__Y6 Passmed Points Flashcards
1
Q
What do these all show?
HBsAg
Anti-HBs
Anti-HBc
HBeAg
A
HBsAg normally implies current acute disease
Anti-HBs implies immunity (either prev exposure or immunisation)
Anti-HBc implies previous (or current) infection
HBeAg is a marker of infectivity as it results from breakdown of core antigen from infected liver cells
2
Q
What do these results show?
1) Anti-HBs + Anti-HBc
2) Anti-HBs alone
A
1) immune due to prev infection
2) immune due to vaccination
3
Q
Histology of coeliac disease?
A
Villous atrophy, raised intra-epithelial lymphocytes, crypt hyperplasia, lamina propria infiltration with lymphocytes
4
Q
Blood marker for Coeliac disease?
A
Diagnosis by TTG abs (also EMA)
5
Q
Villous atrophy, raised intra-epithelial lymphocytes, crypt hyperplasia, lamina propria infiltration with lymphocytes
A
Coeliac disease
6
Q
Severity score for UC flares?
A
Truelove and Witts
7
Q
Markers of severe UC flare?
A
Truelove and Witts severity score
> 6 stools a day, containing blood with evidence of any systemic disturbance (fever, tachy, abdo distension, anaemia, ESR)
8
Q
Define toxic megacolon
A
transverse colon >6cm in combo with signs of systemic upset
Need to urgency decompress bowel ± surgery if not improved within 24 hrs
9
Q
Inducing remission in UC flare
A
Oral aminosalicylates e.g. mesalazine
Oral pred 2nd line if no improvement
if severe manage in hosp with IV steroids
10
Q
Maintaining remission in UC
A
Oral aminosalicylates, azathioprine and mercaptopurine
11
Q
Inducing remission in Crohn’s flare
A
- Oral pred if mild
- IV hydrocort if severe
- (2nd line 5-ASA e.g. mesalazine, less effective)
If conventional therapy unsuccessful start biologic therapy (anti-TNFα agents e.g. infliximab or adalimumab)
Azathioprine or mercaptopurine as add on therapy
12
Q
Maintaining remission in Crohn’s disease
A
Azathioprine/mercaptopurine
2nd line methotrexate
13
Q
Criterea for diagnosis of malnutrition
A
Any one of:
BMI < 18.5kg/m²
Unintentional weight loss > 10% within the last 3-6 months
BMI <20kg/m² + unintentional weight loss > 5% within the last 3-6 months
14
Q
RF for acute mesenteric ischaemia
A
AF, HTN, T2DM
15
Q
Acute hx of bloody diarrhoea with intense abdo pain out of proportion to signs
A
Acute mesenteric ischaemia
16
Q
1st line investigation in suspected acute mesenteric ischamia
A
check for high lactate
17
Q
Most common site for ischaemic colitis?
A
Watershed areas eg. splenic flexure
18
Q
Upper GI bleed scores
A
Blatchford score (first assessment) - incl. urea, Hb, sysBP
Rockall score after endoscopy
19
Q
Upper GI bleed vs lower GI bleed?
A
Check urea
High urea levels suggest upper (breakdown of RBC in stomach act as ‘protein meal’)
20
Q
1st line intervention to stop variceal bleed
A
Band ligation
21
Q
Acute pancreatitis cause
A
GET SMASHED
Gallstones ETOH Trauma Steroids Mumps Autoimmune Scorpion bite Hyper-trig/Ca, hypothermia ERCP Drugs - azathiprine, mesalazine, bendroflum, sodium val
22
Q
Abdo pain with relief on defaction, mucus passage, lethargy, nausea, feeling of incomplete evacuation
A
IBS
23
Q
Primary biliary cholangitis
Definition and markers
A
AI condition, characterised by damage to intra-lobular bile ducts by chronic inflammation
leads to progressive cholestasis and cirrhosis
IgM, anti-Microbial abs, M2 subtype
24
Q
Treatment of IBS
A
Loperamide (for diarrhoea), antispasmodic agents (for pain), laxatives (for constipation)
25
Autoimmune hepatitis abs
Anti-nuclear abs (ANA) and anti-smooth muscle abs (SMA)
26
Most common causes of cirrhosis
Alcohol, NAFLD, viral hep (B, C)
27
Investigation of choice to detect liver cirrhosis?
Transient elastography (Fibroscan)
28
Grading of hepatic encephalopathy
I – irritability
II – confusion, inappropriate behaviour
III – incoherent, restless
IV – coma
29
# Define achalasia
Key signs
Failure of oesophageal peristalsis and of relaxation of the lower oesophageal sphincter
Due to degenerative loss of ganglia from Auerbach’s plexus
Key signs -
Dysphagia (both solids and liquids), heartburn, regurgitation of food
30
Melanosis coli
Seen with laxative abuse
| Disorder of pigmentation of the bowel
31
Hepatorenal syndrome types
Type 1 – rapidly progressive, rapid onset (<2 weeks), usually due to acute event e.g. upper GI bleed
Type 2 – slowly progressive, gradual decline in renal function, assoc ascites
32
Colon cancer genetic cause
| and mode of inheritance
95% sporadic
Most common inherited:
HNPCC - hereditary non-polyposis colorectal carcinoma (auto dom)
Rarer:
FAP - familial adenomatous polyposis (auto dom)
33
Diagnostic marker of carcinoid syndrome
5 HIAA diagnostic marker – measure in 24 urine collection
34
Numerous harmartomatous polyps in GI tract + pigmented freckles on lips, face, palms, soles
Peutz-Jeghers
35
Spontaneous rupture of the oesophagus due to +++vomiting
| → Vomiting, thoracic pain, subcutaneous emphysema (crepitus)
Boerhaave syndrome
36
Persistent ST elevation after previous MI?
Very suggestive of a left ventricle aneurysm
37
Most common cause of drug-induced angioedema?
ACE inhibitors
38
What are varenicline and bupropion?
Varenicline (nicotine receptor partial agonist) or bupropion (NA and DA reuptake inhibitor and nicotinic antagonist) for smoking cessation
39
P mitrale
Bifid p wave with LA enlargement/hypertrophy
Enlarged LA makes a greater contribution to P wave contour
Most commonly due to mitral stenosis
40
ASD murmur
Ejection systolic, radiates through to back, fixed splitting of S2, beware paradoxical embolisms (→ stroke)
41
Aortic stenosis common causes:
Young pts <65 years – bicuspid aortic valve
Older pts >65 years – calcification
Also: post-rheumatic disease, HOCM
42
At what QRISK2 score are statins recommended?
Statins should be given to all pts with QRISK2 (10yr CV risk score) of ≥ 10%
43
Doses of statin for primary and secondary prevention?
```
Primary prevention (QRISK2 >10%, most T1DM, CKD if eGFR<60)
→ 20mg Atorvastatin
```
```
Secondary prevention (known IHD, CVD, peripheral artery disease)
→ 80mg Atorvastatin
```
44
When should Warfarin be stopped presurgery and what INR should be aimed for?
Warfarin pre-surgery - usually stopped 5 days before
Surgery can proceed once INR is <1.5
45
Warfarin and bleeding
Management of a bleed
Any major bleed → stop warfarin, give IV vit K, give prothrombin complex concentrate
If minor bleeding but INR >8 → stop warfarin, give IV vit K
If INR 5-8 → withhold next warfarin and reduce maintenance dose
46
ALS protcol for CPR
| After three defib attempts what can be given?
Give amiodarone 300mg IV and adrenaline 1mg after three defib attempts
(Can give further adrenaline 1mg IV after alternate shocks)
47
Post-MI treatment to send pt home on
```
ACE-i
BB
Statin
Aspirin
Clopidogrel (for 1st month, can continue)
```
48
Side effects of BB
Bronchospasm, cold peripheries, fatigue, sleep disturbance (nightmares)
49
Contraindictions for BB
Asthma, SSS, uncontrolled HF
Cannot be given alongside non-dihydropyridine e.g. verampamil or diltiazem
50
Pulsus alternans
Definition and condition seen in?
Alternation of the force of arterial pulse, seen in severe LVF
51
Bisferens pulse
Definition and condition seen in?
Double pulse with two systolic peaks seen in mixed aortic valve disease and occ HOCM
52
‘Jerky’ pulse seen in:
seen in HOCM
53
Pulsus paradoxus
Definition and condition seen in?
Greater than normal (>10mmHg) fall in sys BP with inspiration (fainter pulse with insp)
Seen in severe asthma or cardiac tamponade
54
Conditions to consider of ↑JVP, persistent hypotension and +++tachy despite fluid resus in pt with chest wall trauma
Cardiac tamponade
| Tension pneumothorax
55
Most common valvuar abnormality in PKD?
Mitral valve prolapse
56
Most common cause of mitral stenosis?
Rheumatic fever
57
Marker for Churg Strauss disaese
p-ANCA
58
Hx asthma and nasal polyps, ↑eosinophilia, impaired kidney function, petechial rash
Churg Strauss disaese
| Aka eosinophilic granulomatosis with polyangiitis
59
Marker for Wegener's granulomatosis
cANCA
60
Affects upper resp tract and kidneys
| Nose bleeds, rhinitis, conjunctivitis, saddle nose, rapidly progressing glomerulonephritis, pulm nodules, arthritis
Wegener’s granulomatosis aka granulomatosis with polyangiitis
61
ECG features of hypokalaemia
* U waves
* Small or absent T waves (occasionally inversion)
* Prolong PR interval
* ST depression
* Long QT (>600ms)
62
J wave (Osborn wave)
Seen in hypothermia
63
Hypothermia ECG findings
```
J waves (Osborn waves)
Bradycardia, 1st degree HB, long QT, other arrythmias
```
64
Inheritance pattern of HOCM
Auto dom
65
Acute pericarditis ECG findings
Saddle-shaped ST elevation (‘concave) and PR depression on ECG
66
Causes of acute pericarditis
Viral infection, TB, uraemia, trauma, post MI, CTD, hypothyroid
67
Notching of the inferior border of the ribs on CXR
Coarctation of the aorta
Aortic obstruction → dilated intercostal collateral vessels (allow sufficient blood flow to descending aorta) → increased pressure of these vessels erodes the inf margin of ribs
68
Tx for pt with bradycardia and signs of shock
500micrograms of atropine (repeated up to max 3mg)
69
Management of AF
When to use rate vs rhythm
NICE say offer RATE as 1st line, unless AF due to reversible cause, presence of HF (due to AF), new-onset AF
Or if rhythm more suitable based on clinical judgement
--
Rate control with BB (e.g. bisoprolol)
If required can add diltiazem or digoxin
Rate favoured if >65 years, or hx IHD
--
Rhythm control with amiodarone + flecainide (to cardiovert to sinus)
Sotalol also used to maintain sinus rhythm
Favoured if <65years, symptomatic, first pres, lone AF, CHF
Also if AF due to a reversible cause (e.g. infection)
70
Management of AF post-stroke
Aspirin for 2 weeks then start life-long anticoag
71
Normal QT intervals
How is it measured?
Normal QT should be <430ms in males, <450ms in females
QT interval between START of Q wave and END of T wave
72
Causes of Long QT syndrome
Causes:
- Congenital
- Drugs – amiodarone, sotalol, TCAs, SSRIs, methadone, erythromycin, haloperidol, chloroquine
- Hypo-Ca/K/Mg, acute MI, myocarditis, hypothermia, SAH
73
Management of long QT syndrome
Avoid precipitants (e.g. strenuous exercise, swimming, stress)
Beta-blockers ± ICD in high risk cases (if QTc >500ms or prev cardiac arrest)
74
Management of SVT
Acute management:
1. Vagal manoeuvres e.g. Valsalva
2. IV adenosine 6mg → 12mg → 12mg (verapamil in asthmatics)
Adenosine has a 10s half-life so must be given fast through a central route or large calibre vein (16G cannula)
3. Electrical cardioversion
75
Management of VT
Give amiodarone 300mg over 10-20mins
Then 900mg over 24 hrs
If this fails or adverse signs (BP<90, CP, HF, syncope) then shock
76
Management of torsades des pointes
IV magnesium sulphate
77
Define pathological Q wave
Older but simpler definition of pathological Q wave:
Q wave ≥0.04 s and amplitude ≥25% R wave in that lead
Now newer definition with parameters dependent on lead
Assoc with prev MI
78
Poor prognostic factors in ACS (GRACE)
Age, HF hx or development, PVD, ↓sys BP, initial creatinine conc, ↑cardiac markers, cardiac arrest on admission
79
Killip class for Acute Coronary Syndrome mortality
I: no signs of HF (6% mortality)
II: lung crackles, S3
III: frank pulm oedema
IV: cardiogenic shock (80% mortality)
80
Management of HF
1st line: ACE-I and BB (bisoprolol, carvedilol)
2nd line: [ARB] or [aldosterone antagonist] or [hydralazine + nitrate]
If sx persist: consider CRT or digoxin (ivabradine in some cases)
Plus diuretics for fluid overload
Consider statins if indicated
Annual influenza vaccine and one-off pneumococcal
81
Orthostatic hypotension criterea
Diagnosed when there is one of:
1. A drop in systolic BP of ≥20mmHg (with or without sx)
2. A drop to <90mmHg on standing (with or without sx)
3. A drop in diastolic BP of 10mmHg with symptoms (less clinically sig)
82
Stages of HTN
Stage 1 - clinic BP ≥ 140/90 (or Home BP average or ABPM ≥ 135/85)
Stage 2 - clinic BP ≥ 160/100 (Home ≥ 150/95)
Severe HTN - clinic systolic BP >180 or clinic diastolic >110)
83
BP targets
Age <80 - clinic BP <140/90
| Age >80 - clinic BP <150/90
84
HTN guidelines
1. ACE-I or CCB
2. ACE-I and CCB
3. Then add in thiazide-like diuretic (indapamide and chlortalidone recommended).
4. Spiro can be used as a fourth agent in resistant HTN if K is <4.5
(if K >4.5 then add higher dose thiazide-like)
85
Aortic dissection management
Type A – ASS
Surgery and systolic management (control BP to 100-120 systolic)
Type B – BooBs
Bed rest and BBs (labetalol)
86
Infective endocarditis
The vast majority caused by gram positive cocci
| Strep viridians, staph aureus (IVDU), staph epidermis (prosthetic)
87
DUKES criteria – infective endocarditis
```
Pathological criteria (1 to diagnose)
+ve histology or microbiology of pathological material obtained at cardiac surgery/autopsy
```
Major criteria (need 2)
• x2 +ve blood cultures showing orgs consistnet with IE (S viridians and HACEK group)
Or persistent bacteraemia from x2 cutlures taken >12 hrs apart or ≥x3 where pathogen is less specific
• Evidence of endocardial involvement
+ve echo or new valvular regurg
Minor criteria (need 1 major 3 minor, or 5 minor)
• Predisp heart condtion or IVDU
• Microbiological evidence that does not meet major criteria
• Fever >38
• Vasc phenom – major embolic, splenomegaly, clubbing, splinter haemorrhages, Janeway lesions, petechiae
• Immunological phenomena – glomerulonephritis, Osler nodes, Roth spots
88
Scoring system: ABCD2
What condition?
TIA prognosis
89
Scoring system: NYHA
What condition?
HF severity
90
Scoring system: DAS28
What condition?
Rheumatoid arthritis disease activity (28 joints examined)
91
Scoring system: Child Pugh
What condition?
Severity of liver cirrhosis
92
Scoring system: HAD, PHQ9, GAD-7
What condition?
Depression and anxiety
93
Scoring system: IPSS
What condition?
International prostate symptom score
94
Scoring system: Gleason
What condition?
Prognosis in prostate cancer
95
Scoring system: Waterlow score
What condition?
Pressure sores
96
Scoring system: FRAX
What condition?
10 year risk of osteoporosis related fracture
97
Scoring system: Ranson Criterea
What condition?
Acute pancreatitis
98
Scoring system: MUST
What condition?
Malnutrition
Malnutrition Universal Screening Tool
99
MOA: Aspirin
Antiplatelet
| Inhibits produciton of thromboxane A2
100
MOA: Clopidogrel
Antiplatelet
Inhibits ADP binding to platelet receptor
101
MOA: Enoxaparin
Activates anti-thrombin III
| Which potentiates inhibition of FXa
102
MOA: Fondaparinux
Activates anti-thrombin III
| Which potentiates inhibition of FXa
103
Abciximab, tirofiban, eptifibatide
Glycoprotein IIb/IIIa receptor antatgonist
104
P450 inducer or inhibitor?
Antiepileptics
Barbituates
Rifampacin
Inducer
105
P450 inducer or inhibitor?
Chronic alcohol intake
Smoking
St Johns wort
Inducers
106
P450 inducer or inhibitor?
Antibiotics - cipro, erythro
Isoniazid
Omeprazole
Inhibitors
107
P450 inducer or inhibitor?
Amiodarine
Allopurinol
Inhibitors
108
P450 inducer or inhibitor?
SSRIs
Sodium valproate
Fluconazole
Inhibitor
109
Painful 3rd nerve palsy differentials?
Posterior communicating artery aneurysm
| Stroke
110
Ophthalmalgia, proptosis, absent corneal reflex, trigeminal nerve lesion (multiple cranial nerves involved)
Consider cavernous sinus thrombosis
111
Hoffman’s sign?
flick nail of middle finger, +ve if flexion and adduction of thumb also
Demonstrates an issue with the corticospinal tract (UMN)
112
Which movement is limited with adhesive capsulitis (frozen shoulder)
Classically limited external rotation of the shoulder seen
113
Essential tremor
Diagnostic features and management?
classically a tremor present with sustained muscle tone (i.e. postural tremor) in hands, can also affect vocal cords
Absent when relaxed (improved by alcohol and rest)
Most common cause of head tremor
Propranolol as 1st line tx
114
Treatment of Myesthenia Gravis
Management of myesthenic crisis?
1st line tx: pyridostigmine (cholinesterase inhibitor)
Add in prednisolone if required
± Thymectomy
Management of myasthenic crisis – plasmapheresis, IV Ig
115
Multiple sclerosis CSF findings?
Oligoclonal bodies in CSF
116
Features of multiple sclerosis
Visual – optic neuritis (common), optic atrophy
Internuclear ophthalmoplegia
Uhthoff’s phenomenon – worsening of vision with ↑temp
Sensory – pins and needles, numbness, trigeminal neuralgia
Lhermitte’s sign – tingling in hands when neck is flexed
Motor – spastic weakness
Cerebellar – ataxia, tremor
Others – urinary incontinence, sexual dysfunction
117
Multiple sclerosis - worsening of vision with ↑temp
Uhthoff’s phenomenon
118
Both upper and lower motor neurone signs
Fasciculations
Absence of sensory signs/symptoms
Wasting of small muscles of hand
Muscle cramps and spasm
Motor neurone disease
119
Features of pseudo-seizures
What can you use to differentiate true from pseudo?
More common in females
Gradual onset
Crying after seizure
pelvic thrusting
Use PROLACTIN to differentiate from true seizure
(true if prolactin elevated 10-20 mins post seizure)
120
General epilepsy management
Generalised seizures – sodium valproate 1st line
Partial seizures – carbamazepine 1st line
121
Generalised tonic clonic management (1st and 2nd line)
1st line: sodium val
2nd line: carbamazepine, lamotrigine
(sodium val avoided in women of childbearing age)
122
Absence seizure treatment options
Sodium val or ethosuximide
123
Myoclonic seizure treatment options
Sodium val, 2nd line: clonazepam, lamotrigine
124
Facial nerve functions
Face, ear, taste, tear
Face – motor
Ear – nerve to stapedius
Taste – ant 2/3 tongue
Tear – parasympathetic fibres to lacrimal and salivary glands
125
Dermatome for:
Thumb and index fingers
C6
put thumb and index finger together to make a 6
126
Dermatome for:
Nipples
T4
127
Dermatome for:
Umbilicus
T10
bellybuTEN
128
Dermatome for:
Kneecap
L4
down on all FOURS
129
Dermatome for:
Big toe
L5
"largest of 5 toes"
130
Dermatome for:
Little toe and lateral foot
S1
"small one"
131
Dorsal columns
Direction, parts and what info they carry
Ascending
Fine touch, proprioception, vibration, pressure
* Fasciculus gracilis (lower trunk and legs)
* Fasciculus cuneatus (upper trunk and arms)
132
Corticospinal tract
Direction and info carried
Descending
| Voluntary muscle movement
133
Spinothalamic
Direction and info carried
Ascending
Sensory pain and temp (lateral)
Crude touch (anterior)
134
Management of migraine
Acute tx and prophylaxis
Acute tx → triptan ± NSAID/paracetamol
Prophylaxis (if ≥2 a month) → topiramate or propranolol
Propranolol if female child-bearing age (topiramate is teratogenic)
Topiramate if asthmatic
135
Severe unilateral pain (sharp, shooting, electric shocks)
| Pain commonly evoked by light touch (washing, shaving, brushing)
Trigeminal neuralgia
136
Management of trigeminal neuralgia
Carbamazepine
137
Management of cluster headaches
Acute tx and prophylaxis
Acute: 100% O2, subcut triptan
Prophylaxis: verapamil
138
Stroke
Different arteries that can be affected and resulting clinical signs of each
Anterior cerebral artery – contralateral hemiparesis and sensory loss
Middle cerebral artery of the dominant side supplies Wernicke’s and Broca’s areas – hence MCA strokes cause aphasia
Plus contralateral hemiparesis and sensory loss
Contralateral homonymous hemianopia
Posterior cerebral artery – visual agnosia, contralateral homonymous hemianopia
Retinal artery – amaurosis fugax
Basilar artery – locked in
139
Anterior cerebral artery stroke signs
Contralateral hemiparesis and sensory loss
140
Middle cerebral artery stroke signs
Aphasia (Wernicke's and Broca's areas supplied by MCA)
Plus contralateral hemiparesis and sensory loss
Contralateral homonymous hemianopia
141
Posterior cerebral artery stroke
Visual agnosia
| Contralateral homonymous hemianopia
142
Stroke with aphasia
Which artery affected?
Middle cerebral artery
143
Stroke follow up
What do you send pt home on?
Aspirin 300mg daily for 2 weeks
Then clopidogrel 75mg daily long term
Plus statin therapy
144
Spinothalamic sensory loss
'Cape-like’ (neck and arms) loss of sensation to temp – but preservation of light touch, proprioception, vib
Syringomyelia
| Collection of CSF in SC
145
Idiopathic intracranial hypertension management
Management is with repeated therapeutic lumbar punctures
→ pressure is lowered by draining off CSF until symptoms settle and with acetazolamide
± a lumboperitoneal or ventriculoperitoneal shunt in resistant cases
Look for assoc causative medications (tetracycline abx, contraceptives, steroids, levothyroxine, lithium)
146
Which vessel is affected subdural hemorrhage?
Bridging veins between cortex and venous sinus
147
Which vessel is affected in an epidural haemorhage
Middle menigeal artery
148
Berry aneurysm rupture leads to a:
Subarachnoid haemorrhage
149
Triad of progressive cognitive impairment, Parkinsonism, Visual hallucinations
Lewy Body Dementia
150
Wernicke's encephalopathy caused by:
+ features:
Thiamine (B1) deficiency
Opthalmoplegia/nystagmus, ataxia, confusion
151
Features of Korsakoff syndrome
Amnesia and confabulation
152
Urinary incontinence, dementia, ataxia (falls, gait abnormality)
Normal pressure hydrocephalus
Wet, Wobbly, Wacky
153
Management of normal pressure hydrocephalus
Management with ventriculoperitoneal shunt
A reversible cause of dementia seen in elderly pts
2ndary to ↓CSF absorption at arachnoid villi
154
Parkinsonism + postural HTN + ataxia (early falls)
Mutisystem atrophy
Parkinsons plus disorder with autnomic instability, earlier falls and faster progression than parkinsons
155
Ataxia, bradykinesia, dementia
| Difficulty moving eyes, particularly vertically (difficulty reading)
Progressive supranuclear palsy
156
Causes of Parkinsonism
```
Parkinson’s disease
Drug induced e.g. antipsychotics, phenothiazines, metoclopramide
Progressive supranuclear palsy
Multiple system atrophy
Wilson’s disease
Toxins – e.g. CO
```
157
Liver and neuro disease
Hepatitis, cirrhosis, dementia, speech/behaviour change, chorea
Wilson's disease
158
Wilsons disease inheritance pattern
Auto recessive (Chr 13)
159
Eye signs in Wilson's disease
Kayser-Fleischer rings
160
Test for Wilson's disease
Management for Wilson's disease
Test with copper studies (serum copper, serum caeruloplasmin, urine copper)
Management – penicillamine (chelates copper)
161
Lethargy, erectile dysfunction, arthalgia, bronze skin
| Chronic liver disease, cardiac failure
Haemochromatosis
162
Haemochromatosis inheritance pattern
Auto recessive (Ch 6)
163
Medical Alzheimer's management
Mild to mod – manage with acetylcholinesterase inhibitors: donepezil, galantamine, rivastigmine
Memantine (NMDA-R antagonist) used 2nd line
164
Bitemporal hemianopia
| Upper vs lower quadrant defects
Upper quadrant defect > lower quadrant defect = inferior chiasmal compression, commonly a pituitary tumour
Lower quadrant defect > upper quadrant defect = superior chiasmal compression, commonly a craniopharyngioma
165
Erb-Duchenne brachial plxus injury
Which nerves and what signs?
C5, C6 – winged scapula
Commonly seen with breech presentation
166
Klumpke’s paralysis
Which nerve and what signs?
T1
Loss of intrinsic hand muscles, due to traction pulling arm up
(Klumpky monkey)
167
Most common complication of menigitis
Sensorineural hearing loss
168
SC lung cancer, weakness worse in legs
| Weakness improves with muscle use
Lambert-Eaton syndrome
169
Hereditary sensory and motor peripheral neuropathy
↓Power, LMN signs (↓reflexes, wasting) and reduced sensation
May see foot drop, distal muscle wasting
Charcot Marie Tooth
170
GCS
M6 V5 E4
MOTOR
6) obeys commands
5) localises to pain
4) withdraws from pain
3) abnormal flexion to pain (decoritcate posture)
2) extending to pain
1) none
VERBAL
5) orientated
4) disoreintated
3) words
2) sounds
1) none
EYE OPENING
4) spontaneous
3) to speech
2) to pain
1) none
171
Nerve roots for reflexes
Ankle
Knee
Biceps
Triceps
Ankle S1-S2
Knee L3-L4
Biceps C5-C6
Triceps C7-C8
172
Which nerve is most likely to be affected in a midshaft humeral fracture?
What deformity, sensory loss and weakness will be present?
Radial
Deformity - wrist drop
Sensory - dorsal aspect of thumb
Weakness - wrist extensors
173
Which nerve is most likely to be affected in a medial epicondyle fracture fracture?
What deformity, sensory loss and weakness will be present?
Ulnar
Deformity: claw hand (hyperext MCP, flex at D/PIP of 4+5th digits)
Hypothenar wasting
Sensory loss - medial palmar surface, medial 1 and 1/2 digits
Weakness - Medial 2 lumbricles, interossei, aDductor pollicis, hypothenar muscles (digiti minimi), flex carpi ulnaris
174
Which nerve is most likely to be affected in a supracondylar fracture or wrist laceration?
What deformity, sensory loss and weakness will be present?
Median
Deformity - thenar wasting
Sensory loss - lateral 2 and 1/2 digits
Weakness -
- Above elbow: reduced wrist flex and forearm pronation
- In hand: LOAF
175
Nerve injured in axillary dissection eg. post masectomy
| Loss of sensation to axilla
Intercosto-brachial
176
Foot drop and loss of sensation to dorsum of foot?
Common peroneal nerve
177
Anaphylaxis management
How to confirm it was anaphylaxis and how long to keep in hospital?
500 mcg (0.5 ml 1 in 1000) Adrenaline
200mg hydrocortisone, 10mg chlorphenamine
Can repeat adrenaline every 5 mins
Back to back salbutamol inhalers as long as resp sx continue
Following anaphylaxis emergency tx, pts must be observed for 6-12 hours from the onset of sx before discharge is allowed
→ Risk of biphasic reaction
Test whether rxn was anaphylaxis – serum tryptase
Can remain elevated for up to 12 hours post-acute episode
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Cancers that metastasise to the lung
Breast, bladder, kidney, prostate, rectum
| BBBBB
Breast, Bladder, Bidney, Brostate, Brectum
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Post op resp difficulty
Fine crackles, areas of collapse with resonant percussion note
Plus management
Atelectasis
Management: chest physio with mobilisation and deep breathing exercises
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COPD treatment
Smoking cessation, annual influenza, one-off pneumococcal
1. SABA or SAMA first line
2. 2nd line:
- FEV1 >50% - LABA or LAMA
- FEV1 <50% - [LABA and ICS] combo or [LAMA]
3. If persistent SOB or exacerbations
- If taking LABA switch to [LABA + ICS] combo
- Or give triple therapy: LAMA and [LABA + ICS]
Note: discontinue SAMA when starting LAMA
Consider theophylline if above therapies ineffective
Consider mucolytics if chronic productive cough
Smoking cessation and long term O2 only factors that improve survival
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COPD severity stages
| Based on FEV1
All have FEV1/FVC ratio <0.7
Stage 1 Mild - FEV1 >80%
Stage 2 Moderate - FEV1 50-79%
Stage 3 Severe - FEV1 30-49%
Stage 4 Very Severe - <30%
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Investigations to confirm asthma
Adults with suspected asthma should have both a FeNO test and spirometry with reversibility
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Causes of CXR mediastinal widening
Technical factors (rotation), vascular (thoracic AA), lymphoma, retrosternal goitre
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Pneumothorax management
Primary (no underlying disease)
<2cm and no SOB – consider discharge
If >2cm and/or persistent SOB – aspirate
Chest drain if this fails, review OP 2-4 weeks if success
Secondary (underlying resp disease)
If >50 years and >2cm and/or SOB – chest drain
If 1-2cm – aspirate first, if no success then chest drain
If <1cm – give O2 and observe 24 hrs
All secondary penumo should be admitted and observed for at least 24 hours
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Indication for surgery in bronchiectasis
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Uncontrollable haemoptysis
Localised disease (e.g. to one lobe)
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Pleural effusion
Chest drain indicated if:
Purulent or cloudy fluid on sample
Presence of organisms shown by G stain or culture of sample
Pleural fluid pH <7.2 in suspected pleural infection
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Pleural effusion
| Exudate vs transudate
Exudates if protein level >30 g/L, transudate if <30
Use Light’s criteria if between 25-35
Exudate likely if ≥1 of:
• Pleural fluid protein/serum protein >0.5
• Plural fluid LDH/serum LDH >0.6
• Pleural fluid LDH >2/3 upper limit of normal serum LDH
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Features of
| Kartagener’s syndrome
Primary ciliary dyskinesia
Features → dextrocardia/sinus inversus, bronchiectasis, recurrent sinusitis, subfertility
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CENTOR criteria
| For Strep pharyngitis
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Age
Presence of tonsillar exudate
Tender ant cervical lymphadenopathy
Hx of fever
Absence of cough
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Pulmonary fibrosis causes
| Affecting upper vs lower lobes
Idiopathic pulmonary fibrosis, CTD (e.g. SLE), drugs – tend to predom affect lower zones
Hypersensitivity pneumonitis, sarcoid, TB – upper zones
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Features of sarcoidosis
Multisystem disorder of unknown aetiology characterised by non-caseating granulomas
Features:
• Acute – erythema nodosum, bilateral hilar lymphadenopathy, swinging fever, polyarthralgia
• Insidious – dyspnoea, cough, malaise, weight loss
• Skin – lupus pernio (raised indurated purple lesion on face)
• Hypercalcaemia (macrophages in granulomas cause ↑conversion of Vit D to active form
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Diseases caused by asbestos
Cause a variety of diseases:
• Benign pleural plaques
• Pleural thickening
• Asbestosis (lower lobe fibrosis, severity = length exposed)
• Malignant mesothelioma (v limited exposure can cause disease, v poor prognosis)
• Risk factor for lung cancer
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Scoring scale and management of obstructive sleep apnoea
Screen using Epworth scale
Definitive diagnosis with sleep studies
Tx: ↓weight, ↓alcohol, sleep on side ± CPAP
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ALS protocol for choking
First ask “are you choking?”
If pt can answer ‘yes’ → mild airway obstruction
Encourage pt to cough
If unable to answer → severe airway obstruction
Other sings: wheezing, silent cough, LOC
1. Give up to 5 back-blows (sharp blow between shoulder blades with heel of hand)
2. Give up to 5 abdominal thrusts (fist between umbilicu and ribcage, pull sharply inwards and upwards)
3. If unsuccessful continue above cycle
If unconscious – call for ambulance, start CPR
