25/04 Flashcards
tb meds
I eat perfect rice
Isoniazid.
Rifampin
Ethambutol
Pyrazinamide.
tertiary hyperparathyroidism signs
Raised alkaline phosphatase levels
This is due to increased bone turnover (osteoblastic activity in particular) as a result of raised parathyroid levels. It is likely this patient has progressed from secondary to tertiary hyperparathyroidism, as persistent secondary hyperparathyroidism leads to autonomous production of parathyroid hormone, regardless of negative feedback from calcium levels.
prolonged PR interval
1st-degree heart block is caused by a delay in conduction from the SA node into the ventricles. As the AV node is supplied by the right coronary artery in 85% of individuals, disease in this artery may lead to first-degree heart block.
Acute Kidney Injury(AKI) and treatment
increase in serum creatinine of 26 μmol/L within 48 hours or an increase in serum creatinine ≥1.5 times above baseline value within 1 week or urine output of <0.5 ml/kg/hr for > 6 consecutive hours.
dialysis
signs of asthma
Tachypnoea- fast breathing
Hyperinflated chest
Hyper-resonance on chest percussion
Investigations in chronic asthma
Spirometry: FEV1/FVC <0.7 (obstructive spirometry)
Bronchodilator reversibility tests: Improvement of FEV1 >12% after bronchodilator therapy is diagnostic
Investigations in acute asthma
ABG: type 2 respiratory failure (low PaO2 and high PaCO2) is a sign of a life-threatening attack.
Routine blood tests (including FBC, CRP): to look for precipitating causes of an asthma attack, such as an infection.
Chest x-ray: to exclude differentials and possibly identify a precipitating infection.
asthma drugs
SABA
+ICS- beclometasone, Prednisolone, hydrocortisone
+LABA- salmeterol
+ Trial oral leukotriene receptor antagonist,/monelukast high-dose steroid, oral B2-agonist
tumours of the caecum and ascending colon
right hemicolectomy
tumours of the distal transverse colon and descending colon
left hemicolectomy
tumours of the sigmoid colon.
sigmoid colectomy
tumours >8 cm from the anal canal or involving the proximal 2/3 of the rectum
Anterior resection
tumours <8 cm from the anal canal or involving the distal 1/3 of the rectum.
Abdomino-perineal (AP) resection
Hepatic Adenoma surgery
<5cm or reducing in size - annual MRI
>5cm or increase in size - for surgical excision
HCC surgery
<2cm
peripheral lesions adenocarcinoma of the lung diagnosis
CT chest abdomen pelvis
then
biopsy would be the next investigation to carry out after a CT CAP to provide a definitive diagnosis. As this is a peripheral lesion it will most likely be obtained via transthoracic needle aspiration.
falls and elderly
Use the Fracture Risk Assessment Tool (FRAX)
This patient is elderly and clearly has a high falls risk, making her liable to have an osteoporotic fracture in the future. The FRAX score offers a formal way to quantify this risk, and if it is above a certain threshold, bisphosphonates should be given. If the risk is low, bisphosphonates do not need to be given, but if the risk is between the two extremes, a DEXA scan should be carried out to guide the need for bisphosphonates.
ramipril side effects
Ramipril causes hyperkalaemia by blocking the aldosterone pathway thereby leading to a retention of potassium.
2 week worsening SoB, stiffness and pain in wrists and fingers, particularly in the morning
dullness to percussion at the right lung base with associated reduced breath sounds
tenderness and boggy swelling at the metacarpo-phalangeal joints bilaterally.
Pleural fluid glucose <3.3 mmol/L
This is the correct answer. The patient presents with a pleural effusion, most likely an extra-articular manifestation of underlying rheumatoid arthritis. Almost 100% of effusions due to rheumatoid arthritis have low glucose levels.
absolute contraindication for diagnostic laparoscopy?
On warfarin with an INR of 2.8
An abdominal aortic aneurysm risks vascular rupture if not directly visualized. However, it is a relative contraindication rather than absolute.
MI and can’t get PCI till 2h and intracranial haemorrhage history
treatment
However, they have a previous intracranial haemorrhage which is an absolute contra-indication for fibrinolysis so PCI is the best option even if outside of the typical window.
diarrhoea after Bangladesh . He describes it as rice water looking and has also been vomiting.
and treatment
lassical description of a cholera infection. It is a Gram-negative aerobic bacterium. It is very rare or extinct in the western world, however in developing nations still exists. It is found in faecally contaminated water. It causes profuse watery diarrhoea and is treated with oral rehydration salts and fluids. Antibiotics can be given if the infection is severe, which lessens the severity and shortens the disease lifespan.- Doxycycline or co-trimoxazole)
Salmonella enterocolitis symptoms
t presents with diarrhoea, fever and cramps (usually within 12-36 hours of exposure). It can cause sepsis or meningitis, as well as septic arthritis.
fatigue, easy bruising, and tooth loss
multiple ecchmoses at non-traumatic sites, perifollicular haemorrhages, coiled hairs, and gingival swelling.
vitamin C deficiency. Refugee populations are at particular risk. There is a risk of intracerebral and endocardial haemorrhage,
5kg weight loss over the last 5 weeks and malaise
He also reports dark-coloured urine. He has a past medical history of familial adenomatous polyposis, for which he had a proctocolectomy 8 years ago.
On physical examination he is cachectic and there is scleral icterus.
Duodenal cancer
This is the correct answer. Patients with familial adenomatous polyposis (FAP) not only have a high risk of colorectal cancer, but are also at increased risk of duodenal cancer. Duodenal cancer is the 2nd highest cause of cancer death in FAP. Duodenal cancer can present with weight loss, nausea/vomiting, abdominal pain, and obstructive jaundice.
Mitral regurgitation
produces a pansystolic murmur that is heard best over the apex.
aortic stenosis
presents with syncope, shortness of breath and angina. It also produces an ejection systolic murmur heard best over the upper right sternal edge.
how to calc units
Units = strength % x volume (ml) ÷ 1000
Plummer Vinson Syndrome
triad of dysphagia, iron deficiency anaemia and glossitis/ inflamed tongue
Peutz-Jeghers syndrome
autosomal dominant
hamartomatous polyps in the GIT
pigmented lesions on the lips, face, palms and soles.
GI bleeding secondary to these polyps, and have an increased risk of developing gastric cancer. Management tends to be conservative, unless complications arise.
Hypothermia ecg sign
J waves
Hyperkalaemia ecg sign
tall tented T waves and flattened P waves.
Ventricular fibrillation ecg
chaotic with no discernible P waves or QRS complexes.
one week history of fevers, myalgia and cough productive of white sputum.
recently abroad in Crete and returned home a week before his symptoms began. A chest X-ray shows diffuse bilateral infiltrates.
Legionella pneumophila
inhalation or aspiration of unsanitary water such as in showers supplied by poorly maintained water tanks. It causes atypical pneumonia, sometimes with bilateral signs of infection on a chest X-ray. It can also cause deranged liver function tests and electrolytes
Congestive cardiac failure
no chest pain
ascities causes
liver disease, however in most cases it results from a combination of portal hypertension and hypoalbuminaemia. It is not related to hyperbilirubinaemia.
raised serum bilirubin,
fatigue, weakness and loss of appetite for the past year as well as abdominal swelling which he says started around a month ago. He is known to abuse alcohol and has been drinking around 70 units a week for the last 10 years.
palmar erythema, Dupuytren’s contracture, multiple spider naevi, and a distended abdomen with shifting dullness on percussion. He also has leuconychia and excoriations on his arms and stomach.
Raised serum bilirubin as seen in chronic liver disease is associated with pruritus and this often results in excoriations where patients scratch themselves with their nails. Itching frequently precedes jaundice in these patients. Although there is some debate in the literature as to the precise cause of pruritus associated with raised serum bilirubin, colestyramine (a bile acid sequestrant) is effective at reducing it.
Barrett’s oesophagus
oesophagal epithelium from squamous to columnar owing to long term acid reflux. Typical symptoms of oesophageal reflux would be heartburn-like pain worsened on lying flat or eating acidic foods. Patients can, however, be asymptomatic
Functional dyspepsia
This is the cause of 60% of dyspepsia cases. It may be caused by gut hypersensitivity, non-erosive reflux disease, motility problems, post infectious bowel upset or psychological factors.
abdominal discomfort, nausea and belching
Peptic ulcer disease
abnormal upper GI endoscopy
Epigastric tenderness would also be likely on examination
duodenal and gastric ulcers; duodenal ulcers most common. The stomach lining protects itself with mucin and bicarbonate secretion and mucosal blood flow; however, damage can occur if these barriers are not sufficient, or if external factors such as Helicobacter pylori (H. Pylori) are present.
mostly due to H. pylori
can be due to NSAIDS - ibuprofen, aspirin
aortic stenosis treatment and symptoms
worsening dyspnoea and an ejection systolic murmur radiating to carotids.
transcatheter aortic valve implantation (TAVI) or open valve replacement, depending on the patient’s fitness.
Medical therapy only as a treatment option should be reserved for patients unsuitable for the above.
63 year old man is admitted to hospital having been found collapsed. His past medical history includes type 2 diabetes and hypertension
partially compensated metabolic acidosis and a high lactate.
lactic acidosis. Sepsis is a well known cause of this and comes about via local tissue hypoxia (secondary to increased metabolic requirement and poor perfusion because of vasodilation).
which hernias are surgically treated
symptomatic ones
CSF predominantly polymorphs, with a cell count of 90-1000+; CSF glucose is less than half of plasma glucose; over 1.5g/L of protein is present
bacterial meningitis
severe UC flare up
> 6 bloody stools per day, a temperature > 37.8, Hb < 108, CRP > 30
Gastro-oesophageal reflux disease (GORD)
retrosternal pain that is associated with meals, belching and regurgitation. Chronic untreated GORD may develop into Barrett’s oesophagus, with potential to transform into oesophageal adenocarcinoma.
Cachexia
a “wasting” disorder that causes extreme weight loss and muscle wasting, and can include loss of body fat
Ecchymosis
bruise
diffuse consolidation
spread out
Pruritus
itchy skin
Leukonychia
white discoloration appearing on nails
mostly at base of nails
excoriations
skin picking
red parts on skin
Aortic regurgitation
left parasternal edge murmur
sudden onset crushing chest pain and diaphoresis/ excess sweating
The pain has persisted for around 25 minutes and an ECG reveals ST depression in the inferior leads.
blood pressure is noted to be 210/90.
medication for lowering BP
Hypertensive emergencies should be treated with IV medication.
Oral amlodipine can be used in the management of hypertensive urgencies
Amlodipine takes longer to work than nifedipine due to a larger volume of distribution. Therefore, both can be given initially and nifedipine discontinued after 3 days by which time amlodipine should start to work.
step 1 hypertension management
ACE-inhibitor (e.g. Ramipril) if <=55 years old
CCB (e.g. Nefedipine) if >55 y OR African or Caribbean ethnicity
If unable to tolerate ACE-inhibitor then switch to Angiotensin Receptor Blocker (e.g. Candesartan)
Step 2 of hypertension management
(If maximal dose of Step 1 has failed or not tolerated)
Combine CCB and ACE-I/ARB
Step 3 of hypertension management
(If maximal doses of Step 2 has failed or not tolerated):
Add thiazide-like diuretic (e.g. Indapamide)
Step 4 of hypertention management
if blood potassium <4.5mmol/L then add Spironolactone
If >4.5mmol/L increase thiazide-like diuretic dose/
Alpha blocker (e.g. Doxacosin)
Beta blocker (e.g. Atenolol)
Referral to cardiology for further advice
sudden onset shortness of breath and pleuritic chest pain. She is currently receiving chemotherapy for metastatic ovarian cancer and is bedbound. Vital signs are: temperature 36.5’C, heart rate 90 beats per minute, respiratory rate 24/minute, oxygen saturation 92% on room air, blood pressure 100/75 mmHg. Chest x-ray and ECG are normal
what sign will be expected
PE!!
In a sub-massive PE there may be signs of right heart strain (such as a raised JVP, parasternal heave, and loud P2).
STEMI diagnosis criteria
men under 40-years-old (≥ 2.5 mm in leads V2-3) and for women (≥ 2.5 mm in leads V2-3).
apart from ST-segment elevation, a new-onset LBBB or hyperacute T-waves are also indicative of a STEMI.
most important direct consequence of refeeding syndrome?
Hypophosphataemia is caused by an increase in insulin production when carbohydrates are re-introduced to the body. This then leads to many of the complications of tumour lysis syndrome such as rhabdomyolysis, fluids shifts, other electrolyte imbalances and arrhythmias.
tension pneumothorax
2nd intercostal space, mid clavicular line!!!
not mid axillary !!
needle decompression with a 14-16 gauge cannula into the right second intercostal space, mid-clavicular line THEN chest drain
Type 1 Diabetes is found collapsed on the floor at a bus stop
treatment
100ml of 20% glucose IV
past medical history of Wolff-Parkinson-White syndrome and waiting for definitive treatment, develops sudden-onset palpitations. She also reported chest pain and momentarily lost consciousness and was brought to A&E by ambulance.
regular rhythm with narrow QRS complexes with a heart rate of 140 beats per minute. P-waves are not seen.
blood pressure is 125/85 mmHg, her JVP is not raised and no pedal oedema was noted.
first step for management
urgent Synchronised electrical cardioversion
This patient has supraventricular tachycardia with adverse features such as syncope and chest pain.
fever. Her symptoms began three weeks ago with a swollen red tongue and a fine rash across her trunk. Her rash has now resolved, but her fever is persistent. On examination, there is an audible pan-systolic murmur, loudest at the apex. Her blood tests reveal a C-reactive protein (CRP) of 124 mg/L.
first step management
IV Benzylpenicillin
. Rheumatic fever is precipitated by Group A beta-haemolytic streptococcal infection,
Rheumatic fever symtoms
recent streptococcal infection
Arthritis
Pancarditis
Affects all layers of the myocardium, endocardial inflammation may predominate causing valvulitis. tachycardia, new murmur or new conduction defect.
Sydenham’s chorea
abrupt, non-rhythmic, involuntary movements along with muscular weakness and emotional disturbance. They are most frequently marked on one side and cease during sleep.
Arthralgia- joint stiffness
Raised acute phase proteins (ESR and CRP)
Prolonged PR interval on ECG
fever
Erythema marginatum
pink/red, nonpruritic rash involving mainly the trunk, thighs and arms.
Subcutaneous nodules- Firm, mobile painless lesions
rheumatic fever management
Eradication of group-A beta-haemolytic streptococcal infection
IV Benzylpenicillin, with a ten day course of Phenoxymethylpenicillin to follow
Analgesia/painkillerts for arthritic symptoms
Aspirin/ (NSAIDs) such as ibuprofen or naproxen.
Aspirin should be used with caution in young children
If carditis is complicated by heart failure
Glucocorticoids (e.g. Prednisolone) can provide benefit (NSAIDs should be stopped concurrently).
Diuretic treatment may also be necessary, and valve surgery if severe.
Sydenham’s chorea for distressing symptoms or risk of harm.
Erythema marginatum is associated with rheumatic fever is temporary and doesn’t require treatment, although antihistamines can help with pruritus.
Management of a Simple Primary Pneumothorax
short of breath OR the pneumothorax is >2 cm the pneumothorax should be aspirated with a 16-18G cannula under local anaesthetic. If this is successful the patient can be discharged. If this fails an intercostal drain is necessary (and the patient must be admitted).
2 month history of constipation, blood in the stool, weight loss
colorectal cancer
so colonoscopy first line not CT!!
CT for staging
sarcoidosis symptoms
Pulmonary (most common manifestation): dry cough, dyspnoea, reduced exercise tolerance, crepitations.
Constitutional: fatigue, weight loss, arthralgia/joint stiffness, and low-grade fever. General signs include lymphadenopathy and ENLARGED PAROTID GLANDS
Neurological: meningitis, peripheral neuropathy, bilateral Bell’s palsy.
Ocular: uveitis, keratoconjunctivitis sicca.
Cardiac: arrhythmias, restrictive cardiomyopathy.
Abdominal: hepatomegaly, splenomegaly, renal stones.
Dermatological: erythema nodosum, lupus pernio.
10-month old baby boy rapid onset abdominal pain.
off his food and not his usual temperament for 3 days prior
regular wet nappies and there are no rashes or vomit
redcurrent jelly stools
pale and his abdomen there is a sausage shaped mass in the right upper quadrant and the boy draws ups his legs and screams uncontrollably on palpation.
Intussusception
most common in 3 months - 12-month-old children and 75% are ileocaecal in location. If the child is relatively well, pneumatic reduction under fluoroscopic guidance can be attempted. If the child is unwell or perforation is suspected laparotomy
Viral gastroenteritis cause, symptoms and treatment
diarrhoea/ vomiting + fever
Rotavirus
Norovirus: common cause of viral
Adenoviruses: resp system and children
management-
fluid replacement
severe-
Salmonella and shigella- ciprofloxacin.
Campylobacter - macrolide, erythromycin.
Cholera - tetracycline
long PR interval and infective endocarditis
Perivavlular or aortic root abscesses are a potential complication of infective endocarditis. They manifest through prolongation of the PR interval on the ECG, which can be followed by higher degrees of heart block. Patients with infective endocarditis are monitored for this complication through daily ECGs.
Risedronate side effect
dyspepsia and acid reflux. Patients should be advised to take the tablet half an hour before breakfast with plenty of water and to remain upright to reduce the risk of mucosal irritation.
dyspepsia
indigestion, refers to discomfort or pain that occurs in the upper abdomen, often after eating or drinking
symptom
Wolff-Parkinson-White syndrome symptoms and management
supraventricular tachycardias. often asymptomatic Palpitations Dizziness Syncope short PR interval Broad QRS
Radiofrequency ablation of the accessory pathway Drug treatment (such as amiodarone or sotalol) to avoid further tachyarrhthmias. These are contraindicate din structural heart disease.
CXR sign for pulmonary oedema
patchy perihilar shadowing
squamous cell carcinoma of tongue
smoking
side of tongue and floor of mouth
>2 week, should be biopsied
linchen planus
itchy rash affecting wrists and shins and sore mouth
white striae and buccul mucosa
smooth, sore, red tongue, cracking at corners
iron deficiency
sore mouth, inflamed palette with white patches that rub off
oral candidiasis
associated with corticosteroids so like people with asthma
treatment- topical miconazole gel
oral fluconazole for severe
pancreatic carcinoma related to
diabetes
acute pancreatitis, worsening SoB, resp acidosis so resp failure , cyanosis around lips, bilateral crackles
acute resp distress syndrome
