Conditions Flashcards

Question

MSK Management of open fracture

Answer 1

Remove foreign material Wash out with saline Cover with sterile dressing with antiseptic IV antibiotics Tetanus prophylaxis Reduce and immobilise Prepare for surgery - orthopaedic emergency - needs wash out

Answer 2

Diagnosis based on points system (>6 points for diagnosis) Criteria involves: - Pattern of joint involvement (small joints more diagnostic) - Serology - RF and/or Anti-citrullinated protein (ACPA) +ve - ESR and/or CRP +ve - Duration > 6 weeks Other Ix - FBE - anaemia of chronic disease (disease activity) - XRAY - Loss of joint space (uniform), bony erosions, soft tissue swelling, juxta-articular osteopenia RF +ve in 70%, not specific, high titre prognostic and associated with higher disease activity ACPA specific for RA

Answer 3

Foot drop (high stepping gait) Lateral leg sensory loss Inability to dorsiflex or evert the foot Bumper-bar accident, compression from plaster cast

Answer 4

Red, hot, swollen joint Very painful Can be associated with fever Clinically impossible to distinguish from septic arthritis Usually first MTP joint (podagra), ankle or midfoot affected Often occurs in middle of the night, sudden onset (cool temp, lower pH) Long term may be associated with deposits of crystals in soft tissue (tophi) and renal issues (stones, interstitial nephritis) Can be triggered by allopurinol, diuretics (thiazide), infection, trauma, surgery

Answer 5

XRAY - juxta-articular punched out erosive leisons Acute attack usually normal or low uric acid (need to remeasure after) Negatively bifringent crystals on arthrocentesis Can be associated with leukocytosis and increased ESR

Answer 6

CVD Renal disease HTN DM

Answer 7

NSAIDs - good for multiple joints Colchicine Intra-articular steroids - good if one joint affected Oral steroids - if older and NSAIDs less suitable

Answer 8

Low dose colchicine - biliary and renal excretion so caution, also risk of leukopenia and pancytopenia Individualised approach to urate lowering therapy (allopurinol) - more used in younger patients with recurrent attacks, erosive changes, long term complications or recurrent attacks Start at least 2 weeks after attack Must provide concurrent colchocine and NSAIDs for first 6months to prevent precipitation of gout Need to be consistent/compliant to avoid attacks Avoid if on azithioprine Risk factor reduction - beer, high purine foods and management of CVD risk factors and diabetes

Answer 9

``` Older males (median 65 yrs) Most common leukaemia ``` Usually asymptomatic and found incidentally on routine FBE Shows marked leukocytosis with predominant lymphocytes Blood film will show small, mature lymphocytes & SMEAR cells DON'T need bone marrow biopsy to confirm

Answer 10

Indolent course that is non-curable 1/3 never progress, 1/3 slowly progress, 1/3 actively progress Median survival ~8-9 years Most die from infection or transformation to lymphoma (Richter's syndrome)

Answer 11

Usually asymptomatic and found incidentally Later symptoms can include LAD, splenomegaly, bone marrow infiltration (anaemia, bleeding/bruising, infection), constitutional symptoms ``` Transformation to high-grade diffuse B cell lymphoma (Richter's syndrome) Recurrent infection (Hypogammaglobulinaemia - IgG) - usually encapsulated bacteria or fungal infection Warm autoimmune haemolytic anaemia ```

Answer 12

Non-curable Observation while symptomatic and stable If become symptomatic can provide gentle symptomatic treatment - Intermittent chemotherapy and immunotherapy (monoclonal antibodies) - Steroids (haemolytic anaemia) - Supportive - IV Immunoglobulin, blood transfusions

Answer 13

Blood-borne | IVDU, transfusion, tattoo, needle-stick injury

Answer 14

Anti-HCV HCV-RNA (on PCR) Elevated ALT/AST

Answer 15

Viral genotype (doesn't influence prognosis) - genotype 1 decreased response to treatment Co-infection with HIV Cirrhosis High HCV-RNA

Answer 16

``` Pegylated INF-alpha + Ribavirin (nucleoside inhibitor) 50-80% success rate Significant side effects - depression, fatigue - haemolysis - bone marrow suppression - precipitates autoimmune disorders ```

Answer 17

HCV - 70% progress to chronic infection and chronic hepatitis HBV - 90% progress to chronic infection if infected at birth and will have asymptomatic acute disease If infected as adult much lower risk of chronic infection but more likely to have severe acute hepatitis with transmission

Answer 18

Virus is difficult to culture Many strains with high international diversity and limited cross protection High mutation rate Poorly immunogenic

Answer 19

Vaccination - Anti-HBs positive only Acute infection - HBsAg, HBeAg positive, Anti-HBe (depending on timing, takes a bit to develop), Anti-HBc (especially IgM) Acute infection that has resolved - Anti-HBs, Anti-HBc, Anti-HBe (sustained for years) and HBcAg negative Chronic infection - HBeAg, Anti-HBe, HBsAg, Anti-HBc positive Anti-HBs negative Anti-HBs determines immunity - whether from vaccination or clearance of prior infection Does not develop in chronic infection and will be negative in acute infection

Answer 20

SCC - Central location - Associated with smoking - Associated with clubbing, HOPA, hypercalcaemia Adenocarcinoma - Peripheral location - Not associated with smoking - Young, female asian - EGFR mutation

Answer 21

Less common than non-small cell lung cancer Highly associated with neuroendocrine, neurological syndromes and paraneoplastic syndromes (Lambert-Eaton, SIADH, Cushings, peripheral neuropathy, cerebellar ``` Always disseminated at presentation Poor prognosis (3-6 months or 1-2 years) ``` Centrally located Neuroendocrine 'oat cells' (small, tightly packed, darkly staining ovoid cells)

Answer 22

Small cell carcinoma - Not resectable as disseminated at presentation (if very early disease may consider but uncommon) - Highly responsive to chemo and RTx but it is not curative - Often relapse Non-small cell - ~25% are resectable at presentation - Excision performed if lung reserve adequate, early disease with no distant spread - If early disease but poor lung reserve RTx can be curative - If advanced disease chemo or RTx, but generally poor response to chemo - Cetuximab if EGFR positive in adenocarcinoma

Answer 23

Local invasion - Haemoptysis - Hoarseness - Dysphagia - Pericarditis - SVC obstruction syndrome Bone mets - Lytic leisons - bone pain, pathological fracture - Hypercalcaemia (SCC) - Anaemia Neurological - Confusion - Fits Liver - Abnormal LFTs, low albumin, prolonged INR

Answer 24

1. Rouleux (red cell aggregates), unexplained anaemia and high ESR 2. High ALP (normal other LFTs) - bone turnover 3. Back pain + renal impairment 4. Back pain > 50 yo 5. High total protein in setting of normal or low albumin 6. Unexplained hypercalcaemia

Answer 25

Occurs at any age but median age is 65 years

Answer 26

Slow and indolent course, often identified incidentally (30%) 3 phases of the disease 1. Chronic phase - asymptomatic 2. Accelerated phase - splenomegaly, some B symptoms 3. Blast transformation - significant B symptoms, features of acute anaemia (pancytopenia, infiltration of other organs) and may result in death Usually occurs 2-3 years after

Answer 27

Hypercellularity on BM | Myeloid leukocytosis of cells of varying stages of maturity

Answer 28

Increased urate levels | Treat both with allopurinol for prevention of gout

Answer 29

> 80% have the philodelphia chromosome (BCR-Abl amplification) Also occurs in 20-30% ALL patients (more commonly in the adult patients than children)

Answer 30

Allopurinol - symptomatic In chronic phase 1. Tyrosine kinase inhibitor (Imatimab/gleevac) - resistance eventually occurs. Now 2nd and 3rd generations available 2. Interferon alpha Blast phase 1. Stem cell transplant may be curative if patient eligible but most are not

Answer 31

Occur rapidly over weeks to months They are rapidly fatal but generally curable More likely to occur in younger patients - ALL mainly occurs in childhood - AML 10-20% are children Symptomatic early

Answer 32

B symptoms - Drenching night sweats - Fever > 38 - Wt loss > 10% over 6 mths Pancytopenia - Overcrowding of bone marrow - Anaemia - SOB, palpitations, dizziness, fatigue, pallor - Thrombocytopenia - petechiae/small bruises, bleeding Infiltration of other organs - LAD - Hepatosplenomegaly - Testes (ALL) - Mediastinum, skin (AML)

Answer 33

Confirmation of diagnosis with BM aspirate | Will demonstrate > 20% blast cells (normally

Answer 34

Leukostasis (due to significant increased WCC) - More common in AML - Increased viscosity, decreased blood flow and increased thrombus risk - SOB, blurry vision, stroke, confusion - Requires plasma exchange and urgent chemotherapy to rapidly reduce cell count DIC (due to depletion of coagulation factors) - Significant bleeding risk which can be fatal quickly - More common in AML and APML - Reverse with FFP (INR), cryoprecipitate (fibrinogen) and platelet transfusion

Answer 35

Blood count and blood film - AML - large blast cells with cytoplasmic granules + auer rods - ALL - small blast cells with no cytoplasmic granules or auer rods - CLL - small mature lymphocytes + smear cells - CML - increased number of myeloid cells of varying maturity Bone marrow sample - Confirms diagnosis of acute (>20% blast cells) - Not required for confirmation of diagnosis in chronic (can be diagnosed from blood film + count) Immunophenotyping - Differentiates between myeloid and lymphoid Cytogenetics - Identify different molecular changes associated with each which affects prognosis and management - Phillodelphia chromosome (BCR-Abl amplification) present in 20-30% ALL patients (mainly adults) and > 80% CML patients

Answer 36

1. Induction chemotherapy - Chemotherapy to rapidly reduce cell count and aims to induce remission 2. Reversal of DIC - FFP, cryoprecipitate, platelets 3. Consolidation therapy - Aims to prevent reoccurence - May increase dose of chemo drugs or use other drugs - May use stem cell transplant for consolidation in young/fit patients 4. Maintenance therapy - ALL only - Has a higher relapse rate than AML so requires ongoing treatment - Chemotherapy for 2-3 years after consolidation (intermittent & low dose) - May have stem cell transplant at any time, particuarly if poor prognosis

Answer 37

Retinoic acid Arsenic Reverse DIC

Answer 38

Tumour lysis syndrome - Massive breakdown of cells leads to increases in urate, K+ and renal failure - Risk if higher if there is increased LDH, urate, creatinine and significant increased WCC and bulky disease (lymphoma), rapidly dividing cancer - To prevent treat with allopurinol and ensure adequate fluids prior to treatment

Answer 39

ALL has a higher relapse rate than AML (requires maintenance therapy) ALL is curable in 70-90% childhood cases but much lower cure/survival rate in adults Poor prognosis in ALL is associated with being male, adult, B cell type and philodelphia chromosome AML has a lower relapse rate but is associated with high mortality (i.e. DIC) Prognosis is better with younger age and is related to cytogenetics (certain mutations have better or worse prognosis)

Answer 40

1. MGUS - Precursor to myeloma but only 1-2% annual risk of progression - Common, particularly in the elderly - Usually incidental finding - Characterised by presence of M protein ( 30 g or > 10% plasma cells - No end-organ damage or symptoms 3. Myeloma - Symptomatic with end-organ damage

Answer 41

Transition from MGUS to MM with acquisition of mutations leading to karotype instability Proliferation of malignant plasma cells Normally 10% significant Presence of M protein (polyclonal Ig) in serum and urine (Urine it is Bence jones protien - light chain only) > 30 g Symptomatic with signs of end-organ damage

Answer 42

CRAB are main clinical features - Hypercalcaemia - bones, stones, groans and moans - Renal impairment - Anaemia - BM infiltration from plasma cells - Lytic bone leisons (bone pain, compression fractures, cord compression) - BM infiltration leads to cytokine release that increase osteoclast activity leading to hypercalcaemia and leisons Others include: - Amyloidosis and hyperviscosity from significant amount of M protein 1. Amyloidosis = cardiac, gastro and neurological 2. Hyperviscosity = stroke, AMI/angina, headache - Infections due to decreased normal Ig

Answer 43

Diagnosis 1. Protein Electropheresis - serum and urine M protein 2. BM biopsy - malignant plasma cell proliferation - FBE - anaemia - Blood film - rouleaux (aggregates of RBCs) - U&Es - renal impairment - Ca2+ - increased - LDH - increased is prognostic - ESR - increased - Total protein + albumin - Bone marrow - quantify plasma cells, immunophenotyping, cytogenetics (prognostic influence) - XRAY - multiple lytic lesions - MRI - if suspect spinal cord compression

Answer 44

Not curable but management - aim to increase QOL and decrease progression 1. Stem cell transplant if

Answer 45

1. > 50 yo with new onset back pain, especially if unexplained renal impairment also 2. Unexplained anaemia + rouleaux + high ESR 3. Unexplained hypercalcaemia 4. High total body protein in setting of normal or low albumin

Answer 46

Classical or other subtypes Malignant proliferation of lymphoid cells with Reed-Sternberg cells (large pale cells) Begins at a single LN and spreads in contiguity with the lymphatics system Peaks at 20 years and again >50 years Associated with EBV

Answer 47

70% asymptomatic LAD - Most commonly cervical, but also axiliary and inguinal - Non-tender, rubbery - Alcohol induced tenderness 50% splenomegaly May have compressive LAD symptoms i.e. sore throat, abdominal swelling Rarely present with mediastinal mass but can cause cough, SOB, SVC syndrome (swelling of face, collaterals on chest wall, pemperton's) and pleural effusion 20% present with B symptoms Extra-nodal invovlement - may have pancytopenia (If BM infiltration but this is less common than in NHL) or hepatomegaly

Answer 48

Diagnostic 1. Excisional biopsy of LN - need architecture FBE and blood film - pancytopenia has worse prognosis LDH - increased, disease monitoring ESR - increased - prognostic LFTs - liver infiltration

Answer 49

Ann Arbour staging Need a CXR, CT/PET thorax, abdo, pelvis +/- bone marrow biopsy if B symptoms and Stage 3/4 Stage 1 - single node involvement Stage 2 - more than one LN involvement on same side of diaphragm Stage 3 - LN involvement on both sides of diaphragm Stage 4 - spread beyond LNs

Answer 50

``` Low albumin Low Hb Male High ESR Older age Bulky disease - mediastinal involvement Stage 3/4 disease ```

Answer 51

1. Early disease Short course of chemo (ABVD) + RTx 2. Late disease Longer course of chemo +/- RTx if bulky disease ABVD cures 80%

Answer 52

Chemotherapy - cardiac, respiratory issues (i.e. interstitial pneumonitis) - Infertility - tumour lysis syndrome - increased K+ and urate (treat with fluids + allopurinol prior to ChemoRx), can cause arhythmias and renal impairment RTx - increased risk of cancer (breast, lung) - CAD - Hypothyroidism

Answer 53

1. Low grade - follicular, mantel 2. High grade - Diffuse B/T cell, most commonly B cell 3. Very high grade - Burkwitt's Malignant proliferation of lymphoid cells (mature or progenitor cells) with NO Reed-Sternburg cells Low grade is a slow progression with symptoms at end-stage, with limited curability Higher grades have more rapid progression with earlier B symptoms and are more curable

Answer 54

Small risk with family hx | Associated with H.pylori infection, HIV, immunosuppression, EBV (Burkwitt's)

Answer 55

Usually widespread disease at presentation Asymptomatic LAD usually > 1 LN region involved and may have compressive symptoms B symptoms less common than in HL. If higher grade will occur earlier and more severely than in lower grades Extra-nodal involvement - GIT (i.e. MALT), testes, bones, kidney, CNS

Answer 56

Low grade - Chemo not effective as slowly progressing - Only treat if symptomatic with compressive symptoms or B symptoms or Stage 1 as it may be curable with RTx High grade (diffuse) - Sensitive to chemo, curable - Treat regardless of symptoms - Use multi-agent chemo + rituximab (B cell) Very high grade (burkwitt's) - Very curable, need urgent chemo High grades need to give prophylaxis for tumour lysis syndrome 1. Adequate hydration 2. Allopurinol 3. Monitor electrolytes

Answer 57

Functional oesophageal disorder Results in progressive dysphagia Initially to liquids then progresses to solids Associated weight loss

Answer 58

Barium swallow - 'bird's beak' Oesophageal manometry - diagnostic Laporoscopic cardiamyotomy - division of lower oesophageal sphincter Oesophageal dilation

Answer 59

Inguinal - Most common type (75%) - Significantly more common in males - Rarely strangulate - Above inguinal ligament and medial to pubic tubercle Femoral - More common in woman - Always repaired as high risk of strangulation and obstruction - Below inguinal ligament and lateral to pubic tubercle

Answer 60

Withhold OHA 12 hours prior to surgery and recommence when normal diet Never withhold basal insulin doses (can stop or modify bolus doses on day of surgery) and provide with IV dextrose Monitor BGLs and provide rapid acting insulin as necessary according to insulin correction scale Preferably diabetics should be operated on in the morning

Answer 61

Hepatocellular - Marked elevation of ALT, elevation of AST Cholestatic - marked elevation of ALP and elevation of GGT Alcoholic hepatitis - moderate elevation of AST and ALT, AST > ALT NASH - ALT > AST

Answer 62

Coeliac trunk - T12 - Abdominal oesophagus to the major duodinal papilla, including spleen, gallbladder, pancreas and liver SMA - L1 - Major duodenal papilla to just short of the splenic flexure (transverse-descending colon junction) IMA - L3 - Just before splenic flexure of transverse colon to the anus

Answer 63

Sublingual GTN for acute attacks1st line = atenolol or calcium channel blocker Atenolol if have HF. Don't combine verapamil + atenolol = complete heart block (ok with long-acting dihydropyridine i.e. nifidipine)AspirinStatin

Answer 64

Prolongs the refractory period in all cardiac tissuesAlso exhibits some Na, K, Ca channel blockade + mild anti-sympathetic action

Answer 65

Most effective anti-arhythmic Atrial fibrillation - in recurrent AF - slows heart rate + acute reversion (not used in permanent AF)Ventricular tachycardia

Answer 66

Non-modified released GTN i.e. isosorbide mononitrate

Answer 67

Erect AXR - Air fluid levels - Dilated bowel loops proximal to obstruction (> 3cm SB, >6cm LB, >9cm caecum) - Valvulae conniventes visible (SBO) - Collapsed distal colon - Signmoid volvulus - coffee bean sign - Caecal volvulus - kidney bean sign

Answer 68

Increasing pain, may be out of proportion to examination, sharper and more constant and more localised Peritonism +/- fever and increased WCC Features of mesenteric ischaemia

Answer 69

Every 1-2 days in first week to determine the correct individual dose.Once established monthly testing is adequate

Answer 70

High clotting risk patients- Recent DVT- Recent stroke- Mechanical valve- CHADsVASc score > or equal to 6Usually clexane unless mechanical valve which needs IV heparin due to extreme risk of clot

Answer 71

Initially it has a pro-thrombotic effect due to decreased Protein C production It has a long half-life so its effect takes some days to be established Consider loading dose or bridging with S/C clexane or heparin if in hospital

Answer 72

Very fast, regular heart beat Instant onset Often experience palpitations prior to severe dizziness or syncope Pre-existing HF or IHD

Answer 73

Green leafy vegetables (vit K) - don't have to reduce, need a stable consumption Chronic alcoholism Vit K supplementsBarbituates

Answer 74

1. DC Convert if unstable 2. O2, IV access, bloods, ECG 3. IV amiodarone 4. Consider implantable DC if EF

Answer 75

Sigmoid colon (left side)

Answer 76

Diverticulae usually found incidentally on colonoscopy Barium enema can clarify if symptomatic (abdominal pain, altered bowel habit)CT gold standard for confirmation of acute diverticulitis - can identify extent of disease + complicationsAbdo XRAY can identify obstruction, free air or fistulae

Answer 77

Barium enema and colonoscopy risk perforation

Answer 78

ABCD Type A - Surgery - resection of tear, graft - Aortic valve repair - Permissive hypotension - beta-blockers Type B - Medically managed if no malperfusion syndrome

Answer 79

Sublingual GTN for acute attacks1st line = atenolol or calcium channel blocker Atenolol if have HF. Don't combine verapamil + atenolol = complete heart block (ok with long-acting dihydropyridine i.e. nifidipine)AspirinStatin

Answer 80

Prolongs the refractory period in all cardiac tissuesAlso exhibits some Na, K, Ca channel blockade + mild anti-sympathetic action

Answer 81

Most effective anti-arhythmic Atrial fibrillation - in recurrent AF - slows heart rate + acute reversion (not used in permanent AF)Ventricular tachycardia

Answer 82

Non-modified released GTN i.e. isosorbide mononitrate

Answer 83

AmiodaroneSoltalolClass 1a antiarrythmics Erythromycin TCA (citalopram)

Answer 84

ABCD Cross match and transfusion No imaging - straight to laparotomy to confirm diagnosis and control bleeding + repair (Diagnosis with CT abdo)

Answer 85

High clotting risk patients- Recent DVT- Recent stroke- Mechanical valve- CHADsVASc score > or equal to 6Usually clexane unless mechanical valve which needs IV heparin due to extreme risk of clot

Answer 86

Initially it has a pro-thrombotic effect due to decreased Protein C production It has a long half-life so its effect takes some days to be established Consider loading dose or bridging with S/C clexane or heparin if in hospital

Answer 87

Liver disease - decreased clotting factors NSAIDs - anti platelet effect, displace warfarin from plasma albuminAmiodarone, ciprofloxacin - interfers with its metabolism (P450 enzyme inhibitiors) Cranberry juiceAlcohol (acute consumption)Corticosteroids Macrolides

Answer 88

Green leafy vegetables (vit K) - don't have to reduce, need a stable consumption Chronic alcoholism Vit K supplementsBarbituates

Answer 89

TALESThyroid - hyper or hypoArrhythmia - prolonged QT interval Liver dysfunction Eyes - corneal deposits Skin - grey discolouration

Answer 90

Blood cultures - need 3 sets separated by time and site Bloods - FBE (anaemia, leukocytosis), U&E (renal impairment), CRP, ESR Urinalysis - GN, haematuria ECG ECHO

Answer 91

Diverticulae usually found incidentally on colonoscopy Barium enema can clarify if symptomatic (abdominal pain, altered bowel habit)CT gold standard for confirmation of acute diverticulitis - can identify extent of disease + complicationsAbdo XRAY can identify obstruction, free air or fistulae

Answer 92

1. Empiric antibiotics - Benzylpenicillin, flucloxacillin and gentamycin - Vancomycin + gentamycin if suspect MRSA, prosthetic valve, nosocomially acquired, penicillin hypersensitivity 2. Tailor antibitoics once culture + sensitivity known, continue treatment for 4-6 weeks 3. Monitor for complications Surgery indicated if complications, refractory CHF, failure with medical treatment

Answer 93

Focal fat stranding adjacent to the diverticulae May see extra-luminal fluid and gas loculesBowel wall thickening May see complications - fistulae, perforation, abscess

Answer 94

Sublingual GTN for acute attacks1st line = atenolol or calcium channel blocker Atenolol if have HF. Don't combine verapamil + atenolol = complete heart block (ok with long-acting dihydropyridine i.e. nifidipine)AspirinStatin

Answer 95

Prolongs the refractory period in all cardiac tissuesAlso exhibits some Na, K, Ca channel blockade + mild anti-sympathetic action

Answer 96

May have a 'clear' chest in setting of severe SOB Pleural rub Pleural effusion - stony dullness, decreased chest expansion, decreased breath sounds Cyanosis Decreased O2 sats Tachycardia, tachypnoea Fever Signs of DVT - swollen, tender calf Signs of pulmonary hypertension (often with massive PE) - TR (pansystolic murmur), elevated JVP with V waves, pulsatile liver, RV heave, Loud/palpable P2

Answer 97

CTPA - gold standard for acute PE, good negative predictive value, less useful for small distal PE V/Q scan - choice for chronic PE, normal scan virtually rules it out D-dimer - good sensitivity but low specificity - if positive likely PE but negative does not rule it out. Only perform if have a low index of suspicion for PE ECQ - not specific for PE but may be abnormal in 70% S1Q3T3 (Deep s in lead 1, Q wave and T inversion in lead 3) RV strain pattern - T wave inversion in V1-V4 +/- inferior leads (II, III, aVF) RBBB - M in V1/2 and or W in V5/V6 Right axis deviation ABG - not diagnostic but classically resp alkalosis due to hyperventilation ECHO - may show RV dysfunction in setting of pulmonary hypertension

Answer 98

AmiodaroneSoltalolClass 1a antiarrythmics Erythromycin TCA (citalopram)

Answer 99

Well's score indicates clinical probability of a PE > 6 = high probability and if > 4 PE is likely 1. Clinical signs of DVT (3) 2. Other DDx less likely (3) 3. Haemoptysis 4. Hx of immobilisation, surgery in past 4 weeks 5. Malignancy 6. Previous DVT/PE

Answer 100

Every 1-2 days in first week to determine the correct individual dose. Once established monthly testing is adequate

Answer 101

``` High clotting risk patients - Recent DVT - Recent stroke - Mechanical valve - CHADsVASc score > or equal to 6 Usually clexane unless mechanical valve which needs IV heparin due to extreme risk of clot ```

Answer 102

Initially it has a pro-thrombotic effect due to decreased Protein C production It has a long half-life so its effect takes some days to be established Consider loading dose or bridging with S/C clexane or heparin if in hospital

Answer 103

Liver disease - decreased clotting factors NSAIDs - anti platelet effect, displace warfarin from plasma albumin Amiodarone, ciprofloxacin - interfers with its metabolism (P450 enzyme inhibitiors) Cranberry juice Alcohol (acute consumption) Corticosteroids Macrolides

Answer 104

Green leafy vegetables (vit K) - don't have to reduce, need a stable consumption Chronic alcoholism Vit K supplements Barbituates

Answer 105

``` TALES Thyroid - hyper or hypo Arrhythmia - prolonged QT interval Liver dysfunction Eyes - corneal deposits Skin - grey discolouration ```

Answer 106

Sigmoid colon (left side)

Answer 107

- Punched out, moist ulcers - Often infected - Typically on weight bearing areas - Surrounded by thickened, calloused skin - Sensory disturbance, decreased proprioception, vibration - Hx of DM - Monofilament predicts risk

Answer 108

Sharp retro-sternal chest pain that is relieved leaning forward and worse with inspiration May have pericardial rub Fever Signs of tamponade - muffled heart sounds, increased JVP, Kussmaul's sign, pulsus paradoxis, tachycardia, hypotension Signs of pericardial effusion - SOB, raised JVP, bronchial breathing

Answer 109

Focal fat stranding adjacent to the diverticulae May see extra-luminal fluid and gas loculesBowel wall thickening May see complications - fistulae, perforation, abscess

Answer 110

Altered bowel habit Left sided colic pain, often relieved with defecation Nausea Flatulance

Answer 111

Diverticulitis - inflammation of the pouch - Left sided colic, fever, increased WCC/ESR/CRP, localised or generalised peritonitis - In immunocompromised patients may have few symptoms and present late Perforation - Ileus, peritonitis +/- shock - mortality 40% Abscess Haemorrphage - Sudden, painless onset - Common cause of rectal bleeding Fistuale LBO

Answer 112

NSAIDs | Treat cause

Answer 113

Depends on site, cause and if there is strangulation Strangulated and large bowel obstructions require surgery Incomplete SBO can be managed conservatively Immediate - NBM, IV fluids and nasogastric tube on free drainage, analgesia, bloods (lipase, FBC, U&E), catheterise to monitor fluids, CT to confirm location and cause if AXR inconclusive Surgery - urgent for strangulation and laparoscopy for caecal volvulus, peritonitis, diverticulitis (no colonoscopy due to risk of perf), sigmoidoscopy for sigmoid volvulus and resection for CRC SBO due to adhesions are managed conservatively

Answer 114

Erect AXR - Air fluid levels - Dilated bowel loops proximal to obstruction (> 3cm SB, >6cm LB, >9cm caecum) - Valvulae conniventes visible (SBO) - Collapsed distal colon - Signmoid volvulus - coffee bean sign - Caecal volvulus - kidney bean sign

Answer 115

Abnormal enlargement of testicular veins Separate to the testes Solid Left-side more commonly affected May be associated with dull ache Subfertility - surgery doesn't seem to improve much

Answer 116

Amoxicillin Co-amoxiclav TCAs OCP Clopidogrel

Answer 117

``` Very fast, regular palpitations Come on suddenly and go away suddenly Shorter duration May feel fluttering May be precipitated by caffeine Vagal maneouvres improve - deep breathing, holding breath ``` Narrow complex tachycardia (QRS complex

Answer 118

Irregular, racing heart beat May have associated SOB, chest pain, faintness and fatigue May be brought on by thyrotoxicosis (associated features of this), alcohol, caffeine, infection, exercise Hx of HTN, mitral valve disease, IHD, heart failure

Answer 119

Very fast, regular heart beat Instant onset Often experience palpitations prior to severe dizziness or syncope Pre-existing HF or IHD

Answer 120

1. Vagal manoeuvres i.e. hold breath, breath out into empty syringe, carotid massage 2. IV adenosine if fails - warn patient about side-effects 3. IV verapamil if fails 4. DC conversion if fails

Answer 121

1. DC Convert if unstable 2. O2, IV access, bloods, ECG 3. IV amiodarone 4. Consider implantable DC if EF

Answer 122

Blood splits the media of the aorta and runs in the intimal layer, forming a false lumen Type A involves the ascending aorta and Type B doesn't Most commonly caused by HTN, but less commonly by CTD (marfan's, Elhors-Danlos), trauma, congenital abnormalities (coarctation of the aorta), atherosclerosis

Answer 123

``` Sudden onset of tearing chest pain that radiates to the back Difference in BP/pulse between arms Symptoms depending on which branches it extends into - Carotids - stroke - coronary - MI - Anterior spinal - paraplegia - Renal - anuria - AKI - Mesenteric ischaemia - Limb ischaemia ``` May rupture into the pleural cavity, pericardium and peritonium - haemothorax, tamponade New diastolic murmur - unseating of aortic valve cusps Symptoms of shock Syncope

Answer 124

CXR - widened mediastinum, pleural effusion CT - gold standard Aortography ECG, ECHO, cardiac enzymes, lactate

Answer 125

ABCD Type A - Surgery - resection of tear, graft - Aortic valve repair - Permissive hypotension - beta-blockers Type B - Medically managed if no malperfusion syndrome

Answer 126

``` Normal aorta is 2-3cm, 3cm is considered an aneurysm Most occur infrarenally Increased risk with - increasing age - males > females (5:1) - Hx of CVD, PVD - family hx ```

Answer 127

``` Most commonly degenerative Also associated with - infection - atherosclerosis - CTDs (Marfans, ehler's-Danlos) ```

Answer 128

Usually asymptomatic and found incidentally or on screening (screen if have popliteal aneurysm) May have epigastric abdominal pain that radiates to the back, iliac fossa or groin Sudden death from sudden rupture Symptoms of rupture or bleeding Acute limb ischaemia due to embolus from aneurysm Uncommonly haematemesis due to aorto-duodenal fistulae

Answer 129

Sudden onset epigastric pain radiating to back (or iliac fossa or groin) Signs of shock - hypotension, tachycardia, tachypnoea, cool, mottled peripheries - Ischaemic bowel, ischaemic limbs (will be bilateral) Pulsatile abdominal mass

Answer 130

If 5-5.5cm then it is at high risk of rupture - surgical repair Open or endovascular - Open close aneurysm sac around graft, invasive - Endovascular insert stent, less invasive, can have endoleak occur (Type II most common - branch vessels fill sac)

Answer 131

``` > 5-5.5cm Increase in size >0.5cm in one year Symptomatic Rupture or leak If it is saccular - normally fusiform (both sides due to degeneration) ```

Answer 132

ABCD Cross match and transfusion No imaging - straight to laparotomy to confirm diagnosis and control bleeding + repair

Answer 133

``` Most commonly S. Viridans (normal flora of skin) S. aureus (acute, virulent) S. epidermidis (subacute) Enterococcus S. Bovis - associated with bowel cancer HACEK group - fastidious organisms Fungus Coxiella (Q fever) - associated with livestock, farming ```

Answer 134

IVDU Immunocompromise - HIV, DM, immunosuppresive medications (chemo, steroids) Prosthetic valve Abnormal valve (more subacute compared to normal valve which is more acute) or cardiac abnormality (i.e. PDA, VSD) Previous endocarditis

Answer 135

Peripheral stigmata - Vascular - janeway lesions (painless, non-blanching red lesions on palms and soles), splinter haemorrphage, petechiae - Immune complex - Roth spots (retinal haemorrphage, pale centre), Osler nodes (painful, raised leisons on digits) New regurgitant murmur (AR - early diastolic, MR - pansystolic) - more concerning as destruction of the vale Fever - most frequent symptom - Chills, rigors, night sweats, weight loss, anorexia Complications - HF, embolic events, glomerular nephritis & arthritis

Answer 136

Congestive heart failure secondary to MR or AR Embolic events - Right side - pulmonary infarct/abscess - Left side - renal or splenic infarct/abscess, stroke, mycotic aneurysm Immune complex - Glomerularnephritis - Arthritis

Answer 137

Duke Criteria 1. 2 major 2. 1 major + 3 minor 3. 5 minor Major - ECHO features (osscilating intracardial mass - vegetation, abscess, dehisence of prosthetic valve) - Persistently positive blood cultures with typical organism Minor - Pre-disposing heart condition or IVDU - Fever >38 - One of vascular or immunological phenomenon

Answer 138

Initially TTE usually first, particularly if IVDU TTE low sensitivity - can't exclude IE from it due to poor image quality, good for right sided valves and aorta as front of heart TOE to confirm after TTE or first if pt very unwell, prosthetic valve or suspected complications Prosthetic valves can't be seen as well on TTE

Answer 139

1. Empiric antibiotics - Benzylpenicillin, flucloxacillin and gentamycin - Vancomycin + gentamycin if suspect MRSA, prosthetic valve, nosocomially acquired, penicillin hypersensitivity 2. Tailor antibitoics once culture + sensitivity known, continue treatment for 4-6 weeks 3. Monitor for complications Surgery indicated if complications, refractory CHF, failure with medical treatment

Answer 140

3 aspects which contribute to the formation of thrombus 1. Stasis - immobilisation, surgery, inpatient 2. Endothelial damage - trauma, atherosclerosis 3. Hypercoaguable state - thrombophilia, dehydration, malignancy, pregnancy, medications

Answer 141

``` Prolonged immobilisation, inpatient Surgery Active malignancy - particularly pancreatic Air travel Pregnancy PHx or family Hx of DVT/PE Thrombophilia disorder Increasing age Weaker - COPD, smoking, OCP, obesity ```

Answer 142

``` Sudden onset SOB Sub-sternal pain or pleuritic chest pain (if infarction) Syncope (if massive PE) Haemoptysis (if infarction) Hx of risk factors Cough Progressive SOBOE - recurrent small emboli Calf pain or swelling ```

Answer 143

May have a 'clear' chest in setting of severe SOB Pleural rub Pleural effusion - stony dullness, decreased chest expansion, decreased breath sounds Cyanosis Decreased O2 sats Tachycardia, tachypnoea Fever Signs of pulmonary hypertension (often with massive PE) - TR (pansystolic murmur), elevated JVP with V waves, pulsatile liver, RV heave, Loud/palpable P2

Answer 144

CTPA - gold standard for acute PE, good negative predictive value, less useful for small distal PE V/Q scan - choice for chronic PE, normal scan virtually rules it out D-dimer - good sensitivity but low specificity - if positive likely PE but negative does not rule it out. Only perform if have a low index of suspicion for PE ECQ - not specific for PE but may be abnormal in 70% S1Q3T3 (Deep s in lead 1, Q wave and T inversion in lead 3) RV strain pattern - T wave inversion in V1-V4 +/- inferior leads (II, III, aVF) RBBB - M in V1/2 and or W in V5/V6 Right axis deviation ABG - not diagnostic but classically resp alkalosis due to hyperventilation ECHO - may show RV dysfunction in setting of pulmonary hypertension

Answer 145

Anti-coagulation ASAP - LMWH (enoxaparin) + warfarin - overlap with LMWH until reach stable, therapeutic INR of 2.5 (+ warfarin initially has some pro-thrombotic properties) - Continue warfarin after for 3-6 months if corrected, provoked PE or 6+ months if unprovoked

Answer 146

Well's score indicates clinical probability of a PE > 6 = high probability and if > 4 PE is likely 1. Clinical signs of DVT (3) 2. Other DDx less likely (3) 3. Haemoptysis 4. Hx of immobilisation, surgery in past 4 weeks 5. Malignancy 6. Previous DVT/PE

Answer 147

Atherosclerosis resulting in chronic occlusion of peripheral arteries, as opposed to acute occlusion which results in acute limb ischaemia Intermittent claudication is pain distal to the site of occlusion - Aorto-iliac - buttocks + hip pain - Femoral-popliteal - calf Pain with walking that is improved with rest Worse going up hills/stairs

Answer 148

Intermittent claudication - leg pain with exertion, relieved with rest Hx of CVD, stroke, DM, HTN, smoking, hypercholesterolaemia, family hx, impotence Reduced or absent pulses Bruits Increased capilliary return Positive Buerger's test - rapid pallor with elevation of leg, cyanosis when legs hung off side of bed ABI

Answer 149

Critical chronic limb ischemia - Night pain, rest pain - Ulcers, gangrene Acute limb ischaemia - 6 Ps - Pain - Paraesthesia - Pulseless - Polar (cold) - Paralysis - bad sign, impending gangrene - Pallor (mottled) - ABI

Answer 150

ABI - compares brachial and pedal systolic BP, PVD = 0.5 - 0.9, critical ischaemia

Answer 151

Risk factor and lifestyle management - aspirin - statins - BP control - weight loss, diet, exercise - Anti-inflammatories - stabilise plaque - Adequate DM control - Smoking cessation - very important If limb is not critically threatened, claudication is significant, not smoking and minimal co-morbidities then reperfusion surgery - Angioplasty +/- stenting - proximal, short segments - Bypass graft surgery - long segments, issues with wound healing, graft thrombus and cardiac issues If limb is critically threatened, smoker or significant co-morbidities then reperfusion surgery C/I - Palliation, amputation

Answer 152

- Severe pain - Commonly located on distal part of toes, foot/ankle and pressure areas - Punched out lesion with regular smooth margins - Dry, no bleeding with debridement - Pale base - Cool, pale surrounding skin - Absent pulses - Signs of PVD - lack of hair, shiny skin, muscle atrophy, cool, pale feet, increased capillary refill time, nail changes, Buerger's test positive

Answer 153

- Usually painless or mild pain - Gaiter area, particularly medial malleolus - Wet with granulation tissue at base - Irregular edges - surrounding tissue warm and oedematous - Hx of varicose veins, DVT - Other features of venous insufficiency - haemosiderin deposits/pigmentation, lipodermatosclerosis, pain with standing that can be relieved with walking, oedema, itchy skin Compression and elevation Sclerotherapy and surgery considered for varicose veins

Answer 154

- Punched out, moist ulcers - Often infected - Typically on weight bearing areas - Surrounded by thickened, calloused skin - Sensory disturbance, decreased proprioception, vibration - Hx of DM - Monofilament predicts risk

Answer 155

Pericarditis - Widespread saddle-shaped ST elevation Effusion - low voltage QRS complexes, electrical alternans - alternating morphologies of QRS complexes

Answer 156

Viral - coxsackie, flu, EBV, HIV, varicella Bacterial - pneumonia, TB, Staph or Strep Fungi Dressler's syndrome - post-MI Drugs - penicillin Rheumatoid - RA, SLE Malignancy

Answer 157

ECG - saddle shaped ST elevation ECHO - if suspect effusion FBE, ESR, U&Es, cardiac enzymes, viral serology, blood cultures CXR - cardiomegaly may indicate effusion

Answer 158

NSAIDs | Treat cause

Answer 159

Separate from testes Posterior or superior to the testes May be associated with PCKD Confirm diagnosis on U/S and remove if symptomatic, otherwise supportive management

Answer 160

Accumulation of fluid in tunica vaginalis (anterior to testes) Separate from testes Soft and non-tender Can get above it Transilluminates Can develop with testicular tumour, epidiymo-orchitis, testicular torsion

Answer 161

Abnormal enlargement of testicular veins Separate to the testes Solid Left-side more commonly affected May be associated with dull ache Subfertility - surgery doesn't seem to improve much

Answer 162

Amoxicillin Co-amoxiclav TCAs OCP Clopidogrel

Answer 163

A palpable gallbladder is not due to gallstones

Answer 164

``` Painless jaundice Palpable gallbladder (Courvoisier's law) Portal hypertension - Hepatosplenomegaly (uncommon) LAD Ascites Pale stools, dark urine Acute pancreatitis Weight loss, anorexia Diabetes ```

Answer 165

1st = U/S of liver and biliary tree - dilation of CBD, stones, pancreatic masses Pancreatic neoplasm - CT Liver or cholangiocarcinoma - MRI/MRCP PET scan for staging

Answer 166

Exposure to pollutants/smoke results in: - neutrophilic inflammation resulting in increased protease production - destruction of alveolar walls and septa - Destruction of cilia - loss of muco-ciliary escalator - mucus plugging - airway narrowing - Goblet cell hyperplasia - increased mucus production - Chronic inflammation - airway narrowing and remodelling Narrowing of airways results in increased airway resistance - SOB Loss of tissue increases lung compliance - decreases elastic recoil - gas trapping (less air expelled in expiration) - Decreased FEV1 and hyperinflation

Answer 167

``` SOB, reduced exercise tolerance Cough - often productive Wheeze (usually expiratory) Prolonged expiratory phase Nicotine stains Reduced breath sounds Decreased chest expansion Hyperinflation - barrel chest, hyper-resonance, ptosis of liver ``` Severe signs Pursed lip breathing Accessory muscle use Signs of pul HTN - TR (pansystolic murmur), loud/palpable P2, raised JVP with prominent V waves, pulsatile liver Signs of cor pulmonale - RV heave, raised JVP, hepatomegaly, peripheral oedema, if severe signs of portal hypertension (ascites, splenomegaly) Cyanosis Metabolic flap

Answer 168

``` Diagnosis from spirometry FEV1/FVC 7 or 11 anterior/lateral ribs present Bullae Narrow heart shadow Prominant hilar vasculature if Pul HTN ``` ABG - May be chronically hypercapnic - may progress to type 2 resp failure (acidosis, hypercapnia, hypoxia) - May be in chronic type 1 resp failure (hypoxia, normal CO2)

Answer 169

Spirometry + Gold's classification Spirometry - must have FEV1/FVC

Answer 170

Optimisation - Smoking cessation - Pulmonary rehab - Medications - SABA/SAMA, LABA/LAMA, ICS - Home O2 Prevention of exacerbations - Yearly flu vax, pneumococcal vax - Adequate nutrition and physiotherapy - Regular monitoring/follow up Develop an action plan - Home supply of antibiotics and oral steroids if signs of infection and exacerbation - Education on signs and symptoms and when to present for treatment

Answer 171

Exacerbation is increased SOB, decreased exercise tolerance or increased RR, which may be associated with increased cough, increased sputum production and change in colour/consistency of sputum 1. Nebulised SA-bronchodilators 2. Careful O2 - maintain O2 Sats 88-92% so not to reduce resp drive 3. Oral corticosteroids - reduce the duration of exacerbation 4. Antibiotics may be beneficial if infective exacerbation (change in sputum, radiological signs) - Doxy + amoxycillin 5. Non-invasive ventilation (BiPaP) if pH 2.5 - 3.5 or invasive ventilation if indicated (Type 2 resp failure)

Answer 172

1. SABA or SAMA - SABA preferred due to better side effect profile - Can be used in combination If symptoms not controlled add: 2. LABA or LAMA - Response is individual, therefore choice depends on patients response If symptoms not controlled: 3. Add 2nd long-acting agent OR ICS if on LABA If still not controlled and/or FEV1

Answer 173

Salbutamol, terbutaline Short-acting beta-adrenoreceptor agonists - activate B-AR to induce bronchodilation No effect on disease modification or survival, only symptomatic control S/E - tremor, palpitations, headache, very high doses - hypokalaemia Preferred to SAMAs due to risk profile

Answer 174

Ipratropium Short-acting muscarinic antagonist - reduce parasympathetic nerve activation by acetylcholine S/E - increased risk of CVD (why SABA preferred), anti-SLUD (dry mouth, dry eyes, urinary retention, constipation)

Answer 175

Salmeterol, eformeterol Long acting agonist of the B-AR Improve QOL, relieve symptoms and reduce frequency and severity of exacerbations Same side effects as SABA

Answer 176

Tiotropium Long-acting muscarinic antagonist Same benefits at LABA - improve QOL, relieve symptoms, reduce frequency and severity of exacerbations Individual response to LABA and LAMA so choice depends on patient - can be used in combination

Answer 177

Fluticasone, budesonide Reduce the frequency of exacerbations and reduce rate of decline but no clear indication if beneficial effect on mortality Effect on reducing exacerbations enhanced when used with a LABA Indicated when FEV1 2 exacerbations S/E - dysphonia, oral thrush, long-term effects of steroids, increased risk of pneumonia (especially with fluticasone)

Answer 178

Typical - Acute, severe - SOB, productive cough, pleuritic chest pain - Fever, rigors - Signs of consolidation - decreased chest expansion, increased fremitus, bronchial breathing, dullness to percusion - Decreased O2 sat Atypical - Gradual, insidious onset and duration - Minimal chest signs - Non-productive cough, may have some SOB - Non-resp features predominant - myalgia, arthralgia, headache, malaise - May have fever

Answer 179

Typical 1. S. pneumoniae (both community + hospital) 2. HIB - less common with vaccination 3. Gram negative rods (hospital) - Klebsiella, pseudomonas 4. S. aureus Others - Morexella (elderly), anaerobes + MRSA (hospital) Atypical 1. Chlaymdia 2. Mycoplasma 3. Legionella Viral - flu, RSV, adenovirus etc Coxiella (Q fever) - farmers, vets, abattoir workers TB

Answer 180

Typical - Lobar or patchy consolidation (bronchopnuemonia) Atypical - Reticular or recticulonodular opacities, typically in the peri-hilar region

Answer 181

Sputum sample - culture + PCR Urine - Legionella antigen U&Es, FBE Blood cultures - 10-15% of S.pneumoniae infections will be positive Serology - mycoplasma + chlamydia ABGs - if severe, may be approaching resp failure CXR ECG, cardiac enzymes if pleuritic chest pain to exclude ACS

Answer 182

CURB-65 Confusion Elevated Urea RR > 30 BP 65 Mild = 1, moderate - 2, severe >2

Answer 183

Mild - amoxycilin (S. pneumonia, HIB) + doxycyclin (atypical cover) Moderate - Same unless require admission then replace amoxycillin with IV benzylpenicillin Severe - 3rd generation cephalosporin (Strep, Gram -ve) + azithromycin (atypical, gram +ve) +/- vancomycin (if MRSA suspected)

Answer 184

Mild - Amoxycillin + doxycyclin Moderate/Severe - Ceftriaxone +/- metronidazole (anaerobes) +/- vancomycin (MRSA) +/- piperacillin/tazobactem (pseudomonas) MRSA and pseudomonas more likely if hospital stay > 5 days or high risk unit (ICU)

Answer 185

Chronic - HF-REF (systolic dysfunction - dilation of ventricle) - HF-PEF (diastolic dysfunction - hypertrophy of ventricle) Acute/decompensated - acute pulmonary oedema

Answer 186

IHD - 70% of cause of heart failure, mainly systolic dysfunction (dilation of ventricle) Cardiomyopathy (dilated) - also causes systolic dysfunction - dilation means decreased ability to contract efficiently to produce adequate SV Hypertension - mainly diastolic dysfunction (LV hypertrophy) Valvular disease - systolic or diastolic dysfunction, may cause left or right sided failure depending on valve and may also affect atria

Answer 187

- Myocardial injury leads to decreased ventricular due to loss of myocardial cells/scar tissue - Decreased SV and CO leads to activation of RAAS which causes fluid retention - increases preload - increased EDV - Frank-Starling mechanism (more volume = more stretch = more contraction) - increased SV and remodelling of LV (dilation)

Answer 188

- HTN = increased afterload to LV - Increased LV EDP to eject same SV - Thickening of LV wall to dissipate increased pressure - Thickening makes it stiff - more difficult to fill

Answer 189

- Regurgitant disease - increased ventricular ESV to chamber behind valve - fluid overload - dilation to accommodate - systolic dysfunction - Stenotic disease - increased afterload to chamber behind valve - increased EDP - thickening to dissipate pressure - diastolic dysfunction

Answer 190

- Decreased CO with HF leads to decreased BP - Decreased perfusion to kidneys - activation of RAAS - Renin - conversion angiotensinogen to Ang I - ACE converts Ang I to Ang II - Ang II acts on adrenal cortex - increase aldosterone - Aldosterone increases Na+ and H2O retention in distal tubules - Increased circulating fluid volume - increased venous return and BP - Decreased BP also increases baroreceptor firing - Increased SAN firing and decreased conduction time to ventricles - increased HR - Increased activation of sympathetic NS - increased HR, increased contractility and further activation of RAAS

Answer 191

Left sided - Exertional SOB - PND - Fatigue - Orthopnoea - Tachycardia, tachypnoea - Displaced apex beat - S3 (gallop) - early sign of LV dilation (filling sound in diastole against a more compliant ventricle) - S4 - atrial kick occurring in diastolic dysfunction due to decreased compliance of ventricle - Pulsus alternans - Murmur - underlying valvular disease Right sided - SOB related to pulmonary oedema (can also occur in decompensated left sided heart failure) - Coarse bi-basal crackles - Raised JVP - Orthopnoea - Peripheral oedema - Hepatomegaly - Ascites, splenomegaly if severe (due to portal hypertension) - Signs of Pulmonary hypertension - TR (pansystolic murmur, raised JVP with prominant V waves, pulsatile liver), palpable/loud P2

Answer 192

Describes the severity of HF based on symptoms and functional limitation 4 classes Class 1 - no symptoms or functional limitations Class 2 - mild limitation, symptoms with normal physical activity Class 3 - marked limitation, symptoms with gentle physical activity Class 4 - significant limitation, symptoms at rest and with any activity

Answer 193

ECHO - Determine if systolic or diastolic dysfunction and whether EF is preserved or reduced - Assess chamber dimensions - Assess underlying causes - valvular, cardiomyopathy, regional wall abnormalities (CAD) ECG - Supportive as may indicate LV hypertrophy (>7 large squares of combined QRS amplitude in V1+V6 or V2+V5) - Identify ischaemia/infarction, arrhythmia as cause or precipitant CXR - Supportive signs - ABCDE - alveolar congestion, kerley B lines, cardiomegaly, upper lobe divergence, pleural effusions ``` Natriuretic proteins (i.e. BNP) - Normally 400 suggestive of APO and poorer prognosis, ```

Answer 194

Clinical diagnosis + ECHO findings of altered chamber dimension and EF Framingham criteria European society of cardiology guidelines Diagnosis based on major and minor clinical features

Answer 195

No specific management for HF-PEF - mainly treatment of underlying cause (i.e. hypertension) and symptomatic fluid control HF-REF - BLADES - Beta-blocker - improves mortality (decreased risk of sudden death from arrhythmia) - Lasix (fruesemide) - no effect on mortality - ACEI - improves mortality, symptoms, increases EF and decreases progression - Digoxin - if have AF - Spironolactone - aim to give early as has benefit on improved mortality, but can't give if renal failure due to hyperkalaemia

Answer 196

LMNOP - Lasix (Fruesemide) - Morphine - Nitrates - O2 if sats

Answer 197

Exercise | Diet

Answer 198

Anterior - V1-V4 - LAD Inferior - Leads II, III avF - Right coronary Lateral - Lead I, aVL, V5-V6 - circumflex

Answer 199

MI - Symptoms of ischaemia - chest pain - ECG changes - Imaging evidence of thrombus or myocardial loss STEMI - New LBBB - ST elevation > 2mm in >1 contigious chest leads or > 1mm in >1 contigious limb leads - Pathologic Q wavs - also sign of old infarction NSTEMI - ST depression - T wave flattening or inversion - may also be sign of old infarct

Answer 200

MONASH-R Morphine - pain + reduced RR (anti-anoxylytic) O2 - only if Sats

Answer 201

PCI more effective than thrombolysis Ideally PCI within 4 hours of pain onset If > 90 minutes before PCI can be achieved thrombolise first then PCI as soon as can If pain onset 12 hours CAN'T do thrombolysis (will be ineffective due to clot organisation) - Still anti-coagulate, dual anti-platelet and CT coronary angiogram (as clot retrival or stenting may still be beneficial) - After 24hrs less likely PCI will be effective Thrombolysis is absolutely C/I if CVA in last 3-6 months, any intra-cranial haemorrphage or bleeding disorder

Answer 202

Bare-metal stent (BMS) or drug-elluting stent (DES) Stent thrombosis is higher in BMS, but requires shorter duration of dual anti-platelet therapy so consider bleeding risk Use dual antiplatelet (aspirin + ticagrelor) for at least 12 months - In BMS can reduce to just aspirin after 6 weeks and in DES after 6 months Ticagrelor reduces risk of stent thrombosis more than clopidogrel

Answer 203

Pharmacological (SAAB) - Continue high dose statin - ACEI - decreases remodelling, HTN, good if diabetic which commonly are, decreased risk of recurrent MI or stroke - Aspirin (+/- ticagrelor if stented) - continue for 12 months to reduce risk of reoccurrence - Beta-blocker - commence 1-2 days after, when more stable. Reduces mortality (from sudden arrhythmias), decreases remodelling and HTN. Don't use in inferior STEMI if heart block Non-pharmacological - Smoking cessation - Weight loss, diet, exercise - Cardiac rehabilitation - Education and counselling on what has happened, new medications (importance of compliance, strategies for compliance), chest pain action plan - Pharmacy involvement - information sheets, webster pack, education on side-effects - Follow-up with GP (inform them of what has happened and management) and cardiac clinic

Answer 204

Need to risk stratify High risk (i.e. ongoing pain, ECG and troponin changes, hx of infarct and CVD) - Consider for early CT coronary angiogram +/- PCI or CABGs - Dual anti-platelet - Anti-coagulation - Beta-blocker - Morphine Moderate risk (prolonged chest pain but no changes on ECG or troponins, diabetes) - Aspirin - Beta-blocker - Morphine - Monitoring and further investigation - reclassify if changes ``` Low risk (more unstable angina symptoms, normal ECG and troponin) - Discharge and manage as outpatient within 2 weeks ```

Answer 205

High risk NSTEMI patient should have early CT coronary angiogram to see if PCI or CABG will be beneficial PCI - if shorter segment CABG - do better if diabetic and if longer or multiple segments If high risk features and think they may need CABG do not load up on clopidogrel/ticagrelor as need to be 5 days off it before CABG - if unsure only give aspirin until have angiogram

Answer 206

Lifestyle modifications first 1. Metformin (2nd line sulphonylurea) 2. Add sulphonylurea (2nd line DDP-4 inhibitor or GLP-1 agonist) 3. Triple OHA therapy or addition of basal insulin - If add basal insulin can stop other OHA except for metformin

Answer 207

Metformin = biguanoside 1st line management of T2DM Decreases hepatic gluconeogensis Not associated with wt gain or hypoglycaemia Need to renally adjust dosage and it is C/I in severe renal failure Accept a small rise in Cr (

Answer 208

``` Medications with prefix 'Gli-' 2nd line treatment of T2DM to metformin Stimulates B-cells to increase insulin Associated with hypoglycaemia and wt gain Rapid onset C/I in severe hepatic disease ```

Answer 209

'Gliptin' medications Reduce metabolism/prolongs effect of GLP-1 - increased pancreatic glucose sensing, increased insulin secretion and decreased glucagon secretion No risk of hypoglycaemia or wt gain Reasonable efficicacy S/E - Nausea, hypersenstivitiy

Answer 210

Exanatide, liraglutide Increases pancreatic glucose sensing and increases insulin secretion Requires injection but good efficacy S/E - N+V C/I in those with Hx of pancreatitis or severe GI disease

Answer 211

1. Identify and treat underlying cause of disease 2. Prevent progression - management of proteinuria (ACEI), BP control, glycaemic control 3. Reduce risk of CVD - as above, plus lifestyle management (smoking, alcohol, diet, weight loss, exercise) 4. Early investigation and management of complications - Anaemia - monitor, supplement, EPO if required - Bone disease - Phosphate binders (calcium supplement), activated Vit D - Oedema - Na restriction, diuretics, fluid restriction - Acidosis - sodium bicarbonate to maintain serum levels > 20mmol/L 5. Medication adjustment/avoidance of renally excreted and nephrotoxic drugs

Answer 212

Trunk of MCA - Upper and lower limb motor deficit - Global aphasia Lentinulostriate branches - Lacunar infarct (small, subcortical strokes in internal capsule, basal ganglia) - Upper and lower limb motor deficit - Language spared and sensory usually spared Superior division - Broca's area - expressive dysphasia - Upper limb motor +/-sensory - usually occur on the dominant side Inferior division - Wernicke's area - receptive dysphasia - Upper limb motor - Upper and lower limb sensory - contralateral superior quadratanopia

Answer 213

Lower limb motor +/- sensory deficit | May have motivation/initiation symptoms as supplying frontal lobe (medial division of pre-frontal cortex)

Answer 214

1. Admission to a stroke unit is better for outcome 2. Urgent CT to exclude haemorrphage - unlikely to see ischaemic changes early on, diagnosis made clinically 3. Other investigations - BGLs, U&Es (to exclude causes of focal neurological symptoms and C/I to thrombolysis), cardiac enzymes + ECG to exclude AMI which can be associated with concomitant stroke 4. If symptom onset

Answer 215

Factors associated with increased risk of bleeding - hypertension, dementia, head injury, prolonged INR or heparin within last 48 hours Other factors - Seizure at time of onset (severe stroke), unsure of time of onset, hypoglycaemia, recent AMI (risk of ventricular rupture)

Answer 216

1. Carotid endarterectomy - If stroke or TIA and there is carotid stenosis then it should be performed within 2 weeks - If carotid stenosis also >70% it is indicated 2. Single anti-platelet therapy - 1st line Aspirin (or dipyridamole) - 2nd line Clopidogrel - modest increased effect at reducing stroke than aspirin but more expensive so less routinely used 3. Reduction of risk factors - Lifestyle - diet, weight, exercise, smoking cessation - BP control - Cholesterol - Ensure adequate diabetic control

Answer 217

- Asymptomatic - incidental finding on PSA, DRE - Bone pain - sclerotic boney mets in advanced disease - Urinary retention - due to obstruction - Obstructive urinary symptoms - hesitancy, weak stream, terminal dribling - DRE - hard, irregular nodule - posterior zone most commonly affected - Bony tenderness on palpation

Answer 218

TRUS biopsy - samples used to determine gleeson score PSA - increased (70% of increased scores not due to cancer) XRAY and bone scan - bony mets MRI for staging LFTs - spread to liver CXR - spread to lungs

Answer 219

Depends on age, grade and stage of cancer and if other comorbidities If local disease: 1. Watchful waiting - if older with shorter life expectancy (

Answer 220

Prostectomy - impotence, incontinence Hormonal - impotence/decreased libido, mood swings, gynacomastia, bone loss, decreased facial hair

Answer 221

TURP - scrape off some of prostate to reduce obstruction Alpha-antagonists - decrease smooth muscle tone in prostate & bladder to reduce obstruction 5-alpha reductase inhibitors - decrease conversion of testosterone to dihydrotestosterone

Answer 222

Ab/Ag serology screening tests using an ELIZA method Diagnosis confirmed with Western blot - Abs present to at least 2 HIV protein bands Consider co-infection with other STIs and chronic infection - TB - Interferon-gamma release assay, mantaux test, CXR - Hep C & B serology - Chlamydia and gonorrhoea - urine & (increase risk of transmission)

Answer 223

It is HIV, not AIDS - HIV is treatable with only moderate increased risk in complications Will require regular medical checks but otherwise won't greatly interfere with future plans Use condoms

Answer 224

Chronic inflammation and immune dysfunction Drug toxicity - less of an issue now Lifestyle and risk factors often associated with HIV - smoking, alcohol, IVDU Associated with more co-moribities - DM, osteoporosis, CVD, HTN, CKD, CLD

Answer 225

- Who they have for support - Can you contact previous sexual contacts and are you willing to? - Have you donated blood or semen in last year? - Symptoms of seroconversion - as may remember and this gives a time frame for infection

Answer 226

Very non-specific, often confused with glandular fever or the flu - Headaches, myalgia, arthralgia, sore throat, LAD, rash, weight loss

Answer 227

Opportunisitic infections - PJP, candida, CMV retinitis, toxoplasma Severe/resistant skin conditions Other chronic infections - TB, viral hep Conditions associated with it - lymphoma, karposi sarcoma Unexplained weight loss with risk factors High-risk group

Answer 228

- Work, accomodation, relationships - Mood and lifestyle issues (alcohol, smoking, drugs) - STI risks and checks - Co-infection with TB, viral hep - Examination for associated conditions (skin, cancers) - Record and monitor wt, CD4 cel count, viral load - Department of health notification

Answer 229

- Anti-retro viral treatment prevents replication thus reducing viral load, allows reconstitution of the immune system and stops generation of resistant strains - 3 tablets per day - 2 x nucleoside reverse transcriptase inhibitors and a protease or integrase inhibitor - Patient must know of benefits and risks of treatment and must be willing to be fully compliant - More likely to get reconstitution of immune system if started when CD4 > 200 - Monitor for complications - Monitor viral load - rising means compliance issue, resistance or both - Immune reconsitution disease can occur (opportunistic infection), particuarly if CD4 count low when commencing

Answer 230

Antibodies - anti-gliadin, anti-tG (transglutaminase), anti-endomysial Gastroscopy with small bowel biopsy FBE - anaemia Iron studies, B12

Answer 231

``` Trauma Electrolyte disturbance (hypocalcaemia, hyper- or hyponatraemia) Infection - meningitis, encephalitis Hypo- or hyperglycaemia Stroke Haemorrphage Pseudoseizure Psychogenic Hippocampal sclerosis, temporal sclerosis Drug/alcohol withdrawral Drugs i.e. TCAs Space-occupying lesion Raised ICP Hypoxia ```

Answer 232

``` Flashing lights Reading/righting Tiredness Emotional - stress Fever Alcohol ```

Answer 233

Before 1. Seizure - moan or cry, sudden onset, may be associated with aura (strange feeling in gut, jamais vu/deja vu), presence of trigger (flashing lights, tiredness, stress, fever, alcohol) 2. Syncope - only when standing (unless seated if cardiac cause), prodrome (N+V, sweeting, light-headed, change with vision and hearing), often warning it is going to happen, hypoglycaemia, dehydrated, fear/anxiety/stress, hx of valvular or heart disease During 1. Seizure - tonic clonic movements, cyanosis, frothing, tongue biting, incontinence, automatisms (i.e. picking at clothes, smacking lips) 2. Syncope - pale, may have a few very brief convulsions, usually no loss of continence (but rarely can) After 1. Seizure - injury (sore tongue, back shoulder - posterior dislocation), post-ictal confusion, fatigue, drowsiness, aphasia, temporary muscle weakness (Todd's palsy), amnesia 2. Syncope - Not confused or tired, on examination may find postural hypotension, bradycardia, ejection systolic murmur (AS), irregularly irregular pulse

Answer 234

EEG or video telemetry (continuous EEG with recording) - Diagnosis of epilepsy syndrome, not a seizure - May have abnormal inter-ictal epileptiform patterns - During a seizure there will be abnormal discharges - VEEG is useful to classify seizure and distinguish from pseudoseizure MRI - may show epileptogenic leisons CTB - rule in or out specific causes of seizure i.e. space-occupying lesion, haemorrphage Genetic epilepsy syndromes confirmed with recurrent seizures with no clinical or radiological evidence of brain damage, Epileptiform discharges > 3 hertz and response to therapy usually good

Answer 235

Do not treat first seizure - unless abnormal EEG/imaging, known underlying neurological condition, use of a motor vehical or dangerous activities for occupation/lifestyle Always attempt monotherapy and introduce drug slowly, change if not effective Education on drugs to ensure compliance Don't acutely treat a seizure unless it is prolonged (status epilepticus) - benzodiazepine Drug choice depends on type of seizure - Generalised seizures (absence or tonic clonic) 1. Valproate 2. Lamatrigine (T-C) or ethosuxamide (absence) - Partial seizures 1. Carbamezipine 2. Lamatrigine 3. Valproate

Answer 236

``` Occupation - dangerous if seizure? Safety around heights and water Driving restrictions Education about avoiding triggers of seizures Pregnancy and medications ```

Answer 237

Topical imiquimod or fluorouracil Cryotherapy Phototherapy RTx - usually adjunct to surgical excision of SCC if it its high risk Pre-malignant lesions such as Bowen's disease and solar (actinic) keratoses

Answer 238

Initial - KUB Xray - 80% stones will be visible CT (non-contrast) abdo - superior to IV pyelogram, can exclude other causes of acute abdomen IV pyelogram (contrast + Xray) - need a plain film as control for interpretation KUB US

Answer 239

FBE (infection) U&E (obstructive nephropathy) Ca2+, phosphate, urate - causes of stones Urine MC&;S, urinalysis - haemturia and infection

Answer 240

Pelvicureteric junction Ureters at point of pelvic brim Vesicoureteric junction

Answer 241

Analgesia & supportive If 5mm - alpha-blockers (tamulosin) or calcium channel blockers (nefidipine) to help expel (reduces smooth muscle tone) - Can consider shockwave lithotripsy to break stone up and surgical removal of stone (rare)

Answer 242

T score compares patient's bones to that of healthy 30 year olds T score >/ -1 = normal T score - 1 to -2.4 = osteopenia T score -2.5 = osteoporosis

Answer 243

Loss of bone mass (loss of cells and matrix) - Late menarch, early menopause - Low BMI/malnutrition - Malabsorptive disorders - Sedentary/immobile - Failure to reach peak bone mass - Other disease - RA, malignancy with bone mets - Increasing age - Cushing's/steroids - Hyperparathyroid - Smoking and alcohol - Decreased calcium

Answer 244

Loss of bone mineralisation (as opposed to bone mass) - Inadequate Vitamin D - malabsorption, diet, lack of sun - Renal osteodystrophy - decreased activation of vitamin D - Liver disease - decreased vitamin D activation

Answer 245

- Decreased activation of Vitamin D by the kidneys reduces absorption of calcium in the gut - Increased phosphate due to inadequate clearance by kidneys - Excess phosphate binds to calcium causing further loss via excretion in gut - Low calcium levels and high phosphate levels leads to increased PTH secretion (2o hyperparathyroidism) which results in bone resorption to correct low calcium levels - Due to constant inadequate activation of Vit D and increased phosphate levels, PTH are constantly high which means bone is constantly demineralised - Eventually to keep up with continued PTH secretion the parathyroid glands undergo hyperplasia (3o hyperparathryoid) Provide activated Vitamin D supplement and Phosphate binders with meals

Answer 246

Osteoporosis - ALP, calcium and phosphate normal - DEXA T score - 2.5 = osteoporosis Osteomalacia - Vit D decreased - Decreased calcium and phosphate - Increased ALP and phosphate

Answer 247

Lifestyle - decrease smoking & alcohol - increase exercise + weight bearing - Increase diet intake of Ca + Vit D Drugs - Bisphosphonates (aldrenoate) - weekly dose, directly toxic to osteoclasts which uncover them when they are resorbing bone, S/E of osteonecrosis of jaw, atypical fractures and oesophagitis - RANKL inhibitor (denosumab) - monoclonal Ab that binds to RANKL. RANKL on Oc interacts with RANK on Ob causing it to become activated - Selective oestrogen receptor modulators (raloxifen) - increases oestrogen effect on bone (increases OPG which binds to RANKL) and decreases RANKL, therefore reducing activation of Oc + prolongs survival of Ob

Answer 248

Thickened gallbladder wall Peri-cholecystic fluid Gallstones in gallbladder - small, round, hyperechoic masses with posterior acoustic shadowing

Answer 249

Round, regular anechoic mass which is wider than it is taller (not invading other planes) Posterior acoustic enhancement

Answer 250

U/S - Hypoechoic, ill-defined mass - Taller than is wide - Hyperechoic, thick halo surrounding - Posterior acoustic shadowing - Calcifications Mammogram - Ill-defined hyperdense mass - Spiculate margins - Microcalcifications

Answer 251

Surgery 1. Lumpectomy with WLE + RTx 2. Mastectomy - if very large tumour vs. breast size, C/I to RTx Endocrine - If ER/PR positive - Tamoxifen (oestrogen receptor antagonist) - pre or post-menopausal woman, increased risk of uterine cancer + VTE but still beneficial, 5-10 year course - Aromatase inhibitor (inhibits enzyme converting androgens to oestrogen) - post-menopausal woman only, requires adjunct bisphosphonates (increased risk of osteoporosis), 5 year course Chemo - Taxanes and/or anthacyclins - Used when there is high risk of reoccurence or advanced disease - 3-6 month course - Risk of reoccurence predicted by - younger or post-menopausal woman (more aggressive cancers), nodal status, receptor status (HER2 more aggressive), size and grade Targeted - Transtuzumab (herceptin) if HER2 receptor amplification (tyrosine kinase activity) - HER2 amplification occurs ~20% early cancers - More aggressive cancer with higher risk of reoccurrence