22/10/2024 Flashcards
Examples of drugs that can cause myelosuppression?
Sulfasalazine
Azathioprine
Trimethoprim
Methotrexate
Cyclophosphamide
Cisplatin / carboplatin
Mercaptopurine
Fluorouracil
Tacrolimus
Linezolid
Clozapine
Carbomazepine
Topoisomerase inhibitors such as etoposide
Anthracyclines e.g. doxorubicin
What causes roseola infntum?
Human herpes virus type 6B
What are the features of the rash in roseola infantum?
Appears on days 3-5 when fever subsides..
Typically small rose-pink or red raised spots that blanch. Mainly affects trunk. Nagayama spots on soft palate and uvula. Non-itchy, painless.
Explain what a positive result in reversibility testing in asthma is?
in adults, a positive test is indicated by an improvement in FEV1 of 12% or more and increase in volume of 200 ml or more
Outline management of subclinical hypothyroidism?
If TSH >10 on 2 occasions 3 months apart - consider offering levothyroxine
If TSH is 5.5-10 on 2 occasions 3 months apart and pt is <65 & symptomatic then consider a 6 month trial of levothyroxine
If older then watch and wait
If asymptomatic then observe and repeat TFTs every 6 months!
Vaccines recommended for a pt post-splenectomy?
Pneumococcal
Haemophilus type B
Meningococcal type C
Annual influenza
Most common causes of post-splenectomy sepsis?
Encapsulated bacteria e.g….
H. Influenzae
Strep pneumoniae
Meningitis
What is the most common cause of primary hyperaldosteronism?
B/L idiopathic adrenal hyperplasia
Features of primary hyperaldosteronism?
Hypertension
Hypokalaemia - may present as muscle weakness, fatigue
Metabolic alkalosis
First line investigation for primary hyperaldosteronism?
Aldosterone:renin ratio - should show high aldosterone and low renin - negative feedback due to sodium retention & hypertension from aldosterone (if renin is high too consider secondary hyperaldosteronism)
Following this - high resolution CT abdo to look for adrenal tumour or hyperplasia
If CT is normal then adrenal vein sampling from both veins is done to determine if U/L or B/L sources of aldosterone excess
What is conns syndrome?
When an adrenal adenoma produces too much aldosterone
What is secondary hyperaldosteronism?
Excessive renin stimulating release of excessive aldosterone
Usually due to disproportionately lower bp in kidneys e.g. renal aretry stenosis, HF, liver cirrhosis
What is chvosteks sign?
tapping over parotid causes facial muscles to twitch in hypocalcaemia
What is trousseaus sign?
carpal spasm if the brachial artery occluded by inflating the blood pressure cuff and maintaining pressure above systolic - wrist flexion and fingers are drawn together
Seen in hypocalcaemia
Features of hypocalcaemia?
Tetany e.g. muscle twitching, cramping and spasm
Perioral paraesthesia
Chvosteks and trousseaus sign positive
If chronic it can lead to depression and cataracts
Causes of hypocalcaemia?
Osteomalacia - vit D deficiency
CKD
Hypoparathyroidism
Pseudohypoparathyroidism
Rhabdomyolysis initially
Magnesium deficiency
Acute pancreatitis
Massive blood transfusions
ECG changes in hypocalcaemia?
QTc prolongation
Features of toxoplasmosis?
Most infections are asymptomatic. If symptomatic its usually self-limiting and often resembles infectious mononucleosis with fever, malaise and lymphadenopathy
If immunocompromised it can cause cerebral toxoplasmosis - headaches, confusion, drowsiness. They may also develop chorioretinitis
What is toxoplasmosis?
A disease caused by the protozoan toxoplasma gondii which infects the body via the GIT, lung or broken skin. Its locusts release trophozoites which migrate widely around the body.
Usual reservoir is the cat and its transmitted by oocysts in cat faeces. Rats can also carry the disease
What is functional neurological disorder?
1 or more Sx of altered voluntary movement or sensory function but incompatibility between Sx and recognised neurological/medical conditions (but not factitious or seeking material gain!)
What features of ED favour an organic cause?
Gradual onset of Sx
Lack of tumescence - spontaneous erections during sleep/when waking
Normal libido
Investigations for erectile dysfunction?
All men should have serum lipids and HbA1c measured to calculate Qrisk (as ED increases risk of CVD)
A fasting serum total testosterone between 9-11am -> if low then repeat with FSH, LH, prolactin -> if any abnormal refer to endocrinology as hypogonadism likely
You may consider additional investigations depending on clinical judgement e.g. PSA< TFTs, LFTs, U&Es
What should you do if a young male presents with difficulty achieving an erection all his life?
Refer to urology
Management of ED?
Lifestyle
1. PDE5 inhibitors such as sildenafil regardless of cause - can be purchased OTC
2. Intracavernosal, intraurethral or topical application of alprostadil (prostaglandin E1) is recommended as second-line therapy under careful medical supervision
3. Vacuum erection devices
Contraindications for sildenafil?
Recent Hx of MI or stroke
Systolic BP <90
Pts taking nitrates
MOA of sildenafil?
It’s a phosphodiesterase type 5 inhibitor which leads to prevention of breakdown of cGMP. This causes vasodilation through an increase in cGMP leading to smooth muscle relaxation in blood vessels supplying the corpus cavernosum = increased blood flow
Important to note it requires sexual arousal to be effective
When do you need to test FSH to confirm menopause?
If pt is <45 (i.e. early menopause or premature menopause)
Management of proteinuria in CKD?
- ACEi (use if ACR >70 OR if ACR >30 and pt has hypertension OR if pt has diabetes and ACR is >3)
- SGLT-2 inhibitors (consider this if pt has T2DM & ACR of >=30)
When should an MSU be sent instead of dipstick testing for UTI?
If woman is…
pregnant
>65
Sx with persistent or recurring UTi within 4 weeks of ABx
Hx of recurrent UTI
has a urinary catheter in or has had one in past 48 hours
has atypical Sx
has visible or non-visible haematuria
What should you measure if you are suspecting a re-infarction within 4-10 days after an NSTEMi
The CK-MB
This cardiac enzyme will only remain elevated for 3-4 days unlike troponin which can remain high for up to 14 days
When do serum troponin levels peak in an MI?
They increase within 3-12 hours from onset of cp
And peak at 24-48 hours
Ca remain high for up to 14 days
How does guttate psoriasis present?
2-4 weeks after streptococcal infection…
Tear drop papules on trunk and limbs which are pink & scaly
Management of guttate psoriasis?
most cases resolve spontaneously within 2-3 months
Topical agents e.g. emolients and potent topical corticosteroids + topical vitamin D preparation
UVB phototherapy
Tonsillectomy can be considered if recurrent episodes
What causes pityriasis rosea?
Herpes hominis virus 7 is thought to play a role
Presentation of pityriasis rosea?
Herald patch on trunk followed by erythematous, oval scaly patches which follow the line of langer and therefore may produce a fir tree appearance
Management of pityriasis rosea?
Self-limiting within 6-12 weeks
If you need to use a PPI in pregnancy what should you use?
Omeprazole
General dietary advised for IBS
have regular meals and take time to eat
avoid missing meals or leaving long gaps between eating
drink at least 8 cups of fluid per day, especially water or other non-caffeinated drinks such as herbal teas
restrict tea and coffee to 3 cups per day
reduce intake of alcohol and fizzy drinks
consider limiting intake of high-fibre food (for example, wholemeal or high-fibre flour and breads, cereals high in bran, and whole grains such as brown rice)
reduce intake of ‘resistant starch’ often found in processed foods
limit fresh fruit to 3 portions per day
for diarrhoea, avoid sorbitol
for wind and bloating consider increasing intake of oats (for example, oat-based breakfast cereal or porridge) and linseeds (up to one tablespoon per day).
If this is ineffective pt may try FODMAP diet under supervision of dietitian
First line pharmacological Tx for IBS?
Prescribing according to Sx:
pain: antispasmodic agents e.g. mebeverine hydrochloride, peppermint oil or alverine citrate (second line is TCA)
constipation: slowly increase dietary fibre e.g. with oats (not too fast to avoid flatulence and bloating) or try bulk-forming laxative such as ispaghula husk
diarrhoea: loperamide is first-line
Causes of erectile dysfunction?
Organic causes:
- vasculogenic is most common - CVD, hypertension, PAD< DM< smoking, obesity, pelvic surgery or radiotherapy
Neurogenic e.g. MS, parkinsons, MSA, stroke, spinal cord trauma, CNS tumours
Anatomical e.g. Peyronie’s disease, cancer, hypospasias, epispadias, phimosis
Endocrine - DM, metabolic syndrome, hypogonadism, hyperprolactinaemia, thyroid disease, Cushing, Hypopituitarism etc
Drugs e,g SSRIs and beta blockers
Psychogenic e.g. lack of arousability, performance issues, relationship problems, stress, mental health
Causes of hypogonadism in males?
Primary:
Klinefelters syndrome
Undescended testicles
Mumps orchitis
Haemochromatoiss
Injury to testicles
Chemo/radiotherapy
Secondary:
Kallmans syndrome
Pituitary disorders e.g. tumour or damage by radiotherapy
Hyperporlactinaemia
Anabolic steroid use
Older age
Obesity
What is Peyronie’s disease?
A condition that causes your penis to curve when its erect due to fibrous scar tissue
It can cause painful erections, ED or a swelling.hard lump on the shaft of the penis
Management of vaginal thrush?
Single dose of oral fluconazole 150mg
(If pregnant use local Tx)
Outline water deprivation test results in nephrogenic diabetes insipidus?
High starting plasma osmolality
Final urine osmolality <300 after fluid deprivation and urine osmolality post desmopressin is still <300
Outline water deprivation test results in cranial diabetes insipidus?
High starting plasma osmolality
Final urine osmolality <300 after fluid deprivation but >600 after desmopressin
Outline water deprivation test results in psychogenic diabetes insipidus?
Low starting plasma osmolality
Final urine osmolality is >400 after fluid deprivation and after desmopressin
A post-void volume of what is considered physiological in pts <65 and >65?
If <65 - <50ml
If >65 then <100ml is physiological
Signs of poor prognosis in Hodgkin lymphoma?
B-symptoms, increasing age, male sex, stage IV disease and lymphocyte depleted subtype
ALS adrenaline dose for anaphylaxis?
0.5ml of 1:1000 IM
ALS adrenaline dose for cardiac arrest?
10ml of 1 in 10,000 IV
OR 1ml of 1 in 1000 IV
What is acute severe hyponatraemia?
Onset <48 hours
Severe is <120 Na+ level
How do you manage acute severe hyponatraemia nd why is it important?
Hypertonia saline typically 3% NaCl - normally in HDU
Important to prevent cerebral oedema which could cause brain herniation
What can cause bile-acid malabsorption?
Excessive production of bile acid
Underlying Gi disorder causing reduced bile acid absorption e.g. crohns, cholecystectomy, coeliac disease, small intestinal bacterial overgrowth
Management of bile acid malabsorption?
Bile acid sequestration e.g. cholestyramine
Monitoring of digoxin?
Digoxin levels do not need monitoring unless suspected toxicity
Monitor serum electrolytes and renal function
What is the likely cause of a chronic sloughy ulcer with duration of months but no systemic symptoms?
It is green in colour and has a classical offensive smell?
Pseudomonas
Why could a lateral rectus palsy possibly indicate a SOL?
The abducens nerve is the thinnest cranial nerve, and also has the longest intracranial course. As a result, it is susceptible to compression when space-occupying lesions such as brain metastases develop in patients.
What is the gold standard test for diagnosing a venous sinus thrombosis?
MR venogram - an MRI examination of the head with either contrast-enhanced or non-contrast sequences to assess patency of the dural venous sinuses and cerebral veins.
Neuropathic pain characteristically responds poorly to opioids. However, if standard treatment options have failed which opioid is it most appropriate to consider starting?
Tramadol
It has a dual mechanism of action, acting as both a weak opioid agonist and a reuptake inhibitor of serotonin and norepinephrine. This unique action profile gives it an edge in managing neuropathic pain compared to other opioids. The UK National Institute for Health and Care Excellence (NICE) guidelines recommend considering tramadol when standard treatment options have failed
Which cause of encephalitis characteristically affects the temporal lobes?
HSV encephalitis
Features of HSV encephalitis?
fever
headache
psychiatric symptoms
seizures
vomiting
focal features e.g. aphasia
