Sunday, March 31, 2019

Pulmonary Embolism Fast Facts: Wells Score Menmonic

Clots can form due to many reasons that we all are aware about. Let's do a quick review of certain facts for this deadly diagnosis.

  • Pulmonary Emboli arise from Proximal DVT (Above the Knee)
  • Distal DVTs in itself does not a risk for PE unless they migrate upwards.
  • Pregnancy PEs are from Pelvic Veins (Risks last upto 2 months post delivery)
  • PE = Alveolar Dead Space Ventilation
  • ~ 50% Lung involved will lead to Pulmonary HTN
  • Massive PE =  >70% Lung Involvement (10% will die in first 1 Hour)
  • Recent Surgery in last 4 weeks poses a risk (mostly it is Orthopedic Surgery: 70% Risks in Knee Surgery)
  • Unexplained DVT: 15 - 20 % of these will develop malignancy in next 2 years 

Monday, May 23, 2016

FRCEM Primary MCQs Part 1

1) 84 years old female is brought by ambulance with history of shortness of breath. On arrival, she is unable to talk in full sentences, but does complain of pain in the right chest. She is unable to take deep breaths while you ask her during auscultation. In her past medical history, she has HTN, DM, and multiple myeloma. Recently she was discharged after staying in the hospital for 7 days following a mechanical fall. She lives in a care home and rarely is seen out of her bed. She is on Flucloxacillin for her right leg cellulitis, apart from her routine medications. Her observations at triage are BP 100/80, Pulse 125/min, RR 19/min, Temperature 37.8 C, SpO2 on room air 82%. The diagnosis under consideration is an example of:

A. Infectious Origin
B. Ventilation Defect
C. Perfusion Defect
D. Diffusion Defect
E. Accidental Overdose of Drugs

2) 12 years old African child is brought to the emergency department with complains of pain in the right knee. He suffers from Type 1 DM and Sickle cell disease, and is on insulins, folic acid and hydroxyurea as prescribed by his physician. The observations noted were BP 120/80, Pulse 115/min, RR 22/min, Temperature 39.2 C, SpO2 on room air 96%. The knee appears swollen, erythematous and tender. A diagnosis of infective etiology was made and appropriate treatment was commenced. What is the pathophysiology behind the presentation?

A) Avascular Necrosis of Distal Femur
B) Opsonization defect due to lack of C3b and IgG
C) Splenic dysfunction
D) High Virulence of Capsulated Organisms such as Salmonella and Staph aureus
E) Depressed functioning of CD8 and Natural Killer Cells

3) 25 years old male came to the ED with dysuria and urethral discharge. He is sexually active with multiple female partners in the past. He is stable but febrile. A Urinalysis is essentially normal. He has had three episodes of urethritis in the last 2 years. The two organisms implicated in this pathology display following features:

a) Gram Negative Capsulated diplococci & gram positive non motile intracellular bacteria
b) Gram Negative Non-Capsulated diplococci & gram negative non motile intracellular bacteria
c) Gram Negative Capsulated diplococci & gram negative non motile intracellular bacteria
d) Gram Negative Non-Capsulated diplococci & gram positive non motile intracellular bacteria
e) Gram Negative Non-Capsulated diplococci & gram negative motile intracellular bacteria

4) 16 years old girl is brought to the emergency department by her colleague because of a 2-day history of fever and a 12-hour history of lethargy. Her colleague say that she has been sleeping most of the day and has been slow to react when awake. Her temperature is 39.2°C (102.6°F). Physical examination shows numerous petechial hemorrhages and neck rigidity. A lumbar puncture yields cloudy cerebrospinal fluid and the microscopic examination of the CSF shows numerous segmented neutrophils, and a Gram stain shows gram negative diplococci. Which of the following is the most likely causal organism?

a) Streptococcus pneumoniae
b) Listeria monocytogenes
c) E. Coli
d) Neisseria Meningitides
e) H. Influenza

5) 38 years old man who recently immigrated to the UK comes to the GP Services because of a 1-month history of cough and a 5 kg weight loss. Physical examination shows no abnormalities. A chest x-ray shows a right upper lobe infiltrate. One of three sputum samples is positive for acid-fast bacilli. Treatment with isoniazid, rifampin, ethambutol, and pyrazinamide is started. Which of the following should be added to the medication regimen to prevent neurologic toxicity in this patient? 

A) Folic acid 
B) Nicotinic acid
C) Vitamin B12 (cyanocobalamin) 
D) Vitamin B6 (pyridoxine) 
E) Vitamin C

6) 54 years old man comes to the physician because of left shoulder pain that began after he injured himself at a tennis game 2 days ago. Examination of the left upper extremity shows no obvious bone deformities or point tenderness. The pain is reproduced when the patient is asked to externally rotate the shoulder against resistance; there is no motor weakness. In addition to the teres minor, inflammation of which of the following tendons is most likely in this patient?

A) Infraspinatus
B) Trapezius
C) Pectoralis
D) Subscapularis
E) Supraspinatus 

7) A young healthy 32 years old lady is anxious about red 1 – 2 mm subcutaneous spots all over her lower limbs bilaterally since last 24 hours. She denies any fever or any significant symptoms. She had some self-limiting diarrhea about 10 days ago. Laboratory findings suggests: Hemoglobin 130, Hematocrit 39.7%, Leukocyte count 7500/mm3, Neutrophils 65%, Lymphocytes 30%, Monocytes 5%, Mean corpuscular volume 82 μm3, Platelet count 20,000/mm3. A peripheral blood smear shows normal red cell morphology; a bone marrow smear shows mature megakaryocytic hyperplasia. Which of the following is the most likely diagnosis? 

A) Acute megakaryocytic leukemia
B) Hemolytic Uremic Syndrome (HUS)
C) Aplastic anemia
D) Immune thrombocytopenic purpura (ITP)
E) Thrombotic thrombocytopenic purpura (TTP)

8) 17 years old lady visited the ED with history of fever, fatigue, and sore throat for 3 days. She recently moved in with a roommate who has a cat. Her temperature is 37.8°C (100°F). Physical examination shows mildly tender cervical adenopathy and pharyngitis with no tonsillar exudates. There is mild splenomegaly. Laboratory studies show: Hemoglobin 13, Hematocrit 41%, Total Leukocyte count 11,500/mm3, Platelet count 150,000/mm3, Heterophile antibody titer positive. The most likely cause of this patient's condition is infection with which of the following?

A) Toxoplasma gondii
B) Bartonella hensleae
C) Epstein-Barr virus
D) Cytomegalovirus
E) Streptococcus species

9) Adolescent male was injured at a baseball match and became unconscious. He was hit on the temple before he passed out. About 15 minutes later, he regained consciousness spontaneously while being transferred to the A & E. As you are examining him, he becomes lethargic, and over the next few minutes, he becomes stuporous again. His pupils are unequal, and his GCS is E1V2M3. You have intubated this patient and are keen to rush him to the CT as you suspect an intracranial hemorrhage. Which of the following vessels is most likely to be the source of the hemorrhage?

A. Anterior cerebral artery
B. Middle cerebral artery 
C. Middle meningeal artery
D. Emissary Veins
E. Anterior communicating artery 

10) 38 years old rugby player is brought to the ED with complaints of unable to feel or move his lower limbs after a forced flexion injury to his spine while dodging. He lies on bed, and a primary survey indicates preserved A, B, and Cs. In examination of disability, we assess the sensory dermatomal distribution from the abdomen downwards, T10 at umbilicus, T12 at pubis, L1 at Inguinal ligament preserved. No sensation below this level (to dull and pin prick), no motor functions, complete loss of muscle tone, No DTRs. No sensations at scrotal skin, but tenderness on pressing the testicles. Log roll done to reveal tenderness and step deformity at L1, and loss of rectal tone. The tender testicles imply:

A) Malingering
B) Somatization
C) Conversion disorder
D) Actual transection of cord at L1 & L2
E) Testicular hematoma

Saturday, April 16, 2016