30/05/22 Flashcards
how to look for bundle branch block?
look at leads v1 and v6
RBBB
Marrow
v1 - is there an M?
v6 - QRS looks normal then it is RBBB
R maRRow
LBBB on ECG
look at v1, V6
v1- is there W?
lead V6 - is there an M?
LBBB
WiLLiaM
causes of LBBB
aortic stenosis IHD hyperkalaemia Digoxin MI
RBBB
causes?
M-V1
V6 usually normal
pulmonary embolism
right ventricular hypertrophy
IHD
normal variant
right ventricular strain pattern
(ST depression and T wave inversion in right ventricle and inferior leads)
ALS
if there are only upper motor neurone signs?
late onset
primary lateral sclerosis
bamford criteria
TACI
unilateral hemiparesis
dysphasia or hemispatial neglect
homonymous hemianopia
LACI
pure motor stoke
or pure sensory stroke mixed sensorimotor
ataxic hemiparesis
lateral medullary syndrome
contraletral loss of pain sensation ipsilateral facial numbness danvah dysphagia ataxia - ipsilateral nystagmus - ipsi vertigo horners
what commonly occurs after an URTI
and presents with vertigo?
vestibular neuritis
vertigo
tinnitus
hearing loss
labyrinthitis
They usually present with unilateral hearing loss and progress to involve cranial nerves 5, 6, 9, 10, and the ipsilateral cerebellum
acoustic neuroma
what antibiotic can cause DI and is used to treat SIADH?
demeclocycline
prostate cancer signs
blood in semen
discomfort in pelvic area
clot retention
prostate cancer risk factors?
african ethnicity
BRCA mutation
family history
increasing age
prostate cancer gleeson
1 Normal tissue, well differentiated cells that are small and uniform
2 Increased stroma between glands
3 Distinctly infiltrative margins, moderately differentiated cells
4 Irregular masses of neoplastic glands. Poorly differentiated
5 Occasional gland formation seen. Very poorly differentiated
symptomatic mx of prostate cancer
GnRH analogues -
goserelin
leuprolide
androgen antagonists -
Bicalutamide and Enzalutamide
Degarelix
GnRH antagonists
prostate cancer
hypotension and tachycardia post MI PCi with a pansystolic murmur
mx?
mitral regurgitation- needs valve repair or replacement
t2n0m0 renal carcinoma management?
radical nephrectomy
hallmark diagnostic test for GBS?
lumbar puncture
albuminocytologic dissociation - raised protein with a normal white cell count
which antibodies are present with GBS?
antiganglioside antibodies
A sigmoid colectomy
Hartmann’s procedure
emergency surgery - obstruction , toxic megacolon, perforation
Panproctocolectomy indications
Typically carried out as an elective procedure in medically-refractory ulcerative colitis. The patient will have a permanent end ileostomy.
large-right sided pleural effusion
Pleural fluid protein: 29 g/L
Pleural fluid protein : serum protein ratio 0.78
Pleural fluid LDH : serum LDH ratio 0.81
worsening sob and decrease in exercise tolerance but no other symptoms?
malignancy cause of pleural effusion must be considered
pseudogout mx?
naproxen
beta thalassaemia major
features
microcytic anaemia
HBa2 and HBf raised
HbA absent
management of beta thalaseamia major
repeat transfusion
iron overload > iron chelation therapy- desferrioaxamine
ototoxicity causes?
gentamicin
vancomycin
loop diuertics
thromboangitis obliterans - buergers
strong association with smoking > intermittent caudication > raynauds > ulcers >superficial thombophlebitis
xray findings of ankylosing spondylitis
subchondral erosions
sclerosis
squaring of lumbar vertebrae
subchondral cysts and osteophyte formation at joint margins
osteoarthritis
periarticular erosions
juxta-articular osteopenia
RA
does of adrenaline in anaphylaxis?
how soon can you give a second dose?
IM adrenaline 500mcg
0.5ml 1 in 1000
5 mins
what measures anaphylaxis acutely?
serum tryptase
if patient has pneumonia 2 days after being in hospital what indicates aspiration > HAP?
risk factors- neuro injury, feeding tube and tracheostomy
right base of pneumonia indicates aspiration as the anatomy of tract makes it more likely to fall down straighter right main bronchi
apyrexia also indicates aspiration
recurrent episode of pseudomonas coilitus
but stable patient
if within 12 weeks of vancomycin
fidaxomin
when is Faecal microbiota transplant used in c diff infection
2 or more previous episodes
familial hypercholesterolaemia
which gene
what inheritance pattern
how does it present?
LDL is mutated
automsomal dominant
what is the extrinsic pathway?
and how does it correlate to clotting screen ?
which common drug targets the extrinsic pathway
what would be the clotting screen results here?
,VII TF
this is measured by the prothrombin time
warfarin
PT ABNORMAL APTT normal
mechanism of warfarin
inhibits carboxylation of 1972
factor 10
factor 9
factor 7
and factor 2
and protein c
warfarin INR target after a recurrent VTE?
3.5
warfarin INR in VTE
2.5
atrial fibrillation target warfin inr?
2.5
what is a common side effect pf thiazide diuretics affecting big toe?
gout
root canal surgery prophylaxis NICE guidelines?
no treatment
TIPS connects which two vessels
hepatic vein and portal vein \
although can connect the portal vein to the IVC. It aims to treat portal hypertension by making route for blood to flow from the portal circulation to the systemic circulation, bypassing the liver
unfractionated heparin reversal?
protamine sulphate
dabitran - direct thrombin inhibitor
if bleeding and want to reverse?
contra
Idarucizumab
Doses should be reduced in chronic kidney disease and dabigatran should not be prescribed if the creatinine clearance is < 30 ml/min
blood film results resemble stack of coins
what condition?
hb low
calcium high
urea and creatinine high
multiple myeloma shows rouleaux fomration
Offer platelet transfusions to patients with a platelet count of <30 x 10 9 with clinically significant bleeding
prolonged epistaxis
melaena
haematemesis
platelet transfusion
Chronic bone marrow failure
Autoimmune thrombocytopenia
Heparin-induced thrombocytopenia, or
Thrombotic thrombocytopenic purpura.
Thiazides SE
HyperGLUC
- hyperGlycemia
- hyperLipidemia
- hyperUricemia
- hyperCalcemia
empyema pleural fluid results
low ph <7.2
HIGHHHH LDH
low glucose
poor prognosis in hodgekins lymphoma
signs of poor prognosis: B-symptoms, increasing age, male sex, stage IV disease and lymphocyte depleted subtype
zollinger elison syndrome presents with?
what is associated with- genetic condition?
gastrinoma - bening growth of pancreas
high levels of gastrin and high levels of acid so you get erosion of stomach
so leads to ulceration
curling ulcers
ischaemia or hypervolaemia
how does a hiatus hernia present?
asymptomatic
GORD worse when lying flat
plapitations or hiccups indicate pericardial irritation
Hiatus hernia
gold standard
barium swallow is the most sensitive test
given the nature of the symptoms many patients have an endoscopy first-line, with a hiatus hernia being found incidentally
what is the most common form of hiatus hernia
what is the more serious concerning hiatus hernia?
sliding with GORd
rolling hernia as it can result in volvulus and ischaemia
Barrets oesophagus what cells changes after metaplasia?
squamous epithelium to columnar epithelium
gold standard for barrets
upper GI endoscopy with biopsy
what does barrest oesophagus risk a progression into?
oesophageal adenocarcinoma
what type of oesopahgeal cancer is most common
Squamous cell carcinoma is the most prevalent esophageal cancer worldwide
Patients with low-grade dysplasia
Barrett’s oesophagus
high dose PPI and followed up with endoscopic surveillance at six monthly intervals
Patients with high-grade dysplasia - barrets
Patients with high-grade dysplasia or early adenocarcinoma usually undergo endoscopic resection of the abnormal areas; methods include radiofrequency ablation, photodynamic ablation, or laser. Patients who are fit for surgery may undergo oesophagectomy.
squamous cell cancer of oesophagus risk factors
alcohol smoking
strictures
achalasia
nitrosamines
gastric cancer aetiology
RF
2 types intestinal - H pylori associated
diffuse : e -cadherin
RF pernicious anaemia H pylori nitrosamine smoking high salt/low vit C blood type A
gastric cancer presentation
vague epigastric abdo pain
weight loss
lymphadenopathy
gastric cancer lymphadenopathy where?
Virchows node - palpable in neck
sister mary joseph nodule - gastric ublicus
krukenburg tumour
bilaterally on ovaries which is a met of gastric cancer
herpes simplex keratitis
what is it
painful
watering
light sensitive red eye
It most commonly presents in adult men many years after primary infection with the herpes simplex virus, where the virus lays dormant in the trigeminal nerve
On examination, the cornea
is injected and examination under cobalt-blue light after the instillation of fluorescein, reveals a branch-like corneal lesion.
what is this pathogenomic for?
herpes simplex keratitis
management of herpes simplex keratitis
Herpes simplex keratitis is treated with topical aciclovir until the ulcer has healed. There is a risk of corneal scarring and blindness so this condition warrants urgent ophthalmological assessment. Steroids are contraindicated as immuno- suppression can lead to increased viral replication and the formation of a larger ulcer
MEN i
MEN type I (Wermer syndrome) includes the presence of
para- thyroid adenomas,
pancreatic islet-cell tumours
pituitary adenomas
so central?
MEN type IIa
parathyroid adenomas,
medullary carcinoma of the thyroid
phaeochromocytoma
MEN type III
presence of the tumours of MEN type IIa but with the addition of multiple mucosal neuromas of the gastrointestinal tract and a marfanoid phenotype
histology of coeliac disease?
villous atrophy, raised intra-epithelial lymphocytes, and crypt hyperplasia
abdominal pain
bloating and change in bowel habits
what condition most likely
Abdominal pain, Bloating and Change in bowel habit are classic features of irritable bowel syndrome
what abx given for SBP?
neutrophil count >250?
ciprofloxacin
what is used to induce remission in CROHNs?
prednisolone 300mg
300mg prednisolone. This can be done alongside a polymeric diet, which is especially successful in younger children
what drug is used to induce remission in UC
Mesalazine is an aminosalicylate and can be trialled to induce remission on failure of steroids. Aminosalicylates are generally first-line for reducing remission in ulcerative colitis
how does a transjugular intraheptic portosystemic shunt cause hepatic encephalopathy
Transjugular Intrahepatic Portosystemic Shunt causes blood from the portal system to bypass the liver and enter the systemic circulation without the metabolism of nitrogenous waste products such as ammonia. As these build up in the systemic circulation, increased ammonia is able to cross the blood brain barrier resulting in hepatic encephalopathy. Hence, Transjugular Intrahepatic Portosystemic Shunt can precipitate hepatic encephalopathy due to inadequate metabolism of nitrogenous waste products by the liver
patient has pin point eyes and reduced respiratory rate how should you manage assuming haemodynamically stable
naloxone boluses 0.8-2mg IV every 2 mins
aiming for gcs 13-14
Drugs that are known to potentiate the action of warfarin
antibiotics (including erythromycin), thyroxine, alcohol, antidepressants, aspirin, amioderone and quinine.
if INR is raised and there is associated active bleeding, what shouold you do?
oral / IV vit K
prothrombin complex concentrate II, VII,IX and X
if not available FFP
in thalassaemia trait if a patient has microcytic hypochromic anaemia how should you treat
how does thalassaemia trait present on electrophresis
no treatment needed
a2 increased on electrophoresis
normal ferritin and serum iron
Mx of HIV
<200 cells/mm3 is when AIDs becomes likely
HAART should be started, typically involving two nucleoside analogue reverse transcriptase inhibitors (NRTIs), such as zidovudine and didanosine, and one of either a protease inhibitor such as indinavir or a
Mx of HIV what is in HAART
2 nucleoside analogue reverse transcriptase inhibitors
and 1 of protease inhibitor/ non-nucleoside reverse transcriptase inhibitor
non-nucleoside reverse transcriptase inhibitor
efavirenz
zidovudine and didanosine examples of?
nucleoside analogue reverse transcriptase inhibitors (NRTIs)
protease inhibitor example
indinavir
what is a scleroderma renal crisis
fibrinoid thickening
and vessel narrowing
affects afferent arterioles causing a renal hypoperfusion
management of asthma- life threatening
what is not used in acute management
A High-flow oxygen
B High-dose nebulised beta-2 agonists C Intravenous magnesium sulphate
D Leukotriene receptor antagonists
E Steroids
D. Leukotriene receptor antagonists
rheumatic fever signs?
mx?
fever swollen red tongue rash on trunk pan systolic murmur loudest at apex CRP elevated
if SBP is suspected what is the next measure?
ascitic tap in 8 hours
thyroid crisis mx?
what is the role of steroids in this?
high dose anti thyroid meds
potassium iodide
beta blockers and high dose steroids which block t4>t3
what are the bony hand swellings in osteoarthritis called?
bouchards
heberdens
what is the surgical management of osteoarthritis?
Joint replacement (arthroplasty) may be required in severe cases (providing that they are fit enough for the procedure). It usually provides excellent pain relief, but will not improve the function of the joint
SLE and RA pleural effusion is it transudate or exudate?
what would the complement level be
exudate
raised ANA
and low complement
if septic arthritis suspected in a knee that has undergone knee replacement surgery ?
prostehtic joints should be admitted and urgently reviewed by ortho
malignant hypertension defn?
fibrinoid necrosis affecting small blood vessels
BP over 180/120 and symptomatic
end organ damage - intracranial haemorrhage > raised ICP and aortic dissection and AKI
malignant hypertension management ?
controlled drop in bp 160/100 over 24 hours
oral drugs preffered ccb - nifedipine
subdural haemorrhage surgical mx?
burr hole
subarachnoid haemorrhage surgical mx options?
endovascular coiling
surgical clipping
pattern of bleeding in haemophilia?
deep bruising into muscles
pattern of bleeding in VWF?
light bleeds - nose bleeds etc
polyarteritis nodosa
features?
skin lesions- ulcverate
orchitis
systemic upset
necrotising medium vessel non granuloma vascultis
hep b association
lhermitte sign?
pain on neck flexion - cervical spondylosis
management of osetomyelitis
flucloxacillin 6 weeks
clindamycin in penincillin allergic
osteomyelitis causes?
Staph. aureus is the most common cause except in patients with sickle-cell anaemia where Salmonella species predominate
osteoporosis
S – Steroid use H – Hyperthyroidism, hyperparathyroidism A – Alcohol and smoking T – Thin (BMI<22) T – Testosterone deficiency E – Early menopause R – Renal/liver failure E – Erosive/inflammatory bone disease D – Diabetes FAMILY HISTORY
side effects of corticosteroids
CORTICOSTEROID Cushing's syndrome Osteoporosis Retardation of growth Thin skin, easy bruising Immunosuppression Cataracts and glaucoma Oedema Suppression of HPA axis Teratogenic Emotional disturbance (including psychosis Rise in BP Obesity (truncal) Increased hair growth (hirsutism) Diabetes mellitus Striae
felt syndrome?
highly active rheumatoid arthritis (often with extrarticular disease), splenomegaly and neutropenia
severity score fo RA?
das28 score
crp /esr
when are DMARDs indicated for RA?
das28 is >5.1
eg methotrexate, sulfasalazine, hydroxychloroquine and leflunomide
what biologic is used for RA
infliximab anti-tnf
in renal failure what is the pattern of
ca2+
phosphate
PTH
ca2+ is low
vit D is low
phosphate is high - due to failure of excretion
pth is high
Biochemical and radiological findings
Typical findings in osteomalacia
↓Calcium ↓Phosphate ↑ALP ↑Parathyroid hormone X-rays: Looser lines (or zones) which are lucencies going part of the way through the bone
vancomycin provides?
gram positive cover
gentamicin ?
gram negative cover
nephrotic syndrome ascitic albumin gradient
gives rise to a low saag due to loss of albumin in urine - resulting in low serum albumin ration
SAAG less than 11?
exudative
peritoneal mass
infection
pancreatitis
