroidism, adrenal insufficiency Major surgery Medications

Answer 190

APO Mx - 6 steps 1. Position upright 2. NIV 3. GTN 4. Furosemide 5. Seek and treat cause 6. HDU

Answer 191

RSI with video laryngoscopy

Answer 192

Obscured airway due to vomitus

Answer 193

1. Large bore IV access 2. MTP - 1:1:1 and seek/treat coagulopathy with ROTEM/TEG guided transfusion 3. Arterial line + permissive hypotension 4. IV fentanyl 5. Urgent vascular referral - CT v direct to OT

Answer 194

Pyogenic cerebral abscess Tuberculoma Toxoplasmosis Cryptococcosis Syphilis Neurocysticercosis

Answer 195

Acute disease process - severity, reversibility, predicted course Life-limiting comorbdities Functional status Quality of life Patient wishes / advanced health care directive

Answer 196

Improper randomisation/allocation concealment -> types of case/controls not representative of population

Answer 197

Outcomes measured differently between study groups, leading to error in observed effect

Answer 198

1. ARDS a. Pulmonary: viral pneumonitis/pneumonia, inhalational injury, pulmonary contusion b. Systemic: SIRS (pancreatitis, trauma, burns), TRALI 2. Neurogenic 3. Re-expansion 4. Negative pressure 5. HAPE

Answer 199

1. ACS/ischaemia 2. Arrhythmia 3. Cardiomyopathy/LV failure 4. PMR 5. Acute valvular dysfuncton - MR/AS 6. High output states - anaemia / thyrotoxicosis

Answer 200

Rx option -> Exchange transfusion, HBOT

Answer 201

1. Dental problems 2. GI - constipation, GORD, food allergy/intolerance, appendicitis 3. Infection - UTI, sore throat, otitis media 4. Medication side effects 5. Any other cause of pain including fractures

Answer 202

Alteplase 10mg bolus then 90mg infusion over 2hrs  then Heparin 18 IU/kg/hr

Answer 203

1. Ovarian torsion 2. Dehydration + electrolyte disturbance + AKI 3. Ascites/pleural/pericardial effusion 4. VTE 5. Sepsis

Answer 204

* Dependent on carer / limited mobility * Higher BMR * Higher BSA:body mass ratio * Smaller absolute blood volume -> more rapid dehydration * Begin sweating at higher temperatures

Answer 205

* Prevertebral edema/haematoma causing airway obstruction * Respiratory failure * Neurogenic shock * Cord injury - immobilisation, urgent decompression * Aspiration risk due to gastroparesis * Urinary retention

Answer 206

Ciprofloxacin 10mg/kg (400mg) BD + Vancomycin if penicillin anaphylaxis

Answer 207

1. MILD - tremor, hyperreflexia, ataxia, agitation 2. MODERATE - rigidity, hypertonia 3. SEVERE - myoclonus, seizures, coma

Answer 208

- Pushed into traffic - Hit by bus / large truck - Rollover - Hit by High Speed Vehicle

Answer 209

1. Placebo control - sham intervention with no therapeutic action 2. Active control - receive current standard of care or established effective Rx 3. Historical control - comparison with group who received care previously 4. No treatment control - receive no specific intervention 5. Dose comparison - same Rx but at different dose

Answer 210

Pros Study rare conditions (large sample size) Useful to generate decision rules for more rigorous testing by prospective trials Useful for generating hypotheses Cheaper Limitations Difficult to establish cause and effect relationship Missing data common Selection bias - only patients found to have index condition included

Answer 211

Poor hygiene Poorly kept clothing Poor dentition Low body weight Severe nappy rash

Answer 212

Extra-articular with volar angulation Above elbow POP in wrist extension + supination

Answer 213

1. Maintain aortic diastolic BP (afterload) to ensure adequate coronary perfusion pressure - noradrenaline 2. Maintain preload - euvolaemia, low dose sedative 3. Avoid tachycardia - avoid pain 4. Maintain SR 5. Consider awake intubation

Answer 214

1. Fewer ambulances available -> delayed pre-hospital/community care 2. Delayed definitive / ED care 3. Financial for ambulance and hospital 4. Adverse publicity -> negative public perceptions of ED/healthcare system 5. Staff stress/morale and interpersonal conflicts 6. Diversion: a. prolonged ED assessment due to data sharing requirements b. repatriation costs

Answer 215

1. NBM 2. NGT if significant vomiting despite stopping feeds 3. Correct dehydration + hypochloraemic hypokalaemia metabolic alkalosis before surgery a. fluid bolus if shocked b. replace deficit + maintenance with 5/0.9 +/- KCl 4. Correct hypoglycaemia/hypokalaemia 5. OT delayed until above corrected - Ramstedt pyloromyotomy

Answer 216

1. Barotrauma - middle ear, sinus, dental, pulmonary 2. Oxygen toxicity - CNS (seizures) or pulmonary (ARDS type features) 3. Hypoglycaemia in DM 4. Claustrophobia

Answer 217

* C5 = elbow flexion * C6 = wrist extension * C7 = elbow extension * C8 = finger flexion (distal phalanx middle finger) * T1 = finger abduction (little finger)

Answer 218

4 units FFP “Connective tissue make you Flexible / floppy”

Answer 219

1. Age ≥ 40 2. Neck pain/stiffness 3. LOC 4. Thunderclap 5. Nuchal rigidity 6. Exertional

Answer 220

* Acute onset * Fluctuating course * Attention deficit - difficult sustaining focus / following conversation * Cognitive deficit - disorientation, visual hallucinations * Evidence of medical cause * +/- disturbance in sleep wake cycle (not core criteria but very common)

Answer 221

1. Shock due to vomiting/3rd spacing 2. Electrolyte imbalance 3. Bowel perforation -> peritonitis and sepsis 4. Bowel obstruction 5. Bowel ischaemia

Answer 222

1. Prolonged mechanical ventilation > 1 week - facilitates weaning, reduces complications of prolonged ETT 2. Upper airway obstruction - tumour, infection 3. Inability to protect airway - neurological/neuromuscular conditions i.e. bulbar palsy 4. Pulmonary toilet - if poor cough, copious secretions. Prevents mucous plugging 5. Facial/upper airway trauma 6. Complex head/neck surgery - elective

Answer 223

Inflate up to 50mls or until bleeding is controlled

Answer 224

= GAS Phenoxymethylpenicillin 500mg QID 5 days IV benpen 1.2g QID if systemically unwell Penicillin anaphylaxis Clindamycin 450mg TDS 5 days OR 600mg IV TDS

Answer 225

S. aureus Flucloxacillin 500mg QID 5 days or IV 2g QID Penicillin anaphylaxis Clindamycin 450mg TDS 5 days OR 600mg IV TDS

Answer 226

RISK FACTORS Marfan’s causing ligamentous laxity Previous dislocation Anatomic mismatch between fossa and articular eminence MECHANISM Extreme mouth opening = yawning, eating Trauma Iatrogenic = dental, laryngoscopy Dystonic reaction Seizure Tetanus

Answer 227

Cone snail Puffer fish ingestion

Answer 228

Immediate severe disabling pain + hyperesthesia

Answer 229

* Diazepam * Lorazepam- preferred in severe liver disease, shorter half life minimises risk of hepatic encephalopathy * Phenobarbitone, propofol if refractory * (standard antiepileptics don't help)

Answer 230

Sharp pleuritic pain  worse when lying flat + relieved sitting forwards

Answer 231

Tibialis anterior = weakness in dorsiflexion foot -> foot drop Deep peroneal nerve = 1st web space Anterior tibial artery

Answer 232

RECOMMENDED * Severe/complicated pneumonia = severe resp distress, marked tachycardia, altered mental state, SpO2 < 80 or requiring HFNP/CPAP, complications e.g. parapneumonic effusion * Deterioration * Failure to improve after 48 hours antibiotic Rx NOT RECOMMENDED * Mild disease * Managed as OP

Answer 233

> 1000 mL or failure to respond to 1st line Tx

Answer 234

Superior TMJ dislocation = intracranial displacement + middle cranial fossa fracture i.e. BOS # Posterior TMJ dislocation = external auditory canal injury

Answer 235

1. Age > 40 2. Smoking 3. Aromatic amines = paints / dyes / plastics 4. Excess analgesia use 5. Chronic cystitis 6. Pelvic radiation

Answer 236

1. Bladder scan 2. 22 Fr 3 way foley, irrigation with manual washout 3. Treat immediately reversible causes - infection, coagulopathy etc. 4. Admit 5. Referral for cystoscopy

Answer 237

* Thoracic outlet syndrome secondary to cervical rib * Pancoast tumour * Cervical stenosis causing radiculopathy * Spinal cord tumour - syringomyelia * Peripheral neuropathy - DM/ETOH/ESRF etc. * Brachial plexus compression - Saturday night palsy * VZV - shingles * Subclavian steal syndrome

Answer 238

INR ≥ 1.5 (synthetic dysfunction Encephalopathy + Sudden onset / disease course < 26 weeks with no underlying cirrhosis

Answer 239

MANAGEMENT Droplet precautions Notifiable disease Most cases self-limiting Tecovirimat if high risk Post-exposure vaccination available for high risk COMPLICATIONS Secondary bacterial infection Others are in immunocompromised: - pneumonia - encephalitis - extensive skin lesions impairing vision etc.

Answer 240

Promotes ionisation of acidic drugs and prevents reabsorption across renal tubular epithelium

Answer 241

Diffusion of low molecular weight, low Vd, low protein bound toxin, across semipermeable membrane into dialysate

Answer 242

Form of systematic review that uses statistical methods to combine results from multiple studies to derive a pooled (overall) estimate of effect PROS Improved statistical power Larger combined sample sizes = more accurate effect estimtaes Increases external validity Helps detect publication bias Reduces false negatives

Answer 243

PHARM Analgesia Deep sedation + paralysis MAP > 80 Keppra 20mg/kg Normal glucose / Na Reverse coagulopathy NON-PHARM Head up 30 degrees, loosen neck ties, head in midline PaCO2 35-40, SpO2 94-98 Normothermia

Answer 244

1. Fever 2. Torticollis 3. Can't fully look up = Bolte's sign 4. Trismus 5. Stridor 6. Retropharyngeal bulge

Answer 245

* Thiamine - Wernicke's * Benzos - enhance GABA inhibitory effects * Disulfiram - inhibits aldehyde dehydrogenase, causing flushing/vomiting with alcohol use * Naltrexone - mu-opioid receptor antagonist, reduces rewarding effects of alcohol * Acamprosate - modulates glutamate transmission, stabilising hyperexcitable state during early abstinence

Answer 246

1. No signs of life in last 10 mins 2. Asystole on arrival + no tamponade 3. Unsurvivable coexistent injuries 4. Definitive surgical intervention not available 5. Poor expertise

Answer 247

* Reduced venous return and cardiac output * Reduce coronary perfusion pressure -> reduces chance of ROSC * Reduced cerebral perfusion due to hypocapnia * O2-Hb dissociation curve shift to left -> hinders release of O2 to tissues * Interference with CPR efficacy * Pulmonary barotrauma * Gastric insufflation and aspiration

Answer 248

Greatest good for greatest number Brief focused assessment Dynamic, repeated multiple times Sort into groups rather than ATS categories

Answer 249

* Immediate care needed * Critical injury, but good chance of survival with simple life saving measures * Not breathing but restored with airway manouvres/adjuncts * RR < 10 or > 20 * CRT > 2 or HR > 120

Answer 250

* Significant injury, not immediately life threatening * Likely to survive if simple care given within hours * Not mobile/walking * Breathing * RR 10-29 * HR < 120 or CRT < 2 seconds

Answer 251

Delayed, walking wounded = minor injuries requiring little care

Answer 252

Triage sieve - at hospital, filter out patients needing most urgent treatment, determine who should go to which treatment area in what order Triage sort - on scene, order of transportation from patient treatment post to hospital

Answer 253

Troponin ST elevation

Answer 254

1. Category 2. ID 3. Time and date of triage - to enable retriage 4. Vital signs 5. Suspected/confirmed injuries 6. Treatments given

Answer 255

ERCP Diagnostic and therapeutic - stone extraction, stent placement Biopsy lesions Cons - risk of pancreatitis, perforation causing sepsis, cholangitis MRCP Non-invasive Diagnose external compressive lesion Anatomical detail of biliary tree/pancreatic duct for operative planning Cons - purely diagnostic, claustrophobia, metal implants

Answer 256

Pros Other causes of chest pain No exercise required Cons No functional assessment GTN and beta blockers pre-procedure Need to be able to breath hold 15 seconds

Answer 257

Pros Detect valvular disease, LVH, EF Cons False negatives with single vessel disease Operator dependent

Answer 258

Pros Anatomical distribution of ischaemia Assess perfusion and contractility simultaneously EF estimate Cons Radioisotope False positives for ischaemia due to diaphragmatic and breast artefacts

Answer 259

1. Decreased BMR causing hypothermia - active rewarming 2. Hypoventilation and laryngeal edema - early intubation and ventilation 3. Reduced drug metabolism and clearance - cautious use of sedatives 4. Hypotension due to reduced contractility, concomitant adrenal insufficiency - stress dose steroids, thyroid hormone replacement 5. Raised ICP - due to combination of hypercapnia, hyponatraemia

Answer 260

Plasma leakage - haemoconcentration, effusions/ascites, shock Bleeding diathesis - epistaxis/purpura/petechiae/GI bleeding Severe organ involvement -> transaminitis > 1000, encephalopathy, myocarditis

Answer 261

* Salbutamol * Corticosteroids * Adrenaline - except in peri-arrest situation * Nebulised saline * Antibiotics

Answer 262

* Relief of aortocaval compression * Reduced maternal O2 demand * Improved FRC due to less diaphragm elevation * Improved chest compression efficacy due to less diaphragm elevation

Answer 263

Fungal peritonitis Exit site infection refractory to Abx Tx

Answer 264

1. Varied case mix including acutely unwell with life threatening illness 2. Undifferentiated patients 3. Stressed carers/relatives 4. High patient turnover 5. Psych/situational crisis patients 6. Front loading of patient care

Answer 265

* Poor project governance e.g. inconsistent project meeting attendance * Lack of mechanisms to engage staff with previous experience in ED design * Inadequate protected time for planning * Failure to discuss pros/cons of other recently constructed/redesigned EDs in Australia/overseas

Answer 266

Government Health planners Architects

Answer 267

1. PPE - universal precautions in well ventilated area 2. Decontamination - remove and bag clothing, wash skin 3. Benzos - for agitation/seizures 4. Atropine - 1.2mg IV (paeds 50mcg/kg), double dose q5min, end-points = drying of respiratory secretions / chest clear. Commence infusion at 10% of cumulative initial dose per hour 5. Pralidoxime - 2g IV in 100ml saline over 15 mins, then infusion 12g over 24 hours, aiming improvement in muscle strength 6. NGT - aspirate stomach contents, then administer AC

Answer 268

Within 72 hours of starting nutrition after prolonged fasting/nutritional deficiency Due to endogenous insulin surge Features are caused by deficiencies in phosphate, and thiamine/K/Mg Risk factors for refeeding: 1. Weight loss > 10% over past 3-6 months 2. BMI < 18.5 3. ETOH use disorder 4. Anorexia nervosa 5. Postoperative with inadequate caloric intake

Answer 269

Resp alkalosis + metabolic alkalosis + HAGMA

Answer 270

1. Optimise ventilation - avoid hypoxia/hypercarbia/acidosis - NIV for COPD/OHS, avoid intubation 2. Optimise preload - cautious diuresis if hypervolaemic (usually case), 250ml boluses if hypovolaemic 3. Maintain SR - cardioversion or digoxin for AF. Don't give beta blockers or CCB due to negative inotropy 4. MAP > 65 for RCA perfusion (decreases with RV pressure) - noradrenaline +/- vasopressin 5. Pulmonary vasodilators to decrease RV afterload - sildenafil, esoprostenol 6. RV inotropy - dobutamine start 2mcg/kg/min, milrinone 0.1-0.75mcg/kg/min

Answer 271

BSL 10-15 Commence 5% dextrose 125 ml/hr when BSL < 15

Answer 272

1. RSI with double set up for FONA 2. Fibreoptic. Cooperative patient requiressdifficult with bleeding 3. Transtracheal wound. Risk tracheal transection. Use ETT small enough to enter with ease 4. Cricothyroidotomy 5. Tracheostomy. Risk loss of haematoma tamponade with incision

Answer 273

CICO kit Connect O2 supply directly, and inflate for 4 seconds, watch for chest rise Then repeat in 1:4 ratio, or 1:8 with rate 6/min if partial or complete obstruction No CICO kit Remove plunger from 5ml syringe and place O2 tubing deeply into secured syringe Inflate for 4 seconds Then repeatedly for 2 second when sats fall 5% from maximum reached

Answer 274

* Fixed stroke volume * Rely on HR to maintain CO * Hypotension late sign

Answer 275

Not recommended Hypotension = late sign -> brink of CV collapse

Answer 276

* Delirium - usual things * Falls - non slip socks, visual cubicle, low bed height * Pressure sores - repositioning, mobilise * Nosocomial infection - mobilise * Medication errors - early reconciliation with pharmacist

Answer 277

Adjustable hinged tip - allows elevation of epiglottis to improve visualisation of VC Risk = trauma to epiglottis if gets caught in hinge

Answer 278

* Caucasian first born male * Postnatal macrolide antibiotic exposure * Family Hx * Formula fed

Answer 279

1. Malignancy - gastric adenoca, pancreatic head ca 2. PUD causing scarring / oedema 3. Pancreatic pseudocyst 4. Scarring from previous caustic ingestion

Answer 280

Requires Hep B infection IVDU Rare in Australia Accelerates Hep B chronic changes Anti-HDV IgM/IgG Delta Ag

Answer 281

Trisomy 21 Osteogenesis imperfecta JIA Marfan’s

Answer 282

* Thoracic elevation device in < 8 years to maintain neutral position - large occiput forces flexion * Parents at head of bed to stop child looking around * Appropriately sized collar * Remove spinal boards on arrival to ED * Analgesia

Answer 283

IV Benpen 50mg/kg

Answer 284

* Usually adds little to Dx in stable patient with PV bleeding if access to US * Most patients with pain/bleeding/adnexal mass do not have ectopic pregnancy * Speculum/bimanual is not routine - only if severe PV bleeding or hypotension -> removal of obstructing endocervical products, exclude vaginal care POSSIBLE EXAM FINDINGS * Shock – may have relative bradycardia * Adnexal tenderness/mass * Cervical excitation * Peritonism

Answer 285

1. Vinegar to sting sites to inactivate undischarged nematocytes 2. Remove adherent tentacles carefully 3. Wash sting sites with sea water 4. IV opioids 5. 1-3 ampoules antivenom in 100ml normal saline over 20 mins if cardiogenic shock / haemodynamic instability 6. 6 ampoules as rapid push in cardiac arrest + prolonged resuscitation

Answer 286

Dose to admit to ICU >0.5mg/kg

Answer 287

- T2DM - HTN - Dyslipidaemia - OSA - NAFLD

Answer 288

Roux-en-Y gastric bypass Sleeve gastrectomy Laparoscopic adjustable gastric band

Answer 289

Seizure - more than one, or prolonged Structural brain lesion Abnormal EEG Previous TBI Occupational concerns e.g. pilot, heavy machinery operator

Answer 290

Jitteriness Benign neonatal sleep myoclonus

Answer 291

Hypochloraemic hypokalaemic metabolic acidosis

Answer 292

* DTPa to all close contacts ASAP * Prophylactic antibiotic therapy if close contact with confirmed case in past 14 days AND: - age < 6 months - less than 3 doses pertussis vaccine - last month of pregnancy - regular contact with infants < 6 months = healthcare/childcare worker * Azithromycin 10mg/kg daily for 5 days (same as treatment)

Answer 293

* History of family violence * Substance misuse * Psych history * Excessive crying of child * Unwanted pregnancy * Neurodevelopmental disorder of childhood

Answer 294

Total cortisol < 150nmol/L strongly suggests ACTH/synacthen test - no cortisol rise If Dx unclear Rx with dexamethasone (won't interfere with cortisol measurement) or send cortisol before treatment

Answer 295

Lower pressure in lower limbs in CoA

Answer 296

Rifampicin -> hepatotoxicity + CYP induction Isoniazid -> peripheral neuropathy Pyrazinamide -> hepatotoxicity Ethambutol -> optic neuritis

Answer 297

Rheumatoid nodules - extensor surfaces - lungs/heart Pulmonary - ILD - pleural effusions Cardiac - pericarditis - accelerated atherosclerosis - conduction abnormalities due to rheumatoid nodules Atlantoaxial subluxation Sjogren’s = dry eyes + dry mouth Mononeuritis multiplex = small-medium vessel vasculitis affecting peripheral nerves Vascular - Raynaud’s/digital infarcts/chronic leg ulceration Eye - uveitis - episcleritis - Sjogren’s

Answer 298

At least one joint with definitive clinical synovitis + Multiple joints – often symmetrical, small joints + Positive RF/anti-CCP > 6 weeks Elevated CRP/ESR

Answer 299

First line is methotrexate + folic acid weekly Others = sulfasalazine, hydroxychloroquine NSAIDs for pain

Answer 300

PHYSIOLOGICAL JAUNDICE

Answer 301

Diagnostic - synovial fluid analysis - assess if laceration communicates with joint space Therapeutic - drain tense effusions / haemarthrosis - intraarticular steroid injection

Answer 302

Folinic acid 15mg PO/IV q6h for minimum 3d and until bone marrow recovery 1. Bone marrow suppression  pancytopenia 2. Megaloblastic anaemia 3. Pulmonary fibrosis 4. GI upset 5. Hepatotoxicity 6. Renal toxicity

Answer 303

1. Slight flexion, small towel roll under popliteal fossa 2. 25G needle with LA 3. Lateral or medial approach 4. 18G needle 1cm inferior to lateral patella edge 5. Direct posterior to patella 6. Milk suprapatellar pouch whilst aspirating

Answer 304

Botulism Diphtheria Measles Typhoid Rabies

Answer 305

Permethrin 5% topical from neck down – leave on minimum 8 hours OR Ivermectin 200mcg/kg with fatty food Repeat at 1 week – stay home from school until this time * Treat all household/close contacts at same time * Antihistamines/emollients/hydrocortisone for itch * Wash sheets/clothes in hot water and dry in sun

Answer 306

Splenic rupture Hepatitis Myocarditis Nonallergic morbilliform rash when Rx with penicillin

Answer 307

* Chronic ETOH * Malabsorption - IBD, pancreatitis * Diarrhoea/vomiting * Diuretics * Hypercalcaemia * Intracellular shift - insulin, beta2 agonists, hyperthyroidism

Answer 308

1. Artefactual - drip arm 2. Reduced intake - acute illness 3. Intracellular shift - metabolic alkalosis, insulin, beta agonists 4. GI losses 5. Renal losses a. with metabolic alkalosis: Cushing's, diuretics b. with metabolic acidosis: RTA

Answer 309

Calcium gluconate 0.5ml/kg Actrapid 0.1 IU/kg + dextrose 10% 5ml/kg NaHCO3 1mmol/kg Calcium resonium 1g/kg PR/PO

Answer 310

Elevated ACE level Hypercalcaemia CXR – bihilar lymphadenopathy LN biopsy – non-caseating granuloma Steroids is main Rx

Answer 311

Unexpected death < 1 year with no cause found on examination/autopsy/review of history RISK FACTORS Maternal - substance use, no antenatal care Infant - premature, URTI Environmental - prone/side/co-sleeping, tight blankets Family history

Answer 312

Head elevated for 20 mins post feeds Thickened feeds Assess feed volumes to identify overfeeding Consider smaller more frequent feeds Observe feeds with MCHN Usually resolves by 1 year

Answer 313

When GOR causes vomiting with complications - aspiration / - FTT / - chronic cough MANAGEMENT Supportive measures as for GOR Refer to paediatrician CMP exclusion diet 2 weeks 4-week trial omeprazole if still no improvement

Answer 314

BSL + ketones VBG/cap gas Urine ketones, amino acids, organic acids Ammonia = URGENT within 60 mins

Answer 315

1. STOP FEEDS 2. Correct shock 3. Then 10% dextrose + 0.9% NaCl to prevent catabolism 4. Pyridoxine for seizures 5. Correct hyperammonaemia - RRT is definitive, sodium benzoate is temporising 6. In discussion with metabolic team: a. IV carnitine 100mg/kg/day b. Hydroxocobalamin 1mg daily c. Biotin 10mg daily

Answer 316

Assoc. pneumothorax Unstable Moderate sized (> 400ml)

Answer 317

1-5 d prodrome of URTI Sx Followed by irregular pink maculopapular rash - starts on face -> spreads to trunk/arms in centrifugal distribution

Answer 318

Peak of crying - 2nd month Unexpected/unpredictable Resists soothing Pain like face Long lasting - up to 5 hours per day Evening - cry more in evening

Answer 319

B-HCG Hepatobiliary US Tox panel - APAP, ETOH, urine drug screen Viral panel - Hep A-E, CMV/EBV, HIV, HSV Autoimmune panel - ANA etc. Complications - ammonia, coags, BSL

Answer 320

Partial disruption Urethrogram: Extravasation Opacification of bladder Mx = Gentile IDC or SPC

Answer 321

Stretch injury Urethrogram: Elongation of urethra No extravasation Mx = Gentle IDC or SPC

Answer 322

Complete transection Urethrogram: Urethral separation > 2cm Extension into prostate/vagina Mx = SPC + urethroplasty

Answer 323

* Pregnancy/postpartum * Malignancy * OCP / Hormone replacement therapy * Surgery/trauma – especially orthopaedic * Chronic inflammatory conditions: RA, IBD Age Obesity Immobility

Answer 324

Unprovoked VTE in < 50 CVST FHx inherited thrombophilia Recurrent early miscarriages (3 or more) Arterial thrombosis in young patient

Answer 325

EARLY Phlegmasia cerulea dolens / alba dolens Stroke if PFO present Proximal extension of clot LATE Post-thrombotic syndrome Chronic venous insufficiency

Answer 326

* Ischaemic ATN = progression of pre-renal damage * Nephrotoxic ATN = myoglobin, tumour lysis syndrome, meds (aminoglycosides, mannitol, cisplatin)), radiocontrast dye * Acute GN = post-strep, Goodpasture's, HSP * AIN = meds (beta lactams, NSAIDs), infection (PN/abscess)

Answer 327

BOTH Perforation Sepsis/opportunistic infection due to immunosuppression Malignancy risk + extraintestinal = derm/joints/eye/hepatobiliary/renal/haem CROHN’S Strictures Fistula Abscess SBO UC Toxic megacolon Bleeding

Answer 328

* ECMO * Inhaled pulmonary vasodilators = Nitric oxide at 20 parts per million * Epoprostenol

Answer 329

1. Paraneoplastic syndrome 2. Bone mets 3. Multiple myeloma 4. Primary hyperparathyroidism = parathyroid adenoma/hyperplasia/Ca 5. Milk-Alkali syndrome 6. Vitamin D excess - lymphoma, sarcoidosis, ingestion

Answer 330

* Inflammatory response to bubbles causes microvascular leakage  intravascular depletion * Aids nitrogen elimination - better tissue perfusion allows it to be carried to lungs more efficiently for exhalation

Answer 331

* Instrumentation - recent IDC, cystoscopy, prostate biopsy * BPH leading to urinary retention * Neurogenic bladder * Immunocompromise * STI

Answer 332

Fevers Dysuria Urinary retention Lower back/perineal pain Tender, enlarged prostate on DRE

Answer 333

1. Unwitnessed 2. No bystander CPR 3. Non-shockable rhythm 4. No ROSC before ED arrival 5. No reversible cause

Answer 334

Agent Dose Intervals Duration e.g. 7 days

Answer 335

Held in FABER - flexion, abduction, external rotation Severe pain with passive motion Acute onset of pain Fever > 38.5 Localised swelling/tenderness/warmth

Answer 336

1. Slow onset 2. Recent significant life event 3. Not extremes of age 4. No cognitive deficit - fully orientated 5. Auditory hallucinations 6. Structured delusions

Answer 337

1. Delirium features - acute onset, fluctuating mental state, attention deficit, cognitive deficit 2. Visual hallucinations 3. Marked new personality changes 4. Lack of concern for nudity 5. Older age at first presentation 6. Abnormal vital signs 7. Neurological deficit - gait, dysarthria, ophthalmoplegia 8. Evidence of head trauma

Answer 338

GI upset Flu-like symptoms Autonomic hyperactivity – HTN/tachycardia if severe Anxiety/restlessness Peaks at 2 days, resolves within a week (delayed onset and duration for methadone)

Answer 339

OPIOID REPLACEMENT THERAPY Methadone 20-40mg/day then up titrate 5% each week OR Suboxone = buprenorphine 2-16mg/day coformulation with naloxone SUPPORTIVE Hyoscine 20mg PO q6h for GI upset Diazepam 10mg PO q6h for 3 days for anxiety/insomnia Clonidine 50mcg TDS and uptitrate (correct dehydration first) + fluids/electrolytes/antiemetics etc.

Answer 340

* Excessive production - exertional, sympathomimetics, thyrotoxicosis, NMS * Diminished heat dissipation - heat stroke, dehydration, anticholinergic toxicity * Hypothalamic dysfunction - CVA, CNS infection, head trauma

Answer 341

NATIVE High energy trauma Assoc. acetabular, femoral head fractures Risk of AVN -> urgent reduction within 6 hours PROSTHETIC Low energy mechanism e.g. twisting out of bed Look for periprosthetic fracture No risk of AVN

Answer 342

1. Uterine rupture 2. Placental abruption 3. Amniotic fluid embolism

Answer 343

MATERNAL Substance/opioid use HTN/eclampsia/DM No antenatal care FETAL Gestation < 35 or > 41 weeks Congenital anomalies IUGR INTRAPARTUM Fetal distress on CTG Prolonged rupture of membranes > 18 hours Precipitate or prolonger labour Meconium stained amniotic fluid

Answer 344

SDH ETOH withdrawal Wernicke's Sepsis/meningitis Hypoglycaemia

Answer 345

* ABO incompatibility screen = cross match + DAT * Haemolysis screen: * FBE/UEC/LFT/haptoglobin/LDH/coags * U/A * TRALI = send HLA + HNA antibodies * Allergic = haptoglobin + tryptase + IgA level * Sepsis / fever > 39 = culture patient and product

Answer 346

1. Consent + Confirm full bladder on US 2. Mark midline 2cm above pubic symphysis 3. LA - infiltrate until aspirate urine + Small incision 4. Insert bladder needle trocar at 30 degree caudal to skin, towards pelvis 5. When urine returns, feed SPC through trocar to full length, inflate balloon, remove trocar 6. Confirm position on US 7. Attach collection bag + sterile dressing to skin 8. Arrange follow up. Do not change for 4 weeks

Answer 347

Two hand compression Copious lubrication + Hold penis with gauze Thumbs push glans penis Fingers pull foreskin over glans Sustained traction for several minutes

Answer 348

* 1 inch compression bandage advanced proximally over edematous area starting at penile tip * Leave for 10 mins * Remove and attempt reduction * +/- repeat

Answer 349

1. Arrhythmias 2. Myocardial depression and hypotenson 3. Aspiration due to absent airway reflxes 4. Cold diuresis 5. Rhabdomyolysis - from shivering and direct colid injury -> AKI 6. DIC

Answer 350

XR chest + sternal views ECG US more sensitive than XR - also checks for effusion MANAGEMENT Discharge if pain controlled + normal vitals + normal ECG at 6 hrs Admit for CCM if IHD, elderly, unstable, on digoxin

Answer 351

Direct extension from pneumonia / oesophageal perforation Haematogenous spread in immunocompromised

Answer 352

CXR - indirect signs of mediastinal haematoma, similar to dissection findings CTA Intraluminal filling defect Mural haematoma Pseudoaneurysm Contrast extravasation Periaortic haematoma TOE can diagnose if intra-op or too unstable for CT MANAGEMENT = as for dissection Urgent surgical repair for grade 2 and above

Answer 353

GRADE I Contusion II Extraperitoneal lac <2cm III Extraperitoneal lac >2cm/Intraperitoneal <2cm IV Intraperitoneal >2cm V Bladder neck/Urethral orifice Extraperitoneal (pelvic fractures) = prolonged IDC Intraperitoneal (direct trauma to bladder dome) = surgical repair

Answer 354

OUTER EAR Wax Otitis externa Trauma MIDDLE EAR AOM with effusion TM perforation Cholesteatoma Petrous temporal bone fracture Otosclerosis

Answer 355

Tongue blade test = > 95% sensitivity Mental nerve function Dental exam Airway assessment - can cause obstruction from displacement of tongue MANAGEMENT Consider open as mucous membrane usually torn - ADT + antibiotics Barton bandage Most require ORIF

Answer 356

1. Leave any penetrating object in situ. Do not probe wound 2. Seal wound with vented occlusive dressing o if ineffective, roughly close the wound 3. Decompress chest through different site 4. PPV last resort if above fails

Answer 357

Spinous process Simple wedge compression < 25% loss of height Isolated avulsion without ligamentous injury TP fracture not involving facet joint

Answer 358

Blunt trauma = spleen Stabbing = liver GSW = bowel

Answer 359

Aberrant right subclavian artery - most common overall Double aortic arch - most common symptomatic Barium swallow + CT/MRI

Answer 360

All cause seizures + coma All get MDAC + IHD in severe toxicity Do a drug level in all to guide Rx PHENYTOIN 100mg/kg = lethal Zero order kinetics -> no driving/operating heavy machinery for 3 days Ataxia Hypernatraemia HD - refractory seizures CARBAMAZEPINE 50mg/kg = lethal Na channel blockade -> broad complex tachycardia Anticholinergic toxicity HD - serum level > 80mg/L VALPROATE 1g/kg = lethal Hepatotoxicity -> hypoglycaemia Hypernatraemia Hyperammonaemia -> cerebral edema Lactic acidosis HD - serum level > 1g/L or cerebral edema/lactic acidosis/unstable **Antidote = Carnitine 100mg/kg**

Answer 361

1. Mid-axial lines between flexor/extensor surfaces 2. Avoid ulnar + common peroneal + posterior tibial nerves 3. Start and finish 1cm into unburned healthy tissue - use LA at these points 4. Full thickness scalpel incision into subcut fat - unzippering of wound edges 5. Run finger along incision to detect residual restrictive areas 6. Dressing

Answer 362

1. Sedation/intubation + asepsis 2. Mark anterior axillary lines + across subcostal margin + across manubriosternal junction 3. Full thickness scalpel incision into subcut fat (but not muscle) - separation/unzippering of wound edges 4. Run finger along incision to detect residual restrictive areas 5. Reassess circulation/respiration post 6. Burns dressings

Answer 363

Haematopoietic stem cell transplant Solid organ transplant Transfusion-associated

Answer 364

Immunocompromised Pregnant Portal HTN Coagulopathy Symptoms > 48 hours

Answer 365

1. Left lateral decubitus position 2. 2% lignocaine with adrenaline 3. Asepsis/skin prep 4. Elliptical incision around the haemorrhoid with 15 blade scalpel to expose thrombosis 5. Remove clot with forceps, and small amount of overlying skin to prevent reaccumulation 6. Pressure dressing and follow up within 48 hours 7. Heal by secondary intention

Answer 366

Forest plot Horizontal axis = effect measure (OR or RR) Width of line = CI Rhomboid = pooled effect in this meta-analysis Vertical axis = line of no effect Biggest study = biggest box

Answer 367

Drug reaction with eosinophilia and systemic symptoms Widespread rash + high fever Hepatitis/deranged LFTs Eosinophilia (Nikolsky negative)

Answer 368

= TBW x (target Na - serum Na) = 30 x (115-105) = 300mmol 3% saline has 513mmol/L So roughly 600ml of 3% saline

Answer 369

1. Sepsis 2. Diabetic mother 3. Prematurity, IUGR 4. Respiratory distress / illness 5. Hypothermia 6. Perinatal asphyxia 7. CAH with adrenal crisis 8. Inborn errors of metabolism 9. GH deficiency 10. Beckwith-Wiedemann syndrome

Answer 370

o Elderly o Mental health o Substance use o Intellectual disability o Psychosocial - homeless, unemployed o Family violence

Answer 371

100ml 3% saline over 10 mins +/- repeat up to 300ml total End point = termination of seizure, Na rise 5, Na > 120

Answer 372

Herpetic whitlow - HSV 1/2 * Most self-resolve over 4 weeks * If severe pain/dehydration give antivirals - PO aciclovir 10mg/kg 5x daily or IV TDS * Dry dressing to prevent spread

Answer 373

1. Flaccid paralysis 2. Areflexia 3. Absent bulbocavernosus reflex 4. Sensory loss - spinothalamic and dorsal column 5. Urinary retention

Answer 374

* HyperK/PO4 - muscle cell lysis * Hypocalcaemia initially - excess phosphate binds circulating calcium; calcium deposits in damaged muscle tissue * Hypercalcaemia later - as damaged muscle heals, calcium released back into serum * AKI - myoglobin nephrotoxicity, hypoperfusion from hypovolaemia, precipitation of uric acid and phosphate crystals in tubules, low urine pH and renal vasoconstriction * Isolated AST rise * DIC

Answer 375

* High frequency linear * Small parts preset * Multiple focal zones within ROI * Turn off compound imaging * Stand-off pad or water bath or copious gel within probe cover

Answer 376

IV alteplase v placebo within 3 hours. Half treated within 90 mins Primary end point = 90 days. NNT 9 for favourable functional outcome. tPA 30% more likely to have minimal/no disability (mRS ≤ 1) Symptomatic ICH 6% v 0.6% No difference in overall mortality

Answer 377

Diffuse maculopapular torso  extremities “White islands in a sea of red” Day 3-4

Answer 378

Peak 2 days Lasts 1 week Prolonged in Methadone > 2 weeks

Answer 379

* 1st deg AV block * MR * Severe MS * Heart failure

Answer 380

Hypoglycaemia Afterdrop Vasodilation and hypotension Rhabdomyolysis  AKI from reperfusion injury

Answer 381

Polyp - intermenstrual bleeding Adenomyosis - painful heavy periods Leiomyoma - palpable on bimanual exam if large Malignancy and hyperplasia Coagulopathy - VWD Ovulatory dysfunction - PCOS, hypothyroidism Iatrogenic - IUD, retained tampon, hormone therapy Endometriosis Not otherwise classified - pregnancy, PID/endometritis, trauma from intercourse

Answer 382

1. Early CVC in massive OD 2. Correct hypoglycaemia with 50ml 50% dextrose 3. Commence infusion - 10% dextrose 100ml/h and titrate, q15min BSL until stable. Change to 50% if refractory 4. Hypokalaemia - maintain K in low-normal range to avoid rebound hypokalaemia 5. Feed complex carbs 6. Admit - hypoglycaemia often lasts > 2 days

Answer 383

Endoscopic detorsion if no ischaemia / perforation by rigid / flexi-sigmoidoscopy Colectomy if strangulation Sigmoid colopexy (surgical fixation if recurrent)

Answer 384

* Males 20-40 * IBD * DM * Carcinoma - esp if recurrent / chronic

Answer 385

Traction apophysitis of tibial tubercle - due to repetitive traction of patellar tendon insertion into tibial tuberosity Presents during growth spurt with anterior knee pain on standing or climbing/descending stairs Tenderness over tibial tuberosity / patellar tendon Conservative Mx with NSAIDs, physio

Answer 386

* Rotational deformity * Fracture of head or base * Angulation > 20 degrees in 5th, 15 degrees in 4th, 10 degrees in 2nd/3rd (some criteria accept twice this value)

Answer 387

* Pain out of proportion / neuropathic in nature in hands/feet distal to injury * Allodynia/hyperesthesia * Edema * Skin/hair changes * Labile autonomic phenomena = alternating hot florid phase with blue cold phase - normal response to injury includes vasoconstriction to prevent edema/blood loss - continues unabated causing ischaemia, proinflammatory mediators, more pain, sympathetic discharge

Answer 388

Fat pads Anterior humeral line - should pass through middle of capitellum Radiocapitellar line - radial head dislocation if displaced Ossification centres

Answer 389

Thiamine Pyridoxine 25mg TDS Doxylamine 25mg nocte 5% dextrose/0.9% saline

Answer 390

BSL/ketones +/- VBG Urine - for UTI/pyelonephritis Fetal US - confirm single IUP Abdominal US - appendicitis, cholelithiasis/cholecystitis TFTs - hyperthyroidism UEC - hypokalaemia

Answer 391

Last month of pregnancy until 5 months postpartum Absence of prior heart disease Absence of other identifiable causes LVEF < 45% or LV dilatation

Answer 392

* Ectopic pregnancy * GTD * UTI/pyelonephritis * Gastro * HyperT4 * Gestational DM -> DKA * Appendicitis * Cholelithiasis/cholecystitis

Answer 393

* > 2 weeks * Due to risk of triggereing crisis = Gentamicin, macrolides (azith/eryth), Doxycycline

Answer 394

1. Tension 2. Significant hypoxia 3. Bilateral 4. Underlying lung disease 5. >50 years with significant smoking history 6. Hemopneumothorax

Answer 395

E Coli = ETEC; EHEC (O157:H7) -> risk HUS Salmonella Shigella Campylobacter Entamoeba histolytica (risk liver abscess) C difficile

Answer 396

Hyperkalemia Risk of hyperK = 72hrs burns, major trauma, crush injury, neuromuscular disease Malignant hyperthermia

Answer 397

* Disruption of blood-ocular barrier * Autoimmune T-cell mediated reaction to ocular antigens * Potential vision loss in uninjured eye

Answer 398

* Direct = crust injury * Indirect o Axial load onto plantarflexed foot o Forced abduction / rotation - change of direction w/ foot planted firmly (horse-riding, motor bike)

Answer 399

Obesity Age > 35 Fibroids Grand multiparity Bleeding disorder Previous PPH

Answer 400

For each 10,000 CTB < 10 years old, 1 excess case of leukaemia + 1 excess case brain tumour Lifetime cancer risk from single head CT 1 in 1,000 in 1 year old 1 in 10,000 in 10 year old

Answer 401

Feed before scan Swaddle Parental presence Oral sucrose 2mls in 0.5mls aliquots

Answer 402

IgE mediated Antibody mediated type I HS reaction Foods, beta-lactams, insects Non-IgE mediated Direct mast cell and basophil activation Radiocontrast dye, morphine, temperature change

Answer 403

GCS < 14 Focal neurological deficit Signs of BOS# Palpable skull # Non frontal scalp haematoma

Answer 404

* Secondary bacterial infection * Severe scarring * Keratitis * Disseminated - Encephalitis, Pneumonia, Hepatitis

Answer 405

- unclear trigger - complex multiple allergic diseases - asthma / eczema - suspected IgE mediated allergy to food / drugs / insects

Answer 406

Ensure ETT appropriate position Sit to 30 degrees Optimise MV - ensure Vt 8ml/kg, increase RR Remove excess ventilator dead space (flex-tube/filters) Decompress stomach Prevent dyssynchrony -> sedation/paralysis

Answer 407

DDAVP 0.3mcg/kg IV TXA 1g Humate-P = plasma derived factor VIII + vWF

Answer 408

HISTORY Gradual onset deep boring painful red eye – worse at night Pain on eye movement Photophobia EXAM Decreased VA Globe tender to palpation through close eyelid Sclera thickened/discoloured/nodular Blue discolouration = pigmented choroid showing through thinned sclera (thinned from inflammation) Engorged vessels don’t blanch with topical phenylephrine, cannot be moved with cotton tipped applicator Autoimmune = RA/Wegener's/SLE

Answer 409

Bronchoscopy Subglottic tracheal narrowing + irregular tracheal margins

Answer 410

Inflammation of external auditory canal, usually diffuse AKA swimmers ear Bacterial = S. aureus, Pseudomonas, Klebsiella 10% fungal = Aspergillus RISK FACTORS Eczema/psoriasis = compromises skin barrier Swimming Local trauma = cotton buds Ear foreign body e.g. hearing aid DM Immunocompromised

Answer 411

CONDUCTIVE Outer ear: - wax - otitis externa - trauma Middle ear: - AOM with effusion - TM perforation – penetrating/blunt/barotrauma - otosclerosis - cholesteatoma - petrous temporal bone fracture SENSORINEURAL Idiopathic sudden SNHL (likely multifactorial of below) Medications: gentamicin, aspirin, furosemide, quinine Vascular: brainstem stroke, vasculitis, small vessel disease affecting CN8 Infection: meningitis/encephalitis, MMR, HSV/VZV, viral labyrinthitis Acoustic schwannoma Inflammatory: sarcoid Trauma: direct or BOS # Meniere’s disease

Answer 412

Aural toilet + remove debris Assess if TM intact Single dose dex if severe/significant canal edema Keep ear dry -> cotton wool ball with vaseline to EAC when showering TM intact Sofradex 3 drops TDS for 7 days GP follow up TM perforation Ciproxin 0.3% 3 drops BD for 7 days (contains steroid) ENT follow up Canal occluded due to edema Insert pope ear wick Saturate with 5 drops sofradex Continue 3 drops TDS for 7 days ENT follow up 48 hours to remove/change wick

Answer 413

VICC CV collapse  syncope / arrest Thrombotic microangiopathy Neurotoxicity - mild / rare

Answer 414

Inflammation of external auditory canal, usually diffuse AKA swimmers ear Bacterial = S. aureus, Pseudomonas, Klebsiella 10% fungal = Aspergillus RISK FACTORS Eczema/psoriasis = compromises skin barrier Swimming Local trauma = cotton buds Ear foreign body e.g. hearing aid DM Immunocompromised Clinical features: Otalgia + otorrhoea Conductive hearing loss Tragus/pinna ++ tender when moved Edematous/narrow ear canal Normal CN

Answer 415

External ear Otitis externa including malignant otitis externa Perichondritis Ramsay Hunt Syndrome Middle ear AOM with effusion Mastoiditis Cholesteatoma Referred Temporal arteritis Tonsillitis/Peritonsillar abscess Dental infection Normal exam + risk factors for malignancy (age > 50/smoker/alcoholism) = MRI + nasoendoscopy + ESR

Answer 416

0 = nil 1 (mild) = renal pelvis 2 (mild) = plus a few calyces 3 (moderate) = all calyceal dilatation, cauliflower appearance, cortical thickness preserved 4 (severe) = plus cortical thinning

Answer 417

- UTI - Trauma - Nephritic syndrome - post strep GN, IgA nephropathy, HSP, HUS - Nephrotic syndrome - MCD, HSP - Bleeding disorder - ITP, Haemophilia - Structural = Wilm’s tumour, PCKD Mumps Cx: Orchitis / Oophoritis Aseptic meningitis / encephalitis SNHL

Answer 418

Febrile + unwell + neck/throat swelling Tx = Tazocin + Metro Anticoag controversial - discuss with vascular Consider drainage Septic thrombophlebitis of IJV - fusobacterium necrophorum Spread from oropharyngeal infection Features of emboli = pulmonary, jaundice, arthralgia Bulbar palsy

Answer 419

* Refreezing after partial thaw i.e. intermittent warming * Mechanical trauma i.e. rubbing * Systemic hypothermia/shock -> worsens peripheral vasoconstriction

Answer 420

* Age < 40 * Atypical symptoms * Symptom free * No known IHD * Normal troponin * Normal ECG * (EF > 40%, Haemodynamically stable) * -> No further objective testing

Answer 421

1. PR prolongation 2. Increased P wave amplitude 3. Widespread STD and T wave flattening/inversion 4. Prominent U waves - best seen in V2-3 5. Apparent long QT due to fusion of T and U waves (= long QU interval) 6. With severe hypokalaemia - ectopics, SVT, VT/TdP/VF

Answer 422

* Systemic toxicity = septic shock, peritonitis * Severe/refractory pain * Failed oral therapy * Pregnancy * Prepubertal - consider sexual abuse * Compliance issues

Answer 423

Positive deflection at J point in precordial / true limb leads Hypothermia < 30C - most specific finding for hypothermia Hypercalcaemia

Answer 424

* Proptosis + dilated pupil + haemorrhagic chemosis * Periorbital swelling + haematoma --> Retrobulbar haemorrhage  risk of orbital compartment syndrome Mx: * Lateral canthotomy if optic neuropathy or IOP > 40 * Medical Tx: Head up 30deg + Acetazolamide 500mg IV/PO +/- mannitol * Q15 mins check IOP + RAPD

Answer 425

1. A = Laryngospasm 2. B = Negative pressure APO / ARDS / Aspiration pneumonitis 3. C = Arrhythmias 4. D = HIE  seizures / persistent coma 5. E = Hypothermia

Answer 426

Endoscopic retrograde cholangiopancreatography Risk of perforation  sepsis + pancreatitis + cholangitis Requires procedural sedation + specialist

Answer 427

* Palpable purpura / petechiae * Symmetrical * Gravity + pressure dependent areas * May spare flexural creases

Answer 428

Eye / skin / throat irritation Bronchospasm Chemical pneumonitis  APO Stridor in severe cases

Answer 429

ATSI have 10-year gap in life expectancy Higher rates of DM, CKD, chronic lung disease, infant mortality Aims to halve or close the gap on: Life expectancy Childhood mortality Reading and writing numeracy Year 12 completion Employment

Answer 430

3 level Collins method * Sum of distances between pleural surfaces at apex, middle, base of lung; divided by 3

Answer 431

Adrenaline Lignocaine Atropine 10x dose diluted in 10ml sterile water

Answer 432

1. Cancer - bronchogenic carcinoma 2. Autoimmune granuloma - Wegener's granulomatosis 3. Vascular - PE with infarction 4. Infection - lung abscess, TB 5. Trauma - pneumatocele

Answer 433

Superior sagittal sinus Transverse sinus (tends to be multiple)

Answer 434

LP = Contraindicated - risk of herniation Causes: 1. Base of skull fracture 2. NSx procedures e.g. VP shunt 3. Contiguous spread of Dental/middle ear/mastoid infection 4. Haematogenous - endocarditis 5. HIV - toxoplasmosis Mx: * Ceftriaxone 2g q12h + metronidazole 500mg q8h +/- vancomycin 30mg/kg load if concern for MRSA * Seizure prophylaxis * Steroids only if raised ICP * Neurosurgery referral - if abscess < 2.5cm + GCS > 12 with known aetiology may be treated with IVABx only

Answer 435

Non selective b-blocker a1 blocker -> vasodilation

Answer 436

Recent illness Meds = compliance / change in dose or type Sleep changes Substance use / withdrawal Physical / emotional stress - including exertion / traumatic injury

Answer 437

1. Contralateral hemisensory loss >>> hemiplegia 2. Thalamic pain syndrome = delayed onset burning pain on contralateral side 3. Eyes down and inwards (paralysis of upward gaze) 4. Aphasia

Answer 438

Postural hypotension  falls Aspiration pneumonia Constipation  sigmoid volvulus NMS

Answer 439

Traumatic ICH CNS - status/seizing Metabolic - hypercapnia, hypoglycaemia, uraemia, hypo/hyperNa Endocrine - myxedema coma, DKA/HHS -> cerebral edema Toxins - CNS depressants, CO/cyanide

Answer 440

PROS Sensitivity > 99% within 6 hours - haematocrit > 30% + isolated thunderclap + no seizure/LOC/neck pain + neuroradiologist report Identify alternate causes of headache CONS Reduced sensitivity: delayed scanning, small volume bleeds, haematocrit < 30%, motion artefact, Hb < 100, previous aneurysmal intervention

Answer 441

PROS With SAH: detect aneurysm, AVM No SAH: detect RCVS (reversible cerebral vasoconstriction syndrome), cervical artery dissection CONS FP: incidental finding -> 2% have asymptomatic unruptured aneurysms. May result in unnecessary interventions FN: Does not detect perimesencephalic; may miss small aneurysms Specialist interpretation, radiation/contrast

RB 4th set Flashcards

(632 cards)