Big Hitters and stuff you've got wrong Flashcards
what is the treatment for ascites secondary to liver cirrhosis
spironolactone
what is the treatment for hepatic encephalopathy
lactulose
low saag indicates what
Low SAAG indicates a peritoneal cause of ascites, including tuberculous peritonitis and peritoneal mesothelioma
high saag indicates what
A high SAAG suggests a non-peritoneal cause of ascites, such as cirrhosis, Budd-Chiari syndrome, and nephrotic syndrome
what is the treatment for anterior uveitis
steroid eye drops with mydriatic eye drops
The steroid treats the underlying infection and the mydriatic eye drop dilates the pupil and reduces the pain
systemic steroids reserved for recurrent uveitis
what is the treatment for dystonia secondary to antipsychotics
procyclidine
how should you Start IV fluid resuscitation in children or young people
with a bolus of 20 ml/kg over less than 10 minutes
what investigation do you need to do before starting anti-TNFα
a chest x ray to look for TB since these drugs can cause reactivation
what antibiotic to treat human bites and animal bites
co-amoxiclav
what should you do if metformin is not tolerated due to GI side effects
try a modified-release formulation before switching to a second-line agent
what should you do with a patient’s oral analgesia if they switch to opiate PCA
stop all concomitant oral opiates but keep on things like paracetamol
how should you treat acute heart failure not responding to treatment 40m IV furosemide
CPAP
preceding influenza predisposes to pneumonia caused by which bacteria
Staphylococcus aureus
how do you treat an inguinal hernia in infants
The high incidence of strangulation necessitates an urgent herniotomy be performed
what is the potassium requirement in maintenance fluids
1 mmol/kg/day
what are the features of wernicke’s encephalopathy
CAN OPEN
Confusion
Ataxia
Nystagmus
Ophthamoplegia
PEripheral
Neuropathy
what are the criteria for urgent and elective EVAR
The three criteria for endoscopic vascular aneurysm repair surgery are:
• An asymptomatic aneurysm larger than 5.5 cm in diameter.
• An asymptomatic aneurysm which is enlarging by more than 1 cm per year.
• A symptomatic aneurysm. This is the only criteria, apart from emergency rupture, which requires urgent surgery rather than an elective procedure.
what is the correct position for women who have had a cord prolapse?
on all fours, on knees and elbows
what form of contraception is UKMEC 3 (not forbidden but advised against) for wheelchair users
Wheelchair users (as this woman is due to below waist paralysis), due to immobility, are at higher risk of DVT and PE than the general population, and that risk will be further increased by talking the COCP.
It is currently UKMEC-3, which means it’s not forbidden, just advised against.
what is the only contraindication to circumcision on religious grounds
Hypospadias is the only contraindication to circumcision in infancy as the foreskin is used in the repair
what is the treatment for a intertrochanteric (extracapsular) proximal femoral fracture
dynamic hip screw
how do you treat myxoedemic coma
Myxoedemic coma is treated with thyroxine and hydrocortisone
how do you treat thyrotoxic storm
Thyrotoxic storm is treated with beta blockers, propylthiouracil and hydrocortisone
for a diagnosis of PTSD how long do symptoms need to be present for
one month
what is the insulin infusion rate in DKA
0.1 unit/kg/hour
what should you also prescribe if someone is on an SSRI and an NSAID
lansoprazole - there is increased GI risk if SSRI and NSAID are combined
what is the first choice SSRI in a patient with a history of cardiovascular disease
sertraline
what is the number one cause of painless massive GI bleeding requiring a transfusion in children between the ages of 1 and 2 years?
meckel’s diverticulum
what are the causes of upper and lower GI bleeding in newborns, from 1 month to 1 year, from 1 year to 2 years and 2 years + (but in children)
- what scoring system is used to judge whether someone will spontaneously go into labour?
- A score of _____ or less suggests that labour is unlikely to start without induction?
*
The Bishop’s score is used to predict whether induction of labor will be required.
A score of 5 or less suggests that labour is unlikely to start without induction.
If angina is not controlled with a beta-blocker, a _______ blocker should be added
calcium channel blocker
not verapamil or diltiazem (contraindicated with B blockers)
what is the first line treatment for SVT
The first-line management of SVT is vagal manoeuvres
what is the treatment of choice for all patients with a displaced hip fracture
Hemiarthroplasty or total hip replacement
lean towards total hip replacement if they are young and can take it and if they have a history of hip osteoarthritis
when should you advise women to stop taking their HRT/COCP before surgery
28 days before
how does osteomalacia or vit d deficiency show on bloods
low calcium, phosphate and vitamin D levels
combined with
a raised alkaline phosphatase
what is the first line and second line treatment for prolactinomas
Dopamine agonists (e.g. cabergoline, bromocriptine)
Surgery is performed for patients who cannot tolerate or fail to respond to medical therapy. A trans-sphenoidal approach is generally preferred
what is the treatment of gonorrhoea
Intramuscular ceftriaxone stat
how does gonorrhoea look down a microscope?
Gram negative diplococcus
what causes a cavitating pneumonia in the upper lobes, mainly in diabetics and alcoholics
Klebsiella pneumoniae
Blood stained discharge from the nipple is most likely to be associated with _____
duct papilloma
how does duct ectasia present
green-brown discharge and an abscess with puss discharging from the nipple. The latter will also be associated with red, swollen, warm skin of the breast.
does nephrotic syndrome cause bleeding or clotting and why
Nephrotic syndrome is associated with a hypercoagulable state due to loss of antithrombin III via the kidneys.
The most common site of thrombosis is the renal vein but patients are also at risk of deep vein thromboses and pulmonary embolisms.
when is platelet transfusion indicated
Platelet transfusion is appropriate for patients with a platelet count < 30 x 109 and clinically significant bleeding
what can CLL, classically, transform into
Richter’s transformation; a transformation of CLL into a fast-growing diffuse large B cell non-Hodgkin’s lymphoma which occurs in 2-10% of people with CLL (Cancer Research UK) and carries a poor prognosis.
three differentials for fever in a previously well patient post-op
- physiological reaction to surgery
- thromboembolism
- infection
when is hand preference abnormal
Hand preference before 12 months is abnormal - it could be an indicator of cerebral palsy
how can you determine whether the position of an NG tube is safe
- aspirate
- If aspirate obtained has a pH <5.5, the NG tube is safe to use.
- If aspirate >5.5, request a chest x-ray to confirm the position of the NG tube.
- If no aspirate can be obtained, the following manoeuvres can be used:
- Turn the patient on to their left side
- Inject 10-20ml air
- Offer a drink (if safe swallow) or mouth care (if nil by mouth) and re-check aspirate in 15-20 minutes
- Advance or withdraw the NG tube by 10-20 cm
- If an aspirate can still not be obtained, request a chest x-ray to confirm the position of the NG tube.
what scoring system for pancreatitis and what does it include
- The Modified-Glasgow Score can be used to stratify patients by risk of severe pancreatitis. A score of ≥3 suggests a significant increase in likelihood of severe pancreatitis. These patients may benefit from intensive care.
- P - PaO2 <8kPa
- A - Age >55-years-old
- N - Neutrophilia: WCC >15x10(9)/L
- C - Calcium <2 mmol/L
- R - Renal function: Urea >16 mmol/L
- E - Enzymes: LDH >600iu/L; AST >200iu/L
- A - Albumin <32g/L (serum)
- S - Sugar: blood glucose >10 mmol/L
why does pancreatitis cause hypocalcaemia
Lipase from pancreatic cells breaks down mesenteric and peripancreatic fat. This results in the liberation of free fatty acids that bind calcium, decreasing the circulating concentration. Approximately 55% of patients had some degree of hypocalcemia at presentation.
what is the treatment for widened QRS or arrhythmia in tricyclic overdose
IV bicarbonate
what is the first line treatment of threadworms
oral Mebendazole
how can you manage acute flares of rheumatoid arthritis
Intramuscular steroids such as methylprednisolone are used to manage the acute flares of rheumatoid arthritis
is the ulcer in syphillis most likely to be painless or painful
painless
what is the definition of a staggered paracetamol overdose and how should these patients be treated
defined as an overdose taken over >1 hour
they should be given NAC immediately
what is the most common mechanism for ankle sprain
Inversion of the foot is the most common mechanism of ankle sprain
how can you treat chronic symptoms of vestibular neuronitis
Vestibular rehabilitation exercises
what cancer do people with PSC go on to get
20% of them get cholangiocarcinoma, a cancer of the biliary tree
vision worse on going down the stairs indicates
4th nerve palsy
how do you manage patients >= 75 years following a fragility fracture,
Start alendronate in patients >= 75 years following a fragility fracture, without waiting for a DEXA scan
what are the two ALS adrenaline doses
- anaphylaxis: 0.5mg - 0.5ml 1:1,000 IM
- cardiac arrest: 1mg - 10ml 1:10,000 IV or 1ml of 1:1000 IV
complete heart block after an MI would indicate that which artery was affected
right coronary artery
what is the first line investigation for acromegaly
Serum IGF-1 levels
90% of genital warts are caused by which HPV viruses
HPV 6 & 11
prophylactic treatment of bleeding oesophageal varices
non-cardioselective B blocker such as propanolol
Transjugular intrahepatic portal shunt (TIPS) for varices that are resistant to other prophylactic treatments such as propranolol and repeat endoscopic banding
what is the second investigation you do for acromegaly
if a patient is shown to have raised IGF-1 levels, an oral glucose tolerance test (OGTT) with serial GH measurements is suggested to confirm the diagnosis
preceding influenza infection predisposes to pneumonia caused by what organism
staphylococcus aureus
what is the inheritance pattern of Hypertrophic obstructive cardiomyopathy
autosomal dominant
what is the antibiotic for otitis media
amoxicillin
how does acute alcohol intake affect risk of hepatotoxicity following paracetamol overdose
acute alcohol intake is not associated with an increased risk of developing hepatotoxicity and may actually be protective
how should women with HIV deliver
- vaginal delivery is recommended if viral load is less than 50 copies/ml at 36 weeks, otherwise caesarian section is recommended
- a zidovudine infusion should be started four hours before beginning the caesarean section (not necessary if vaginal delivery)
- zidovudine is usually administered orally to the neonate if maternal viral load is <50 copies/ml. Otherwise triple ART should be used. Therapy should be continued for 4-6 weeks.
what sort of antibiotics can cause torsades des pointes
Macrolides such as clarithromycin can cause QT interval prolongation and therefore may trigger polymorphic ventricular tachycardia, particularly in patients with an underlying channelopathy.
what is the most common adverse effect of the progesterone only pill
Progestogen-only pill: irregular vaginal bleeding is the most common adverse effect
All patients with peripheral arterial disease should take _______ and _______
All patients with peripheral arterial disease should take clopidogrel and atorvastatin
what is the empirical antibiotic of choice in neutropenic sepsis
Piperacillin with tazobactam (Tazocin) is the empirical antibiotic of choice for neutropenic sepsis
in what skin presentation do you see a herald patch?
Pityriasis rosea
what is the treatment for a unstable patient in VT
synchronised cardioversion
what are the conditions required for lactational amenorrhoea to be a reliable form of contraception
Lactational amenorrhoea is a reliable method of contraception as long as amenorrhoeic, baby <6 months, and breastfeeding exclusively
what steroid do you give ladies who are at risk of preterm labour
dexamethasone
Bilious vomiting on the first day of life is likely due to _______
intestinal atresia
what’s the rash like in scarlet fever
sandpaper rash
what are the indications for thoracotomy in haemothorax
Indications for thoracotomy in haemothorax include >1.5L blood initially or losses of >200ml per hour for >2 hours
Orthostatic hypotension can be diagnosed when there is:
- a. A drop in systolic BP of 20mmHg or more (with or without symptoms)
- b. A drop to below 90mmHg on standing even if the drop is less than 20mmHg (with or without symptoms)
- c. A drop in diastolic BP of 10mmHg with symptoms
what is the investigation of choice for reflux nephropathy
Micturating cystography is the investigation of choice for reflux nephropathy
what are the blood test results in osteoporosis
Osteoporosis is commonly associated with normal blood test values (e.g. normal ALP, normal calcium, normal phosphate, normal PTH)
when is breast cancer screening offered
Breast cancer screening is offered to all women aged 50-70 years (mammogram every 3 years)
how is local anaesthetic toxicity treated
Local anesthetic toxicity can be treated with IV 20% lipid emulsion
what is the antibiotic for GBS prophylaxis in pregnancy
IV Benzylpenicillin is the antibiotic of choice for GBS prophylaxis
which drugs trigger haemolysis in G6PD deficiency
G6PD deficiency: sulph- drugs: sulphonamides, sulphasalazine and sulfonylureas can trigger haemolysis
what biochemical abnormality does cushing’s cause
Cushing’s syndrome - hypokalaemic metabolic alkalosis
what is the firstline investigation for pre-term, pre-labour rupture of membranes
Careful speculum examination to look for pooling of amniotic fluid in the posterior vaginal vault is the first-line investigation for preterm prelabour rupture of the membranes
can you have erythromycin during pregnancy
yes
can pregnant patients have clarithromycin
no - especially not in the first trimester
indications for thrombolysis with alteplase in PE
- Massive PE causing right heart failure associated with hypotension and a low bleed risk
- Non-massive PE with the patient deteriorating after initial anticoagulation (without hypotension and with a low bleeding risk).
absolute contraindications to thrombolysis
- Structural intracranial disease
- Prior intracranial haemorrhage
- Active bleeding
- Ischaemic stroke less than 3 months ago
- Recent spinal or brain surgery
- Recent brain injury
- Recent head trauma with fracture
- Bleeding diathesis (such as antiphospholipid syndrome and haemophilia).
how long does the mirena coil last
5 years
how long does the copper IUD last
5-10 years depending on the type
what is the reversal agent for dabigatran
Idarucizumab
what is the treatment for rosacea
- mild/moderate: topical metronidazole
- severe/resistant: oral tetracycline
if patients are going to start taking long term steroids what should you do about their bone protection
- bone protection should start immediately
- if Ca2+ and vit D are replete then the first step alendronate
- if they’re Ca2+ and vit D deficient then these should be replaced before bisphosphonates are started
what are the stages of CKD
what is the treatment for pernicious anaemia
life long IM hydroxocobalamin injections - loading dose and then repeated at 2-3 monthly intervals.
how do you calculate a breakthrough dose with morphine
Breakthrough dose = 1/6th of daily morphine dose
what is the investigation of choice for prostate cancer
multiparametric MRI
whatis the routine with which you should take hydrocortisone in addison’s
hydrocortisone dose is split with the majority given in the first half of the day
what is the investigation of choice in renal colic
Non-contrast CT-KUB is the imaging of choice in suspected renal colic
are you more likely to have weight loss in crohns or UC
crohns
extra intestinal features of Crohns and UC
- Crohn’s
- gallstones
- oxalate renal stones
- Ulcerative colitis
- PSC
- Both
- Arthritis
- Pyoderma Gangrenosum
- Erythema Nodosum
- Uveitis (mostly UC)
draw the Crohn’s and UC venn diagram
describe the histology found in crohn’s and UC
- crohn’s
- inflammation in all layers from mucosa to serosa
- increased goblet cells
- granulomas
- UC
- no inflammation beyond submucosa
- crypt abscesses (formed by neutrophils)
describe the endoscopic appearance of Crohn’s and UC
- Crohn’s
- Deep ulcers
- Skip lesions
- “cobblestone appearance”
- UC
- Pseudopolyps
grade severity of ulcerative colitis
- mild:
- <4 stools/day
- moderate:
- 4-6 stools per day
- severe
- >6 stools per day and features of severe systemic upset
UC: how to induce remission in mild to moderate proctitis
- topical rectal aminosalicylate (mesalazine)
- if remission not achieved in 4 weeks add oral aminosalicylate
- if remission not achieved in 4 weeks add oral or rectal corticosteroids
UC: how to induce remission in mild to moderate proctosigmoiditis & left sided disease
- rectal aminosalicylate (mesalazine)
- if no improvement in 4 weeks then add oral mesalazine
- OR switch to oral mesalazine with rectal corticosteroid
- if remission still not achieved then oral mesalazine and oral corticosteroids
UC: how to induce remission in mild to moderate extensive disease
- topical aminosalicylate with oral aminosalicylate
- if remission not achieved in 4 weeks then stop topical treatments and start oral mesalazine and oral corticosteroids
how do you induce remission in severe ulcerative colitis
- these patients should always be treated in hospital
- IV steroids are first line
how do you maintain remission in UC
- following mild to moderate flare
- proctitis and proctosigmoiditis
- rectal mesalazine +/- oral mesalazine
- left sided and extensive disease
- low dose oral mesalazine
- proctitis and proctosigmoiditis
- following a severe flare
- oral azathioprine or oral mercaptopurine
crohn’s management
- STOP SMOKING
- inducing remission
- 1st line: glucocorticoids
- 2nd line: mesalazine
- azathioprine or mercaptopurine can be used as add ons but not as a monotherapy
- 3rd line: infliximab
- maintaining remission
- 1st line: azathioprine or mercaptopurine
- 2nd line: methotrexate
- surgery
what is the glasgow blatchford score for
it is for use before endoscopy to establish whether the patient can be treated as an outpatient
what is the rockall score for
it is for after endoscopy in upper GI bleed patients to establish their risk of re-bleeding and mortality
things included in glasgow blatchford
- urea
- Hb
- systolic BP
- pulse >100
- melaena
- syncope
- hepatic disease
- cardiac failure
patients with a score of 0 may be considered for early discharge
managment of upper GI bleed
- resuscitation
- ABC
- platelet transfusion if actively bleeding and platelets less than 50
- FFP if INR >1.5
- prothrombin complex if patient taking warfarin and actively bleeding
- endoscopy immediately after resuscitation
- non-varicael bleed
- don’t give PPI until after endoscopy
- varicael bleed
- terlipressin and abx
- band ligation
- injection if N-butyl-2-cyanoacrylate
- TIPS if bleeding not controlled by above measures
- non-varicael bleed
diseases associated with PBC
sjorgens
rheumatoid arthritis
systemic sclerosis
thyroid disease
management of PBC
- ursodeoxycholeic acid slows disease progression
- pruritis: cholesytramine
- fat soluble vitamin supplementation
- liver transplant
- recurrence in graft is rare
how do you diagnose PBC
- AMA M2 subtype = sensitive + specific
- imaging with RUQ US or MRCP
how do you grade C.diff
- mild
- WCC Normal
- moderate
- WCC <15
- 3-5 loose stools per day
- severe
- WCC >15
- AKI
- Temp >38.5
- life threatening
- hypotension
- partial or complete ileus
- toxic megacolon
management of first episode of non-life threatening C.diff
- first line: oral vancomycin for 10 days
- second line: oral fidaxomycin
- third line: oral vancomycin +/- IV metronidazole
managment of recurrent episode of non-life threatening C.diff
- within 12 weeks: oral fidaxomycin
- after 12 weeks: oral vancomycin or fidaxomycin
- if they’ve had more than two episodes then consider fecal transplant
treatment of life threatening C.diff
- oral vancomycin and IV metronidazole
- surgical referral
investigation for PSC
- ERCP or MRCP: multiple biliary strictures and “beading”
- p-ANCA may be positive
complications of PSC
cholangiocarcinoma
increased risk of colorectal cancer
difference of SAAG in ascites and what it means
- SAAG >11
- indicates portal hypertensio
- most commonly liver disorders
- also
- right heart failure
- constrictive pericarditis
- budd chiari
- portal vein thrombosis
- indicates portal hypertensio
- SAAG <11
- hypoalbuminaemia
- nephrotic syndrome
- severe malnutrition
- malignancy
- peritoneal carcinomatosis
- infections
- TB
- other
- pancreatitis
- hypoalbuminaemia
managment of ascites
- reduce dietary sodium
- if sodium is low then restrict fluids
- spironolactone
- drainage of tense ascites with albumin cover
- to protect against paracentesis induced circulatory dysfunction and mortality
- abx for prophylaxis of SBP
- TIPS
grade hepatic encephalopathy
- Grade I: irritability
- Grade II: confusion and inappropriate behaviour
- Grade III: incoherent restlessness
- Grade IV: coma
what are the LFT findings in alcoholic hepatitis
AST:LFT ratio is 2:1
what is the treatment for alcoholic encephalopathy
- lactulose
- works by increasing the excretion of urea and increasing the metabolism of it by gut bacteria
- rifaximin
- modulates gut flora to decrease ammonia production
what malignancy does coeliac predispose to
enteropathy associated T-Cell lymphoma
what malignancy does chronic H.pylori infection predispose to?
MALT
what is the investigation of choice for liver cirrhosis
transient elastography
how do you diagnose malnutrition
unintentional weight-loss of >10% in 3-6 months
SLE antibody
anti-dsDNA
PSC antibody
p-ANCA
Primary biliary cholangitis antibody
AMA M2 subtype is highly sensitive and specific
what is the UC antibody
p-ANCA
what is the wegener’s granulomatosis antibody
c-ANCA
What are the coeliac antibodies
Anti-endomysial / gliadin / transglutamase
what are the CREST / Scleroderma antibodies
anti-centromere
what is the sjorgen’s syndrome antibody
anti-Ro and anti-La
two typical antipsychotics
Haloperidol
Chlopromazine
three atypical antipsychotics
Clozapine
Risperidone
Olanzapine
side effects of antipsychotics
- typical
- extrapyramidal side effects
- hyperprolatinaemia
- atypical
- metabolic effects
- reduced swizure threshold
- both
- antimuscarinic: dry mouth, blurred vision, urinary retention, constipation
- sedation, weight gain
- impaired glucose tolerance
- neuroleptic malignant syndrome: pyrexia, muscle stiffness
extrapyramidal side effects
- Parkinsonism
- acute dystonia
- sustained muscle contraction (e.g. torticollis, oculogyric crisis)
- may be managed with procyclidine
- akathisia (severe restlessness)
- tardive dyskinesia (late onset of choreoathetoid movements, abnormal, involuntary, may occur in 40% of patients, may be irreversible, most common is chewing and pouting of jaw)
causes of AF
- AF affects Mrs SMITH
- sepsis
- mitral stenosis/regurge
- IHD
- thyrotoxicosis
- HTN
