2017 (Paper 1) Flashcards

Question

***Lady with palmar erythema, raised ALT, raised bilirubin, strongly positive ANA*** Options AI hepatitis SLE Drug induced cholestasis PBC

Answer 1

**Autoimmune hepatitis** ... is condition of unknown aetiology which is most commonly seen in young females. Recognised associations include other autoimmune disorders, hypergammaglobulinaemia and HLA B8, DR3. Three types of autoimmune hepatitis have been characterised according to the types of circulating antibodies present * Type I * Anti-nuclear antibodies (ANA) and/or anti-smooth muscle antibodies (SMA) * Affects both adults and children * Type II * Anti-liver/kidney microsomal type 1 antibodies (LKM1) * Affects children only * Soluble liver-kidney antigen * Affects adults in middle-age _Features_ * may present with signs of chronic liver disease * acute hepatitis: fever, jaundice etc (only 25% present in this way) * amenorrhoea (common) * ANA/SMA/LKM1 antibodies, raised IgG levels * liver biopsy: inflammation extending beyond limiting plate 'piecemeal necrosis', bridging necrosis _Management_ * steroids, other immunosuppressants e.g. azathioprine * liver transplantation _Chronic liver disease:_ * General * Jaundice * Ascites * Cachexia * Tattoos and track marks * Pigmentation * Hands * Clubbing (esp. in PBC) * Leukonychia * Terry’s nails (white proximally, red distally) * **Palmer erythema** * Dupuytren’s contracture * Face * Pallor: ACD * Xanthelasma: PBC * Keiser-Fleischer rings * Parotid enlargement (esp. c¯ EtOH) * Trunk * Spider naevi * Gynaecomastia * Loss of 2O sexual hair * Ankles * Peripheral oedema * Abdomen * Inspection * Distension ± Para- / umbilical hernia * Dilated veins * Drain scars * Palpation * ± hepatomegaly * ± splenomegaly * Shifting dullness

Answer 2

**IV crystalloid** *PPI not given before endoscopy, O-ve blood – no evidence of anaemia and acute resuscitation is with crystalloids to maintain BP first, Terlipression only if suspected/confirmed variceal bleed* *_ABCDE: CIRCULATION!_* * Resuscitate: * Head down * Airway: Early control of airway is vital (e.g. Drowsy patient with liver failure) -\> protect the airway * Breathing: 100% O2 * Circulation: * 2x 14G cannulae: * Bloods: cross match blood, check FBC, LFTs (ETOH abuse), U+E (protein meal) and Clotting and ABG (lactate + Hb) and glucose * IV crystalloid infusion up to 1L (avoid dilution) * D: * blood glucose, GCS, Temperature, expose (PR; maleana) Other: * Major H'gge protocol: on-going bleeding and haemodynamic instability are likely to require O negative blood pending cross matched blood. keep Hb \>10 * Upper GI endoscopy (scoring systems) * all within 24 hours of admission. * If unstable = immediately after resuscitation or in tandem with it. Specific: * Varices: * terlipressin prior to endoscopy (splanchnic vasopressor) * Prophylactic ABx e.g. ciprofloxacin 1g/24h * Varices should be banded or subjected to sclerotherapy, adrenaline coagulation * If this is not possible owing to active bleeding then a Sengaksten- Blakemore tube(or Minnesota tube) should be inserted. This should be done with care; gastric balloon should be inflated first and oesophageal balloon second. Remember the balloon with need deflating after 12 hours (ideally sooner) to prevent necrosis. * Portal pressure should be lowered by combination of medical therapy +/- TIPSS. * Oesophagitis/gastritis: * Patients with erosive oesophagitis / gastritis should receive a **proton pump inhibitor.** * Patients with diffuse erosive gastritis who cannot be managed endoscopically and continue to bleed may require gastrectomy * Haemostasis of vessel or ulcer * Identifiable bleeding points should receive combination therapy of injection of: adrenaline and either a thermal/laser coagulation, fibrin glu, endoclips. * All who have received intervention should receive a continuous infusion of a proton pump inhibitor (IV omeprazole for 72 hours) to reduce the re-bleeding rate. * Bleeding ulcers that cannot be controlled endoscopically may require: Gastric ulcer * Under-running of the bleeding site * Partial gastrectomy-antral ulcer * Partial gastrectomy or under running the ulcer- lesser curve ulcer (involving left gastric artery) * Total gastrectomy if bleeding persists * Duodenal ulcer: * Laparotomy, duodenotomy and under running of the ulcer. If bleeding is brisk then the ulcer is almost always posteriorly sited and will have invaded the gastroduodenal artery. Large bites using 0 Vicryl are taken above and below the ulcer base to occlude the vessel. The duodenotomy should be longitudinal but closed transversely to avoid stenosis. * Mallory Weiss: tears will typically resolve spontaneously

Answer 3

**Thiamine** ....is a water soluble vitamin of the B complex group. One of it's phosphate derivates, thiamine pyrophosphate (TPP), is an important coenzyme. Thiamine is therefore important in the catabolism of sugars and aminoacids. The clinical consequences of thiamine deficiency are therefore seen first in highly aerobic tissues such as the brain (Wenicke-Korsakoff syndrome) and the heart (wet beriberi). _Causes of thiamine deficiency:_ * alcohol excess * malnutrition _Conditions associated with thiamine deficiency:_ * Wernicke's encephalopathy: nystagmus, ophthalmoplegia and ataxia * Korsakoff's syndrome: amnesia, confabulation * dry beriberi: peripheral neuropathy * wet beriberi: dilated cardiomyopathy _Wernicke's encephalopathy_ ...is a neuropsychiatric disorder caused by thiamine deficiency which is most commonly seen in alcoholics. Rarer causes include: persistent vomiting, stomach cancer, dietary deficiency. A classic triad of ophthalmoplegia/nystagmus, ataxia and confusion may occur. In Wernicke's encephalopathy petechial haemorrhages occur in a variety of structures in the brain including the mamillary bodies and ventricle walls _Features_ * nystagmus (the most common ocular sign) * ophthalmoplegia * ataxia * confusion, altered GCS * peripheral sensory neuropathy _Investigations_ * decreased red cell transketolase * MRI _Treatment_ is with urgent replacement of thiamine Relationship with _Korsakoff syndrome_ * *If not treated Korsakoff's syndrome may develop as well. This is termed Wernicke-Korsakoff syndrome and is characterised by the addition of antero- and retrograde amnesia and confabulation in addition to the above symptoms.*

Answer 4

**GBS** _Guillain-Barre syndrome_ describes an immune mediated demyelination of the peripheral nervous system often triggered by an infection classically Campylobacter jejuni) _Pathogenesis_ * cross reaction of antibodies with gangliosides in the peripheral nervous system * correlation between anti-ganglioside antibody (e.g. anti-GM1) and clinical features has been demonstrated * anti-GM1 antibodies in 25% of patients _Features_ The characteristic features of Guillain-Barre syndrome is progressive weakness of all four limbs. The weakness is classically ascending i.e. the lower extremities are affected first, however it tends to affect proximal muscles earlier than the distal ones. Sensory symptoms tend to be mild (e.g. distal paraesthesia) with very few sensory signs. Some patients experience back pain in the initial stages of the illness. *Other features* * areflexia * cranial nerve involvement e.g. diplopia * autonomic involvement: e.g. urinary retention * Less common findings * papilloedema: thought to be secondary to reduced CSF resorption _Miller Fisher syndrome_ * variant of Guillain-Barre syndrome * associated with ophthalmoplegia, areflexia and ataxia. The eye muscles are typically affected first * usually presents as a descending paralysis rather than ascending as seen in other forms of Guillain-Barre syndrome * anti-GQ1b antibodies are present in 90% of cases

Answer 5

**DIC** * *DIC = low fibrinogen, low platelets (consumption), petechiae, raised BT/PT/aPTT, signs of cause (sepsis, malignancy, trauma, obstetric)* * *Liver disease = clotting factors deficiency, low* *fibrinogen synthesis, chronic history, abnormality of platelet function, but **_no quantitative deificiency_*** Disseminated intravascular coagulation _(DIC):_ * Widespread activation of coagulation * Clotting factors and platelets are consumed → ↑ risk of bleeding * Causes: Malignancy, sepsis, trauma, obstetric complications, toxins. * Low plts, low fibrinogen, high FDP/ddimer, long PT/INR. * Treat the cause and give transfusions, FFP, platelets, cryo etc. Liver disease: * ↓ synthesis of II, V, VII, IX, X, XI and fibrinogen * ↓ absorption of vitamin K * Abnormalities of platelet function.

Answer 6

**Renal Biopsy** 24hr urine/PCR for Dx of syndrome but Renal Biopsy (in adults, treat for minimal change with steroid in children) is method for Dx Nephrotic syndrome Triad of: 1. Proteinuria (\> 3g/24hr) causing 2. Hypoalbuminaemia (\< 30g/L) and 3. Oedema Loss of antithrombin-III, proteins C and S and an associated rise in fibrinogen levels predispose to thrombosis. Loss of thyroxine-binding globulin lowers the total, but not free, thyroxine levels Diagnosis: Secondary to Systemic Disease * DM: glomerulosclerosis * SLE: membranous * Amyloidosis Primary: * Minimal Change Glomerulonephritis * Membranous Nephropathy * FSGS * Membranoproliferative / Mesangiocapillary GN

Answer 7

**chemotherapy** *and radiotherapy* Lung cancer: small cell _Features_ * usually central * arise from APUD\* cells * associated with ectopic ADH, ACTH secretion * ADH → hyponatraemia * ACTH → Cushing's syndrome * ACTH secretion can cause bilateral adrenal hyperplasia, the high levels of cortisol can lead to hypokalaemic alkalosis * Lambert-Eaton syndrome: antibodies to voltage gated calcium channels causing myasthenic like syndrome _Management_ * usually metastatic disease by time of diagnosis * patients with very early stage disease (T1-2a, **N0**, M0) are now considered for surgery. NICE support this approach in their 2011 guidelines * however, most patients with limited disease receive a combination of ***chemotherapy*** and radiotherapy * patients with more extensive disease are offered palliative chemotherapy _Non-small cell_ 1. Squamous cell cancer * typically central * associated with parathyroid hormone-related protein (PTHrP) secretion → hypercalcaemia * strongly associated with finger clubbing * hypertrophic pulmonary osteoarthropathy (HPOA) 2. Adenocarcinoma * typically peripheral * most common type of lung cancer in non-smokers, although the majority of patients who develop lung adenocarcinoma are smokers 3. Large cell lung carcinoma * typically peripheral * anaplastic, poorly differentiated tumours with a poor prognosis * may secrete β-hCG Management * only 20% suitable for surgery * mediastinoscopy performed prior to surgery as CT does not always show mediastinal lymph node involvement * curative or palliative radiotherapy * poor response to chemotherapy * Surgery contraindications * assess general health * stage IIIb or IV (i.e. metastases present) * FEV1 \< 1.5 litres is considered a general cut-off point\* * malignant pleural effusion * tumour near hilum * vocal cord paralysis * SVC obstruction

Answer 8

Clarithromycin

Answer 9

**Cefotaxime** Klebsiella pneumoniae is a Gram-negative rod that is part of the normal gut flora. It can cause a number of infections in humans including pneumonia (typically following aspiration) and urinary tract infections. Features of Klebsiella pneumonia * more common in alcoholic and diabetics * may occur following aspiration * 'red-currant jelly' sputum * often affects upper lobes Prognosis * commonly causes lung abscess formation and empyema * mortality is 30-50%

Answer 10

**Co-Trimoxazole** _Pneumocystis jiroveci_ is an unicellular eukaryote, generally classified as a fungus but some authorities consider it a protozoa PCP is the most common opportunistic infection in AIDS all patients with a CD4 count \< 200/mm³ should receive PCP prophylaxis _Features_ * dyspnoea * dry cough * fever * very few chest signs Pneumothorax is a common complication of PCP. Extrapulmonary manifestations are rare (1-2% of cases), may cause * hepatosplenomegaly * lymphadenopathy * choroid lesions _Investigation_ * CXR: typically shows bilateral interstitial pulmonary infiltrates but can present with other x-ray findings e.g. lobar consolidation. May be normal * exercise-induced desaturation * sputum often fails to show PCP, bronchoalveolar lavage (BAL) often needed to demonstrate PCP (_silver stain_ shows characteristic cysts) _Management_ * co-trimoxazole * IV pentamidine in severe cases * steroids if hypoxic (if pO2 \< 9.3kPa then steroids reduce risk of respiratory failure by 50% and death by a third)

Answer 11

**Aortic dissection** *nb Chest pain (= acute dissection), followed by acute limb ischaemia (mural thrombus) MI mural thrombus would be more delayed* _Associations_ * hypertension * trauma * bicuspid aortic valve * collagens: Marfan's syndrome, Ehlers-Danlos syndrome * Turner's and Noonan's syndrome * pregnancy * syphilis _Features:_ * chest pain: typically severe, radiates through to the back and 'tearing' in nature * aortic regurgitation * hypertension * other features may result from the involvement of specific arteries. For example: * coronary arteries → angina * spinal arteries → paraplegia * distal aorta → limb ischaemia

Answer 12

**Aorta Bifemoral** Treatment: revascularization typically using either angioplasty or a type of vascular bypass * Kissing balloon angioplasty +/- stent, so named because the two common iliacstents touch each other in the distal aorta. * Aorto-iliac bypass graft * "aorto-bifem" - aortic to both femoral arteries. Used when there is disease at the aortic bifurcation, known as Leriche syndrome, or in _both iliac arteries_ * Occasionally: * Axillary-bi-femoral and femoral-femoral bypass (sometimes abbreviated "ax-fem fem-fem")

Answer 13

**Aorta Bifemoral** aortoiliac occlusive disease, aka Leriche's syndrome, involved blockage of the abdominal aorta as it transitions into the common iliac arteries. Classic signs/symptoms: 1. claudication of the buttocks and thighs 2. absent or decreased femoral pulses 3. erectile dysfunction Treatment: *revascularization typically using either angioplasty or a type of vascular bypass* * Kissing balloon angioplasty +/- stent, so named because the two common iliacstents touch each other in the distal aorta. * Aorto-iliac bypass graft * *"aorto-bifem" - aortic to both femoral arteries. Used when there is disease at the aortic bifurcation, known as Leriche syndrome, or in both iliac arteries* * Axillary-bi-femoral and femoral-femoral bypass (sometimes abbreviated "ax-fem fem-fem")

Answer 14

Cerebral oedema Hyponatraemia may be caused by water excess or sodium depletion. Causes of pseudohyponatraemia include hyperlipidaemia (increase in serum volume) or a taking blood from a drip arm. Urinary sodium and osmolarity levels aid making a diagnosis * Urinary sodium \> 20 mmol/l * Sodium depletion, renal loss (patient often hypovolaemic) * diuretics * Addison's * diuretic stage of renal failure * Patient often euvolaemic * SIADH (urine osmolality \> 500 mmol/kg) * hypothyroidism * Urinary sodium \< 20 mmol/l * Sodium depletion, extra-renal loss * diarrhoea, vomiting, sweating * burns, adenoma of rectum * Water excess (patient often hypervolaemic and oedematous) * secondary hyperaldosteronism: heart failure, cirrhosis * reduced GFR: renal failure * IV dextrose, psychogenic polydipsia Medical emergency: * nausea and vomiting (\<136 mmol/l) * confusion (\<131 mmol/l) * seizures, non-cardiogenic pulmonary oedema (\<125 mmol/l) * coma (\<117 mmol/l) and eventual death

Answer 15

***Early parkinsonism*** *Parkinson's disease is a progressive neurodegenerative condition caused by degeneration of dopaminergic neurons in the substantia nigra.. This results in a classic triad of features: bradykinesia, tremor and rigidity. The symptoms of Parkinson's disease are characteristically asymmetrical.* Epidemiology * around twice as common in men * mean age of diagnosis is 65 years Features: * Bradykinesia * poverty of movement also seen, sometimes referred to as hypokinesia * short, shuffling steps with reduced arm swinging * difficulty in initiating movement * Tremor * most marked at rest, 3-5 Hz * worse when ***stressed*** or tired * typically 'pill-rolling', i.e. in the thumb and index finger * Rigidity * lead pipe * cogwheel: due to superimposed tremor * Other characteristic features * mask-like facies * flexed posture * micrographia * drooling of saliva * psychiatric features: depression is the most common feature (affects about 40%); dementia, psychosis and sleep disturbances may also occur * impaired olfaction * REM sleep behaviour disorder

Answer 16

**NG** * swollowing may recover, thus, in the early stages a PEG is not indicated. If the patient is determined to have long term swallowing difficulties a PEG _may_ be placed but this would more likely occur at a later date.* * Stroke:* Watch the patient swallow a small volume of water; if signs of aspiration (a cough or voice change) make nil by mouth until formal assessment by a speech therapist. Use IV fl uids, then semi-solids (eg jelly; avoid soups and crumbly food). Avoid early **NG** tube feeds (needed only in the few with established chronic swallowing problems). Speech therapists skilled in assessing swallowing diffi culties are invaluable here. _Enteral feeding_ * Identify patients as malnourished or at risk * Eaten nothing or little \> 5 days, who are likely to eat little for a further 5 days * Poor absorptive capacity * High nutrient losses * High metabolism * Identify unsafe or inadequate oral intake with functional GI tract * Consider for enteral feeding * _Gastric_ feeding unless upper GI dysfunction (then for duodenal or jejunal tube) * Check NG placement using aspiration and pH (check post pyloric tubes with AXR) * Gastric feeding \> 4 weeks consider long-term gastrostomy * Consider bolus or continuous feeding into the stomach * ITU patients should have continuous feeding for 16-24h (24h if on insulin) * Consider motility agent in ITU or acute patients for delayed gastric emptying. If this doesn't work then try post pyloric feeding or parenteral feeding. * ***PEG can be used 4 hours after insertion, but should not be removed until \>2 weeks after insertion*** * PEG: *Percutaneous endoscopic gastrostomy tubes are useful in patients who have a functioning gastrointestinal tract, but where oral feeding is considered unsafe or not possible (e.g. patients with swallowing insuf ficiency following cerebrovascular accident).*

Answer 17

**Urinary antigen** legionnaire's disease is caused by the intracellular bacterium Legionella pneumophilia. It is typically colonizes water tanks and hence questions may hint at air-conditioning systems or foreign holidays. Person-to-person transmission is not seen _Features_ * flu-like symptoms including fever (present in \> 95% of patients) * dry cough * relative bradycardia * confusion * lymphopaenia * hyponatraemia * deranged liver function tests * pleural effusion: seen in around 30% of patients _Diagnosis_: urinary antigen _Management_: treat with erythromyci

Answer 18

**Thomas's Splint** : step 1 splint the # * May have been remembered incorrectly:* * Dirty, _compound_ fracture - Thomas splint* *_Comminuted_ fracture - external fixation; skin infection/soft tissue loss* *Paediatric fracture involving the epiphysis requires traction paeds* Open fractures require urgent attention: 6As * Analgesia: M+M * Assess: NV status, soft tissues, photograph * Antisepsis: wound swab, copious irrigation, cover with betadine-soaked dressing. * Alignment: align # and **splint** * Anti-tetanus: check status (booster lasts 10yrs) * Abx * Fluclox 500mg IV/IM + benpen 600mg IV/IM * Or, augmentin 1.2g IV Mx: debridement and fixation in theatre (commonly external fixation to prevent deep seeing of infection) Gustillo Classification of Open #s 1. Wound \<1cm in length 2. Wound ≥1cm c¯ minimal soft tissue damage 3. Extensive soft tissue damage _Clostridium perfringes_ * Most dangerous complication of open # * Wound infections and gas gangrene * ± shock and renal failure * Rx: debride, benpen + clindamycin _Thomas splint:_*most commonly refers to a splinting device that uses straps attaching over the pelvis or hip as an anchor, a metal rod(s) to mimic normal bone stability and limb length, and a mechanical device to apply traction(used in an attempt to reduce pain, realign the limb, and minimize vascular and neurological complication) to the limb.* *A traction splint is commonly used to treat complete long bone fractures of the thigh, femur and not for tibia and fibula area. Their use is common in prehospital care.*

Answer 19

**Refer urgently to phthalmology** Glaucoma is a group disorders characterised by optic neuropathy due, in the majority of patients, to raised intraocular pressure (IOP). It is now recognised that a minority of patients with raised IOP do not have glaucoma and vice versa In acute angle closure glaucoma (AACG) there is a rise in IOP secondary to an impairment of aqueous outflow. Factors predisposing to AACG include: * hypermetropia (long-sightedness) * pupillary dilatation * lens growth associated with age _Features_ * severe pain: may be ocular or headache * decreased visual acuity * symptoms worse with mydriasis (e.g. watching TV in a dark room) * hard, red eye * haloes around lights * semi-dilated non-reacting pupil * corneal oedema results in dull or hazy cornea * systemic upset may be seen, such as nausea and vomiting and even abdominal pain _Management_ * urgent referral to an ophthalmologist * management options include reducing aqueous secretions with acetazolamide and inducing pupillary constriction with topical pilocarpine

Answer 20

**SFA** * Calf pain* = superficial femoral disease (commonest) * Buttock pain* = iliac disease (internal or common) _Clinical Classification = Fontaine_ 1. Asympto (subclinical) 2. Intermittent claudication a. \>200m b. \<200m 3. Ischaemic rest pain 4. Ulceration / gangrene

Answer 21

**Posterior dislocation** _Posterior hip dislocation_= shortened and internally rotated with flexion and adduction at the hip _Anterior dislocation_= externally rotated, abducted, and extended at the hip _NOF_= shortened and externally rotated _Femur shaft fracture_=shortened with obvious deformity (and potentially low BP)

Answer 22

**9** Eyes opening response: 1. No response 2. To pain 3. To Speech 4. Spontaneous Verbal response: 1. No response 2. Incomprehensible sounds 3. Inappropriate words 4. Confused 5. Oriented to time, person, place Motor Response: 1. No response 2. Abnormal extension 3. Abnormal flexion 4. Flex to withdraw from pain 5. Moves to localise pain 6. Obeys command

Answer 23

**Oropharyngeal** 1+5+2=8 GCS 8 =\> Oropharyngeal “(GCS) LESS THAN 8, intubate” Cuffed endotracheal tube * Provides optimal control of the airway once cuff inflated * May be used for long or short term ventilation * Errors in insertion may result in oesophageal intubation (therefore end tidal CO2 usually measured) * Paralysis often required * Higher ventilation pressures can be used

Answer 24

**Secure his airway** *??C-Spine first if an option?*

Answer 25

**Gastroscopy** _Investigations_ for GORD (Isolated symptoms don’t need Ix!) * Bloods: FBC * CXR: hiatus hernia may be seen * OGD if: * **\>55yrs** * Wt. loss * Persistent symptoms despite Rx * Dysphagia * Symptoms \>4wks * OGD allows grading by Los Angeles Classification * Ba swallow: hiatus hernia, dysmotility * 24h pH testing ± manometry * pH \<4 for \>4hrs _Endoscopically proven oesophagitis_ * full dose proton pump inhibitor (PPI) for 1-2 months * if response then low dose treatment as required * if no response then double-dose PPI for 1 month _Endoscopically negative reflux disease_ * full dose PPI for 1 month * if response then offer low dose treatment, possibly on an as-required basis, with a limited number of repeat prescriptions * if no response then H2RA or prokinetic for one month OTC antacids: Gaviscon, Mg trisilicate 1: Full-dose PPI for 1-2mo Lansoprazole 30mg OD 2: No response → double dose PPI BD 3: No response: add an H2RA Ranitidine 300mg nocte Control: low-dose acid suppression PRN

Answer 26

**Pyoderma Gangrenosum** _Features_ * typically on the lower limbs * initially small red papule * later deep, red, necrotic ulcers with a violaceous border * may be accompanied systemic symptoms e.g. Fever, myalgia _Causes_ * idiopathic in 50% * inflammatory bowel disease: ulcerative colitis, Crohn's * rheumatoid arthritis, SLE * myeloproliferative disorders * lymphoma, myeloid leukaemias * monoclonal gammopathy (IgA) * primary biliary cirrhosis _Management_ * the potential for rapid progression is high in most patients and most doctors advocate oral steroids as first-line treatment * other immunosuppressive therapy, for example ciclosporin and infliximab, have a role in difficult cases

Answer 27

**R****adiotherapy** *metastatic bone pain may respond to strong opioids, bisphosphonates or radiotherapy. The assertion that NSAIDs are particularly effective for metastatic bone pain is not supported by studies. Strong opioids have the lowest number needed to treat for relieving the pain and can provide quick relief, in contrast to radiotherapy and bisphosphonates\*. All patients, however, should be considered for referral to a clinical oncologist for consideration of further treatments such as radiotherapy* Most common tumour causing bone metastases (in descending order) * prostate * breast * lung Most common site (in descending order) * spine * pelvis * ribs * skull * long bones ??2008 SIGN guidelines: metastatic bone pain may respond to strong opioids, bisphosphonates or radiotherapy. The assertion that NSAIDs are particularly effective for metastatic bone pain is not supported by studies. Strong opioids have the lowest number needed to treat for relieving the pain and can provide quick relief, in contrast to radiotherapy and bisphosphonates\*. All patients, however, should be considered for referral to a clinical oncologist for consideration of further treatments such as radiotherapy

Answer 28

**Fibroadenoma** _Fibroadenoma_: * Develop from a whole lobule * Mobile, firm breast lumps * 12% of all breast masses * Over a 2 year period up to 30% will get smaller * No increase in risk of malignancy * Treatment: If \>3cm surgical excision is usual, Phyllodes tumours should be widely excised (mastectomy if the lesion is large) _Breast cysts:_ * Usually presents as a smooth discrete lump (may be fluctuant) * Small increased risk of breast cancer (especially if younger) * Treatment: Cysts should be aspirated, those which are blood stained or persistently refill should be biopsied or excised _Sclerosing adenosis_, (radial scars and complex sclerosing lesions) * Usually presents as a breast lump or breast pain * Causes mammographic changes which may mimic carcinoma * Cause distortion of the distal lobular unit, without hyperplasia (complex lesions will show hyperplasia) * Considered a disorder of involution, no increase in malignancy risk * Treatment: Lesions should be biopsied, excision is not mandatory _Epithelial hyperplasia_ * Variable clinical presentation ranging from generalised lumpiness through to discrete lump * Disorder consists of increased cellularity of terminal lobular unit, atypical features may be present * Atypical features and family history of breast cancer confers greatly increased risk of malignanc * Treatment: If no atypical features then conservative, those with atypical features require either close monitoring or surgical resection _Fat necrosis_ * Up to 40% cases usually have a traumatic aetiology * Physical features usually mimic carcinoma * Mass may increase in size initially * Treatment: Imaging and core biopsy _Duct papilloma_ * Usually present with nipple discharge * Large papillomas may present with a mass * The discharge usually originates from a single duct * No increase risk of malignancy * Treatment: Microdochectomy

Answer 29

**Anti TTG abs** _Coeliac disease_ is caused by sensitivity to the protein gluten. Repeated exposure leads to villous atrophy which in turn causes malabsorption. Conditions associated with coeliac disease include dermatitis herpetiformis (a vesicular, pruritic skin eruption) and autoimmune disorders (type 1 diabetes mellitus and autoimmune hepatitis). Diagnosis is made by a combination of immunology and jejunal biopsy. Villous atrophy and immunology normally reverses on a gluten-free diet. *NICE issued guidelines on the investigation of coeliac disease in 2009. If patients are already taking a gluten-free diet they should be asked, if possible, to reintroduce gluten for at least 6 weeks prior to testing.* * Immunology * *tissue transglutaminase (TTG) antibodies (IgA) are first-choice according to NICE* * endomyseal antibody (IgA) * anti-gliadin antibody (IgA or IgG) tests are not recommended by NICE * anti-casein antibodies are also found in some patients * Jejunal biopsy * villous atrophy * crypt hyperplasia * increase in intraepithelial lymphocytes * lamina propria infiltration with lymphocytes * Rectal gluten challenge has been described but is not widely used Investigate for coeliac if... * signs and symptoms: * Chronic or intermittent diarrhoea * Failure to thrive or faltering growth (in children) * Persistent or unexplained gastrointestinal symptoms including nausea and vomiting * Prolonged fatigue ('tired all the time') * Recurrent abdominal pain, cramping or distension * Sudden or unexpected weight loss * Unexplained iron-deficiency anaemia, or other unspecified anaemia * Conditions: * Autoimmune thyroid disease * Dermatitis herpetiformis * Irritable bowel syndrome * Type 1 diabetes * First-degree relatives (parents, siblings or children) with coeliac disease Complications of coeliac disease include: * anaemia: iron, folate and vitamin B12 deficiency (folate deficiency is more common than vitamin B12 deficiency in coeliac disease) * hyposplenism * osteoporosis, osteomalacia * lactose intolerance * enteropathy-associated T-cell lymphoma of small intestine * subfertility, unfavourable pregnancy outcomes * rare: oesophageal cancer, other malignancies

Answer 30

**Flucloaxacillin** _Mastitis_ ...affects around 1 in 10 breast feeding women. The BNF advises to treat 'if systemically unwell, if nipple fissure present, if symptoms do not improve after 12-24 hours of effective milk removal of if culture indicates infection'. The first-line antibiotic is flucloxacillin for 10-14 days. Breast feeding or expressing should continue during treatment. If left untreated, mastitis may develop into a breast abscess (Red, hot tender swelling). This generally requires incision and drainage.

Answer 31

**Clinical exam + imaging + core biopsy** \<35 USS \>35 Mammography Cystic = Cytology/FNA sold = Histology/Core Bx

Answer 32

**LP** Subarachnoid Haemorrhage Features classically: sudden onset severe occipital headache - 'kicked in the back of the head' Causes 85% are due to rupture of berry aneurysms (conditions associated with berry aneurysms include adult polycystic kidney disease, Ehlers-Danlos syndrome and coarctation of the aorta) AV malformations trauma tumours Investigations CT: negative in 5% lumbar puncture: done after 12 hrs (allowing time for xanthochromia to develop) Complications rebleeding (in 30%) obstructive hydrocephalus (due to blood in ventricles) vasospasm leading to cerebral ischaemia Management neurosurgical opinion: no clear evidence over early surgical intervention against delayed intervention post-operative nimodipine (e.g. 60mg / 4 hrly, if BP allows) has been shown to reduce the severity of neurological deficits but doesn't reduce rebleeding\*

Answer 33

**Treat if symptomatic**

Answer 34

**Recurrent laryngeal** Complications following Thyroidectomy * Anatomical such as recurrent laryngeal nerve damage. * Bleeding. Owing to the confined space haematoma's may rapidly lead to respiratory compromise owing to laryngeal oedema. * Damage to the parathyroid glands resulting in hypocalcaemia.

Answer 35

**Squamous Cell Carcinoma** _Squamous cell cancer_ * typically central * associated with parathyroid hormone-related protein (PTHrP) secretion → hypercalcaemia * strongly associated with finger clubbing * hypertrophic pulmonary osteoarthropathy (HPOA) _Adenocarcinoma_ * typically peripheral * most common type of lung cancer in non-smokers, although the majority of patients who develop lung adenocarcinoma are smokers _Large cell lung carcinoma_ * typically peripheral * anaplastic, poorly differentiated tumours with a poor prognosis * may secrete β-hCG _Small Cell_ * usually central * arise from APUD\* cells * associated with ectopic ADH, ACTH secretion * ADH → hyponatraemia * ACTH → Cushing's syndrome * ACTH secretion can cause bilateral adrenal hyperplasia, the high levels of cortisol can lead to hypokalaemic alkalosis * Lambert-Eaton syndrome: antibodies to voltage gated calcium channels causing myasthenic like syndrome

Answer 36

**Pulmonary fibrosis** _Symptoms_ * Dry cough * Dyspnoea * Malaise, wt. loss * Arthralgia * OSA _Signs_ * Cyanosis * Clubbing * Crackles: fine, end-inspiratory _Complications_ * ↑ risk Ca lung * Type 2 respiratory failure and cor pulmonale: * raised JVP!

Answer 37

Give acetylcysteine ...give acetylcysteine as he has taken 200mg/kg, and anything over 150 is probably toxic so should be treated 32x0.5=16g Single acute overdose is defined as an ingestion of \>4 g (or \>75 mg/kg) in a period of \<1 hour. -\>acetylcystein Management of paracetamol overdoes * activated charcoal if ingested \< 1 hour ago * N-acetylcysteine (NAC) * liver transplantation The following is based on 2012 Commission on Human Medicines (CHM) review of paracetamol overdose management. The big change in these guidelines was the removal of the 'high-risk' treatment line on the normogram. All patients are therefore treated the same regardless of risk factors for hepatotoxicity. The National Poisons Information Service/TOXBASE should always be consulted for situations outside of the normal parameters. Acetylcysteine should be given if: * there is a staggered overdose\* or there is doubt over the time of paracetamol ingestion, regardless of the plasma paracetamol concentration; or * the plasma paracetamol concentration is on or above a single treatment line joining points of 100 mg/L at 4 hours and 15 mg/L at 15 hours, regardless of risk factors of hepatotoxicity Acetylcysteine is now infused over 1 hour (rather than the previous 15 minutes) to reduce the number of adverse effects. _King's College Hospital criteria for_ l_iver transplantation_ (paracetamol liver failure) * Arterial pH \< 7.3, 24 hours after ingestion * or all of the following: * prothrombin time \> 100 seconds * creatinine \> 300 µmol/l * grade III or IV encephalopathy

Answer 38

**_Cardiovascular_** (transient reduction in blood flow to the brain) * Arrhythmia: bradycardia (heart block), tachycardia * Outflow obstruction: aortic stenosis, Hypertrophic obstructive cardiomyopathy (HOCM), pulmonary embolism, pulmonary stenosis * Postural hypotension: hypovolaemia, autonomic neuropathy (e.g. diabetes), antihypertensive medication (e.g. ACE inhibitors) * MI, aortic dissection, any condition that reduces cardiac output **_Neurological_** * Epilepsy * Stroke/transient ischaemic attack (TIA) (rarely) **_Vasovagal_** (reflex bradycardia) * Prolonged standing esp. in warm surroundings, emotion * Other causes of vagal overactivity: micturition, cough, carotid sinus hypersensitivity (e.g. on shaving the neck or head turning) * Metabolic: hypoglycaemia Note: There is no clearcut loss of consciousness in drop attacks

Answer 39

**Keratoderma blenhorrhagicum** Can't see, can't pee can't climb a tree Reactive arthritis is one of the HLA-B27 associated seronegative spondyloarthropathies. It encompasses Reiter's syndrome, a term which described a classic triad of urethritis, conjunctivitis and arthritis following a dysenteric illness during the Second World War. Later studies identified patients who developed symptoms following a sexually transmitted infection (post-STI, now sometimes referred to as sexually acquired reactive arthritis, SARA). Reactive arthritis is defined as an arthritis that develops following an infection where the organism cannot be recovered from the joint. _Features_ * typically develops within 4 weeks of initial infection - symptoms generally last around 4-6 months * *arthritis* is typically an asymmetrical oligoarthritis of lower limbs * ***dactylitis*** * symptoms of *urethritis* * eye: conjunctivitis (seen in 50%), anterior *uveitis* * skin: ***circinate balanitis*** (painless vesicles on the coronal margin of the prepuce), ***keratoderma blenorrhagica*** (waxy yellow/brown papules on palms and soles) Around 25% of patients have recurrent episodes whilst 10% of patients develop chronic disease

Answer 40

**Aspiration** _Pneumothorax_ * May occur following thoracic trauma when a lung parenchymal flap is created. * This acts as a one way valve and allows pressure to rise. * The trachea shifts and hyper-resonance is apparent on the affected side. * Treatment is with needle decompression (aspiration) and chest tube insertion.

Answer 41

**Sjogrens** .... is an autoimmune disorder affecting exocrine glands resulting in dry mucosal surfaces. It may be primary (PSS) or secondary to rheumatoid arthritis or other connective tissue disorders, where it usually develops around 10 years after the initial onset. Sjogren's syndrome is much more common in females (ratio 9:1). There is a marked increased risk of lymphoid malignancy (40-60 fold) _Features_ * dry eyes: keratoconjunctivitis sicca * dry mouth * vaginal dryness * arthralgia * Raynaud's, myalgia * sensory polyneuropathy * renal tubular acidosis (usually subclinical) _Investigation_ * rheumatoid factor (RF) positive in nearly 100% of patients * ANA positive in 70% * anti-Ro (SSA) antibodies in 70% of patients with PSS * anti-La (SSB) antibodies in 30% of patients with PSS * Schirmer's test: filter paper near conjunctival sac to measure tear formation * histology: focal lymphocytic infiltration * also: hypergammaglobulinaemia, low C4 _Management_ * artificial saliva and tears * pilocarpine may stimulate saliva production

Answer 42

**Pancreatic cancer** ...is often diagnosed late as it tends to present in a non-specific way. Over 80% of pancreatic tumours are adenocarcinomas which typically occur at the head of the pancreas. _Associations_ * increasing age * smoking * diabetes * chronic pancreatitis (alcohol does not appear an independent risk factor though) * hereditary non-polyposis colorectal carcinoma * multiple endocrine neoplasia * BRCA2 gene _Features_ * classically painless jaundice * however, patients typically present in a non-specific way with anorexia, weight loss, epigastric pain * loss of exocrine function (e.g. steatorrhoea) * atypical back pain is often seen * migratory thrombophlebitis (Trousseau sign) is more common than with other cancers _Investigation_ * ultrasound has a sensitivity of around 60-90% * high resolution CT scanning is the investigation of choice if the diagnosis is suspected _Management_ * less than 20% are suitable for surgery at diagnosis * a Whipple's resection (pancreaticoduodenectomy) is performed for resectable lesions in the head of pancreas. Side-effects of a Whipple's include dumping syndrome and peptic ulcer disease * adjuvant chemotherapy is usually given following surgery * ERCP with stenting is often used for palliation

Answer 43

**Weight loss** _Idiopathic intracranial hypertension_ (also known as pseudotumour cerebri and formerly benign intracranial hypertension) is a condition classically seen in young, overweight females. Features * headache * blurred vision * papilloedema (usually present) * enlarged blind spot * sixth nerve palsy may be present _Risk factors_ * obesity * female sex * pregnancy * drugs\*: oral contraceptive pill, steroids, tetracycline, vitamin A, lithium _Management_ * weight loss * diuretics e.g. acetazolamide * topiramate is also used, and has the added benefit of causing weight loss in most patients * repeated lumbar puncture * surgery: optic nerve sheath decompression and fenestration may be needed to prevent damage to the optic nerve. A lumboperitoneal or ventriculoperitoneal shunt may also be performed to reduce intracranial pressure \*if intracranial hypertension is thought to occur secondary to a known causes (e.g. Medication) then it is of course not idiopathic

Answer 44

**Mesenteric Ischaemia** Lower GI ischaemia _Common predisposing factors_ * increasing age * atrial fibrillation - particularly for ***mesenteric ischaemia*** * other causes of emboli: endocarditis, malignancy * cardiovascular disease risk factors: smoking, hypertension, diabetes * cocaine: ischaemic colitis is sometimes seen in young patients following cocaine use _Common features_ * abdominal pain - in acute mesenteric ischaemia this is often of sudden onset, severe and out-of-keeping with physical exam findings * rectal bleeding * diarrhoea * fever * bloods typically show an elevated white blood cell count associated with a lactic acidosis _Diagnosis_: CT is the investigation of choice

Answer 45

**Advise to stop taking meds and reassess in a month.** _Medication overuse headache_ * Present for 15 days or more per month * Developed or worsened whilst taking regular symptomatic medication * Patients using opioids and triptans are at most risk * May be psychiatric co-morbidity

Answer 46

**Fluid restrict** Hyponatraemia: * High osmolality * Glucose/mannitol infusion * Normal osmolality: * Spurious * Drip arm sample * Pseudohyponatraemia (hyperlipidaemia/ paraproteinaemia) * Low osmolality * True hyponatraemia True: * hypervolaemia * CCF, Cirrhosis, Nephrotic syndrome * Are they overloaded? * euvolaemia * Hypothyroidism, adrenal insufficiency, SIADH * TFT, short synacthen test, paired urine and serum osmolality * Hypovolaemia * Diarrhoea, vomiting, diuretics, salt losing nephropathy? * need fluid restoring? ***_SIADH_*** _Causes_: * Malignancy * small cell lung Ca * also: pacncreas, prostate * Neurological * Stroke * SAH * SDH * meningitis, encephalitis, abscess * Infections: * TB * pneumonia * Drugs: * sulphonylureas * SSRIs, tricyclics * carbamazepine * vincristine * cyclophosphamide * Other: * PEEP * porphyrias _Management_ * correction must be done slowly to avoid precipitating central pontine myelinolysis * ***_fluid restriction_*** * demeclocycline: reduces the responsiveness of the collecting tubule cells to ADH * ADH (vasopressin) receptor antagonists have been developed

Answer 47

**Wegener’s** Granulomatosis with polyangitis Signs and symptoms * _Kidney_: rapidly progressive glomerulonephritis (75%), leading to chronic kidney failure * _Upper airway, eye and ear disease:_ * _Nose_: pain, stuffiness, nosebleeds, rhinitis, crusting, saddle-nose deformity due to a perforated septum * _Ears_: conductive hearing loss due to auditory tube dysfunction, sensorineural hearing loss (unclear mechanism) * _Oral cavity_: strawberry gingivitis, underlying bone destruction with loosening of teeth, non-specific ulcerations throughout oral mucosa * _Eyes_:pseudotumours, scleritis, conjunctivitis, uveitis, episcleritis * _Trachea_: subglottal stenosis * _Lungs_: pulmonary nodules (referred to as "coin lesions"), infiltrates (often interpreted as pneumonia), cavitary lesions, pulmonary haemorrhage causing haemoptysis, and rarely bronchial stenosis. * _Arthritis_: Pain or swelling (60%), often initially diagnosed as rheumatoid arthritis * _Skin_: nodules on the elbow, purpura, various others (see cutaneous vasculitis) * _Nervous system:_ occasionally sensory neuropathy (10%) and rarely mononeuritis multiplex * Heart, gastrointestinal tract, brain, other organs: rarely affected.

Answer 48

**Oesophageal candidiasis** .... is the most common cause of oesophagitis in patients with HIV. It is generally seen in patients with a CD4 count of less than 100. Typical symptoms include dysphagia and odynophagia. Fluconazole and itraconazole are first-line treatments GORD primarily presents as dysPEPSIA over dysPHAGIA (difficulty swallowing) Investigationg of dyspepsia * OGD if \>55 or ALARMS * Try conservative measures for 4 wks * Stop drugs: NSAIDs, CCBs (relax LOS) * Lose wt., stop smoking, ↓ EtOH * Avoid hot drinks and spicy food * OTC * Antacids: magnesium trisilicate * Alginates: gaviscon advance * Test for H. pylori if no improvement: breath or serology * +ve → eradication therapy * Consider OGD if no improvement * -ve → PPI trial for 4wks * Consider OGD if no improvement * PPIs can be used intermittently to control symptoms. * Proven GORD * Full dose PPI for 1-2mo * Then, low-dose PPI PRN

Answer 49

**Multiple myeloma** Multiple myeloma _Clinical features_ * bone disease: bone pain, osteoporosis + pathological fractures (typically vertebral), osteolytic lesions * lethargy * infection * ***hypercalcaemia*** (see below) * ***renal failure*** * other features: amyloidosis e.g. Macroglossia, carpal tunnel syndrome; neuropathy; hyperviscosity _Investigations_ * monoclonal proteins (usually IgG or IgA) in the serum and urine (Bence Jones proteins) * increased plasma cells in the bone marrow * historically a skeletal survey has been done to look for bone lesions. However, whole-body MRI is increasingly used and is now recommended in the 2016 NICE guidelines The diagnostic criteria for multiple myeloma requires one major and one minor criteria or three minor criteria in an individual who has signs or symptoms of multiple myeloma. _Major criteria_ * Plasmacytoma (as demonstrated on evaluation of biopsy specimen) * 30% plasma cells in a bone marrow sample * Elevated levels of M protein in the blood or urine _Minor criteria_ * 10% to 30% plasma cells in a bone marrow sample. * Minor elevations in the level of M protein in the blood or urine. * Osteolytic lesions (as demonstrated on imaging studies). * Low levels of antibodies (not produced by the cancer cells) in the blood. _Hypercalcaemia in myeloma_ * primary factor: due primarily to increased osteoclastic bone resorption caused by local cytokines (e.g. IL-1, tumour necrosis factor) released by the myeloma cells * much less common contributing factors: impaired renal function, increased renal tubular calcium reabsorption and elevated PTH-rP levels

Answer 50

**Wrist extension** _Lateral epicondylitis_ typically follows unaccustomed activity such as house painting or playing tennis ('tennis elbow'). It is most common in people aged 45-55 years and typically affects the dominant arm. _Features_ * pain and tenderness localised to the lateral epicondyle * pain worse on wrist extension against resistance with the elbow extended or supination of the forearm with the elbow extended * episodes typically last between 6 months and 2 years. Patients tend to have acute pain for 6-12 weeks _Management options_ * advice on avoiding muscle overload * simple analgesia * steroid injection * physiotherapy Medial epicondylitis=Golfer's elbow=wrist flexion

Answer 51

Varicocele Inguinal hernia COUGH IMPULSE Epididymal cyst TRANSLUMINATES Varicocele * Palpation * Pt. must be standing * Can get above mass * Separate from testis * Feels like a bag of worms * Doesn’t transilluminate * May have palpable cough impulse * Often disappear on lying supine * PC: 'dull ache'

Answer 52

**Graves' disease** ...is the most common cause of thyrotoxicosis. It is typically seen in women aged 30-50 years. _Features_ * typical features of thyrotoxicosis * specific signs limited to Grave's (see below) _Features_ seen in Graves' but not in other causes of thyrotoxicosis * eye signs (30% of patients): exophthalmos, ophthalmoplegia * pretibial myxoedema * thyroid acropachy _Autoantibodies_ * TSH receptor stimulating antibodies (90%) * anti-thyroid peroxidase antibodies (75%) _Thyrotoxicosis symptoms:_ * Diarrhoea * ↑ appetite but ↓ wt. * Sweats, heat intolerance * Palpitations * Tremor * Irritability * Oligomenorrhoea ± infertility _Signs_ * Hands * Fast / irregular pulse * Warm, moist skin * Fine tremor * Palmer erythema * Face * Thin hair * Lid lag * Lid retraction * Neck * Goitre or nodules

Answer 53

**Diabetic insipidus** Adverse effects of _lithium_ * nausea/vomiting, diarrhoea * fine tremor * nephrotoxicity: polyuria, secondary to nephrogenic diabetes insipidus * thyroid enlargement, may lead to hypothyroidism * ECG: T wave flattening/inversion * weight gain * idiopathic intracranial hypertension _Hypothyroidism_: * Weight gain, lethargy, cold intol * skin; dry, cold, yellow, non-pitting ordema, dry coarse hair, loss of lat aspect of eyebrows * GI constipation * Gynae: menorrhagia * Neurological: decreased deep tendon reflexed, carpal tunnel syndrome

Answer 54

**Oral glucose tolerance test at 28 weeks** Screening and diagnosis * ***Screening*** * All women get oral glucose challenge test at 26/40 * Fasted or fed - 50 mg glucose given, BM taken at 1 hour post-challenge * Screen +ve if \>7.8 mmol/L * ***Diagnosis*** * 75 mg OGTT at 28/40 * t = 0, \> 6 mmol/L +ve * t = 2hr, \>7.8 mmol/L +ve

Answer 55

**Viral thyroiditis** Subacute thyroiditis (also known as De Quervain's thyroiditis and subacute granulomatous thyroiditis) is thought to occur following viral infection and typically presents with hyperthyroidism. There are typically 4 _phases_; 1. phase 1 (lasts 3-6 weeks): hyperthyroidism, painful goitre, raised ESR 2. phase 2 (1-3 weeks): euthyroid 3. phase 3 (weeks - months): hypothyroidism 4. phase 4: thyroid structure and function goes back to normal _Investigations:_ globally reduced uptake on iodine-131 scan _Management_ * usually self-limiting - most patients do not require treatment * thyroid pain may respond to aspirin or other NSAIDs * in more severe cases steroids are used, particularly if hypothyroidism develops

Answer 56

**Metformin** Biguanides – metformin. Sulfonylureas – gliclazide, glimepiride, glipizide, glyburide. Thiazolidinediones (Tzd) – pioglitazone, Actos generic. DPP2 inhibitors - sitagliptin Incretin mimetics (GLP1 agonist) - exenatide Alpha-glucosidase inhibitors – Acarbose SGLT-2 inhibitors - Glioflozin

Answer 57

**Post op ileus** * due to Fluid sequestration and loss of electrolytes* * defined as ileus which persists for more than 3 days following surgery*

Answer 58

Subphrenic abscess Subphrenic abscess is a disease characterized by an accumulation of infected fluid between the diaphragm, liver, and spleen. This abscess develops after surgical operations like splenectomy. Presents with *_cough*_, increased _*respiratory rate*_ with shallow respiration, diminished or absent breath sounds, _*hiccups*_, dullness in percussion, tenderness over the 8th–11th ribs, fever, chills, _*anorexia_* and shoulder tip pain on the affected side. Lack of treatment or misdiagnosis could quickly lead to sepsis, septic shock, and death. It is also associated with peritonitis.

Answer 59

**Erect CXR** An erect chest x-ray is a useful investigation in patients with an acute abdomen as it may demonstrate free air in the abdomen (pneumoperitoneum) - an abnormal finding suggestive of a perforated abdominal viscus (e.g. a perforated duodenal ulcer). Rigler's sign (double wall sign) may be seen on an abdominal film. CT is now the preferred method for detecting free air in the abdomen.

Answer 60

**Supine AXR** *Looking for small and large bowel obstruction is one of the key indications for performing an abdominal film.* * Small bowel * Maximum normal diameter = **35** mm * Valvulae conniventes extend all the way **across** * Large bowel * Maximum normal diameter = **55** mm * Haustra extend about a **third** of the way across

Answer 61

**CT KUB** **Passmed says: abdominal US but this is referring to the OLD guidelines!** Management: * Ureteric calculi less than 5mm * Manage expectantly * Stone burden of less than 2cm in aggregate * Lithotripsy * Complex renal calculi and staghorn calculi * Percutaneous nephrolithotomy * Stone burden of less than 2cm in pregnant females * Ureteroscopy

Answer 62

**Pyelonephritis** * Loin pain * Fever and rigors * Vomiting * If ARF: oliguria * dysuria, freq, foul smelling urine * +ve urine dip For patients with sign of acute pyelonephritis hospital admission should be considered local antibiotic guidelines should be followed if available the BNF currently recommends a broad-spectrum ***cephalosporin or a quinolone*** (for non-pregnant women) for 10-14 days

Answer 63

**Felodipine** CCB * ACEi*= CI in peripheral vascular disease * Diltiazem* = (non-DHP calcium channel blocker) caution in patients with bradycardia (avoid if severe); first degree AV block; _heart failure_; prolonged PR interval; significantly impaired left ventricular function B-blockers= cause peripheral vasoconstriction + worsen ischaemia in PVD ARBs= caustion in afro-Caribbean patients—particularly those with left ventricular hypertrophy (may not benefit from an angiotensin-II receptor antagonist); aortic or mitral valve stenosis; elderly (lower initial doses may be appropriate); hypertrophic cardiomyopathy; patients with a history of angioedema; patients with primary aldosteronism (may not benefit from an angiotensin-II receptor antagonist); renal artery stenosis

Answer 64

**Polymyalgia rheumatica** _Pathophysiology_ * overlaps with temporal arteritis * histology shows vasculitis with giant cells, characteristically 'skips' certain sections of affected artery whilst damaging others * muscle bed arteries affected most in polymyalgia rheumatica _Features_ * typically patient \> 60 years old * usually rapid onset (e.g. \< 1 month) * aching, morning ***stiffness*** in proximal limb muscles (not ***weakness***) * also mild polyarthralgia, lethargy, depression, low-grade fever, anorexia, night sweats _Investigations_ * ESR \> 40 mm/hr * note CK and EMG normal * reduced CD8+ T cells _Treatment:_ prednisolone e.g. 15mg/od - dramatic response In polymyositis: CK raised and WEAKNESS! * Inclusion Body Myositis * Asymmetric weakness affecting distal and prox muscles * Early involvement of quads, ankle dorsiflexor and wrist/finger flexors * → loss of grip strength and ↓dexterity * Dysphagia is very common * Myalgia is relatively uncommon

Answer 65

**Take to theatre** _Testicular torsion_ * Twist of the spermatic cord resulting in testicular ischaemia and necrosis. * Most common in males aged between 10 and 30 (peak incidence 13-15 years) * Pain is usually severe and of sudden onset. * Cremasteric reflex is lost and elevation of the testis does not ease the pain. * Treatment is with _surgical exploration_. If a torted testis is identified then both testis should be fixed as the condition of bell clapper testis is often bilateral.

Answer 66

**Embolectomy** Most likely emboli (AF; mural thrombosis) therefore best method of treatment within 6 hrs is embolectomy This is an emergency and may require urgent open surgery or angioplasty. If diagnosis is in doubt, do urgent arteriography. If the occlusion is embolic, the options are surgical _embolectomy_ (Fogarty catheter) or local _thrombolysis_, eg tissue plasminogen activator (t-PA, p339), balancing the risks of surgery with the haemorrhagic complications of thrombolysis. Anticoagulate with heparin after either procedure and look for the source of emboli. Be aware of possible post-op reperfusion injury and subsequent compartment syndrome. Surgical: Revascularisation within 6 hours in order to salvage limb. Operative risk is often high due to underlying heart disease. Postoperative anticoagulation is essential.

Answer 67

**Peritonsillar abscess** (quinsy) ... typically develops as a complication of bacterial tonsillitis. Features include: * severe throat pain, which lateralises to one side * deviation of the uvula to the unaffected side * trismus (difficulty opening the mouth) * reduced neck mobility Patients need urgent review by an ENT speciailist. Most patients are treated with needle aspiration under local anaethaesia.

Answer 68

**Treponema Pallidum** _Painful_= Herpes-HSV2 (more commonly) then Chancroid-Haemophilus ducreyi _Painless_=Syphilis-Treponema Pallidum (more commonly) then Lymphogranuloma venereum -Chlamydia * _Genital herpes_ is most often caused by the herpes simplex virus (HSV) type 2 (cold sores are usually due to HSV type 1). Primary attacks are often severe and associated with fever whilst subsequent attacks are generally less severe and localised to one site * _Chancroid_ is a tropical disease caused by Haemophilus ducreyi. It causes painful genital ulcers associated with unilateral, painful inguinal lymph node enlargement. The ulcers typically have a sharply defined, ragged, undermined border. * _Syphilis_ is a sexually transmitted infection caused by the spirochaete Treponema pallidum. Infection is characterised by primary, secondary and tertiary stages. A painless ulcer (chancre) is seen in the primary stage. The incubation period= 9-90 days * _Lymphogranuloma venereum_ (LGV) is caused by Chlamydia trachomatis. Typically infection comprises of three stages * stage 1: small painless pustule which later forms an ulcer * stage 2: painful inguinal lymphadenopathy * stage 3: proctocolitis LGV is treated using doxycycline. Other causes of genital ulcers: * Behcet's disease * carcinoma * granuloma inguinale: Klebsiella granulomatis

Answer 69

**Acne rosacea** ...is a chronic skin disease of unknown aetiology _Features_ * typically affects nose, cheeks and forehead * flushing is often first symptom * telangiectasia are common * later develops into persistent erythema with papules and pustules * rhinophyma * ocular involvement: blepharitis _Management_ * topical metronidazole may be used for mild symptoms (i.e. Limited number of papules and pustules, no plaques) * more severe disease is treated with systemic antibiotics e.g. Oxytetracycline recommend daily application of a high-factor sunscreen camouflage creams may help conceal redness laser therapy may be appropriate for patients with prominent telangiectasia

Answer 70

**SCC** _Risk factors include:_ * excessive exposure to sunlight / psoralen UVA therapy * *actinic keratoses and Bowen's disease* * immunosuppression e.g. following renal transplant, HIV * smoking * long-standing leg ulcers (Marjolin's ulcer) * genetic conditions e.g. xeroderma pigmentosum, oculocutaneous albinism _Treatment_: Surgical excision with 4mm margins if lesion \<20mm in diameter. If tumour \>20mm then margins should be 6mm. Mohs micrographic surgery may be used in high-risk patients and in cosmetically important sites. *_Actinic_*, or solar, keratoses (AK) is a common premalignant skin lesion that develops as a consequence of chronic sun exposure * Features * small, crusty or scaly, lesions * may be pink, red, brown or the same colour as the skin * typically on sun-exposed areas e.g. temples of head * multiple lesions may be present * Management options include * prevention of further risk: e.g. sun avoidance, sun cream * fluorouracil cream: typically a 2 to 3 week course. The skin will become red and inflamed - sometimes topical hydrocortisone is given following fluorouracil to help settle the inflammation * topical diclofenac: may be used for mild AKs. Moderate efficacy but much fewer side-effects * topical imiquimod: trials have shown good efficacy * cryotherapy * curettage and cautery

Answer 71

**Superficial spreading** _Classification of Malignant Melanoma_ * Superficial Spreading: 80% * Irregular boarders, colour variation * Commonest in Caucasians * Grow slowly, metastasise late = better prognosis * Lentigo Maligna Melanoma * Often elderly pts. * Face or scalp * Acral Lentiginous * Asians/blacks * Palms, soles, subungual (c¯ Hutchinson’s sign) * Nodular Melanoma * All sites * Younger age, new lesion * Invade deeply and metastasis early = poor prog * Amelanotic * Atypical appearance → delayed Dx *Staging and Prognosis* * *Breslow Depth* * Thickness of tumour to deepest point of dermal invasion * \<1mm = 95-100% 5ys * \>4mm = 50% 5ys * *Clark’s Staging* * Stratifies depth by 5 anatomical levels * Stage 1: Epidermis * Stage 5: sc fat nb metastasis to liver/eye!

Answer 72

**Dx - decrease in exocrine pancreatic function** _Chronic pancreatitis_...is an inflammatory condition which can ultimately affect both the exocrine and endocrine functions of the pancreas. Around 80% of cases are due to alcohol excess with up to 20% of cases being unexplained * Features * pain is typically worse 15 to 30 minutes following a meal * steatorrhoea: symptoms of pancreatic insufficiency usually develop between 5 and 25 years after the onset of pain * diabetes mellitus develops in the majority of patients. It typically occurs more than 20 years after symptom begin * Investigation * abdominal x-ray shows pancreatic calcification in 30% of cases * CT is more sensitive at detecting pancreatic calcification. Sensitivity is 80%, specificity is 85% * *functional tests: faecal elastase may be used to assess exocrine function if imaging inconclusive* * Management * pancreatic enzyme supplements * analgesia * antioxidants: limited evidence base - one study suggests benefit in early disease

Answer 73

**Femoral nerve block** Paracetamol, not working NSAIDs CI opiods: IV repeated bolus of morphine Patient controlled pethidine: used post op for major abdominal surgery * 1.3 Analgesia* * 1.3.1Assess the patient's pain:* * immediately upon presentation at hospital and* * within 30 minutes of administering initial analgesia and hourly until settled on the ward and* * regularly as part of routine nursing observations throughout admission. [2011]* * 1.3.2Offer immediate analgesia to patients presenting at hospital with suspected hip fracture, including people with cognitive impairment. [2011]* * 1.3.3Ensure analgesia is sufficient to allow movements necessary for investigations (as indicated by the ability to tolerate passive external rotation of the leg), and for nursing care and rehabilitation. [2011]* * 1.3.4Offer paracetamol every 6 hours preoperatively unless contraindicated. [2011]* * 1.3.5Offer additional opioids if paracetamol alone does not provide sufficient preoperative pain relief. [2011]* * 1.3.6Consider adding nerve blocks _if paracetamol and opioids_ do not provide sufficient preoperative pain relief, or to limit opioid dosage. Nerve blocks should be administered by trained personnel. Do not use nerve blocks as a substitute for early surgery. [2011]* * 1.3.7Offer paracetamol every 6 hours postoperatively unless contraindicated. [2011]* * 1.3.8Offer additional opioids if paracetamol alone does not provide sufficient postoperative pain relief. [2011]* * 1.3.9Non-steroidal anti-inflammatory drugs (NSAIDs) are not recommended. [2011]*

Answer 74

**Symptom control with NSAID** Management of musculoskeletal AND prolapsed disc: * analgesia, physiotherapy, exercises * if symptoms persist then referral for consideration of MRI is appropriate Investigation * lumbar spine x-ray should not be offered * MRI should only be offered to patients with non-specific back pain 'only if the result is likely to change management' and to patients where malignancy, infection, fracture, cauda equina or ankylosing spondylitis is suspected Advice to people with low back pain * try to encourage self-management * stay physically active and exercise * Analgesia * NSAIDS are now recommended first-line for patients with back pain. This follows studies that show paracetamol monotherapy is relatively ineffective for back pain * proton pump inhibitors should be co-prescribed for patients over the age of 45 years who are given NSAIDs * NICE guidelines on neuropathic pain should be followed for patients with sciatica Red flags for lower back pain * age \< 20 years or \> 50 years * history of previous malignancy * night pain * history of trauma * systemically unwell e.g. weight loss, fever

Answer 75

**IgE** Allergic rhinitis The underlying mechanism involves IgE antibodies attaching to the allergen and causing the release of inflammatory chemicals such as histamine from mast cells. Diagnosis is usually based on a medical history in combination with a skin prick test or blood tests for allergen-specific IgE antibodies. These tests, however, are sometimes falsely positive. The symptoms of allergies resemble those of the common cold; however, they often last for more than two weeks and typically do not include a fever.

Answer 76

**slow rising pulse** _Symptoms_ * Triad: angina, dyspnoea, syncope (esp. c¯ exercise) * LVF: PND, orthopnoea, frothy sputum * Arrhythmias * Systemic emboli if endocarditis * Sudden death _Signs_ * Slow rising pulse c¯ narrow PP * Aortic thrill * Apex: Forceful, non-displaced (pressure overload) * Heart Sounds * Quiet A2 * Early syst. ejection click if pliable (young) valve * S4 (forceful A contraction vs. hypertrophied V) * Murmur * ESM * Right 2nd ICS * Sitting forward in end-expiration * Radiates to carotids _Clinical Indicators of Severe AS_ * Quiet / absent A2 * S4 * Narrow pulse pressure * Decompensation: LVF

Answer 77

**Empyema** Presentation * Symptoms * Asymptomatic * Dyspnoea * Pleuritic chest pain * Signs * Tracheal deviation away from effusion * ↓ expansion * Stony dull percussion * ↓ air entry * Bronchial breathing just above effusion * ↓VR Empyema=Pus in the pleural cavity * Anaerobes, Staph, Gm-ve * Assoc. c¯ recurrent aspiration * Pt. c¯ resolving pneumonia develops recurrent fever * Tap: turbid, pH\<7.2, ↓glucose, ↑LDH * Mx: US guided chest drain + Abx

Answer 78

**Pyridoxine** Isoniazid * mechanism of action: inhibits mycolic acid synthesis * peripheral neuropathy: prevent with pyridoxine (Vitamin B6) * hepatitis, agranulocytosis * liver enzyme inhibitor Rifampicin * mechanism of action: inhibits bacterial DNA dependent RNA polymerase preventing transcription of DNA into mRNA * potent liver enzyme inducer * hepatitis, orange secretions * flu-like symptoms Pyrazinamide * mechanism of action: converted by pyrazinamidase into pyrazinoic acid which in turn inhibits fatty acid synthase (FAS) I * hyperuricaemia causing gout * arthralgia, myalgia * hepatitis Ethambutol * mechanism of action: inhibits the enzyme arabinosyl transferase which polymerizes arabinose into arabinan * optic neuritis: check visual acuity before and during treatment * dose needs adjusting in patients with renal impairment

Answer 79

**Negative pressure room + respiratory measures for staff** * Isolate patient in a side room with ***negative pressure ventilation*** or ventilated to an outside window * Wear gowns and masks if the patient has multi-drug-resistant TB (or when performing aerosol-generating procedures if non MDR-TB) * Ensure the patient wears a mask if moving outside the side room

Answer 80

**Flexi sigmoidoscopy** ~Investigations: * FBC - anaemia due to blood loss; leukocytosis * ESR - increased; correlates with active disease * CRP - raised; but less so than in Crohn's disease * biochemistry - in active disease, biochemical abnormalities may include hypokalaemia, hyponatraemia, hypomagnesaemia, hypocalcaemia, and hyoalbuminaemia. Abnormal LFTs due to associated chronic active hepatitis - increased ALT - or sclerosing cholangitis - increased alkaline phosphatase * ANCA - found in HLA-DR2 associated form of ulcerative colitis * radiology: * plain abdominal x-ray - excludes toxic dilatation, which is more than 5.5 cm in diameter in adults * barium enema: * diagnosis of extent and severity of the disease * procedure is contraindicated in those patients at risk of a toxic dilatation * rectal biopsy - taken at sigmoidoscopy * colonoscopy - this is contraindicated in those patients at risk of toxic dilatation. Allows multiple biopsies to be taken throughout the colon and delineation of the extent and activity of the disease * white cell scan - allows imaging in severe disease * molecular biology - a high intensity of CD44v6 and v3 epitope expression on crypt epithelial cells in patients with UC has been noted. This observation may have diagnostic potential in distinguishing UC from Crohn's Diagnosis: * proctosigmoidoscopy or colonoscopy with characteristic changes of ulcerative colitis (loss of the typical vascular pattern, granularity, friability, and ulceration) * biopsy - to distinguish UC from infectious colitis * negative stool examination - for infectious causes

Answer 81

**Phenytoin loading** This is a medical emergency. The priority is termination of seizure activity, which if prolonged will lead to irreversible brain damage. First-line drugs are benzodiazepines such as diazepam or lorazepam. If ineffective within 10 minutes it is appropriate to start a second-line agent such as phenytoin, sodium valproate, levetiracetam, or phenobarbital. If no response within 30 minutes from onset, then the best way to achieve rapid control of seizure activity is induction of general anaesthesia.

Answer 82

**Pneumococcus** *The increased risk of infection in patients with hyposplenism is lifelong, but is highest early after splenectomy, the highest risk being from pneumococcal infection*. _Hyposplenism_ may complicate certain medical conditions where splenic atrophy occurs or may be the result of medical intervention such as splenic artery embolization and splenectomy for trauma. Diagnosis of hyposplenism is difficult and whilst there may be peripheral markers of the splenectomised state (e.g. Howell-Jolly bodies) these are neither 100% sensitive or specific. The most sensitive test is a radionucleotide labelled red cell scan. Hyposplenism, by whatever mechanism it occurs dramatically increases the risk of post-splenectomy sepsis, particularly with encapsulated organisms. Since these organisms may be opsonised, but this then goes undetected at an immunological level due to loss of the spleen. For this reason, individuals are recommended to be vaccinated and have antibiotic prophylaxis. Key recommendations * All those with hyposplenism or may become so (such as prior to an elective splenectomy) should receive *pneumococcal, Haemophilus type b and meningococcal type C vaccines*. These should be administered 2 weeks prior to splenectomy or two weeks following splenectomy. The vaccine schedule for meningococcal disease essentially consists of a dose of Men C and Hib at 2 weeks and then a dose of the MenACWY vaccine one month later. Those aged under 2 may require a booster at 2 years. A dose of pneumococcal polyvalent polysaccharide vaccine (PPV) is given at two weeks. A conjugated vaccine (PCV) is offered to young children. The PCV is more immunogenic but covers fewer serotypes. Boosting PPV is either guided by serological measurements (where available) or by routine boosting doses at 5 yearly intervals. * Annual influenza vaccination is recommended in all cases * Antibiotic prophylaxis is offered to all. The risk of post-splenectomy sepsis is greatest immediately following splenectomy and in those aged less than 16 years or greater than 50 years. Individuals with a poor response to pneumococcal vaccination are another high-risk group. High-risk individuals should be counselled to take _penicillin or macrolide prophylaxis_. Those at low risk may choose to discontinue therapy. All patients should be advised about taking antibiotics early in the case of intercurrent infections. * Asplenic individuals travelling to malaria endemic areas are at high risk and should have both pharmacological and mechanical protection.

Answer 83

**Obstruction of IVC** IVCS is a result of obstruction of the inferior vena cava. Presentation * Edema of the lower extremities (peripheral edema), caused by an increase in the blood pressure in the veins. * Tachycardia. This is caused by the decreased preload, causing the heart to increase its frequency. * In pregnant women, signs of fetal hypoxia and distress may be seen in the cardiotocography. This is caused by decreased perfusion of the uterus, resulting in hypoxemia of the fetus. * Supine hypotensive syndrome Causes * Obstruction by deep vein thrombosis or tumors (most commonly _renal cell carcinoma_) * Compression through external pressure by neighbouring structures or tumors, either by significantly compressing the vein or by promoting thrombosis by causing turbulence by disturbing the blood flow. This is quite common during the third trimester of pregnancy when the uterus compresses the vein in the right side position. * Iatrogenic causes may be suspected in patients with a medical history of liver transplantion, vascular catheters, dialysis and other invasive procedures in the vicinity * Budd-Chiari syndrome

Answer 84

1. How is the patient? 2. Is the patient hypoxaemic? *the Pa02 on air should be \>10 kPa* 3. Is the patient acidaemic (pH \<7.35) or alkalaemic (pH \>7.45) 4. Respiratory component: What has happened to the PaCO2? * *PaCO2 \> 6.0 kPa suggests a respiratory acidosis (or respiratory compensation for a metabolic alkalosis)* * *PaCO2 \< 4.7 kPa suggests a respiratory alkalosis (or respiratory compensation for a metabolic acidosis)* 5. Metabolic component: What is the bicarbonate level/base excess? * *bicarbonate \< 22 mmol/l (or a base excess \< - 2mmol/l) suggests a metabolic acidosis (or renal compensation for a respiratory alkalosis)* * *bicarbonate \> 26 mmol/l (or a base excess \> + 2mmol/l) suggests a metabolic alkalosis (or renal compensation for a respiratory*

Answer 85

**Anal fissure** ...longitudinal or elliptical tears of the squamous lining of the distal anal canal. If present for less than 6 weeks they are defined as acute, and chronic if present for more than 6 weeks. Around 90% of anal fissures occur on the posterior midline _Risk factors_ * constipation * inflammatory bowel disease * sexually transmitted infections e.g. HIV, syphilis, herpes _Features_ painful, bright red, rectal bleeding _Management_ of an acute anal fissure (\< 6 weeks) * dietary advice: high-fibre diet with high fluid intake * bulk-forming laxatives are first line - if not tolerated then lactulose should be tried * lubricants such as petroleum jelly may be tried before defecation * topical anaesthetics * analgesia * topical steroids do not provide significant relief _Management_ of a chronic anal fissure (\> 6 weeks) * the above techniques should be continued * topical glyceryl trinitrate (GTN) is first line treatment for a chronic anal fissure * if topical GTN is not effective after 8 weeks then secondary referral should be considered for surgery or botulinum toxin

Answer 86

**Decrease frequency of ventilations** -\>CO2 retention-\>acidosis Respiratory alkalosis occurs when an increase in ventilatory volume and/or rate causes a decrease in PaCO2. Such increased ventilation is often in response to pain, anxiety, hypoxia or fever – or when the patient on mechanical mandatory ventilation is ‘over-ventilated’. Metabolic alkalosis is characterised by an increase in bicarbonate with or without a compensatory increase in CO2. It may occur from: * Excess acid loss (such as in pyloric stenosis). * Excess ingestion of alkali (rare). * Renal bicarbonate retention (rare). * As a consequence of hypokalaemia (causing a shift in H+).

Answer 87

**Pulmonary fibrosis** _Obstructive lung disease_ * Spirometry * FEV1 - significantly reduced * FVC - reduced or normal * FEV1% (FEV1/FVC) - reduced * DDx * Asthma * COPD * Bronchiectasis * Bronchiolitis obliterans Restrictive lung disease * spirometry * FEV1 - reduced * FVC - significantly reduced * FEV1% (FEV1/FVC) - normal or increased * DDx * Pulmonary fibrosis * Asbestosis * Sarcoidosis * Acute respiratory distress syndrome * Infant respiratory distress syndrome * Kyphoscoliosis * Neuromuscular disorders

Answer 88

**Chronic Bronchitis** *cough and sputum production on most days for 3mo of 2 successive years.* * Obstructive lung disease * Spirometry * FEV1 - significantly reduced * FVC - reduced or normal * FEV1% (FEV1/FVC) - reduced * DDx * Asthma * COPD * Bronchiectasis * Bronchiolitis obliterans * Restrictive lung disease * spirometry * FEV1 - reduced * FVC - significantly reduced * FEV1% (FEV1/FVC) - normal or increased * DDx * Pulmonary fibrosis * Asbestosis * Sarcoidosis * Acute respiratory distress syndrome * Infant respiratory distress syndrome * Kyphoscoliosis * Neuromuscular disorders

Answer 89

**Staph Aureus** The following types of patients are affected: * previously normal valves (50%, typically acute presentation) * rheumatic valve disease (30%) * prosthetic valves * congenital heart defects * intravenous drug users (IVDUs, e.g. typically causing tricuspid lesion) Causes * historically Streptococcus viridans was the most common cause of infective endocarditis. This is no longer the case, except in developing countries. Staphylococcus aureus is now the most common cause of infective endocarditis. Staphylococcus aureus is also particularly common in acute presentation and IVDUs * coagulase-negative Staphylococci such as Staphylococcus epidermidis commonly colonize indwelling lines and are the most cause of endocarditis in patients following prosthetic valve surgery, usually the result of perioperative contamination. After 2 months the spectrum of organisms which cause endocarditis return to normal (i.e. Staphylococcus aureus is the most common cause) * Streptococcus viridans still accounts for around 20% of cases. Technically Streptococcus viridans is a pseudotaxonomic term, referring to viridans streptococci, rather than a particular organism. The two most notable viridans streptococci are Streptococcus mitis and Streptococcus sanguinis. They are both commonly found in the mouth and in particular dental plaque so endocarditis caused by these organisms is linked with poor dental hygiene or following a dental procedure * Streptococcus bovis is associated with colorectal cancer * non-infective: systemic lupus erythematosus (Libman-Sacks), malignancy: marantic endocarditis Culture negative causes: * prior antibiotic therapy * Coxiella burnetii * Bartonella * Brucella * HACEK: Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella)

Answer 90

**Crohn's** ...is a form of inflammatory bowel disease. It commonly affects the terminal ileum and colon but may be seen anywhere from the mouth to anus. Pathology * cause is unknown but there is a strong genetic susceptibility * inflammation occurs in all layers, down to the serosa. This is why patients with Crohn's are prone to strictures, fistulas and adhesions Crohn's disease typically presents in late adolescence or early adulthood. Features include: * presentation may be non-specific symptoms such as weight loss and lethargy * diarrhoea: the most prominent symptom in adults. Crohn's colitis may cause bloody diarrhoea * abdominal pain: the most prominent symptom in children * perianal disease: e.g. Skin tags or ulcers * extra-intestinal features are more common in patients with colitis or perianal disease Investigations * raised inflammatory markers * increased faecal calprotectin * anaemia * low vitamin B12 and vitamin D

Answer 91

**Mitral regurgitation** * MI-\>Papillary muscle / chordae → MR * (PSM + Pulmonary oedema) * MI-\> _Septum rupture_ * (PSM + ↑JVP + Heart failure) * Mi-\> Left ventricular free wall rupture -\>Cardiac tamponade * (Beck’s triad (↓BP, ↑JVP, muffled heart sounds) + Pulsus paradoxus) ***_Mitral Regurgitation:_*** _Causes_ * Mitral valve prolapse * LV dilatation: AR, AS, HTN * Annular calcification → contraction (elderly) * Post-MI: papillary muscle dysfunction/rupture * Rheumatic fever * Connective tissue: Marfan’s, Ehlers-Danlos _Symptoms_ * Dyspnoea, fatigue * AF → palpitations + emboli * Pulmonary congestion → HTN + oedema _Signs_ * AF * Left parasternal heave (RVH) * Apex: displaced * Volume overload as ventricle has to pump forward SV and regurgitant volume * -\> eccentric hypertrophy * Heart Sounds * Soft S1 * S2 not heard separately from murmur * Loud P2 (if PTH) * Murmur * Blowing PSM * Apex * Left lateral position in end expiration * Radiates to the axilla

Answer 92

**Brown-Sequard syndrome (spinal cord hemisection)** Tracts affected: 1. Lateral corticospinal tract 2. Dorsal columns 3. Lateral spinothalamic tract Clinical notes 1. *Ipsilateral spastic paresis below lesion* 2. *Ipsilateral loss of proprioception and vibration sensation* 3. *Contralateral loss of pain and temperature sensation*

Answer 93

**Antero-lateral** =Circumflex artery