2017 (Paper 2) Flashcards

Question

**Sickle cell girl with severe back pain (?) What do you do first?** *Options:* Exchange transfusion Epidural anaesthesia Paracetamol/ibuprofen Fluid bolus

Answer 1

**Fluid bolus** Sickle cell anaemia is characterised by periods of good health with intervening crises Four main types of crises are recognised: 1. Thrombotic crises/Vaso-occlusive ‘painful’ crisis: * precipitated by infection, dehydration, deoxygenation * infarcts occur in various organs including the bones (e.g. avascular necrosis of hip, hand-foot syndrome in children, lungs, spleen and brain * may cause mesenteric ischaemia, mimicking an acute abdomen 2. Sequestration crises * sickling within organs such as the spleen or lungs causes pooling of blood with worsening of the anaemia * acute chest syndrome: dyspnoea, chest pain, pulmonary infiltrates, low pO2 - the most common cause of death after childhood 3. Aplastic crises * caused by infection with parvovirus * sudden fall in haemoglobin 4. Haemolytic crises * rare * fall in haemoglobin due an increased rate of haemolysis Give prompt, generous analgesia, eg IV opiates (see p576). • Crossmatch blood. FBC, reticulocytes, blood cultures, MSU ± CXR if T° or chest signs. • Rehydrate with IVI and keep warm. Give O2 by mask if Pa O2 or O2 sats \<95%. • ‘Blind’ antibiotics (eg cephalosporin, p382) if T° \>38°, unwell, or chest signs. • Measure PCV, reticulocytes, liver, and spleen size twice daily. • Give blood transfusion if Hb or reticulocytes fall sharply. Match blood for the blood group antigens Rh(C, D, E) and Kell, to prevent alloantibody formation. This helps oxygenation, and is as good as exchange transfusion (reserved for those who are rapidly worsening: it is a process where blood is removed and donor blood is given in stages). 40 Indications: severe chest crisis, suspected CNS event or multiorgan failure—when the proportion of HbS should be reduced to \<30%. Mx Acute Crises * General * Analgesia: opioids IV * Good hydration * O2 * Keep warm * Ix * FBC, U+E, reticulocytes, cultures * Urine dip * CXR * Rx * Blind Abx: e.g. ceftriaxone * Transfusion: exchange if severe

Answer 2

**CLL** Chronic lymphocytic leukaemia is caused by a monoclonal proliferation of well-differentiated lymphocytes which are almost always B-cells (99%) Features * often none * constitutional: anorexia, weight loss * bleeding, infections * lymphadenopathy more marked than CML Complications * hypogammaglobulinaemia leading to recurrent infections * warm autoimmune haemolytic anaemia in 10-15% of patients * transformation to high-grade lymphoma (Richter's transformation) **Investigations** * blood film: smudge cells (also known as smear cells) * immunophenotyping

Answer 3

**OGD on next endoscopy list (\<24hrs)** Ideally all patients admitted with upper gastrointestinal haemorrhage should undergo Upper GI endoscopy within 24 hours of admission. In those who are unstable this should occur immediately after resuscitation or in tandem with it. The endoscopy department is a potentially dangerous place for unstable patients and it may be safer to perform the endoscopy in theatre with an anaesthetist present. Management of GI bleed ABCDE: CIRCULATION! * Resuscitate: * Head down * **A**irway: Early control of airway is vital (e.g. Drowsy patient with liver failure) -\> protect the airway * **B**reathing: 100% O2 * **C** 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) * 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.

Answer 4

**Adrenaline** IM 500 micrograms (0.5ml 1 in 1,000) hydrocortisone (200mg) Chlorphenamine (10mg) Salbutamol (5mg)

Answer 5

**anti-mitochondrial antibodies (AMA)** **M2** subtype are present in 98% of patients and are highly specific Primary biliary cirrhosis (now increasingly referred to as primary biliary cholangitis) is a chronic liver disorder typically seen in middle-aged females (female:male ratio of 9:1). The aetiology is not fully understood although it is thought to be an autoimmune condition. Interlobular bile ducts become damaged by a chronic inflammatory process causing progressive cholestasis which may eventually progress to cirrhosis. The classic presentation is itching in a middle-aged woman Associations: * Sjogren's syndrome (seen in up to 80% of patients) * rheumatoid arthritis * systemic sclerosis * thyroid disease Diagnosis * anti-mitochondrial antibodies (AMA) M2 subtype are present in 98% of patients and are highly specific * smooth muscle antibodies in 30% of patients * raised serum IgM Management * pruritus: cholestyramine * fat-soluble vitamin supplementation * ursodeoxycholic acid * liver transplantation e.g. if bilirubin \> 100 (PBC is a major indication) - recurrence in graft can occur but is not usually a problem

Answer 6

**Granulomatous** * PBC: intrahepatic destruction by chronic _granulomatous inflammation_ results in cirrhosis* * PSC: inflammation, _fibrosis and strictures_ and _intra and extrahepatic ducts_* Primary biliary cirrhosis (now increasingly referred to as primary biliary cholangitis) is a chronic liver disorder typically seen in middle-aged females (female:male ratio of 9:1). The aetiology is not fully understood although it is thought to be an autoimmune condition. Interlobular bile ducts become damaged by a chronic inflammatory process causing progressive cholestasis, which may eventually progress to cirrhosis. The classic presentation is itching in a middle-aged woman Clinical features early: may be asymptomatic (e.g. raised ALP on routine LFTs) or fatigue, pruritus cholestatic jaundice hyperpigmentation, especially over pressure points xanthelasmas, xanthomata also: clubbing, hepatosplenomegaly late: may progress to liver failure Complications malabsorption: osteomalacia, coagulopathy sicca syndrome occurs in 70% of cases portal hypertension: ascites, variceal haemorrhage hepatocellular cancer (20-fold increased risk)

Answer 7

absence of Renal failure =\> **Morphine sub cut infusion** Fentanyl transdermal Opioids should be used with caution in patients with chronic kidney disease. Alfentanil, buprenorphine and fentanyl are preferred Vominting, therefore not: Morphine subcut prn Oral morph slow release tablets Oral morph solution prn

Answer 8

**Septic Arthrisis** Symptoms * Acutely inflamed tender, swollen joint. * ↓ROM * Systemically unwell Investigations * Joint aspiration for MCS * ↑↑ WCC (e.g. \>50,000/mm3) : mostly PMN * ↑ESR/CRP, ↑WCC, Blood cultures * X-ray Management * IV Abx: vanc + cefotaxime * Consider joint washout under GA * Splint joint * Physiotherapy after infection resolved

Answer 9

**Folate deficiency** Complications of coeliac disease * anaemia: iron, folate and vitamin B12 deficiency (folate deficiency is more common than vitamin B12 deficiency in coeliac disease) * hyposplenism * osteoporosis, osteomalacia (*vit D)* * lactose intolerance * enteropathy-associated T-cell lymphoma of small intestine * subfertility, unfavourable pregnancy outcomes * rare: oesophageal cancer, other malignancies Coeliac disease is an autoimmune condition caused by sensitivity to the protein gluten. It is thought to affect around 1% of the UK population. 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). It is strongly associated with HLA-DQ2 (95% of patients) and HLA-DQ8 (80%). Signs and symptoms: *(indications for coeliac disease screening)* * 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 associated condictions: *(indications for coeliac disease screening)* * Autoimmune thyroid disease * Dermatitis herpetiformis * Irritable bowel syndrome * Type 1 diabetes * First-degree relatives (parents, siblings or children) with coeliac disease

Answer 10

**Extrinsic allergic alveolitis** (**EAA**, also known as **hypersensitivity pneumonitis**) ...is a condition caused by hypersensitivity induced lung damage due to a variety of inhaled organic particles. It is thought to be largely caused by immune-complex mediated tissue damage (type III hypersensitivity) although delayed hypersensitivity (type IV) is also thought to play a role in EAA, especially in the chronic phase. Examples * *bird fanciers' lung: avian proteins* * *farmers lung*: spores of *Saccharopolyspora* rectivirgula (formerly Micropolyspora faeni) * *malt workers' lung*: Aspergillus clavatus * *mushroom workers' lung*: thermophilic actinomycetes\* Presentation * acute: occur 4-8 hrs after exposure, SOB, dry cough, fever * chronic Investigation * chest x-ray: upper/mid-zone fibrosis * bronchoalveolar lavage: lymphocytosis * blood: NO eosinophilia

Answer 11

**Colchicine** _BNF_: *Colchicine is an alternative in patients in whom NSAIDs are contra-indicated. Aspirin is not indicated in gout. Allopurinol, febuxostat, and uricosurics are not effective in treating an acute attack and may prolong it indefinitely if started during the acute episode.* *The use of colchicine is limited by the development of toxicity at higher doses, but it is of value in patients with heart failure since, unlike NSAIDs, it does not induce fluid retention; moreover, it can be given to patients receiving anticoagulants.* Gout is a form of microcrystal synovitis caused by the deposition of monosodium urate monohydrate in the synovium. It is caused by chronic hyperuricaemia (uric acid \> 450 µmol/l) Acute management * NSAIDs * intra-articular steroid injection * colchicine\* has a slower onset of action. The main side-effect is diarrhoea * oral steroids may be considered if NSAIDs and colchicine are contraindicated. A dose of prednisolone 15mg/day is usually used * if the patient is already taking allopurinol it should be continued Chronic Management Allopurinol prophylaxis * allopurinol should not be started until 2 weeks after an acute attack has settled as it may precipitate a further attack if started too early * initial dose of 100 mg od, with the dose titrated every few weeks to aim for a serum uric acid of \< 300 µmol/l * NSAID or colchicine cover should be used when starting allopurinol * Indications * recurrent attacks - 'if a second attack, or further attacks occur within 1 year' * tophi * renal disease * uric acid renal stones * prophylaxis if on cytotoxics or diuretics Lifestyle modifications * reduce alcohol intake and avoid during an acute attack * lose weight if obese * avoid food high in purines e.g. Liver, kidneys, seafood, oily fish (mackerel, sardines) and yeast products Other points * losartan has a specific uricosuric action and may be particularly suitable for the many patients who have coexistant hypertension * calcium channel blockers also decrease uric acid levels, possibly by a renal vasodilatory effect * increased vitamin C intake (either supplements or through normal diet) may also decrease serum uric acid levels

Answer 12

**Raynaud’s phenomena** **...**may be primary (Raynaud's disease) or secondary (Raynaud's phenomenon) Raynaud's disease typically presents in young women (e.g. 30 years old) with symmetrical attacks Factors suggesting underlying connective tissue disease * onset after 40 years * unilateral symptoms * rashes * presence of autoantibodies * features which may suggest rheumatoid arthritis or SLE, for example arthritis or recurrent miscarriages * digital ulcers, calcinosis * very rarely: chilblains Secondary causes * connective tissue disorders: scleroderma (most common), rheumatoid arthritis, SLE * leukaemia * type I cryoglobulinaemia, cold agglutinins * use of vibrating tools * drugs: oral contraceptive pill, ergot * cervical rib Management * first-line: calcium channel blockers e.g. nifedipine * IV prostacyclin infusions: effects may last several weeks/months

Answer 13

**PCP** ...Whilst the organism Pneumocystis carinii is now referred to as Pneumocystis jiroveci, the term Pneumocystis carinii pneumonia (PCP) is still in common use * 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 14

**Otosclerosis** _Rinne's test_ * tuning fork is placed over the mastoid process until the sound is no longer heard, followed by repositioning just over external acoustic meatus * air conduction (AC) is normally better than bone conduction (BC) * if BC \> AC then conductive deafness _Otosclerosis_ describes the replacement of normal bone by vascular spongy bone. It causes a progressive conductive deafness due to fixation of the stapes at the oval window. Otosclerosis is autosomal dominant and typically affects young adults Onset is usually at 20-40 years - features include: * conductive deafness * tinnitus * normal tympanic membrane\* * positive family history Management * hearing aid * stapedectomy \*10% of patients may have a 'flamingo tinge', caused by hyperaemia _Conductive_: Impaired conduction anywhere between auricle and round window. Canal obstruction: wax, FB TM perforation: trauma, infection Ossicle defects: otosclerosis, infection Fluid in middle ear _SNHL:_ Defects of cochlea, cohlear N. or brain Congenital * Alports: SNHL + haematuria * Jewell-Lange-Nielsen: SNHL + long QT Acquired * Presbyacussis * Drugs: gentamicin, vancomycin * Infection: meningitis, measles * Tumour: vestibular schwannoma Other: Meniere's, MS, CPA lesion (e.g. acoustic neuroma), ↓B12

Answer 15

**Erythema nodosum** Overview * inflammation of subcutaneous fat * typically causes tender, erythematous, nodular lesions * usually occurs over shins, may also occur elsewhere (e.g. forearms, thighs) * usually resolves within 6 weeks * lesions heal without scarring **Causes** * infection: _streptococci_, TB, brucellosis * systemic disease: sarcoidosis, inflammatory bowel disease, Behcet's * malignancy/lymphoma * drugs: penicillins, sulphonamides, combined oral contraceptive pill * pregnancy

Answer 16

**HSV** * Causes: bacterial, herpetic, fungal, protozoa, vasculitic (RA) * Dendritic ulcer = _Herpes simplex_ * Acanthamoeba: protazoal infection affecting _contact lens wearers swimming in pools._ Presentation * Pain, photophobia * Conjunctival hyperaemia * ↓ acuity * White corneal opacity Risk factors: contact lens wearers Ix: green c¯ fluorescein on slit lamp Rx: refer immediately to specialist who will * Take smears and cultures * Abx drops, oral/topical aciclovir * Cycloplegics/mydriatics ease photophobia * Steroids may worsen symptoms: professionals only Complications: Scarring and visual loss *Ophthalmic Shingles Zoster of CNV1 20% of all Shingles (only commoner in thoracic dermatomes) Presentation* * Pain in CNV1 dermatome precedes blistering rash * *40% → keratitis, iritis* * *Hutchinson’s sign* * *Nose-tip zoster due to involvement of nasociliary branch.* * *↑ chance of globe involvement as nasociliarry nerve also supplies globe* * *Ophthalmic involvement* * *Keratitis + corneal ulceration (fluorescein stains)* * *± iritis*

Answer 17

**VZV** (or Herpes Zoster) Shingles is an acute, unilateral, painful blistering rash caused by reactivation of the Varicella Zoster Virus (VZV). * Reactivation is due to ↓ immunity/stress * Lifetime prevalence = 20% * Painful vesicular rash in dermatomal distribution * Thoracic and ophthalmic most commonly * Herpes zoster ophthalmicus (HZO) describes the reactivation of the varicella zoster virus in the area supplied by the ophthalmic division of the trigeminal nerve. It accounts for around 10% of case of shingles. * Multidermatomal / disseminated in immunocomp * Ramsay Hunt = ear zoster, facial palsy, ↓ taste, ↓ hearing * Rx may ↓ progression to post-herpetic neuralgia \<72hrs: * Aciclovir PO/IV * Famciclovir * Valaciclovir * Post-Herpetic neuralgia = severe dermatomal pain *

Answer 18

**H.pylori stool antigen testing** urgent specialist referral for endoscopic investigation (i.e. seen within 2 weeks) is indicated for patients of any age with dyspepsia when presenting with any of the following: * chronic gastrointestinal bleeding * progressive unintentional weight loss * progressive difficulty swallowing * persistent vomiting * iron deficiency anaemia * epigastric mass or suspicious barium meal * *nb. also indicated if recent onset rapidly progressive symptoms* Routine endoscopic investigation of patients of any age, presenting with dyspepsia and without alarm signs, is not necessary * however, for patients over 55 years old, consider endoscopy **_when_** symptoms *persist despite Helicobacter pylori (H. pylori) testing and acid suppression therapy,* and when patients have one or more of the following: previous gastric ulcer or surgery, continuing need for NSAID treatment or raised risk of gastric cancer or anxiety about cancerReference:

Answer 19

**HSV** From the meninges, the virus extends to the adjacent brain where it affects the _temporal and inferior frontal lobes_ first and more severely, and then spreads to the rest of the brain. Adult HSV encephalitis is limited to the brain. Its symptoms are fever, confusion, coma, and seizures. In addition, because of the involvement of the frontal and temporal lobes, patients often display bizarre behaviour, personality changes, anosmia, and gustatory hallucinations. Survivors may have Korsakoff's amnesia, because of bilateral damage of the hippocampus, dementia, and seizures. The brain in advanced HSV encephalitis shows diffuse softening and edema, accentuated by _hemorrhagic necrosis_ of the i_nferior frontal and temporal lobes_.

Answer 20

**Toxoplasmosis** Toxoplasma gondii is a protozoa which infects the body via the GI tract, lung or broken skin. It's oocysts release trophozoites which migrate widely around the body including to the eye, brain and muscle. The usual animal reservoir is the cat, although other animals such as rats carry the disease. Toxoplasmosis * accounts for around 50% of cerebral lesions in patients with HIV * constitutional symptoms, headache, confusion, drowsiness * CT: usually single or multiple ring enhancing lesions, mass effect may be seen * management: sulfadiazine and pyrimethamin

Answer 21

**Acromegaly** In acromegaly there is excess growth hormone secondary to a pituitary adenoma in over 95% of cases. A minority of cases are caused by ectopic GHRH or GH production by tumours e.g. pancreatic Features * coarse facial appearance, spade-like hands, increase in shoe size * large tongue, prognathism, interdental spaces * excessive sweating and oily skin * features of pituitary tumour: hypopituitarism, headaches, bitemporal hemianopia * raised _prolactin_ in 1/3 of cases → galactorrhoea * 6% of patients have MEN-1 Complications * hypertension * diabetes (\>10%) * cardiomyopathy * colorectal cancer * Growth hormone (GH) levels vary during the day and are therefore not diagnostic. The definitive test is the oral glucose tolerance (OGTT) with serial GH measurements. Serum IGF-1 may also be used as a screening test and is sometimes used to monitor disease Oral glucose tolerance test * in normal patients GH is suppressed to \< 2 mu/L with hyperglycaemia * in acromegaly there is no suppression of GH * may also demonstrate impaired glucose tolerance which is associated with acromegaly

Answer 22

Norovirus * SRVS (small round structured virus) * Incubation 12–48h mean≈34h * Features= Fever, P, D & projectile V; 80 ‘winter vomiting illness’. : * no leucocytes in faeces; PCR * \*Fecal-oral (vomit is infectious); very contagious, and common. Infectious for up to 48h after symptoms resolve _Clostridium Difficile_ nitrofurantoin is less likely to cause C.Diff. This is more common with the use of quinolones, cephalosporins, clindamycin and amoxiclav Presents: * Bloody diarrhoea, abdo pain, fever- foul smelling * Pseudomembranous colitis * Toxic megacolon * GI perforation nb, _Secretory diarrhoea:_ * Bacteria only found in lumen: don’t activate innate immunity * No / low fever * No faecal leukocytes * Caused by bacterial toxins: Cholera, E. coli (except EIEC), S. aureus * Toxin → ↑cAMP→ open CFTR channel → Cl loss followed by HCO3, Na and H2O loss → secretory diarrhoea

Answer 23

**ABO incompatibility** _Febrile non-haemolytic transfusion reaction_ * Signs and symptoms: Fever, chills, headache, malaise, flushing * Mechanism: host abs vs donor MHC antigens or due to cytokines from leukocytes in donor blood * Treatment: discontinue transfusion, fever resolves in 15-30 mins without specific treatment. Paracetamol may be used * Other: most common transusion reaction, can be prevented with leukocyte filters or irradiation *_Haemolytic transfusion reaction_* * *Signs and symptoms: Fever, chills, pain at the infusion site, dark urine, nausea, shock* * *Mechanism: ABO incompatibility with host abs vs antigens on donor RBCs* * *Treatment: discontinue transfusion, administer fluids* * *Other: most SEVERE reaction* _Allergic transfusion reaction_ * Signs and symptoms: Uritcaria, pruritus * Mechanism: allergic reaction to plasma proteins in transfused blood * Treatment: DOES NOT require discontinuing transfusion, symptomatic treatment with antihistamines * Other: can be prevented with anti-histamine pre-treatment _Anaphylactic transfusion reaction_ * Signs and symptoms: Uritcaria, angioedema, wheezing, laryngeal oedema, abdo pain, hypotension, shock * Mechanism: Host abs vs IgA antibodies in the donor plasma * Treatment: discontinue transfusion, administer adrenaline * Other: Seen in pts with IgA deficiency, can be prevented by administering washed IgA decifient products _Transfusion relatied acute lung injury (TRALI)_ * Signs and symptoms: dyspnoea, hypoxaemia, bilateral chest infiltrates * Mechanism: donor Abs to MHC class I/II/Human neutrophil antigens. Activated neutrophils cause endothelial damage * Treatment: discontinue transfusion, provide airway support * Other: most common cause of transfusion related DEATH _Transfusion associated circulatory overload_ * Signs and symptoms: dyspnoea, pulmonary oedema, HTN, peripheral oedema * Mechanism: rapid volume expansion. * Treatment: supportive, diuretics can be used * Other: seen in elderly pts with HF/anaemia, can be prevented with slower transfusions and diuretics

Answer 24

**Hyperventilation syndrome** HVS may present with chest pain and a tingling sensation in the fingertips and around the mouth (paresthesia) and may accompany a panic attack.

Answer 25

**Rhabdomyolysis** ...will typically feature in the exam as a patient who has had a fall or prolonged epileptic seizure and is found to have acute renal failure on admission _Features_ * acute renal failure with disproportionately raised creatinine * elevated CK * myoglobinuria * hypocalcaemia (myoglobin binds calcium) * elevated phosphate (released from myocytes) _Causes_ * seizure * collapse/coma (e.g. elderly patients collapses at home, found 8 hours later) * ecstasy * crush injury * McArdle's syndrome * drugs: statins Management * IV fluids to maintain good urine output * urinary alkalinization is sometimes used

Answer 26

**AN** Potassium – Hypokalemia is extremely common in anorexia nervosa purging subtype and severe bulimia nervosa Urea - Low urea is commonin low weight patients due to general malnutrition. A high urea (even with a normal creatinine) is concerning as it may indicate dehydration or renal failure Macrocytic anaemia - too little vitamin B12 and/or folate

Answer 27

**Normal FVC and low FEV1** ...consider a diagnosis of COPD in patients over 35 years of age who are smokers or ex-smokers and have symptoms such as exertional breathlessness, chronic cough or regular sputum production. The following investigations are recommended in patients with suspected COPD: * post-bronchodilator spirometry to demonstrate airflow obstruction: FEV1/FVC ratio less than 70% * FEV1 - significantly reduced * FVC - reduced or normal * FEV1% (FEV1/FVC) - reduced * chest x-ray: hyperinflation, bullae, flat hemidiaphragm. Also important to exclude lung cancer * full blood count: exclude secondary polycythaemia * body mass index (BMI) calculation

Answer 28

**Adenocarcinoma** Ulcerative pathophysiology results in adenocarcinoma * pernicious anaemia=Gastric carcinoma (adenocarcinoma) * H. pylori = Gastric adenocarcinoma and MALT lymphoma * Coeliac disease= Intestinal lumphoma _Pernicious anaemia_ Epidemiology of pernicious anaemia: * more common in females (F:M = 1.6:1) * typically develops in middle to old age * more common if blood group A Pathophysiology * autoimmune disease caused by antibodies to gastric parietal cells or intrinsic factor * results in vitamin B12 deficiency * associated with thyroid disease, diabetes, Addison's, rheumatoid and vitiligo * predisposes to gastric carcinoma Features * lethargy, weakness * dyspnoea * paraesthesia * also: mild jaundice, diarrhoea, sore tongue * possible signs: retinal haemorrhages, mild splenomegaly, retrobulbar neuritis Treatment of the disorder is with 3 monthly treatment of vitamin B12 injections. Folic acid supplementation may also be required.

Answer 29

**Refer to urology** refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for bladder cancer if they are: * aged 45 and over and have: * unexplained visible haematuria without urinary tract infection or * visible haematuria that persists or recurs after successful treatment of urinary tract infection, or * aged 60 and over and have unexplained non-visible haematuria **and** either dysuria or a raised white cell count on a blood test * consider non-urgent referral for bladder cancer in people aged 60 and over with _recurrent or persistent unexplained urinary tract infection_ CT urogram Transitional cell carcinoma * Accounts for 90% of lower urinary tract tumours, but only 10% of renal tumours * Males affected 3x more than females * Occupational exposure to industrial dyes and rubber chemicals may increase risk * Up to 80% present with *painless haematuria* * Diagnosis and staging is with *CT IVU* * TRATMENT: Radical nephroureterectomy

Answer 30

**CT urogram without contrast** *Imaging* * BAUS guidelines recommend ultrasound as the initial imaging modality of choice. The sensitivity of ultrasound for stones is around 45% and specificity is around 90%. Complications such as hydronephrosis can also be quickly identified * following an ultrasound, BAUS recommend a **non-contrast CT (NCCT) to confirm the diagnosis**. 99% of stones are identifiable on NCCT. Some GPs now have direct access to NCCT Stones \< 5 mm will usually pass spontaneously. Lithotripsy and nephrolithotomy may be for severe cases.

Answer 31

**Renal biopsy** All *adults* presenting with nephrotic syndrome should recieve a biopsy (in children steroids are sufficient, as the majority of these have minimal change nephropathy) Cuases of nephrotic syndrome (i.e. Specific diagnosises) _secondary_ to systemic disease: * **DM** * **SLE**: membranous * **Amyloidosis** _Primary_ 1. **Minimal Change Glomerulonephriti**s: * commonest cause of nephrotic syndrome in children * assoc: URTI * Bx: normal light micro, fusion of podocytes on EM * Rx; steroids * Prog: 1%-\> ESRF 2. **Membranous Nephropathy** * 20-30% of adult nephrotic syndrome * Assoc: * ca: lung, colon, breast * AI: SLE, thyroid disease * Infections: HBV * Drugs: Penicillamine, gold * Bx: subepithelial immune complexes * Rx: immunosuppresion if renal dunction declines * Progn: 40% spontaneous remision 3. FSGS: * commoner in afrocarribean * idiopathic/secondary VUR, Berger's, SCD, HIV * Bx: focal scarring, IgM deposition * Rx: steroids or cyclophosphamide/ciclosporin * Prog: 30-50% -\> ESRF (may occur in transplants!) 4. Membranoproliferative / Mesangiocapillary GN * Rare * May-\> nephrotic (60%) or nephritic (30%) * assoc HBV, HCV, endocarditis * Prog: 50%-\> ESRF

Answer 32

**Peripheral oedema** Lymphoedema implies Ca so more likely see weight loss! CHF= scrotal oedema and weight gain

Answer 33

**IV fluids** The initial management of hypercalcaemia is *_rehydration with normal saline_*, typically 3-4 litres/day. Following rehydration *_bisphosphonates_* may be used. They typically take *2-3 days* to work with maximal effect being seen at *7 days* Other options include: * calcitonin - quicker effect than bisphosphonates * steroids in sarcoidosis Loop diuretics such as furosemide are sometimes used in hypercalcaemia, particularly in patients who cannot tolerate aggressive fluid rehydration. However, they should be used with caution as they may worsen electrolyte derangement and volume depletion.

Answer 34

**Multiple myeloma** ....is a neoplasm of the bone marrow plasma cells. The peak incidence is patients aged 60-70 years. Clinical features * bone disease: *bone pain*, osteoporosis + pathological fractures (typically vertebral), osteolytic lesions * *lethargy* (anaemia) * 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 35

Serum vitamin D _Osteomalacia_ * normal bony tissue but decreased mineral content * rickets if when growing * osteomalacia if after epiphysis fusion _Types_ * vitamin D deficiency e.g. malabsorption, lack of sunlight, diet * renal failure * drug induced e.g. anticonvulsants * vitamin D resistant; inherited * liver disease, e.g. cirrhosis _Features_ * rickets: knock-knee, bow leg, features of hypocalcaemia * osteomalacia: bone pain, fractures, muscle tenderness, proximal myopathy _Investigation_ * _low calcium, phosphate, 25(OH) vitamin D_ * _raised alkaline phosphatase_ * _raised pTH_ * x-ray: children - cupped, ragged metaphyseal surfaces; adults - translucent bands (Looser's zones or pseudofractures) _Treatment_: calcium with vitamin D tablets

Answer 36

**Osteomalacia**

Answer 37

24 hour ECG

Answer 38

**MCA** Classic example of right parietal stoke, most often involved the parietal lobule. The artery infarcted is the R MCA. Because the MCA continues in a nearly straight line from the ICA, is it a common route for small emboli originating from the ica. The parietal lobs is responsible for the primary and sesnosry information. One of the types of sensory information provided by this region is the ability to localise objects in space. People with lesions in the right parietal lobe live in 'right-sided worlds' and ignore the left dise of their bodies and all objects in space. Because the fibres from the lateral fields of the optic tract run through the parietal lobe of the contralateral side, a visual defect often accompanies strokes in this region and patients don't blink in response to rand-waving in this field.

Answer 39

**Optic chiasm** _Bitemporal hemianopia:_ * lesion of optic chiasm * upper quadrant defect \> lower quadrant defect = i*nferior chiasmal compression, commonly a pituitary tumour* * lower quadrant defect \> upper quadrant defect = *superior chiasmal compression, commonly a craniopharyngioma* _Other visual field defects:_ The main points for the exam are: * left homonymous hemianopia means visual field defect to the left, i.e. Lesion of right optic tract * homonymous quadrantanopias: PITS (Parietal-Inferior, Temporal-Superior) * incongruous defects = optic tract lesion; congruous defects = optic radiation lesion or occipital cortex A congruous defect simply means complete or symmetrical visual field loss and conversely an incongruous defect is incomplete or asymmetric. Please see the link for an excellent diagram. Homonymous hemianopia * incongruous defects: lesion of optic tract (differently shaped defect in both eyes) * congruous defects: lesion of optic radiation or occipital cortex (similarly shaped defect in both eyes) * macula sparing: lesion of occipital cortex Homonymous quadrantanopias\* * superior: lesion of temporal lobe * inferior: lesion of parietal lobe * mnemonic = PITS (Parietal-Inferior, Temporal-Superior)

Answer 40

**ECG** Initially: ECG *(shows structural and ?arythmic changes)* * ECG: * left ventricular hypertrophy, often gross * ischaemic changes e.g. T wave inversion * chest X-ray: * normal until left ventricular dilatation in heart failure * echocardiography is generally diagnostic, showing: * septal hypertrophy * mid-systolic closure of aortic valve * an anterior movement of mitral valve during systole * 24 hour tape - patients at risk of arrhythmias HOCM: nb also arrhythmogenic right ventricular dysplasia (and mixed) _Echo_ - mnemonic - MR SAM ASH * mitral regurgitation (MR) * systolic anterior motion (SAM) of the anterior mitral valve leaflet * asymmetric hypertrophy (ASH) _ECG_ * left ventricular hypertrophy * progressive T wave inversion * deep Q waves * atrial fibrillation may occasionally be seen _Arrhythmogenic right ventricular dysplasia (and mixed)_ Right ventricular myocardium is replaced by fatty and fibrofatty tissue Around 50% of patients have a mutation of one of the several genes which encode components of desmosome ECG abnormalities in V1-3, typically T wave inversion. An epsilon wave is found in about 50% of those with ARV - this is best described as a terminal notch in the QRS complex

Answer 41

**Upper Brachial Plexus** Erb-Duchenne palsy ('waiter's tip') * due to damage of the upper trunk of the brachial plexus (C5,C6) * may be secondary to shoulder dystocia during birth * the arm hangs by the side and is internally rotated, elbow extended

Answer 42

Migraine * Recurrent, severe headache which is usually unilateral and throbbing in nature * May be be associated with aura, nausea and photosensitivity * zig zag lines * Aggravated by, or causes avoidance of, routine activities of daily living. Patients often describe 'going to bed'. * In women may be associated with menstruation Acute angle closure glaucoma: * 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

Answer 43

**Fibre** Haemorrhoidal tissue is part of the normal anatomy which contributes to anal continence. These mucosal vascular cushions are found in the left lateral, right posterior and right anterior portions of the anal canal (3 o'clock, 7'o'clock and 11 o'clock respectively). Haemorrhoids are said to exist when they become enlarged, congested and symptomatic Clinical features * painless rectal bleeding is the most common symptom * pruritus * pain: usually not significant unless piles are thrombosed * soiling may occur with third or forth degree piles Types of haemorrhoids * External * originate below the dentate line * prone to thrombosis, may be painful * Internal * originate above the dentate line * do not generally cause pain Grading of internal haemorrhoids * Grade I: Do not prolapse out of the anal canal * Grade II: Prolapse on defecation but reduce spontaneously * Grade III: Can be manually reduced * Grade IV: Cannot be reduced Management * soften stools: increase dietary fibre and fluid intake * topical local anaesthetics and steroids may be used to help symptoms * outpatient treatments: rubber band ligation is superior to injection sclerotherapy * surgery is reserved for large symptomatic haemorrhoids which do not respond to outpatient treatments * newer treatments: Doppler guided haemorrhoidal artery ligation, stapled haemorrhoidopexy Acutely thrombosed external haemorrhoids * typically present with significant pain * examination reveals a purplish, oedematous, tender subcutaneous perianal mass * if patient presents within 72 hours then referral should be considered for excision. Otherwise patients can usually be managed with stool softeners, ice packs and analgesia. Symptoms usually settle within 10 days

Answer 44

**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

Answer 45

**Machinery murmur** Patent Ductus Arteriosis * a form of congenital heart defect * generally classed as 'acyanotic'. However, uncorrected can eventually result in late cyanosis in the lower extremities, termed differential cynaosis. * connection between the pulmonary trunk and descending aorta * more common in premature babies, born at high altitude or maternal rubella infection in the first trimester Features * left subclavicular thrill * continuous 'machinery' murmur * large volume, bounding, collapsing pulse * wide pulse pressure * heaving apex beat Management * indomethacin closes the connection in the majority of cases * if associated with another congenital heart defect amenable to surgery then prostaglandin E1 is useful to keep the duct open until after surgical repair

Answer 46

**Osteoarthritis** Bouchards nodes: Hard, bony outgrowths or gelatinous cysts on the proximal interphalangeal joints (the middle joints of fingers or toes.) They are a sign of osteoarthritis, and are caused by formation of calcific spurs of the articular cartilage. (NB: RA is a disease of the synovium, DIPs are not synovial!) Heberdens nodes: Typically develop in middle age, beginning either with a chronic swelling of the affected joints or the sudden painful onset of redness, numbness, and loss of manual dexterity. This initial inflammation and pain eventually subsides, and the patient is left with a permanent bony outgrowth that often skews the fingertip sideways.

Answer 47

**Axillary nerve** * Axillary nerve* (C5,C6): Motor=Shoulder abductions (deltoid) I Sensory=Inferior region of the Deltoid muscle I Injured=humeral neck #/dislocation, Result=deltoid wasting * Radial nerve* (C5-C8): Motor=Extension (forearm, wrist, fingers, thumb) I Sensory= Small area between the dorsal aspect of the 1st and 2nd metacarpals I Injured=Humeral midshaft fracture, Result=Palsy results in wrist drop * Median nerve* (C6, C8, T1): Motor=LOAF\* muscles, @wrist=paralysis of thenar muscle, opponens pollicis, @elbow=loss of pronation of forearem and weak wrist flexion I Sensory=Palmar aspect of lat 3.1/2 fingers I Injured=wrist lesion (CTS) * Ulnar nerve* (C8, T1): Motor=Intrinsic hand muscles except LOAF\* and wrist flexion I Sensory=Medial 1.1/2 fingers. I Injured= medial epicondyle #, damage may result in claw hand * Musculocutaneous nerve* (C5-C7): Motor=Elbow flexion (supplies biceps brachii) and supination I Sensory=Lateral part of the forearm I Injured=Isolated injury rare - usually injured as part of brachial plexus injury * Long thoracic nerve* (C5-C7): Motor=Serratus anterior I Injured=Often during sport e.g. following a blow to the ribs. Also possible complication of mastectomy. Result= in a winged scapula

Answer 48

**Urinary Tract Infection** Risk due to instumentation Early causes of post-op pyrexia (0-5 days) include: * Blood transfusion * Cellulitis * Urinary tract infection * Physiological systemic inflammatory reaction (usually within a day following the operation) * Pulmonary atelectasis - this if often listed but the evidence base to support this link is limited Late causes (\>5 days) include: * Venous thromboembolism * Pneumonia: resp signs * Wound infection * Anastomotic leak: Generalised sepsis causing mediastinitis or peritonitis depending on site of leak

Answer 49

*Bladder washout*

Answer 50

**Cholesteatoma** ...*consists of squamous epithelium that is 'trapped' within the skull base causing local destruction. It is most common in patients aged 10-20 years.* Main features * foul smelling discharge * hearing loss Other features are determined by local invasion: * vertigo * facial nerve palsy * cerebellopontine angle syndrome Otoscopy: 'attic crust' - seen in the uppermost part of the ear drum Management: patients are referred to ENT for consideration of surgical remova

Answer 51

**Stool culture and microscopy** Gastroenteritis may either occur whilst at home or whilst travelling abroad (travellers' diarrhoea) Travellers' diarrhoea may be defined as at least 3 loose to watery stools in 24 hours with or without one of more of abdominal cramps, fever, nausea, vomiting or blood in the stool. The most common cause is *Escherichia coli* Another pattern of illness is 'acute food poisoning'. This describes the sudden onset of nausea, vomiting and diarrhoea after the ingestion of a toxin. Acute food poisoning is typically caused by Staphylococcus aureus, Bacillus cereus or Clostridium perfringens. Incubation period * 1-6 hrs: Staphylococcus aureus, Bacillus cereus\* * 12-48 hrs: Salmonella, Escherichia coli * 48-72 hrs: Shigella, Campylobacter * \> 7 days: Giardiasis, Amoebiasis

Answer 52

**Nephritic Syndrome?**?Hypertensive Nephropathy Orthostatic proteinuria is a benign condition

Answer 53

**LMWH** Deep vein thrombosis may develop insidiously in many surgical patients. Untreated it may progress to result in pulmonary embolism. The following surgical patients are at increased risk of deep vein thrombosis: * Surgery greater than 90 minutes at any site or greater than 60 minutes if the procedure involves the lower limbs or pelvis * Acute admissions with inflammatory process involving the abdominal cavity * Expected significant reduction in mobility * Age over 60 years * Known malignancy * Thrombophilia * Previous thrombosis * BMI \>30 * Taking hormone replacement therapy or the contraceptive pill * Varicose veins with phlebitis Mechanical thromboprophylaxis * Early ambulation after surgery is cheap and is effective * Compression stockings (contra -indicated in peripheral arterial disease) * Intermittent pneumatic compression devices * Foot impulse devices Low molecular weight heparin: MODA=Binds antithrombin resulting in inhibition of factor Xa. Notes=In patients with normal renal function, low doses typically given in those with moderate to high risk of thromboembolic events. It is given as once daily subcutaneous injection Unfractionated heparin: MODA=Binds antithrombin III with affects thrombin and factor Xa. Notes=Effective anticoagulation, administered intravenously it has a rapid onset and its therapeutic effects decline quickly on stopping and infusion. Its activity is measured using the APTT. If need be it can be reversed using protamine sulphate Dabigatran: MODA=Orally administered direct thrombin inhibitor. Notes=Used prophylaxis in hip and knee surgery. It does not require therapeutic monitoring. It has no known antidote and should not be used in any patient in whom there is a risk of active bleeding or imminent likelihood of surgery

Answer 54

**Bell’s Palsy** ....may be defined as an acute, unilateral, idiopathic, facial nerve paralysis. The aetiology is unknown although the role of the herpes simplex virus has been investigated previously. The peak incidence is 20-40 years and the condition is more common in pregnant women. Features * lower motor neuron facial nerve palsy - forehead affected\* * patients may also notice post-auricular pain (may precede paralysis), altered taste, dry eyes, hyperacusis Management * in the past a variety of treatment options have been proposed including no treatment, prednisolone only and a combination of aciclovir and prednisolone * following a National Institute for Health randomised controlled trial it is now recommended that prednisolone 1mg/kg for 10 days should be prescribed for patients within 72 hours of onset of Bell's palsy. Adding in aciclovir gives no additional benefit * eye care is important - prescription of artificial tears and eye lubricants should be considered Prognosis: if untreated around 15% of patients have permanent moderate to severe weakness

Answer 55

**Bisphosphonate** Management of patients at risk of corticosteroid-induced osteoporosis 1. Patients over the age of 65 years or those who've previously had a fragility fracture should be offered bone protection. 2. Patients under the age of 65 years should be offered a bone density scan, with further management dependent: The first-line treatment is alendronate. Patients should also be calcium and vitamin D replete.

Answer 56

**Long thoracic** Long thoracic nerve (C5-C7): Motor=Serratus anterior I Injured=Often during sport e.g. following a blow to the ribs. Also possible complication of mastectomy. Result= in a winged scapula Axillary nerve (C5,C6): Motor=Shoulder abductions (deltoid) I Sensory=Inferior region of the Deltoid muscle I Injured=humeral neck #/dislocation, Result=deltoid wasting Radial nerve (C5-C8): Motor=Extension (forearm, wrist, fingers, thumb) I Sensory= Small area between the dorsal aspect of the 1st and 2nd metacarpals I Injured=Humeral midshaft fracture, Result=Palsy results in wrist drop Median nerve (C6, C8, T1): Motor=LOAF\* muscles, @wrist=paralysis of thenar muscle, opponens pollicis, @elbow=loss of pronation of forearem and weak wrist flexion I Sensory=Palmar aspect of lat 3.1/2 fingers I Injured=wrist lesion (CTS) Ulnar nerve (C8, T1): Motor=Intrinsic hand muscles except LOAF\* and wrist flexion I Sensory=Medial 1.1/2 fingers. I Injured= medial epicondyle #, damage may result in claw hand Musculocutaneous nerve (C5-C7): Motor=Elbow flexion (supplies biceps brachii) and supination I Sensory=Lateral part of the forearm I Injured=Isolated injury rare - usually injured as part of brachial plexus injury

Answer 57

**Small cell** _Paraneoplastic syndrome_ Small cell * ADH: SIADH * ACTH - not typical, hypertension, hyperglycaemia, hypokalaemia, alkalosis and muscle weakness are more common than buffalo hump etc * Lambert-Eaton syndrome Squamous cell * parathyroid hormone-related protein (PTH-rp) secretion causing hypercalcaemia * clubbing * hypertrophic pulmonary osteoarthropathy (HPOA) * hyperthyroidism due to ectopic TSH Adenocarcinoma * gynaecomastia * hypertrophic pulmonary osteoarthropathy (HPOA)

Answer 58

**Curative chemotherapy** Staging (Ann Arbor system) Influences treatment and prognosis. Done by CXR, CT/PET of thorax, abdo, pelvis ± marrow biopsy if B symptoms, or stage III–IV disease. 1. I Confined to single lymph node region. 2. II Involvement of two or more nodal areas on the same side of the diaphragm. 3. III Involvement of nodes on both sides of the diaphragm. 4. IV Spread beyond the lymph nodes, eg liver or bone marrow. Each stage is either ‘A’—no systemic symptoms other than pruritus; or ‘B’—presence of B symptoms: weight loss \>10% in last 6 months, unexplained fever \>38°C, or night sweats (needing change of clothes). * favourable early stage disease * with the current available data, the standard of care for treatment of patients with early stage favourable HL includes combination modality therapy using adriamycin, bleomycin, vinblastine, and decarbazine (ABVD) for 2 cycles and 20 Gy radiotherapy * unfavourable early stage disease * currently four cycles of ABVD followed by 30 Gy RT is widely considered the standard of care for unfavourable early stage HL * another treatment option for unfavourable early stage HL is 2 cycles of bleomycin/etoposide/adriamycin/cyclophosphamide/vincristine/procarb (BEACOPP) escalated doses + 2 x ABVD and 30Gy RT * advanced stage disease * patients aged 16 to 60 with advanced stage HL should receive either 6-8 cycles of ABVD or 6 cycles of escalated BEACOPP * the European Society for Medical Oncology (ESMO) recommend localised radiation with 30 Gy to residual lymphoma greater than 1.5cm

Answer 59

**Stricture** Peptic stricture: Longer history of dysphagia, often not progressive. Usually symptoms of GORD. Often lack systemic features seen with malignancy, weight loss, anorexia or vomiting during eating Adenocarcinoma: Progressive dysphagia, may have previous symptoms of GORD or Barretts oesophagus. Achalasia: Dysphagia of both liquids and solids from the start. Heartburn. Regurgitation of food - may lead to cough, aspiration pneumonia etc Squamous cell carcinoma: History of progressive dysphagia. Often signs of weight loss. Usually little or no history of previous GORD type symptoms. But Hx of smoking/drinking?

Answer 60

CRC A bit about screening... The following patients should be referred urgently (i.e. within 2 weeks) to colorectal services for investigation: * patients \>= 40 years with unexplained _weight loss_ **AND** _abdominal pain_ * patients \>= 50 years with _unexplained rectal bleeding_ * patients \>= 60 years with _iron deficiency anaemia_ OR _change in bowel habit_ An urgent referral (within 2 weeks) should be 'considered' if: * there is a rectal or abdominal mass * there is an unexplained anal mass or anal ulceration * patients \< 50 years with rectal bleeding AND any of the following unexplained symptoms/findings: * -→ abdominal pain * -→ change in bowel habit * -→ weight loss * -→ iron deficiency anaemia National screening programme offering screening every 2 years to all men and women aged 60 to 74 years. Patients aged over 74 years may request screening. In addition FOBT should be offered to: * patients \>= 50 years with _unexplained abdominal pain_ OR _weight loss_ * patients \< 60 years with _changes in their bowel habit_ **Or** _iron deficiency anaemia_ * patients \>= 60 years who have _anaemia_ even in the absence of i_ron deficiency_ *

Answer 61

Colonoscopy

Answer 62

Gallstone in CBD

Answer 63

****ACTH and cortisol levels (/Short synACTHen)** In a patient with suspected Addison's disease the definite investigation is a ACTH stimulation test (short Synacthen test). Plasma _cortisol_ is measured before and 30 minutes after giving _Synacthen_ 250ug IM. Adrenal autoantibodies such as anti-21-hydroxylase may also be demonstrated. If a ACTH stimulation test is not readily available (e.g. in primary care) then sending a _9 am serum cortisol_ can be useful: * \> 500 nmol/l makes Addison's very unlikely * \< 100 nmol/l is definitely abnormal * 100-500 nmol/l should prompt a ACTH stimulation test to be performed Associated electrolyte abnormalities are seen in around one-third of undiagnosed patients: * hyperkalaemia * hyponatraemia * hypoglycaemia * metabolic acidosis

Answer 64

**Thiamine** Confusion + Ataxia (+nystagmus)= wernicke's encephalopathy = thiamin vit B1 defficiency _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 _Alcohol withdrawal_ * Mechanism * chronic alcohol consumption enhances GABA mediated inhibition in the CNS (similar to benzodiazepines) and inhibits NMDA-type glutamate receptors * alcohol withdrawal is thought to be lead to the opposite (decreased inhibitory GABA and increased NMDA glutamate transmission) * Features * symptoms start at 6-12 hours: tremor, sweating, tachycardia, anxiety * peak incidence of seizures at 36 hours * peak incidence of delirium tremens is at 48-72 hours: coarse tremor, confusion, delusions, auditory and visual hallucinations, fever, tachycardia * Management * first-line: benzodiazepines e.g. chlordiazepoxide. Typically given as part of a reducing dose protocol * carbamazepine also effective in treatment of alcohol withdrawal * phenytoin is said not to be as effective in the treatment of alcohol withdrawal seizures

Answer 65

Duodenal ulcer PUD: Epigastric pain * There may be a history of NSAID use or alcohol excess. * Duodenal ulcers: more common than gastric ulcers, epigastric pain relieved by eating * Gastric ulcers: epigastric pain worsened by eating * Features of upper gastrointestinal haemorrhage may be seen (haematemesis, melena etc)

Answer 66

**Refer to local specialist alcohol services** ^In a patient with a history of DT it is important that they are carefully monitored

Answer 67

**anti-Ro? or Biopsy** [GP Notebook, Sjogren's syndrome is diagnosed if there is more than one focus where there are more than 50 lymphocytes per 4 mm2 in the salivary tissues] Sjogren's syndrome 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 68

Anti-dsDNA (=specific and sensitive), anti- Smith (=most specific, less sensitive) Immunology * 99% are **ANA** positive * 20% are rheumatoid factor positive * **anti-dsDNA**: highly specific (\> 99%), but less sensitive (70%) * **_anti-Smith_**: most specific (\> 99%), sensitivity (30%) * also: anti-U1 RNP, SS-A (anti-Ro) and SS-B (anti-La) Monitoring * ESR: during active disease the CRP is characteristically normal - a raised CRP may indicate underlying infection * complement levels (C3, C4) are low during active disease (formation of complexes leads to consumption of complement) * _anti-dsDNA titres can be used for disease monitoring_ (but note not present in all patients)

Answer 69

Venous duplex _DVT Investigation_ Wells score Clinical probability simplified score If a DVT is 'likely' (2 points or more) * a proximal leg vein ultrasound scan should be carried out within 4 hours and, if the result is negative, a D-dimer test * if a proximal leg vein ultrasound scan cannot be carried out within 4 hours a D-dimer test should be performed and low-molecular weight heparin administered whilst waiting for the proximal leg vein ultrasound scan (which should be performed within 24 hours) If a DVT is 'unlikely' (1 point or less) * perform a D-dimer test and if it is positive arrange: * a proximal leg vein ultrasound scan within 4 hours * if a proximal leg vein ultrasound scan cannot be carried out within 4 hours low-molecular weight heparin should be administered whilst waiting for the proximal leg vein ultrasound scan (which should be performed within 24 hours)

Answer 70

**atenolol** CI in asthma: * B-blockers e.g. atenolol, carvidilol * NSAIDs (with the excesption of aspirin) * NB: If asthmatic patient had no wheeze with ibuprofen, may continue it – don’t necessarily have to stop it, as means asthma not NSAID sensitive

Answer 71

USS guided tap (?could be asbestos/mesothelioma) and send aspirate to Chemistry, microbiology and cytology Pleural effusions may be classified as being either a transudate or exudate according to the protein concentration. Transudate (\< 30g/L protein) * heart failure (most common transudate cause) * hypoalbuminaemia (liver disease, nephrotic syndrome, malabsorption) * hypothyroidism * Meigs' syndrome Exudate (\> 30g/L protein) * infection: pneumonia (most common exudate cause), TB, subphrenic abscess * connective tissue disease: RA, SLE * neoplasia: lung cancer, mesothelioma, metastases * pancreatitis * pulmonary embolism * Dressler's syndrome * yellow nail syndrome Features * dyspnoea, non-productive cough or chest pain are possible presenting symptoms * classic examination findings include dullness to percussion, reduced breath sounds and reduced chest expansion

Answer 72

**Another dose of adrenaline** Guidance for a non-shockable rhythm: Give adrenaline every 3-5minutes Pericardiocentiesis: only if indicated (US)

Answer 73

**Haemothorax** Differential for 'Life threatening chest injury': ATOMIC * Airway obstruction * Tension Pneumothorax * Open pneumothorax (sucking) * Massive haemothorax * Intercostal disruption and pulmonary contusion * Cardiac Tamponade _Massive Haemothorax_ * Accumulation of \>1.5L of blood in chest cavity * Usually caused by disruption of hilar vessels * Presentation: * Signs of chest wall trauma * ↓BP * ↓ expansion * ↓ breath sounds and ↓VR * Stony dull percussion * Mx * X-match 6u * Large-bore chest drain c¯ hep saline for autotransfusion * Thoracotomy if \>1.5L or \>200ml/h

Answer 74

**CT abdo** Because of the varying symptoms and signs of aortic dissection depending on the initial intimal tear and the extent of the dissection, the proper diagnosis is sometimes difficult to make. While taking a good history from the individual may be strongly suggestive of an aortic dissection, the diagnosis cannot always be made by history and physical signs alone. Often, the diagnosis is made by visualization of the intimal flap on a diagnostic imaging test. Common tests used to diagnose an aortic dissection include a CT scan of the abdomen. Investigations: * Bloods: FBC, cross-match 10 units of blood, U&E (renal function), clotting. * CT-abdomen: False lumen of dissection can be visualized.

Answer 75

**Adverse drug effect** Drugs which may occasionally cause may erectile dysfunction include: * phenothiazines * benzodiazepines * butyrophenones * tricyclic antidepressants * monoamine oxidase inhibitors Antihypertensive drugs * diuretics * beta-blockers Others * finasteride * cimetidine * oestrogens * antiandrogens

Answer 76

**Urethral stricture**

Answer 77

**Naloxone**

Answer 78

giving IV fluids with IV insulin _Management_ * fluid replacement: most patients with DKA are deplete around 5-8 litres. Isotonic saline is used initially. Please see an example fluid regime below. * insulin: an intravenous infusion should be started at 0.1 unit/kg/hour. Once blood glucose is \< 15 mmol/l an infusion of 5% dextrose should be started * correction of hypokalaemia

Answer 79

Exercise induced **hypertrophic** cardiomyopathy

Answer 80

**ANDI** _Aberrations in the Normal Development and Involution of the breast_ (ANDI) is an all-encompassing term that is used to describe a wide spectrum of the benign breast diseases. As the name suggests, it is based on the theory that most of the encountered benign breast disorders are essentially minor aberrations in the normal development process, hormonal response and involution of the breast _Fibroadenoma_ Under the age of 25 years the breast is usually classified as undergoing development. Lobular units are being formed and a dense stroma is formed within the breast tissue. This may result in the development of fibroadenomas. As a group fibroadenomas account for 13% of all palpable breast lesions. However, in women aged 18-25 they constitute up to 60% of all palpable breast lesions. The are classified as juvenile, common and giant. The former occur in early adolescence and the latter are characterised by a size greater than 4cm. In young females with small fibroadenomas (less than 3cm on imaging) a policy of watchful waiting without biopsy may be adopted. A size of greater than 4cm attracts a recommendation for core biopsy to exclude a phyllodes tumour. The natural history of fibroadenomas is that 10% will increase in size, 30% regress and the remainder stay the same. This does not apply during pregnancy and lactation when they may increase in size substantially and subsequently sequester milk. Some women may wish to have their fibroadenomas excised, they can usually be shelled out through a circumareolar incision. Smaller lesions may be removed using a mammotome. _Breast cysts_ Palpable cysts constitute 15% of all breast lumps. They occur most frequently in perimenopausal females and are caused by distended and involuted lobules. They may be readily apparent on clinical examination as soft, fluctuant swellings. It is important to exclude the presence of an underlying mass lesion. On imaging they will usually show a 'halo appearance' on mammography. Ultrasound will confirm the fluid filled nature of the cyst. Symptomatic cysts may be aspirated and following aspiration the breast re-examined to ensure that the lump has gone. _Duct ectasia_ As women progress through the menopause the breast ducts shorten and dilate. In some women this may cause a cheese like nipple discharge and slit like retraction of the nipple. No specific treatment is required.

Answer 81

**Oral prednisolone** Rx Wheeze

Answer 82

**Haemorrhage** - \> Haematoma - \> stridor Also: Risk of damage to the Hypoglossal nerve and sympathetic plexus

Answer 83

Dietary advice * encourage high fibre, low glycaemic index sources of carbohydrates * include low-fat dairy products and oily fish * control the intake of foods containing saturated fats and trans fatty acids * limited substitution of sucrose-containing foods for other carbohydrates is allowable, but care should be taken to avoid excess energy intake * discourage use of foods marketed specifically at people with diabetes * initial target weight loss in an overweight person is 5-10% Next=Metformin

Answer 84

Better soft tissue detail

Answer 85

Aspirin and alteplase In the absence of contraindications, all patients should be given * aspirin * P2Y12-receptor antagonist. Clopidogrel / ticagrelor / prasugrel * unfractionated heparin (pt going for PCI) Alternatives = LMWH * THEN: * PCI (but is not available in all centres) * Thrombolysis * alteplase/tenecteplase