CCE1 Specialities revision Flashcards
What is the anion gap
Difference between certain measured cations and the measured anions in serum, plasma, or urine.
How do you calculate the anion gap
Anion Gap = (Na + K) − (Cl + HCO3)
Normal anion gap
High anion gap
How does this occur and give examples of causes
Normal anion gap Metabolic acidosis
- Primary loss HCO3- but with compensatory Cl-
- Diarrhoea, Carbonic anhydrase inhibitors, Addison’s disease
High anion gap Metabolic acidosis
- Increased [organic acids] but NO compensatory Cl- increase
- Cyanide, Ethanol, Paracetamol
DSM 5 criteria for GAD
What screen could you do?
At least 3 of the following symptoms AND chronic, excessive worry >6 months (causing distress/ impairment)
- Muscle tension
- Sleep disturbance
- Feeling on edge/ Restless
- Fatigue
- Irritabilty
- Poor concentration
Screen: GAD-7
Haemophillia A
Genetic inheritance and what is the pathophysiology?
X linked recessive
FVIII deficiency
Haemophillia B
Genetic inheritance and what is the pathophysiology?
VWD
Genetic inheritance
Autosomal dominant
(vWF normally binds to FVIII which when FVIIIa & FIXa combined –> activation FX)
On the intrinsic pathway what helps activate prothrombinase
Once prothrobinase is activated what is the cascade?
What can thrombin directly activate
- FVIIIa & FIVa
Common pathway
- Prothrobinase (FXa) + Ca + FVa –> Prothrombin to Thrombin
- Thrombin activates fibrinogen –> Fibrin
- Thrombin activates FXIII–> FXIIIA
FXIIIa + Fibrin form cross linkages
Thrombin can directly activate FV (helps convert more prothrombin) & FVII
Give some examples of HEREDITARY THROMBOPHILIAS
What inheritance are they?
- Factor V Liden (mutation of FV –> hypercoagulable state)
- Antithrombin III (normally bind and inactivate FXa & thrombin)
- Protein s (if low causes overactivity of FV & FVIII)
Generally autosomal dominant
Rheumatoid Arthritis
- Genetics
- Patho
1/ HLA- DR4
2/
- Citrulination of own antigens –> immune response
- RF usually IgM but can be IgG or IgA. When not present referred to as seronegative RA.
- IgM targets Fc portion of IgG antibody in joint synovium= synovial inflammation
- Recruitment of PMNs (granules- neutrophils, basophils..), macrophages, lymphocytes TNF alpha, IL-1, IL-6
- Phagocytosis of complex and release of lysosomal enzymes
- Destruction of joint cartilage, vasodilation redness swelling= hyperplasia of synovium and angiogenesis- vascular granulation tissue= pannus formation
- Inflammatory cells in pannus destroy cartilage and bone= ankylosis (stiffening and fusion)
Ankylosing spondylitis
- Features on Examination
- X-Ray
- Genetic component
1/
- Lower back & SI pain. Worse on rest & improve with movement
- Schober’s test positive
- Extra-articular:
- Weight loss, Fatigue, CP, Enthesitis, Dactylitis, Anaemia, Anterior uvelitis, Heart block, Restrictive lung disease, IBD
2/
- Bamboo spine
Psoriatic arthritis
- O/E
- X-ray
O/E: (multiple presentations)
- Oligarthritics
- Symmetrical- hands, wrists, DIPS (less common MCP)
- Asymmetrical pauciarthritis- digits & feet
- Spondylitic presentaiton
- Oncholysis, Dactylitis, Enthetisis
- Psoriatic plaques
X-ray:
- Periostitis (thickened & irregular bone outline)
- Ankylosis
- Osteolysis
- `Dactylitis (digit appears as soft tissue swelling)
- Pencil in a cup
What types of chronic joint disease often have extra-articular manifestations
- Ankylosing spondylitis (HLA-B27)
- Systemic sclerosis
- Milder form is scleroderma/ limited cutaneous systemic sclerosis
- SLE (HLA- DR2/3)
eg: all cause pulmonary fibrosis
There are 3 types of emergencgy contraception
a) Name them
b) When can you use them
Levonorgestrel
- Up to 72hrs post intercourse
Ulipristal
- Up to 120hrs post intercourse
Interuterine device- copper coil
- 5 days before unprotected intercourse or within 5 days of unprotected intercourse
What are the 3 theories that can cause depression
- HPA dysregulation
- Monoamine theory- underactivity of 5HT & NA
- Brain-derived neurotrophic factor
- promotes cell growth & long term potentiation
- Depression = [BDNF]
DSM V- Major Depressive Disorder
>5 symptoms for during a 2 week period AND at least one of them must be: depressed mood OR loss of interest or pleasure
- Depressed mood most of the day, nearly every day
- Diminished interest of pleasure in almost all activities, most of the day, nearly every day
- Weight loss, Weight gain, Loss of appetite
- Insomnia, Hypersomnia
- Psychomotor agitation or retardation
- Fatigue/ loss of energy
- Fellings of worthlessness, excessive or inappropriate worry
- Diminished abilty to concetrate/ think
- Suicidal ideal
- Mild:* Enough to make dx with minor functional impairment
- Moderate:* More than required for dx. Moderate funcitonal impairment
- Severe:* Many symptoms for dx. Intense impairment- psychotic features possible
What is the difference between Bioplar I & II according to the DSMV?
What sort of behaviours would you expect to see during a manic/ hypomanic episode
Bipolar 1: 1 or more manic (>1 week) OR mixed episodes- mania followed by hypomanic or MDD
Bipolar 2: Never had a full manic episode. At least 1 hypomanic episode (>4- <7 days) & 1 MDD episode
During mania/ hypomanic episode >3 symtoms:
- Inflated self-esteem/ granduosity
- Pressured speech
- Racing thoughts/ flight of ideas
- Distractability
- Increased activity
- Excess pleasurable or risky activities
What are the 5 key symptoms of psychosis
Psychosis- grossly distorted version of reality
DH-DAN
- Delusions
- Hallucinations
- Disorganised thought (eg- Flight of ideas, Loosening of associations, Word salad)
- Abnormal motor behaviour (eg- catonia)
- Negative symptoms
- Apathy, Alogia/poverty of thought, Blunting, Social isolation, Poor self-care & Cog impairment
What pathways in the brain cause psychosis
-
Mesocortical (negative symptoms)
- Ventral tegmental- low Dopamine levels –> PFC D1 receptors
-
Mesolimbic (positive symptoms)
- Ventral tegmental- high dopamine levels –> Nucleus accumbens D2 receptors
What is the pathophysiology behind schizophrenia?
Not enitrely sure!
Imbalance between: Dopamine, Seratoning, Glutamate
Hyperdopaminergic theory: Hyperactivity of DA in mesolimbic tract is key to imbalance.
DSM-V Schizophrenia diagnosis
>2 present:
- Delusions
- Hallucinations
- Disorganised speech, Disorganised behaviour, Catatonic behaviour
- Negative symptoms
- Avolition, Anhedonia, Alogia, Apathy
At least one of above must be a +ve symptom
Occur for a period of 1month & are assoicated with at least a 6 month period of funcitonal decline
MSE
- Appearance
- Behaviour- including eye contact
-
Speech
- Rate, Quantity, Tone, Volume, Fluency
-
Mood & Affect
- Affect (what you see currently)
- Mood (what they tell you eg- anxious, low, euphoric)
-
Thought
- Form (processing & organisation)
- Content
- Possession (eg- insertion, withdrawal, broadcasting)
- Perception (hallucinations)
- Cognition
- Insight & Judgement
Most common bacterial cause of
a) Acute otitis media
b) Tonsilitis
c) UTI
d) Meningitis
a) Step pneumoniae
* Heamophilus influenzae, Moraxella cararrhalis
b) Group A strep
c) E.Coli
d) Nsisseria meningitidis (diplococcus, grame negative) OR if neonates consider- Group B Strep
CENTOR criteria
- Fever >38
- Exudate
- Anterior cervical lymph node tenderness
- No cough
Score 3/4 give Abx
What organisms cause
a) genital discharge (5)
b) Genital ulcers
a)
- Chlamydia
- Gonorrhea
- Candidia
- Bacterial vaginosis
- Trichomonas vaginalis
What testing would you order for
a) Chlamydia
b) Gonorrhoea
c) Syphilis
a) NAAT
b) Charcol swab- mc&s OR NAAT
c) Dark field microscopy or PCR
What type of epithelium can chlamydia & gonorrhoea be found in?
Types of MND
- ALS (lateral corticospinal damage)
-
Progressive Bulbar palsy (CN 9,10,11,12)
- Psueobulbarpalsy (5,7,9,10,11,12)
- Progressive muscular atrophy (anterior horn cells- often LMN of UL)
- Primary lateral sclerosis (corticospinal)
Classic characteristics of PD
Classic triad of NPH
- Hydrocephalus
- Gait apraxia
- Incontinence or cognitive impairment
Postpartum
a) Uterine involution
b) Lochia- how does this change
c) Lactation- hormones and composition
a) After delivery uterus to size at 20 weeks. By day 10 it’s a pelvic organ. Normal size after 6-8 weeks
b) Lochia Rubra (4 days post); Lochia Serosa (2-3 weeks)- brown, red, watery; Lochia alba (1-2) weeks
* Pass for around 4 weeks post partum
c)
- Prolactin (AP): Stimulation of continued lactogenesis & disruption of pulsitile GnRH
- Oxytocin (PP): Milk letdown (myoepithelial cells) & uterine contractions
Colostrum- Ig & protein rich –> Mature milk
When MUST you start using contraception- after what day post partum?
Lactational amenorrhea- how long and how frequent must you be feeding
IUD insertion
21 days post partum
6months must feed every 4 hours in day & 6hrs at night
up to 48hrs post partum OR after 28 days
Trimesters in pregnancy
- 1-13 weeks
- 14-28 weeks
- 29-40 weeks
Define a wart and what is it oftern caused by
Hyperkeratosis and hyperplasis of epidermis often caused by HPV
What is seborrheic keratosis
Begnign growth of immature keratinocytes
(in elderly, dark pigmented papule- sharply demarcated & soft)
Where would you find a ganglion cyst and what property does it have O/E
Tendons/ joints
Transilluminates or gel filled nodule
What is a dermatofibroma? What sign O/E?
Proliferation of fibroblasts
O/E: dimple sign on pinching
What is Bowen’s disease (dermatology)
- SCC in situ in skin
What is a BCC & how does it present
Slow growing, locally invasive arising from epidermal basal cells
Pearly, nodule with raised red edge.
SCC & O/E
Has gone beyond BM & invaded dermis
- Actinic keratosis is a precursor
- Rough, scaly pathches. Browny- erythematous plaque
SCC: Solitary nodule/ papule. Eroded at centre- purulent, crusting, bleeding. Slow growing
Examaning a lump
Size and shape
Position
Attachment
Consistence
Edges
Transillumination
Inflammation
Thrills/ pulsitations
Causes of Pruritis
-
Scabies
- Papular rash
-
Urticaria
- Pale, blanching superficial swellings
- Exzema
- Insect bites
-
Dermatitis
- Herpetiformis associated with coeliac disease. Blisters & papules
-
Lichen planus
- Chornic inflammatory found on limbs, mucus membranes & genitalia (due to keratinocytes apoptosis)
- Forearms, wrists, legs, symmetrical, flat topped papules. Wickham’s striae on oral mucuos membrane
- Generalised itching- liver, renal, haematological
Acute skin rashes
- Erythroderma
- Dermatitis (contact & seborrheic)
- Contact
- Seborrheic- often caused by fungus. Nasolabial folds can be found. Scaling of scalp and erythema
- Drug
- Toxic epidermal necrolysis
- SJS
- Urticarial
- Infective (herpes, varicella, impetigo)
- Purpuric (meningococcal, septic emboli)
Erythroderma presentation & causes
- Skin appears inflamed, oedematous & scaly
- Systemically unwell with lymphadenopathy & malaise
Causes- exsiting skin conditions, drugs-penicillin, idiopathic
SJS and TEN
SJS:
- Mucocutaneous necrosis (>2 sites)
- Drugs, infection main causes
- Few inflammatory cells on histopathology
TEN:
- Usually drug induced
- Extensive severe skin & muscosal necrosis
- Full thickness epidermal necrosis & subepidermal detachement
Herpes Simplex
Varicella Zoster
HSV (see below)
- HSV1
- HSV2 often on genitalia
VZV- Dermatomal like pattern. Painful. Shingles
Impetigo classic characteristic of what organis
Golden crust (Staph A)
Septic emboli O/E
- Small-red purpuric spots
- DON’T BLANCH
- Flat or raised and painful
Chronic skin rashes
- Acne vulgaris
- Lichen Planus
- Eczema
- Psoriasis
- Seborrheic wart
- Infective
- Fungal
- Tinea versicolour
- Tricophyton- athletes foot
- Fungal
- TB
- Vasculitis
- Often purpura (larger & rasied) or petechiae. Suggests bleeding
Lupus Vulgaris (TB) O/E
redish, brown nodules with gelatinous consistency
Skin infections
Viral
Bacterial
Funal
- Viral warts (see warts)
- Molloscum contagiosum
- Herpes simplex & zoster
- Folliculitis
- Impetigo
- Streptococcal cellulitis
- Candida
- Candidiasis albicans most common
- Tinea versicolor aka Pityarisis versicolor
Molluscum contagiosom
- Pearl smooth papule with small depression
- Non tender
What kind of symptoms can cannabis produde?
- Anxiety/ depression
- Schizophrenia
- Slowing of thorught process & memory loss
Effect of cocaine
Stimulant (DA release) –> autonomic arounsal- short lived.
Nausea, jitteriness, anxiety, paranois, euphonia, cardiotoxic
CAGE
Screening test
- felt you should Cut down
- Annoyned by people critising your drinking
- Guilty about drinking
- have you ever had a drink first thing in the morning to steady your nerves or to get rid of a
hangover (Eye opener)?
>2 suggests significant alcohol problems
What other alcohol assessment tools are there?
- FAST
- >3 on all sections OR scoring greater than 3 on first question complete AUDIT
- AUDIT- C (>5 complete audit)
- AUDIT
List some risks of alcohol abuse
- Pancreatitis
- Peptic ulcers from increased gastric secretion
- Liver
- Alcoholic liver disease starts as: fatty liver –> alcoholic heptitis (inflam & necrosis) –> aloholic liver cirrhosis
- Bleeding as clotthing factors 2,7,9,10 reduced
- Reduced albumin –> peripheral oedema
- Asterexis
- Jaundice
- Seizure (NS oversimulation)
- HTN
- Depression & anxieity
- Weknicke’s and Korsakoff’s
