7) repro, resp, psych Flashcards

Question

TESTICULAR CANCER - 1st line imaging? 1 - additional imaging needed? 2 - tumour markers to do? 3 - which tumour markers are raised in which sub-type?

Answer 1

1st) ULTRASOUND - do NOT do trans-scrotal biopsy! - can cause spread!! CT of abdo pelvis + norm chest too for stagting (as can spread a lot!) 1) AFP - always high in: yolk sac (F is for Foetal - ie in a yolk sac!) - may be high in: mixed germ cell 2) HCG - always high in: choriocarcinoma (C for Chorio) - may be high in: mixed germ cell 3) LDH - non-specific marker of cell turnover (lactate dehydrogenase) - marker of prognosis (response to Tx) and detects relapse i.e. metastatic disease

Answer 2

metastasise to PARA-AORTIC lymph nodes (these are retroperitoneal) Prior to surgery: sperm cryopreservation RADICAL INGUINAL ORCHIECTOMY (ie pull out through inguinal canal - to avoid haem spread) if stage I (confined to testes, no lymph node spread) then can do active surveillence but most get chemo and/or radio too - and all that have spread to lymph nodes (stage II) or distant mets (stage III) get chemo! testicular tumours are very chemo responsive and is about 95% cure rate!

Answer 3

nb most common breast lesion! Mobile, firm breast lumps - a 'breast mouse' - doesn't getr bigger/smaller with periods, no pain! age 20-40 triple assessment! - exam, USS (under 40) or mammogram (over 40) and core needle biopsy NO CANCER RISK! (except see below) - 1/3 regress, 1/3 stay same, 1/3 enlarge if over 3cm then tend to surgically remove! nb rarely can get Complex Fibroadenomas - Moderately differentiated cells - Slight ↑risk of Ca

Answer 4

inflammation of the breast parenchyma occurs in up to 10% of BREASTFEEDING mothers (particularly 2–4 weeks postpartum) anything that causes insufficient drainage of milk -> milk stasis: - infrequent feeding - quick weaning - illness in either mother or baby norm STAPH AUREUS

Answer 5

- Tender, firm, swollen, erythematous breast (generally unilateral) - Pain during breastfeeding - Reduced milk secretion flu-like symptoms - malaise - fever - chills is a clinical diagnosis! can get reactive lymphadenopathy

Answer 6

``` CONTINUE BREASTFEEDING (baby already has the bug!) - if can't then use breast pump but breastfeeding better! ``` - NSAIDs (fine for breastfeeding) - cold comresses fluclox 10-14 days if: - systemically unwell - nipple fissure present - symptoms don't improve after 24hrs of effective milk removal ^keep breastfeeding while have abx! can develop a BREAST ABSCESS (norm if they stop breast feeding) nb if inadequate response to treatment, do breast milk cultures

Answer 7

complicaiton of mastitis a TENDER, FLUCTUANT mass - Breast pain, erythema, and oedema - Purulent discharge from the nipple of the affected breast - Fever - nausea mx - antibiotics - incision + drainage! nb Overlying skin necrosis is an indication for surgical debridement, which may be complicated by the development of a subsequent mammary duct fistula

Answer 8

around 50 typically obese women with large breasts trauma (although many women don't report any or it may be very minor trauma!) Initial inflammatory response, the lesion is typical firm and round but may develop into a hard, irregular breast lump - norm painless - may get associated skin and nipple changes triple assessment - clinical exam - imaging - core biopsy is rare and often presents very similar to breast Ca so always fully investigate!

Answer 9

- aka fibroadenosis - aka benign mammary dysplasia benign changes characterised by the formation of fibrotic and/or cystic tissue middle aged pre-menopausal women - Premenstrual bilateral multifocal breast pain - Tender or nontender breast nodules - may have Clear or slightly milky nipple discharge Mx = Mainly supportive with analgesia for pain control Hormone therapy can be considered for those with >6m symptoms of severe breast pain + impact on ADLs. These treatments are infrequently used bc of adverse effects.

Answer 10

PHYSIOLOGICAL - during breast feeding - can also get a bit during pregnancy GALACTORRHOEA - Commonest cause may be response to emotional events, drugs such as histamine receptor antagonists are also implicated (can also get in end-stage kidney disease) HYPERPROLACTINAEMIA - Commonest type of pituitary tumour - -- Microadenomas <1cm in diameter - -- Macroadenomas >1cm in diameter - Pressure on optic chiasm may cause bitemporal hemianopia INTRADUCTAL PAPILLOMA - Commoner in younger patients but also middle-aged women! - May cause blood stained discharge - There is usually no palpable lump MAMMARY DUCT ECTASIA - Dilatation breast ducts. - Most common in menopausal women - Discharge typically thick and green in colour - Most common in smokers CARCINOMA - Often blood stained - May be underlying mass or axillary lymphadenopathy any antidopaminergic drugs - metoclopramide - 1st gen (and 2nd gen) antipsychotics

Answer 11

measure PROLACTIN if not high, no pathological cause for galactorrhoea do VISUAL FIELD test (looking for bitemporal hemianopia) if elevated do: - TSH (primary hypothyroidism) - bHCG (pregnancy) - creatinine (chronic kiney disease) ^if these three tests are normal and priolactin is high: do MRI of head (to look for pituatory adenoma)

Answer 12

send for triple assessment - incl biopsy if this negative: measure prolactin and then see previous flashcard for other investigations! nb signs that suggest malignancy: - Spontaneous, unilateral, uniductal, and bloody discharge - Presence of a breast mass or abnormalities in imaging - Age > 40 years

Answer 13

if bilateral galactorrhoea with NORMAL prolactin and non lump then can reassure! intraductal papilloma: - if troubling can have: microdochectomy (if young) or total duct excision (if older) ``` mammary duct ectasia - smoking cessation advice - mx usually not needed - if troubling can have: microdochectomy (if young) or total duct excision (if older) (nb may progress to breast abscess) ```

Answer 14

FIBRADENOMA - Solitary, well-defined, non-tender, rubbery, and mobile mass FIBROCYSTIC CHANGES - Premenstrual breast tenderness - Multiple breast nodules bilaterally BREAST CYSTS - well circumscribed (may feel like a grape, or water-balloon in the breast) - usually firm but not hard, and mobile - may get larger and smaller depending on stage of menstrual cycle PHYLLODES TUMOUR - Painless, smooth, multinodular lump - Variable growth rate - Generally > 3 cm - needs surgical excision! FAT NECROSIS - Irregularly defined and dense periareolar breast mass - Skin retraction, erythema, and ecchymosis GALACTOCELE - Painless, firm mass - most common lesion in breast feeding women INTRADUCTAL PAPILLOMA - Solitary lesions - Bloody nipple discharge - Palpable breast lump close to or behind the nipple - nb Multiple lesion are usually asymptomatic MAMMARY DUCT ECTASIA - Unilateral greenish or bloody discharge - Nipple inversion - Firm, stable, painful mass under the nipple BREAST CANCER - hard, painless (90%), irregular margins, fixed to skin or chest wall - skin dimpling may occur, may have unilateral nipple discharge +/or nipple retraction

Answer 15

2WW 1) aged 30 years or more - unexplained breast lump (with or without pain) 2) aged 50 or more - UNILATERAL discharge, retraction, any other nipple changes also consider 2WW for: - pt w skin changes that suggest breast cancer - 30 years and over with an unexplained lump in the axilla non-urgent referral: - under 30 with unexplained breast lump

Answer 16

``` HYDROCELE - Fluctuant swelling of the scrotum - transilluminates - nb MAY be presenting feature of testicular Ca! = Hypoechoic mass around the testis ``` SPERMATOCELE = aka EPIDIDYMAL CYSTS - Fluctuant swelling of the upper testicular pole - transilluminates = Hypoechoic dilation of epididymal duct or rete testis ^ie hydrocele is fluid surrounding testes, spermatocele is fluid filled sac on top iof epididymis VARICOCELE - Usually painless (can be a dull pain) swelling may be reduced when supine - norm on Left (may be 1st presentation of renal Ca) - Visible or palpable strands and “bag of worms” sensation - bilateral varicoceles may affect fertility - doesn't transilluminate = Dilated hypoechoic pampiniform vessels ``` SCROTAL HERNIA - can't get above it on exam! - cough impulse may be present + may be reducible - doesn't transilluminate = Herniated bowels on USS ``` ``` TESTICULAR TUMOUR - Usually painless mass (however, may feel dull ache or "heavy" sensation in the testicle) - Palpation of solid mass - doesn't transilluminate = Solid mass with variable echogenicity ```

Answer 17

TESTICULAR TORSION - Sudden onset unilateral painful testis/lower abdomen w nausea or vomiting - Swollen, edematous, tender testis - Abnormal position of testis (e.g., transverse lie, scrotal elevation) - Negative Prehn sign (elevating testicles doesn't relieve pain) - Absent cremasteric reflex = normal inflam markers + urine dip ACUTE EPIDIDYMO-ORCHITIS - onset over a few days, painful swelling with possible induration - possible history of urethral discharge, fever, dysuria, urinary freq - Very tender (physical examination is painful) - Positive Prehn sign - Positive cremasteric reflex = increase in inflamm markers, possible pyuria on urine dip/MSU TORSION OF TESTICULAR APPENDAGE - Insidious onset of unilateral scrotal pain - Usually seen in boys 3–5 years of age - Tender testis May manifest with blue dot sign = typically norm inflamm markers and urine dip TESTICULAR TUMOUR - Slow progression (e.g., weeks to months) Usually painless mass (however, the patient may experience a dull ache or describe a “heavy” sensation in the testis) - Easy palpation of solid mass - Possible manifestations of metastatic disease (e.g., distant lymphadenopathy, chest pain, GI symptoms) - Possible swelling of the ipsilateral lower limb (venous engorgement due to obstruction) = possible increase in serum tumour markers: AFP, HCG, LDH also STRANGIULATED INGUINAL hernia can also get HAEMATOCELE (following acute trauma) - admit if acute! - if it is chronic or does not follow trauma - refer as out patient USS! - still need to be seen!

Answer 18

USS scrotum nb if high suspision of testicular torsion - just go straight to surgery! DON'T biopsy trough scrotum!!

Answer 19

TORSION OF TESTICULAR APPENDAGE - NSAIDs for pain, can be maged conservatively - may need surgical exploration HYDROCELE - Hydrocele should be managed depending on whether it is congenital or non-congenital, as well as the size of the hydrocele - always needs USS to see if underlying Ca! SPERMATOCELE - aka EPIDIDYMAL CYSTS - should be reassured, as they rarely need treatment VARICOCELE - norm managed conservatively - If concerns about infertility then surgery or radiological mx can be considered SCROTAL HERNIA - if strangulated or causing obstruction - admit immediately - if not, refer in 2 weeks for infant or young boy! - refer for elective surgery for men or older boys

Answer 20

Panic attack is excessive fear without an obvious trigger; associated with symptoms of autonomic arousal: - sweating - tremors - tingling fingers - periorbital tingling - dizziness - nausea - palpitations - tight chest / chest pain - breathlessness - worry - irritability - fear - derealisation = tremor = high HR = high RR usually lasts < 30 mins

Answer 21

Basically think about the differentials for SOB and chest pain (and match with risk factors, incl age) will NOT do all of these but may do some of: - ECG - troponin - FBC - TFTs - glucose if blood gas: resp alkalosis (low CO2) ACUTE Mx 1) Breathe into paper bag if hyperventilating (increases CO2 uptake to manage symptoms) 2) Careful explanation of what is happening, that they wont pass out, and explore what is causing it 3) short-acting benzo (eg lorazepam) if really struggling if repeated (panic disorder), go to GP, for: - CBT - antidepressants - propranolol (pill in pocket) additional ?helpful advice: - Breathing exercises (silently counting up to 10) - Visualisation techniques (imagine colour/place) - Relaxation music - Yoga

Answer 22

a self-limiting lower respiratory tract infection (RTI) characterized by inflammation of the bronchi >90% are caused by viruses ``` Influenza A and B Parainfluenza Adenovirus RSV Rhinovirus Coronavirus ```

Answer 23

norm preceeded by an URTI - runny nose - sore throat COUGH - >5days (resolves in 2-3 wks) - sputum (50%) (purulence doesn't always mean bacterial cause!) - chest pain - SOB - headache - myalgia - malaise fever (uncommon) - if fever, likely dt influenza (or actually pneumonia!)

Answer 24

nb if in small child - think bronchiolitis! clinical diagnosis may get a bit of wheezing on auscultation (but ?may also get crackles?? - check this!!**) - rest + adequate hydration (promotes mucus secretion) - simple analgesia for myalgia/headache antibiotic not recommended!!! generally self-limiting main complicaiton = secondary bacterial infection, ie pneumonia at risk for complications: - elderly - pre-existing lung conditions - immunocompromised

Answer 25

ie cough < 3 weeks in adults! - upper resp tract infections - acute bronchitis - pneumonia - acute exacerbation of asthma/COPD - acute PE - congestive heart failure - acute inhalational injury (eg smoke or chemicals) nb acute pericarditis can rarely have a cough ALSO COVID! how could I forget?

Answer 26

Primary (PSP) = patient has NO underlying lung pathology (on Hx, exam or CXR) - norm tall young men Secondary (SSP) = patient has underlying lung pathology (COPD, asthma, pneumonia, Ca, TB, fibrosis etc) NON-SPONTANEOUS - iatrogenic ( eg secondary to pleural aspiration, +ve pressure ventilation) - trauma (eg rib #)

Answer 27

- Very high RR - ↑HR - ↓BP - resp distress - distended neck veins - cyanosis - agitation - tracheal deviation (late) basically if someone with symptoms/signs of a pneumothorax becomes HAEMODYNAMICALLY UNSTABLE

Answer 28

1st line: = ERECT chest X-ray - Hypodense area with loss of vascular markings, can see lung edge - Small < 2cm - Large > 2cm Should never order if tension (would see mediastinal shift) also do bloods depending on clinical picture, incl ABG if hypoxic 2nd line: CT scan - if uncertainty on CXR or complex case MANAGE URGENTLY IF: - tension - bilateral give: - high flow O2 - needle decompression AND urgent chest drain!

Answer 29

PRIMARY spontaneous pneumothorax (PSP) If size < 2cm and not SOB: - consider discharge (review in OPD in 2-4wks) If size > 2cm and/or SOB: - Aspirate with cannula - -- If success: consider discharge (see above) - -- If no success: chest drain (& admit) TREAT primary based on SHORTNESS OF BREATH, not size! If discharge, safety net to come back if get SOB (& NO FLYING until full resolution)

Answer 30

this is for SECONDARY - ie have underlying lung disease (either on Hx, exam or test results - eg chronic CO2 retainer) If size < 1cm and not SOB: 1) High-flow oxygen (unless retain CO2!) 2) Observe for 24hrs If size 1-2cm and not SOB: 1) Aspirate with cannula - -- If success (ie <1cm): High flow O2 and 24hr observe (see above) - -- If no success: chest drain (& admit) If size > 2cm and/or SOB: 1) chest drain (& admit) always re-CXR before removing chest drain to check fully resolved! consult surgeons if: - persistent air leak or failure of lung to re-expand with drain at 3-5 days

Answer 31

1) Surgery to remove bullae / diseased lung | 2) Pleurodesis (if not fit / don’t want surgery)

Answer 32

as a general rule pleural effusions form as a result of increased fluid formation and/or reduced fluid reabsorption TRANSUDATES - Think ↑Venous pressure and/or Hypoproteinaemia! - More likely to be BILATERAL EXUDATES - Think infection, inflammation, infarction or malignancy! - More likely to be UNILATERAL

Answer 33

TRANSUDATES = LEFT ventricular failure = liver cirrhosis - Hypoalbuminaemia - Peritoneal dialysis - Hypothyroidism - Nephrotic syndrome - Mitral stenosis nb other rarer causes of transudates: Constrictive pericarditis, Urinothorax, Meigs’ syndrome EXUDATES = Malignancy = Parapneumonic effusions = Tuberculosis - PE - Pancreatitis - Rheumatoid arthritis (+ other autoimmune pleuritis) - Benign asbestos effusion - Post-myocardial infarction - Post-coronary artery bypass graft nb other rarer causes of exudates: Yellow nail syndrome (& other lymphatic disorders), Some medications, Fungal infections

Answer 34

Typical Hx: - Progressive dyspnoea (days-wks) - pleuritic chest pain - cough Typical exam findings: - Stony dull (percussion) - reduced breath sounds (auscultation) Malignancy red flags: - Weight loss - anorexia - fatigue - haemoptysis - smoker (or ex) - asbestos exposure

Answer 35

1st line: = CXR - Opacity at base of lung with meniscus / blunting of costophrenic angle(s) need >200ml on PA or >50ml on Lateral to be visible (‘normal’ x-ray doesn’t exclude effusion!) If likely transudate from clinical presentation & CXR, treat this (ie don’t need to do aspiration) 2nd line: = US-guided pleural aspiration AND bloods pleural USS can visualise septations (indicating exudate) and can pick up smaller effusions than CXR Look at & smell aspirate (putrid odour, milky, bloody, ‘anchovy sauce’) Tests for ALL pleural aspirates: = LDH & protein (for Light’s criteria) = Microscopy & culture = Cytology (malignant & immune cells) Bloods: = LDH and Total protein (Light’s criteria) = PLUS others to find cause eg FBC, LFTs nb Other aspirate tests if high clinical suspicion: - pH (infection) - Glucose (low = likely rheumatoid) - TB culture - Triglycerides & cholesterol (chylothorax) - Amylase (pancreatitis) - Haematocrit (haemothorax) LIGHT'S CRITERIA - distinguish between exudate & transudate = Ratios between protein and LDH in serum vs pleural fluid Specific values but simply: INCREASED protein and LDH in pleural fluid = likely exudate Nb 3rd line: CT scan - to distinguish between malignant & benign causes of exudate (if aspiration not definitive)

Answer 36

TREAT EFFUSION 1st) chest drain (if exudate) if recurrent: - long-standing drain (managed by district nurses) - pleurodesis (tetracycline, bleomycin or sterile talc) TREAT UNDERLYING CAUSE - eg chemo for cancer, diuretics for HF for transudate: norm just treat underlying cause and this will treat!

Answer 37

SMALL CELL - SIADH (syndrome of inappropriate anti-diuretic hormone) - CUSHINGS (ectopic ACTH) - LAMBERT-EATON syndrome "when you're SMALL: you PEE a lot, you're CHUBBY and your MUSCLES don't work that well" lambert-eaton = antibodies against presynaptic calcium channels in NMJ -> weakness that improves with repetitive stimulation (similar to myasthenia gravis) nb cushings due to lung ca is not typical: HTN, high glucose, low K, alkalosis are more common than buffalo hump etc SQUAMOUS CELL - parathyroid hormone-related protein (PTH-rp) secretion -> HYPERCALCAEMIA - hypertrophic pulmonary OSTEOARTHROPATHY (HPOA) - HYPERTHYROIDISM (dt ectopic TSH) HPOA = clubbing and painful joint swelling (periostitis) - can also get in adeno! "In QUebec they get more bone probs = HIGH CALCIUM + CLUBBING - also GOITERS" ADENOCARCINOMA - THROMBOPHLEBITIS MIGRANS (aka Trousseau syndrome) - GYNAECOMASTIA (also large cell) "ADenocarcinoma ADDS BREAST tissue to men, and ADDs VEINS everywhere too!" nb Thrombophlebitis migrans is also associated with pancreatic adenocarcinoma ALL LUNG CA: - Thrombocytosis + DIC - Hypercoagulability (higher risk in adeno) - Dermatomyositis - Acanthosis nigricans

Answer 38

SUPERIOR VENA CAVA - SVC syndrome (see oncological emergencies) RECURRENT LARYNGEAL NERVE (esp pancoast tumours) - hoarse voice PHRENIC NEVRE - dyspnoea - diaphramatic elevation ANOTHER BIT OF LUNG - lobe/lung collapse - postobstructive pneumonia OESOPHAGIUS - dysphagia recurrent respiratory infections (e.g. pneumonia) in the same pulmonary region in patients ≥ 40 years old should always raise suspicion for lung cancer! nb pancoast are nonrm NSCLC: - Horner’s synd. – miosis (anisocoria), anhidrosis, ptosis - Pancoast’s synd. – pain in nerve root distribution

Answer 39

over 50% have metastatic disease at the time of presentation BLAB! - "lung cancers like to blab! BRAIN - headache (raised ICP features) - seizures - focal motor deficits - behavioural changes LIVER - typically asymptomatic - may manifest with nausea, jaundice, ascites ADRENAL GLANDS - typically asymptomatic BONES - bone pain - elevated serum alkaline phosphatase (ALP) and calcium Bone mets in Lung Ca are LYTIC!!

Answer 40

a mulit-system disorder characterised by widespread, immune-mediated formation of NON-CASEATING GRANULOMAs nb cause or underlying pathology is not known! - female (2:1) - 25-35 years old (2nd peak at: 50-65) 10 TIMES higher in black ethnicity (compared to white) - acute (1/3rd) - chronic (2/3rds) ^acute only rarely develops into chronic! (chronic norm develops without acute!)

Answer 41

Typically has a sudden onset and remits spontaneously within approx. 2 years Progression to chronic sarcoidosis is rare - fever - malaise - lack of appetite - weight loss PULM - SOB - cough - chest pain EXTRA PULM - arthritis - anterior uveitis - erythema nodosum

Answer 42

Gradual disease course; may be recurrent or progressive - can rarely be preceeded by acute sarcoidosis often ASYMPTOMATIC in early stages - can be picked up on CXR as incidental finding! PULM (most common) - interstital fibrosis - -- cough - -- SOB ENLARGED LYMPH NODES (40%) - in 90% found within thorax (ie mediastinum) OCULAR (25%) - Granulomatous uveitis (norm anterior, can be posterior) - if sarcoidosis diagnosed: see opthalmologist to exclude this!! SKIN FINDINGS (25%) - lupus pernio - facial rash, similar to lupus - scar sarcoidosis (inflamed, purple skin infiltration and elevation of old scars or tattoos) lupus pernio = pathognomic for sarcoidosis - extensive, purple skin lesions (violaceous skin plaques) on the nose, cheeks, chin, and/or ears - aka epithelioid granulomas of the dermis nb sarcoidosis can affect ANY organ! OTHER MANIFESTATIONS (don't worry about learning all!) - MSK (arthritis similar to RA, bone lesions) - NEURO (CN palsy - facial most common, diabetes insipidus, meningitis, hypopit) - HEART (restrictive cardiomyopathy, pericardial effusion, AV block, sudden cardiac death) - LIVER (hepatic granulomas, hepatomegaly in 30% of cases) - KIDNEYS (norm related to calcium metabolism - eg nephrocalcinosis, nephrolithiasis) - SPLEEN (splenomegaly in 30%) Features of sarcoidosis are GRUELING: - Granulomas - aRthritis - Uveitis - Erythema nodosum - Lymphadenopathy - Interstitial fibrosis - Negative TB test - Gammaglobulinemia

Answer 43

1st) CXR - Bilateral hilar lymphadenopathy +/- Bilateral reticular or ground-glass opacities there is a staging system (based on CXR) for chronic sarcoidosis from normal -> fibrosis nb pts with chronic sarcoidosis often have moderate clinical manifestations but radiographic findings of extensive disease gold standard = BRONCHOSCOPY with BIOPSY of lung + lymph nodes - NON-CASEATING GRANULOMAS with GIANT cells (central necrosis is absent) - ASTEROID bodies, SCHAUMANN bodies INFLAMMATORY markers - raised in acute + chronic (CRP + ESR) - can also get lymphopenia (low WCC) raised in CHRONIC: - ACE (angiotensin coverting enzyme) raised in 60% (used for monitoring disease progression) - high CALCIUM (10%) ALP is raised if liver involvement! nb IgG is also raised in 50% of pts but ?rarely tested for nb can do CT scan if CXR not clear / to rule out differentials! nb can get restrictive or obstructive patterns on spirometry

Answer 44

Isolated pulmonary sarcoidosis: In most cases, no treatment is required. The disease is often asymptomatic, non‑progressive, and has a high rate of spontaneous remission ``` 1st) CORTICOSTEROIDS indications: - CXR stage 2 or 3 disease who are symptomatic - hypercalcaemia - eye, heart or neuro involvement ``` nb asymptomatic and stable stage 2 or 3 disease who have only mildly abnormal lung function do not require treatment can use NSAIDs for symptom relief!! if bad, can use: - methotrexate - azathioprine - chloroquinine / hydroxychloroquinine lung transplant is last resort!

Answer 45

norm only get major complications with stage 3 or 4! - lung cancer - malignant lymphomas - brochiectasis - lung fibrosis - chronic renal failure (esp in pts w hypercalcaemia)

Answer 46

mycobacterium tuberculosis (also rarely: m. bovis + m. africanum) Spread via resp droplets (only pulm version is infectious) TB infection vs TB disease - 90% of those infected, TB is dealt with effectively by immune system without symptoms - 10% will go on to develop into TB disease at some point – usually within 1-2 years Latent TB vs active disease - Latent TB occurs due to granuloma formation around the infection ‘sealing’ it off, asymptomatic - Active disease occurs when then elderly, malnourished or immunocompromised etc and re-activates Mycobacteria reach lung alveoli and get engulfed by macrophages where they replicate Lymphocytes + fibroblasts surround the macrophage forming a defensive barrier (granuloma - AKA ghon focus) - pathogenesis of latent TB ^if this fails the mycobacterium can spread + cause extra-pulmonary TB active infection: when malnourished, immunosuppressed or elderly, Ghon focus becomes reactivated → spreads to upper lobes (apex) of lungs (high oxygen area) → memory T-cells release massive amounts of cytokines → caseous necrosis causing cavitation → TB disseminates via pulmonary venous system → systemic Miliary TB Miliary TB: whole body-wide haematogenous spread of TB, poor prognosis

Answer 47

SYSTEMIC - weight loss - fever - night sweats (+/-rigors) - anorexia - malaise - palpable LYMPH NODES (rubbery) PULMONARY (70%) - persistent/chronic PRODUCTIVE COUGH (>3 wks) - breathlessness (late) - haemoptysis (late) GENITO-URINARY - Sterile Pyuria (on MSU) or Haematuria - Dysuria or loin pain - Infertility (females) or Swollen epididymis (males) (or prostatitis symps) MSK - joint pain (arthritis) - bone pain (osteomyelititis) - Pott's disease (osteomyelitis + arthritis involving multiple vertebrae) - abscess formation (loin or psoas) CNS - TB meningitis (?presents same as normal meningitis? - think over 1-3wks though?) SKIN - erythema nodosum - lupus vulgaris (painful nodular lesions affecting the face) PERICARDIAL - SOB - chest pain - ankle swelling GI - abdo pain / distension - constipation / bowel obstruction ADRENAL - presents as adrenal insufficiency in children: - porr weight gain / faltering growth - fatigue - persistent fever MILIARY = massive lymphohematogenous spread of Mycobacterium tuberculosis bacilli from a pulmonary or extrapulmonary focus with multiple organ involvement and very small granuloma lesions (1–2 mm)

Answer 48

can't find an exhaustive list but: - contacts of known positve cases - prisons - homeless people - new entrants from high prevelence country - immunocompromised (incl HIV) - about to start immunosuppression (eg anti- TNF drugs: infliximab - also need CXR) - new NHS employees 1) MANTOUX TEST - tests for hypersensitivity to tuberculin = positive if >5mm after 2-3 days (if <5mm can give BCG vaccine) - if 6-15mm norm prev infection or BCG vaccine (don't need BCG vaccine) - if over 15mm highly suggestive of active TB disease false negative mantoux test may be caused by: - miliary TB - HIV - sarcoidosis - lymphoma - very young age (eg <6 months) 2) INTERFERON GAMMA RELEASE ASSAY (IGRA) TEST - blood test detecting response of WBCs to TB antigens use if: - mantoux is positive or equivocal - mantoux test may be falsely negative (see above) nb sometimes if someone high risk - just use IGRA first, instead of doing mantoux first! nb the heaf test is NOT used anymore!

Answer 49

gold standard = SPUTUM CULTURE - 3 deep cough samples (one early morn) - stained with ZIEHL-NEELSON stain for acid-fast bacilli (all mycobacteria will stain positive!) - can take 1-3 weeks to come back - can also assess drug sensitivities! nb can just do the stain and this is faster but less good! - called a sputum smear! other = NUCLEIC ACID AMPLIFICATION TESTS (NAAT) - allows rapid diagnosis (within 24-48hrs) - more sensitive than smear but less sensitiove than culture - can show some drug resistance (but not as good as culture) do CHEST X-RAY in ALL (ie ANY suspision of TB!) - upper lobe caviation - bilateral hilar lymphadenopathy If think have EXTRA-PULMONARY TB - get a sample from this site / nearby lymph nodes if possible + try to culture If have high suspision of TB - take cultures and then treat before they've come back!

Answer 50

LATENT = Hilar lymphadenopathy, Ghon focus SECONDARY / ACTIVE - Evidence of Apical consolidation - Cavitating lesions - Fibro-calcification → Tracheal shift toward Miliary lesion Reticular pattern (millet seeds) - multiple 1-9mm lesions across whole lung field nb google x-ray for milliary TB

Answer 51

DO NOT DELAY TREATMENT IF WAITING FOR CXR/SPECIMEN RESULTS Put patient in side room, limit contacts, treat symptoms managed by specialist TB physician! ``` ACTIVE = "RIPE" - Rifampicin (6 months) - Isoniazid (6 months) - Pyrazinamide (2 months) - Ethambutol (2 months) ^all are 3 doses/wk ``` LATENT - Rifampacin + Isoniazid for 3 months or Isoniazid alone for 6 months TB MENINGITIS - same abx as for active (but continue R + I for 1 year, instead of 6 months!) - also have dexamethasone! nb isoniazid is always with pyroxidine too! if pts likely to have poor concordance (homeless, prison) then can do DIRECTLY OBSERVED therapy with 3x a week dosing! TB = NOTIFIABLE DISEASE - inform public health and do contact tracing!

Answer 52

``` RIFAMPICIN = PY450 inducer - flu-like symptoms - hepatitis (?stop if LFT derange) - orange secretions ``` ``` ISONIAZID = PY450 inhibitor - peripheral neuropathy (prevent w pyroxidine = vit B6) - hepatitis - agranulocytosis ``` ``` PYRAZINAMIDE - hyperuricaemia -> gout - arthralgia, myalgia - hepatitis CI: acute gout, porphyria ``` ETHAMBUTOL - optic neuritis (check visual acuity before + during treatment) ^"eyes go blurry when you have ethanol!"

Answer 53

``` SARCOIDOSIS - RF: black women - dry cough, erythema nodosum, lupus pernio, uveitis = non-caseating granulomas, giant cells - high ACE levels in blood ``` TUBERCULOSIS - RF: immunocompromised, prev TB or recent TB exposure - fever, weight loss, night sweats, productive cough (not responsive to pneumonia abx), haemoptysis = caseating granuloma, langerhan giant cells, epithelioid macrophages, acid-fast bacilli HODGKIN LYMPHOMA - RF: EBV infection - pel-ebstein fever, alvohol-induced pain, pruritis = non-caseating granulomas, reed-sternberg cells, inflam cell infiltrates (eosinophils, fibroblasts, plasma cells) - single or combined cytopenias (RBC, platelets, WBC) NON-HODGKINS LYMPHOMA - RF: infections (EBV, Hpylori), cell damage (toxins, immunosuppresion, radiation) - lymph nodes, splenomegaly, evidence of bone marrow suppression = non-caseating granulomas (NO reed-sternberg cells), B or T cells, inflamm cell infiltrate - single or combined cytopenias PNEUMOCONIOSIS - RF: exposure to mineral dust (eg silica) - often asymptomatic (may have: progressive exertional SOB, chronic cough, clubbing, crackles) = non-caseating granulomas (silica/asbestos bodies) - positive beryllium lymphocyte proliferation test (BeLPT) ``` GRANULOMATIS W POLYANGITIS (WEGNER'S) - RF: white people 65-75years - chronic rhinosinusitis with thick purulent/bloodty discharge, treatment resistant pneumonia, glomerulonephritis = non-caseating granulomas - positice c-ANCA ``` HISTOPLASMOSIS - RF: HIV, exposure to bird/bat excrement - pulmonary (dry cough, oral ulcers) or extra-pulm (splenomegaly) = caseating granuloma, Identification of H. capsulatum yeast with silver stain - Positive polysaccharide urine and serum antigen test DON'T WORRY ABOUT THE RARER ONES AND DIAGNOSTIC TESTS TOO MUCH! - JUST BE AWARE OF DIFFERENT CAUSES OF GRANULOMATOUS DISEASES

Answer 54

intermittent closure/collapse of pharyngeal airway → apnoeic episodes during sleep → terminated by partial arousal - OBESITY macroglossia: - acromegaly - hypothyroid - amyloidosis - marfans - large tonsils

Answer 55

- Loud SNORING (often witnessed by parter, who may also witness partial apnoeas) - Daytime somnolence (falling asleep/fatigued in day) - Poor sleep quality - Morning headache - ↓ libido - ↓ cog performance COMPLICATIONS - HTN - type 2 resp failure (resp acidosis w compensation) - pulmonary HTN

Answer 56

- Epworth Sleepiness Scale (questionnaire completed by patient +/- partner) - Multiple Sleep Latency Test (MSLT) (measures the time to fall asleep in a dark room (using EEG criteria)) diagnostic = POLYSOMNOGRAPHY (sleep studies) - monitors O2 sats, airflow of now & mouth, ECG, EMG chest & abdo wall during sleep - numbewr of apnoeas determine if mild, mod or severe

Answer 57

- loose weight - decrease alcohol - decrease smoking if mod/severe = air-driven CPAP overnight! occasionally: - intra-oral devices - surgery to remove obstruction (eg tonsillectomy)

Answer 58

- fire/smoke inhalation - poor housing (eg student, caravans etc) - suicide attempt! - headache (90%) - nausea + vomiting (50%) - vertigo (50%) - confusion (30%) - subjective weakness (20%) severe toxicity: - 'pink' skin and mucosae - hyperpyrexia - arrhythmias / ischaemias - extrapyramidal features - coma -> death

Answer 59

O2 SATS ARE MISLEADING! (as they measure carboxy and oxyhaemoglobin!) - so will often have sats of 100%! ABG ASAP (see conc of carboxyhaemoglobin - nb norm slightly raised in smokers!) - can use VBG if really struggling but levels not as reliable! do ECG (look for arrythmias/ischaemia) Mx: 100% OXYGEN NRBM - give for a min of 6hours - continue until all symptoms have resolved (ie rather than monitoring CO levels) HYPERBARIC OXYGEN if: - any LOC - neuro signs (other than headache) - myocardial ischaemia or arrythmia - pregnancy EARLY INTUBATION if: - poisoning as result of fire / inhalational injury - eg: Burns to the face Soot in nostrils or mouth and/or Stridor or hoarseness or drooling

Answer 60

Pneumoconiosis = accumulation of dust in the lungs and the response of the bodily tissue to its presence, most commonly used in relation to coal worker’s pneumoconiosis often asymptomatic initially - decades between exposure and symptoms - SOB on exertion - cough +/- black sputum can present with really severe disease and generalised fibrosis!

Answer 61

CXR - UPPER LOBE FIBROSIS - Round irregular, nodular opacities in upper zones!! - can have bilateral hilar lymphadenopathy - can have mass like area of opacification (sausage shaped) in progressive massive fibrosis SPIROMETRY - Obstructive: FEV1/FVC < 0.7, ↓↓FEV1 = Simple - Mixed obstructive/restrictive = Fibrosis management is supportive! - incl chest physio etc

Answer 62

PLEURAL PLAQUES - benign, don't become malignant (very clear on xray!) - most common form of asbestosis-related lung disease - latent period of 20-40 years PLEURAL THICKENING - looks like an empyema or haemothorax on CXR ASBESTOSIS - severity is linked to length of exposure - latent period: 15-30 years - LOWER LOBE FIBROSIS - SOB + reduced exercise tolerance! MESOTHELIOMA - Crocidolite (blue) asbestos is the most dangerous form - risk is unrelated to duration of exposure - progressive SOB, chest pain, pleural effusion remember asbestosis is also a risk factor for normal lung Ca too! nb for mesothelioma: Patients are usually offered palliative chemotherapy and there is also a limited role for surgery and radiotherapy. Unfortunately the prognosis is very poor, with a median survival from diagnosis of 8-14 months.

Answer 63

RISK FACTORS: - high risk for aspiration (eg post-stroke, reduced GCS) - brochial obstruction (lung Ca, FB aspiration, bronchial stenosis) - immunocompromised state - pneumonia SYMPTOMS - Cough with production of FOUL-SMELLING sputum - haemoptysis - SWINGING fever - night sweats - anorexia / weight loss

Answer 64

ALSO do: Gram stain, culture, and sensitivity of expectorated sputum!!! CXR/CT: irregular rounded cavity with an AIR-FLUID LEVEL that is dependent on body position (most commonly in the RIGHT lung) 1st) antibiotics that cover ANAEROBES! 2nd) if abx fail: drainage or surgical resection!

Answer 65

pus in pleural space Suspect if pt w/ RESOLVING pneumonia develops FEVER CXR - pleural effusion (almost always unilateral!) PLEURAL ASPIRATION - plurulent/ turbid/ yellow - low glucose - high LDH - pH < 7.2 treat with: CHEST DRAIN! (do repeat CXR before emove) nb not ever pleural effusion associated with pneumonia is an empyema! - have to do aspiration to confirm!

Answer 66

SEVERE LUNG INFLAM - bronchiectasis - tuberculosis - aspergilloma PULM VASCULAR - pulmonary embolism - raised pulm capillary pressure (ie pulm oedema secondary to LHF) AIRWAY TRAUMA - incessant coughing - foreign body - iatrogenic OTHERS - bronchogenic carcinoma - coagulopathy nb also make sure it's not coming from throat/nose or GI system! do CXR whenever have haemoptysis! - if massive, stabilise before imaging!

Answer 67

skin appears dusky blue sign of deoxygenation central - lips and tongue peripheral - limbs poor sign in people who are not white!

Answer 68

= alzheimers (>50%) = vascular dementia = mixed alzheimers + vascular - frontotemporal dementia - lewy body dementia RARE: - parkinsons dementia - huntington disease - CJD - HIV (50% of advanced HIV pts) - progressive supranuclear palsy (PSP)

Answer 69

- hypothyroidism - addison's - B12 deficiency - folate deficiency (B9) - thiamine deficiency (B1) - syphillis - normal pressure hydrocephalus - brain tumour - subdural haematoma - depression - chronic drug use (eg alcohol, barbituates)

Answer 70

aka PICK'S DISEASE - nb technically pick's disease is a sub-type of frontotemporal that can only be diagnosed on biopsy.... progressive degeneration of frontal and/or temporal lobe due to aggrigation of TAU PROTEIN to form PICKS BODIES nb 10-20% are familial onset = 40-60years 1st) INAPPROPRIATE SOCIAL BEHAVIOUR - apathy - disinhibition - exagerated emotional displays - irritability LATER - aphasia - lack of attention - parkinsonism - pyramidal signs (eg hyperreflexia, babinski sign) MEMORY GENERALLY REMAINS INTACT until very end! nb alzheimers is still the most common type of dementia in this age group but this start with memory signs!

Answer 71

aka PICK'S DISEASE - nb technically pick's disease is a sub-type of frontotemporal that can only be diagnosed on biopsy.... is a clinical diagnosis but may be: - atrophy of frontal and/or temporal lobes on CT/MRI general mx - supportive therapy (behavioural or speech) - exercise meds - DON'T use cholinesterase inhibitors or memantadine (will make worse!) - may use meds for associated symptoms! depression: SSRIs agitation, hallucinations, insomnia: atypical antipsychotics (SGA) prognosis is average 6 years from symptom onset - progression is faster than alzheimers - common cause of death is intercurrent infection, eg pneumonia!

Answer 72

- sporadic (85%) - familial (10-15%) - acquired (<1%) nb aquired can can be iatrogenic (via organ transplant or blood donation) or variant CJD (from injestion of beef infected with BSE) CJD is caused by misfolded proteins (PRIONS, PrPSc) that are either produced by affected individual themselves, or taken up from an exogenous source main features: = RAPDILY progressive DEMENTIA (wks-months) = MYOCLONIC JERKS other features - cerebellar disturbances (eg gait instability) + extra-pyramidal deficits - seizures - akinetic mutism - visual hallucinations - depression nb there other forms of prion diseases but CJD is by far the most common

Answer 73

the latency period until symptom onset varies greatly with the type of exposition (e.g., between 5 and 30 years in some cases of iatrogenic CJD) - CSF (tau + other proteins) - MRI (Signal amplification in basal ganglia + head of the caudate nucleus - EEG (triphasic periodic sharp wave complexes with a frequency of 1–2 Hz) nb don't worry too much about findings - just know which investigations to do! BIOPSY = spongiform degeneration (e.g., intracytoplasmic vacuoles within the neurons of cerebral and cerebellar cortex that can be seen on H&E), gliosis (+ in rare cases, amyloid plaques) sporadic CJD has life expectancy of 1 year from symptom onset (variant CJD is months) main management is supportive + palliative care!

Answer 74

Dissemination of HIV into the CNS (particularly in advanced HIV infection and/or untreated patients) - is generally a diagnosis of exclusion in advanced HIV 30-50% of people with advanced/untreated HIV get it subcortical dementia = memory loss = depression = moevemtn disorders progresses to severe neuro deficits: - impaired vigilance/concentraition - aphasia - gait disturbances

Answer 75

MRI: multiple subcortical hyperintense non-enhancing lesions BIOPSY = giant cells with multiple nuclei (formed through fusion of HIV-infected monocytes) Mx - HAART - supportive therapy (as with all dementias)

Answer 76

CEREBRAL TOXOPLASMOSIS (50%) - reactivation of a prior infection w Toxoplasmosis Gondii (most common neurological AIDS-defining condition) = headache, fever, altered mental state, seizures - contrast CT: MULTIPLE RING-ENHANCED lesions (mainly in basal ganglia) - thallium SPECT NEGATIVE - CSF: lots of lymphocytes, elevated protein = Mx: pyrimethamine + sulfadiazine PRIMARY CNS LYMPHOMA (30%) - extra-nodal non-hodgkins lymphoma, associated with EBV infection = headache, focal neuro deficits, neuropsych symps (eg personality changes), seizures (<15%) - contrast CT: SINGLE SOLID (homogenous) enhanced lesion, thallium SPECT POSITIVE - CSF: EBV positive (also do biopsy of lesion) = Mx: high dose methotrexate +/- whole brain irradiation (plus steroids, after biopsy confirmed!) CEREBRAL ABSCESS - abscess formation (lots of different causes) = disseminated infection, fever, headache, symptoms of raised ICP, neuro deficits, seizures - contrast CT: focal intraparenchymal lesion with a central hypodense (necrotic) area and peripheral ring enhancement - do biopsy to confirm! = Mx: antibiotics +/- surgical drainage PROGRESSIVE MULTIFOCAL LEUKOENCEPHALOPATHY (PML) - Demyelinating disease of the CNS caused by reactivation of the JC virus = rapidly progressing focal neuro deficits (eg visual field, hemiparesis), cognitive impairment, impaired vigilance - contrast CT: disseminated, non-enhancing white matter lesions without mass effect - CSF: JC virus DNA on PCR - Mx: supportive therapy HIV-ASSOCIATED DEMENTIA - Dissemination of HIV into the CNS (norm a diagnosis of exclusion) = subcortical dementia proggressing to severe neuro deficits - MRI: multiple subcortical hyperintense non-enhancing lesions - histopathology: giant cells with multiple nuclei - Mx: HAART + supportive therapy DON'T NEED TO KNOW ALL THESE (HIV-dementia was only a minor condition) - but I just found it interesting! - actually be aware of them as AIDS-defining conditions!