18/06 Flashcards
cANCA
granulomatosis with polyangitis
pANCA
eosinophilic granulomatosis
Ulcerative colitis (70%)
Primary sclerosing cholangitis (70%)
Anti-GBM disease (25%)
Crohn’s disease (20%)
paradoxical rise in APTT and thrombocytopenia
APS
APS primary prophylaxis
low dose aspirin
APS secondary prophylaxis
initial venous thromboembolic events: lifelong warfarin with a target INR of 2-3
recurrent venous thromboembolic events: lifelong warfarin; if occurred whilst taking warfarin then consider adding low-dose aspirin, increase target INR to 3-4
APS tx of arterial thrombosis
lifelong warfarin target INR 2-3
azathioprine prior test
TPMT test
azathioprine adverse effects
bone marrow suppression
n/v
pancreatitis
> risk of non-melanoma skin cancer
but safe in preg !!
azathioprine drug interaction
allopurinol so lower doses needed
oral ulcers, genital ulcers and anterior uveitis
behcets
HLA B51
behcets
behcets pathergy test
puncture site following needle prick becomes inflamed with small pustule forming
bisphosphonates MOA
inhibit osteoclasts by reducing recruitment and promoting apoptosis
bisphosphonates adverse effects
oesophageal reactions
osteonecrosis of the jaw
> risk atypical stress fractures
acute phase response
hypocalcaemia
important check before starting bisphosphonates
Hypocalcemia/vitamin D deficiency should be corrected before
benign ‘overgrowth’ of bone, most typically occuring on the skull
osteoma
cartilage-capped bony projection on the external surface of a bone
osteochondroma
X-ray shows a ‘double bubble’ or ‘soap bubble’ appearance
giant cell tumour
occurs most frequently in the metaphyseal region of long bones prior to epiphyseal closure
codman triangle and sunburst appearance
Rb gene
osteosarcoma
small round blue cell tumour
onion skin appearance
ewings sarcoma
malignant tumour of cartilage
chondrosarcoma
CFS mx
specialist service
energy mx
physical activity and exercise
CBT
denosumab MOA
human monoclonal antibody that prevents the development of osteoclasts by inhibiting RANKL
prevention of skeletal-related events (i.e. pathological fractures)
denosumab
drug induced lupus antibodies
ANA +ve, dsDNA -ve
anti-histone
anti-ro anti-smith
drug induced lupus
procainamide
hydralazine
consequence of ileaocaecal resection in crohns
b12 def
Normal/raised total gas transfer with raised transfer coefficient
asthma or pulmonary haemorrhage
when should dex not be given in meningitis
suspected menigococcal septicaemia
ehlers danlos syndrome
type III collagen
fibromyalgia diagnosis
American College of Rheumatology
classification criteria which lists 9 pairs of tender points on the body
If a patient is tender in at least 11 of these 18 points it makes a diagnosis of fibromyalgia more likely
fibromyalgia mx
explanation
aerobic exercise: has the strongest evidence base
cognitive behavioural therapy
medication: pregabalin, duloxetine, amitriptyline
gout precipitating drug
thiazides
HLA-DQ2/DQ8
coeliac disease
HLA-DR2
narcolepsy
good pastures
marfans syndrome
protein fibrillin 1
methotrexate adverse effects
mucositis
myelosuppression
pneumonitis
pulmonary fibrosis
liver fibrosis
methotrexate co-prescription
folic acid 5mg once weekly
methotrexate interactions
trimethoprim or co-trimoxazole
high dose aspirin
methotrexate toxicity
folinic acid
myopathies
symmetrical muscle weakness (proximal>distal)
DIP, PIP joints
OA
MCP, PIP joints
RA
osteomalacia invx
low vit D, calcium and phosphate
raised alkaline phosphatase
xray - translucent bands
what is z score adjusted for
age, gender and ethnic factors
bones affected pagets
skull, spine/pelvis, and long bones of the lower extremities
mx of pagets
bisphosphonate
polymyositis antibodies
anti-synthestase
anti-JO1
DIPs affected
OA or PSORIATIC
raynauds mx
CCB eg nifedipine
post STI form of reactive arthritia
chlamydia
what invx should be done in all pts with suspected rheumatoid
xrays of hands and feet
supraspinatus
aBDucts arm before deltoid
Most commonly injured
infraspinatus
Rotates arm laterally
teres minor
aDDucts & rotates arm laterally
subscapularis
aDDuct & rotates arm medially
malignancy from sjogrens
lymphoid
stills disease diagnosis
Yamaguchi criteria
cautions sulfasalazine
G6PD deficiency
allergy to aspirin or sulphonamides (cross-sensitivity)
adverse effects sulfasalazine
oligospermia
Stevens-Johnson syndrome
pneumonitis / lung fibrosis
myelosuppression, Heinz body anaemia, megaloblastic anaemia
may colour tears → stained contact lenses
SLE
type 3 hypersensitivity reaction
what does raised CRP in sle indicate
infection as levels are usually normal during flares
sle complement c3 c4 levels
usually low during active disease
limited cutaneous systemic sclerosis
face and distal limbs predominately
anti-centromere antibodies
diffuse cutaneous systemic sclerosis
trunk and proximal limbs
anti-scl70
evolving visual loss temporal arteritis tx
IV methylprednisolone
SAMA
ipratropium
what meds can trigger haemolysis in G6PD def
sulph- drugs: sulphonamides, sulphasalazine and sulfonylureas
UC most commonly affected area
rectum
bradycardia mx
atropine, up to a maximum of 3mg
transcutaneous pacing
isoprenaline/adrenaline infusion
post heel pain
achilles tendon disorder
achilles tendon disorder RF
quinolone eg ciprofloxacin use
hypercholesterolaemia
adhesive capsulitis assoc
diabetes
otawa rules for ankle xray
pain in the malleolar zone and any one of the following findings:
bony tenderness at the lateral malleolar zone
bony tenderness at the medial malleolar zone
inability to walk four weight bearing steps immediately after the injury and in the emergency department
weber type A fracture
below the syndesmosis
weber type B fracture
start at the level of the tibial plafond and may extend proximally to involve the syndesmosis
weber type c fracture
above the syndesmosis which may itself be damaged
Maisonneuve fracture
spiral fibular fracture that leads to disruption of the syndesmosis with widening of the ankle joint, surgery is required
AVN of the hip causes
long-term steroid use
chemotherapy
alcohol excess
trauma
avn hip invx of choice
mri
most freq loc of biceps rupture
proximal
long tendon which attaches to the glenoid
biceps rupture invx
USS
wasting in carpal tunnel
thenar eminence
carpal tunnel EPS findings
motor + sensory: prolongation of the action potential
carpal tunnel mx
6 wk trial of conservative mx if mild-mod
steroid inj + wrist splints at night
if severe or trial failed
surgical decompression (flexor retinaculum division)
tinels sign
tapping causes paraesthesia
phalens sign
flexion of wrist causes symptoms
colles fracture
Dorsally Displaced Distal radius → Dinner fork Deformity
complication colles fracture
median nerve injury: acute carpal tunnel syndrome presenting with weakness or loss of thumb or index finger flexion
De Quervain’s tenosynovitis
pain on radial side of wrist
finklesteins test
duputryens contracture affected fingers
ring and pinkie
duputryens contracture causes
+ve FH
manual labour
phenytoin treatment
alcoholic liver disease
diabetes mellitus
trauma to the hand
smiths fracture
reverse colles fracture caused by falling backwards
Volar angulation of distal radius fragment (Garden spade deformity)
bennets fracture
Intra-articular fracture of the first carpometacarpal joint
bartons fracture
Distal radius fracture (Colles’/Smith’s) with associated radiocarpal dislocation
fat embolism invx
CTPA
greater trochanter pain syndrome/trochanteric bursitis
pain over the lateral side of hip/thigh
tenderness on palpation of the greater trochanter
T1DM UGI symptoms and erratic blood glucose
gastroparesis -> metoclopramide
hip disclocation
POSTERIOR - shortened, adducted and internally rotated leg
hip fracture
shortened and externally rotated leg
classification of hip fracture
garden system
undisplaced intracapsular hip fracture
internal fixation, or hemiarthroplasty if unfit
displaced intracapsular hip fracture
arthroplasty (total hip replacement or hemiarthroplasty)
THR if prev fit and well well
extracapsular fracture - stable intertorchanteric
dynamic hip screw
extracapsular fracture - reverse oblique, transverse or subtrochanteric
intramedullary device
iliopsoas abscess invx
CT abdo
iopsoas abscess mx
IV abx
percutaneous drainage
if this fails -> surgery
lateral knee pain in runner
iliotibial band syndrome
unhappy knee triad following lateral blow to knee damage
anterior cruciate ligament
medial collateral ligament
meniscus
twisting injuries
ACL or menisci
dashboard injuries
PCL
skiiing/valgus stress
MCL
chondromallacia patellae
Teenage girls, following an injury to knee e.g. Dislocation patella
Typical history of pain on going downstairs or at rest
tibial plateau fractures
Schatzker Classification
buttock claudication and impotence
leriche syndrome
spina stenosis diagnosis
MRI
Sensory loss over anterior thigh
Weak hip flexion, knee extension and hip adduction
Reduced knee reflex
Positive femoral stretch test
L3
sensory loss anterior aspect of knee and medial malleolus
Weak knee extension and hip adduction
Reduced knee reflex
Positive femoral stretch test
L4
Sensory loss dorsum of foot
Weakness in foot and big toe dorsiflexion
Reflexes intact
Positive sciatic nerve stretch test
L5
Sensory loss posterolateral aspect of leg and lateral aspect of foot
Weakness in plantar flexion of foot
Reduced ankle reflex
Positive sciatic nerve stretch test
S1
Injury results in a positive Trendelenburg sign
superior gluteal nerve
lumbar spinal stenosis
central canal is narrowed by tumour, disk prolapse or other similar degenerative changes
lumbar spinal stenosis tx
laminectomy
pain is aggravated by wrist flexion and pronation
medial epicondylitis
froments sign
ulnar nerve palsy
osteomyelitis in sickle cell pts
salmonella
?osteoporotic vertebral fracture invx
xray
salter harris I
Fracture through the physis only (x-ray often normal)
salter harris II
Fracture through the physis and metaphysis (up the way)
salter harris III
Fracture through the physis and epiphysis to include the joint (down the way)
salter harris IV
Fracture involving the physis, metaphysis and epiphysis
salter harris V
Crush injury involving the physis (x-ray may resemble type I, and appear normal)
heel pain in adults
plantar fasciitis
rib fracture invx
ct chest
proximal scaphoid pole fractures
surgical fixation
shoulder dislocation
ANTERIOR
Painful arc of abduction between 60 and 120 degrees
Tenderness over anterior acromion
supraspinatus tendonitis
humeral neck fracture/dislocation
axillary nerve
humeral midshaft fracture
radial nerve
medial epicondyle fracture
ulnar nerve
thumb, middle, or ring finger
trigger finger
talipes equinovarus tx
ponseti method
pulled elbow tx
passively supination of the elbow joint whilst the elbow is flexed to 90 degrees
AACG
hypermetropia
OAG
myopia
osteomyelitis kids
metaphysis
osteomyelitis adults
epiphysis
adrenaline dose anaphylaxis
0.5ml 1:1,000 IM
adrenaline dose cardiac arrest
10ml 1:10,000 IV or 1ml of 1:1000 IV
mx of accidental adrenaline injection
local infiltration of phentolamine
disulfram
promotes abstinence
acamprosate
reduces craving
main SE of alpha blockers
postural hypotension
slate gray appearance
amiodarone
beta blocker overdose
atropine
in resistant cases glucagon may be used
cocaine toxicity
benzos
when should digoxin levels be measured if suspected toxicity
within 8 to 12 hours of the last dose
statins
LFTs
ACEi
U+Es
amiodarone
TFT, LFT
methorexate
FBC, LFT, U&E
azathioprine
FBC, LFT
lithium
Lithium level, TFT, U&E
valproate
LFT
glitazones
LFT
invasive diarrhoea
cipro
CK in PMR
normal
allergic contact dermatitis
type IV hypersensitivity
Otitis externa in diabetics
treat with cipro to cover pseudomonas
haemophilia
APTT increased
PT normal
bleeding time normal
von willebrands
APTT increased
PT normal
bleeding time increased
vit K def
APTT increased
PT increased
bleeding time normal
acute intermittent porphyria enzyme defect
porphobilinogen deaminase
abdominal, neuro and neuropsychiatric symptoms in 20-40 year olds
urine turns deep red on standing
acute intermittent porphyria
acute intermittent porphyria tx
IV haematin/haem arginate
IV glucose should be used if haematin/haem arginate is not immediately available
assoc with t(15;17)
fusion of PML and RAR-alpha genes
presents younger than other types of AML (average = 25 years old)
Auer rods (seen with myeloperoxidase stain)
DIC or thrombocytopenia often at presentation
good prognosis
Acute promyelocytic leukaemia M3
APS pregnancy mx
low-dose aspirin once the pregnancy is confirmed on urine testing
low molecular weight heparin once a fetal heart is seen on ultrasound. This is usually discontinued at 34 weeks gestation
blood film: spherocytes and reticulocytes
positive direct antiglobulin test (Coombs’ test).
AI haemolytic anaemia
antibody in warm AIHA
IgG
antibody cold AIHA
IgM
warm AIHA tx
steroids (+/- rituximab)
absence of beta globulin chains
HbA2 & HbF raised
beta thalassaemia major
beta thalassaemia major tx
repeated transfusion + iron chelation therapy
microcytosis disproportionate to anaemia
beta thalassaemia trait
target cells
Sickle-cell/thalassaemia
Iron-deficiency anaemia
Hyposplenism
Liver disease
‘Tear-drop’ poikilocytes
myelofibrosis
spherocytes
Hereditary spherocytosis
Autoimmune hemolytic anaemia
basophillic stippling
Lead poisoning
Thalassaemia
Sideroblastic anaemia
Myelodysplasia
howell jolly bodys
hyposplenism
heinz bodies
G6PD def
alpha thalassaemia
schistocytes/helmet cells
Intravascular haemolysis
Mechanical heart valve
Disseminated intravascular coagulation
‘Pencil’ poikilocytes
iron deficiency anaemia
hypersegmented neutrophils
megaloblastic anaemia
blood transfusion anaphylaxis cause
Can be caused by patients with IgA deficiency who have anti-IgA antibodies
RBC transfusion threshold in pts without ACS
70
RBC transfusion threshold in pts with ACS
80
burkitts lymphoma genetics
c-myc gene translocation, usually t(8:14)
starry sky appearance
burkitts lymphoma
CLL richters transformation
-> high grade lymphoma
smudge cells/smear cells
CLL
CLL invx
immunophenotyping: most cases can be identified using a panel of antibodies specific for CD5, CD19, CD20 and CD23
CML genetics
translocation between the long arm of chromosome 9 and 22 - t(9:22)(q34; q11) -> BCR-ABL gene -> tyrosine kinase activity in excess of normal
CML transformation
blast transformation -> AML, ALL
CML tx
imatinib
dabigatran MOA
direct thrombin inhibitor
rivaroxaban, apixaban and edoxaban MOA
direct XA inhibitors
apixaban and rivaroxaban reversal
Andexanet alfa
dabigatran reversal
Idarucizumab
DIC picture
↓ platelets
↓ fibrinogen
↑ PT & APTT
↑ fibrinogen degradation products
schistocytes due to microangiopathic haemolytic anaemia
most common inherited thrombophilia
factor V leiden/activated protein C resistance
heinz bodies, bite and blister cells
G6PD
G6PD diagnosis
G6PD enzyme assay 3 months after an acute episode of haemolysis
drugs causing haemolysis in G6PD
anti-malarials: primaquine
ciprofloxacin
sulph- group drugs: sulphonamides, sulphasalazine, sulfonylureas
acute GVHD
within 100 days of transplantation
chronic GVHD
after 100 days following transplantation
t(9;22) - Philadelphia chromosome
CML
t(15;17)
acute promyelocytic leukaemia (M3)
t(8;14)
burkitts lyphoma
t(11;14)
mantle cell lymphoma
t(14;18)
follicular lymphoma
hereditary spherocytosis long term tx
folate replacement
splenectomy
reed sternberg cell
hodgkins lymphoma
hodgkins lymphoma tx
chemo - ABVD or BEACOPP