Cookshoot learning points Flashcards
Cardiac chest pain + no ECG changes mgmt
Aspirin + 12 hour troponin
What ABG would you expect in acute asthma attack
Respiratory alkalosis
Resp failure → Type 2 = near fatal asthma
Classic triad of wernickes
ophthalmoplegia/nystagmus, ataxia and confusion if unTx → kormokoff
Meningitis + behavioural disturbance/altered conciousness
encephalitis
Describe phempugoid vulguis
Younger patients, intradermal, break down easily
Common causes of blisters
Mechanical, stings, burns, contact dermatitis
Upper GI bleed • Use of glasgow blatchford score • When to offer endoscopy • Who gets terlipressin + when? • How to stop active bleeding • How to ↓ portal hypertension • All patients who have an intervention should have what IV drugs and for how long
- GBS: scores of 6 or more were associated with a greater than 50% risk of needing an intervention
- If patient is unstable → after resus immediate endoscopy otherwise within 24 hours
- Suspected variceal bleed, give before endoscopy + continue until definite haemostasis or after 5 days.
- If can stop bleeding Minnesota tube - max 12 hours
- Medical + TIPPS procedure
- IV omeprazole for 72 hours
Describe blatchford score
The need for admission and timing of endoscopic intervention may be predicted by using the Blatchford score. This considers a patients Hb, serum urea, pulse rate and blood pressure. Those patients with a score of 0 are low risk, all others are considered high risk and require admission and endoscopy.
Use of rockall score
Following endoscopy it is important to calculate the Rockall score for patients to determine their risk of rebleeding and mortality. A score of 3 or less is associated with a rebleeding rate of 4% and a very low risk of mortality and identifies a group of patients suitable for early discharge.
Angina Hx with +ve ECG finding on exercise tolerance test
1st line angina: BB + GTN spray
Prevention meds: Aspirin 75mg, atorvostatin 20mg, HTN control
• outpatient angiogram
When ever giving a fluid what to say in OSCE after
I would monitor there fluid status → by listening to HS, lung bases and monitoring UO
Complications of DKA - which is common in children
gastric stasis
thromboembolism
arrhythmias secondary to hyperkalaemia/iatrogenic hypokalaemia
iatrogenic due to incorrect fluid therapy: cerebral oedema*, hypokalaemia, hypoglycaemia
acute respiratory distress syndrome
acute kidney injury
Cerebral oedema is common in children - if suspect CT head + senior review
Hyperkalaemia
Flattened p wave, wide QRS, Tall T waves
>6 + ECG changes or >6.5
30mls - 10% calcium gluconate IV 2 mins 50ml - 50% insulin IV 10 mins 10 units of insulin IV - 10 mins Salbutamol calcium resonium - 15 g oral 6-8hrs
Review: intake, meds.
Name extra intestinal features of crohns and UC
- Scleritis
- Erythema nodusum
- Pyoderma gangrenosum
- apothous stomatitis
- Primary sclerosis cholangitis
What is the child pugh scoring system used for?
What is it comprised off?
Bilirubin Albumin Prothrombin time Encephalopathy Ascites
Causes of gout
Comps
Primary - idiopathic renal under secretion
Secondary -
Dietry excess
Under-excretion - 2 renal failure, dehydration
Overproduction - ↑nucleaic acid (malignancy + chemo)
Medications - Thiazides
Comps: chronic destructive gout, urate nephropathy
Unprovoked DVT
Malignancy or thrombophilia
Name the 4 types of melanoma
How to measure risk?
Superficial spreading melanoma
Nodular melanoma
Lentigo meligna melanoma
Acral lentinginous melanoma
Breslow thickness >0.7 = medium/high risk
Fundoscopy of papillodema + causes
The following features may be observed during fundoscopy:
venous engorgement: usually the first sign
blurring of the optic disc margin
elevation of optic disc
loss of the optic cup
Paton’s lines: concentric/radial retinal lines cascading from the optic disc
Causes of papilloedema space-occupying lesion: neoplastic, vascular malignant hypertension idiopathic intracranial hypertension hydrocephalus hypercapnia
HTN retinopathy
Stage 1: Silver wiring
Stage 2: Narrowing + focal narrowing + AV nipping
Stage 3: Retinal haemorrhage, hard exudates, cotton-wool spots
Stage 4: Swelling of optic disc + macular star
What does acute anterior uveitis look like? Causes
Painful red eye, with decreased vision and photophobia.
Ex: red eye, irregular pupil, miosis and pain on consensual pupillary response
Causes: idiopathic, HLA-B27 conditions + seronegative = ankylosing spondylitis and reactive arthritis
c-ANCA - what does it stand for and what conditions
cytoplasmic-anti neutrophilic cytoplasmic antibodies
• granulmatosis with polyangitis (GPA) - wegeners
p-ANCA - what does it stand for and what conditions
perinuclear - -anti neutrophilic cytoplasmic antibodies
- Churg-straus syndrome
- inflammatory bowel disease (UC > crohns)
- CTD (RA, SLE, sjogrens)
- autoimmune hepatisis
Rheumatoid factor
Circulating antibody IgM which reacts with Fc portion of IgG
\+ve • Rheumatoid arthritis • Sjogren's syndrome (around 100%) • Felty's syndrome (around 100%) • infective endocarditis (= 50%) • SLE (= 20-30%) • systemic sclerosis (= 30%)
anti-dsDNA
Specific for a certain condition - what is it?
anti-dsDNA is a type of ANA what does that stand for?
What other antibodies maybe be present for the condition above?
SLE - very specific
ANA - anti-nuclear antibodies - against nucleus
99% are ANA positive
20% are rheumatoid factor positive
anti-dsDNA: highly specific (> 99%), but less sensitive (70%)
anti-Smith: most specific (> 99%), sensitivity (30%)
also: anti-U1 RNP, SS-A (anti-Ro) and SS-B (anti-La)
anti-CCP
Anti-cyclic citrullinated peptide antibody
Anti CCP maybe detectable up to 10 years before the development of rheumatoid arthritis. It may therefore play a key role in the future of rheumatoid arthritis, allowing early detection of patients suitable for aggressive anti-TNF therapy. It has a sensitivity similar to rheumatoid factor (around 70%) with a much higher specificity of 90-95%.
anti-nuclear antibodies
ANAs are found in many disorders, as well as some healthy individuals. These disorders include: systemic lupus erythematosus (SLE), rheumatoid arthritis, Sjögren’s syndrome, scleroderma, polymyositis, dermatomyositis, primary biliary cirrhosis, drug induced lupus, autoimmune hepatitis, multiple sclerosis, discoid lupus, thyroid disease, antiphospholipid syndrome, juvenile idiopathic arthritis, psoriatic arthritis, juvenile dermatomyositis, idiopathic thrombocytopaenic purpura, infection and cancer. These antibodies can be subdivided according to their specificity, and each subset has different propensities for specific disorders.[7
HLA-B27
Human leukocyte antigen B27 is a class I surface antigen encoded by the B locus in the major histocompatibility complex (MHC) on chromosome 6 and presents antigenic peptides (derived from self and non-self antigens) to T cells.
Associated conditions: PAIR psoriasis ankylosing spondylitis inflammatory bowel disease reactive arthritis
serum ACE
Sarcoidal granulomas produce angiotensin-converting enzyme (ACE), and ACE levels are elevated in 60% of patients with sarcoidosis.
Lupus pernio is a skin manifestation of what disorder
Sarcoidosis
Effects: lung, skin, eyes
CXR → bilateral hilar lymphdenopathy
Bloods → ↑ Ca
Fundooscopy
Legs → erythema nodosum
Fractured KOF is classified using which system
Gardners
Type I: Stable fracture with impaction in valgus
Type II: Complete fracture but undisplaced
Type III: Displaced fracture, usually rotated and angulated, but still has boney contact
Type IV: Complete boney disruption
Antibodies present in diffuse scleroderma
anti-scl-70
antibodies present in limited
anti-centromere
Complications of diffuse scleroderma
CREST + pulmonary HTN Calcinosis Raynauds Oesophageal dysmobility telangiectasia
Kayser-Fleischer rings - what condition?
Complications of this condition?
Medical management
Iron deposits in
1) basal ganglion → parkinsons
2) Liver → hepatitis, cirrhosis
3) Kidney → renal tubular acidosis
Measure:
reduced serum caeruloplasmin
reduced serum copper (counter-intuitive, but 95% of plasma copper is carried by ceruloplasmin)
Tx
penicillamine (chelates copper)
Causes of sudden vision loss
Retinal vein occlusion → severe retinal haemorrhage on fundoscopy
Retinal artery occlusion → cherry red spot
ischaemic optic neuropathy - giant cell arteritis, atherosclerosis → altutinal defect (upper or lower vision)
vitreous haemorrhage → lots of dark spots, big bleed in retina
retinal detachment → 1. posterior vitreous detachment (flashing lights, floaters) then retinal (dark shadow from peripherary to central vision) + bubble on fundoscopy
optic neuritis
features of congenital syphilus
blunted upper incisor teeth (Hutchinson’s teeth)
saber shins
saddle nose
deafness
LMN causes of facial nerve palsy
Bell's palsy Ramsay-Hunt syndrome (due to herpes zoster) acoustic neuroma parotid tumours HIV multiple sclerosis* diabetes mellitus
Herpes zoster ophthalmicus
Herpes zoster ophthalmicus (HZO) describes the reactivation of the varicella zoster virus in the area supplied by the ophthalmic division of the trigeminal nerve. It accounts for around 10% of case of shingles.
What patients are effected in infective endocarditis
- normal valves (50%)
- rheumatic disease (30%)
- prosthetic valves
- Congenital heart defects
- IVDU
Most common bacteria to cause endocarditis
1) overal
2) post-prosthetic valve surgery
1) Staphylococcus aureus
2) Staphylococcus epidermidis
what criteria is used to diagnose infective endocarditis
Modified Duke’s Criteria
• positive blood cultures (may be to be 12 hours apart if less specific bacteria)
• ECHO evidence
• New murmur
Signs of endocarditis
Hands: osler nodes (tender), janeaway lesions
Eyes: Roth spots
Heart murmur
Nephiritis (segmental
Bifasicular block
1) ECG appearance
2) causes
RBBB + Left axis deviation
IHD, HTN
Trifasicular block
features of bifascicular block as above + 1st degree heart block
What are they two types of ventricular tachycardia?
monomorphic VT: most commonly caused by myocardial infarction
polymorphic VT: A subtype of polymorphic VT is torsades de pointes which is precipitated by prolongation of the QT interval.
Causes: Congenital: Drugs: amiodarone, TCAs Electrolytes: ↓Ca, ↓Mg, ↓K Cardiac: ACS, myocarditis Other: hypothermia, SAH
Mgmt of VT
Adverse signs (MI, shock, LOC HF)
Yes → DC shock
No → Amiodarone 300mg IV 20-60 mins (via central line then 900mg over 24 hours
Causes of gynaecomastia
physiological: normal in puberty syndromes with androgen deficiency: Kallman's, Klinefelter's testicular failure: e.g. mumps liver disease testicular cancer e.g. seminoma secreting hCG ectopic tumour secretion hyperthyroidism haemodialysis
Drugs: finasteride, spironolactone (most common cause), anabolic steroids
Risk factors for oesophageal cancer
Risk factors smoking alcohol GORD Barrett's oesophagus achalasia Plummer-Vinson syndrome
features of oesophageal cancer
dysphagia: the most common presenting symptom
anorexia and weight loss
vomiting
other possible features include: odynophagia, hoarseness, melaena, cough
Ankylosing spondylitis - background
Ankylosing spondylitis is a HLA-B27 associated spondyloarthropathy. It typically presents in males (sex ratio 3:1) aged 20-30 years old.
Ankylosing spondylitis- symptoms
Features
typically a young man who presents with lower back pain and stiffness of insidious onset
stiffness is usually worse in the morning and improves with exercise
the patient may experience pain at night which improves on getting up
What is schobers test?
reduced forward flexion - Schober’s test - a line is drawn 10 cm above and 5 cm below the back dimples (dimples of Venus). The distance between the two lines should increase by more than 5 cm when the patient bends as far forward as possible
Other signs
+ what are the 6 A’s
↓ lateral flexion
↓ chest expansion
Other features - the 'A's Apical fibrosis Anterior uveitis Aortic regurgitation Achilles tendonitis AV node block Amyloidosis and cauda equina syndrome peripheral arthritis (25%, more common if female)
Investigation of ankylosing spondylitis
↑ESR, CRP
Xray sacroiliac joints
• sacroilitis: subchondral erosions, sclerosis
• squaring of lumbar vertebrae
• ‘bamboo spine’ (late & uncommon)
• syndesmophytes: due to ossification of outer fibers of
• annulus fibrosus
chest x-ray: apical fibrosis
Mgmt of ankylosing spondylitis
encourage regular exercise such as swimming
physiotherapy
NSAIDs are the first-line treatment
Unsure evidence on anti-TNF
What are gottron’s patches and what condition are they associated to?
roughened red papules over extensor surfaces of fingers
Dermatomyositis
Other features of dermatomyositis
Inflammatory disorder causing symmetrical, proximal muscle weakness and characteristic skin lesions
• cab be idiopathic, associated to other CTD or underlying malignancy
proximal muscle weakness
respiratory muscle weakness
skin lesions:
• photosensitive macular rash over back and shoulder
• heliotrope rash in the periorbital region
• Gottron’s papules
• nail fold capillary dilatation
Osteoarthritis on hand
swollen bouchards and heberdens node, Z thumb
What factors of raynauds would suggest an underlying CTD?
onset after 40 years unilateral symptoms rashes presence of autoantibodies features which may suggest rheumatoid arthritis or SLE, for example arthritis or recurrent miscarriages digital ulcers, calcinosis
Most common cause of secondary raynauds
Scleroderma
others SLE + rheumatoid arthritis
Mgmt of raynauds
Keep hands warm, nifedipine (CCB)
Causes of bilateral hilar lymphadenopathy
Sarcoid
TB
Lymphoma + other malignancy
Fungi
Main cause of acromegaly
pituitary adenoma (95%)
CF of acromegaly
overbite (prognathism), ↑hand or feet size,
features of pit tumour: headache, bitemporal hemianopia
Test for acromegaly
oral glucose tolerance test and measure CG (should by suppressed by ↑glucose)
complications of acromegaly
HTN, cardiomyopathy, DM, colorectal cancer
Features and complications of Ehler-danlos
elastic, fragile skin
joint hypermobility: recurrent joint dislocation
easy bruising
aortic regurgitation, mitral valve prolapse and aortic dissection
subarachnoid haemorrhage
angioid retinal streaks
Features of marfans
tall stature with arm span to height ratio > 1.05
high-arched palate
arachnodactyly
pectus excavatum
pes planus
scoliosis of > 20 degrees
heart: dilation of the aortic sinuses (seen in 90%) which may lead to aortic aneurysm, aortic dissection, aortic regurgitation, mitral valve prolapse (75%),
lungs: repeated pneumothoraces
eyes: upwards lens dislocation (superotemporal ectopia lentis), blue sclera, myopia
dural ectasia (ballooning of the dural sac at the lumbosacral level)
what arthritis causes severe deformity fingers/hand, ‘telescoping fingers’ that is not RA
arthritis mutilans - psoriatic arthritis
Types of psoriatic arthritis
rheumatoid-like polyarthritis: (30-40%, most common type)
asymmetrical oligoarthritis: typically affects hands and feet (20-30%)
sacroilitis
DIP joint disease (10%)
arthritis mutilans (severe deformity fingers/hand, ‘telescoping fingers’)
What is the most common cause of purpura in adults?
What is important to exclude (adult + children)?
Immune thrombocytopenic purpura
Meningococcal septicaemia
For investigations for lung cancer - would should you offer a 2 week chest XR?
- Age > 40 + never smoked + 2 of following symptoms:
- Age > 40 + ever smoked + 1 symptom:
cough fatigue shortness of breath chest pain weight loss appetite loss
Who should you consider for a chest XR in 2 weeks?
persistent or recurrent chest infection finger clubbing supraclavicular lymphadenopathy or persistent cervical lymphadenopathy chest signs consistent with lung cancer thrombocytosis
Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for lung cancer if they - what?
have chest x-ray findings that suggest lung cancer
are aged 40 and over with unexplained haemoptysis
Differentials for caveatting lung lesion on CXR
CAVIT Cancer - squamous cell lung cancer Autoimmune - SLE/RA Vascular - PE, Wegener's granulomatosis Infection - (TB, Staph aureus, Klebsiella and Pseudomonas) Trauma
Where can rheumatoid nodules occur?
Elbow, hands, lung + other internal organs (gut, brain)
Causes for raised akaline phosphatase
liver: cholestasis, hepatitis, fatty liver, neoplasia
Paget’s
osteomalacia
bone metastases
hyperparathyroidism
renal failure
physiological: pregnancy, growing children, healing fractures
Isolated raised alkaline phosphatase
Pagets? Primary biliary sclerosis
↑ alkaline phosphatase + ↑ Ca
Hyperparathyroid
Bone mets
↑ alkaline phosphatase + ↓ Ca
Osteomalacia
Renal failure
Who gets pagets, and how does it present
Common disease (5%) but few have symptoms (1 in 20). More common with >age, M>F and northern hemisphere
Symptoms: bone pain, bowing of tibia, bossing of skull
Tx of pagets
Bisphophantes
Complications of pagets
deafness
osteosarcoma
fractures
high-output cardiac failure
Name a few causes of bradycardia
< 60 beats per min Athlete BB Hypothyroid ↑ ICP Heart block Drugs
If adverse features in bradycardia - what do you do?
Atropine 500mcg IV
What if that doesn’t give a satisfactory response?
Atropine 500mcg IV repeat to maximum of 3g or Trancutanous pacing or Other drugs such as adrenaline
If there were no adverse features, who would you be concerned are at high risk of asystole?
recent asystole
Mobitz II
Complete heart block with prolonged QRS
Ventricular pause > 3 seconds
What cancers commonly cause virchows node? Where is this node? What sign is it if you can see it.
The L sided supraventriculae node takes it supply from lymph vessels supplying the intra-abdominal cavity
→ gastric, ovarian, testicular and kidney cancer
Sign: Troisiers sign
Causes of unilateral pleural effusion
Malignancy
Cancer
Trauma
Investigate unilateral pleural effision
High resolution CT
Pleural tap - cytology, microbiology, protein, sugar, LDH, TB
How much protein in transudate and what causes
< 30,
Causes of exudate
infection (pneumonia or TB)
malignancy
CTD
PE
Risk factors for pneumothorax
Spontaneous: tall + thin, male
Iatrogenic - needles
Lung: COPD, asthma, cancer, brochiectasis
CTD (marfans, ED)
Often 1st presenting compliant of pneumothorax
shoulder tip pain
How to categorise lung fibrosis in terms of pathophysiology
Fibrosis predominately affecting the upper or lower zones
Which zone does idiopathic pulmonary fibrosis effect
what other disorders affect this zone
Lower zone
idiopathic pulmonary fibrosis
most connective tissue disorders (except ankylosing spondylitis)
drug-induced: amiodarone, bleomycin, methotrexate
asbestosis
hypersensitivity pneumonitis (also known as extrinsic allergic alveolitis) affect which zone
upper
young person with clubbing and generalised bronchiectasis? + 1 differential
CF
Kartagener’s syndrome (also known as primary ciliary dyskinesia)
Signs of mitral stenosis
What is seen on CXR
Features mid-late diastolic murmur (best heard in expiration) loud S1, opening snap low volume pulse malar flush atrial fibrillation
enlarged atria
often causes by rheumatic heart disease
How can pericarditis appear on ECG
QRS alterans
A pericardial effusion with enough pressure to adversely affect heart function is called?
Cardiac tamponade
Signs of cardiac tamponade
dyspnea (kausmals sign), low blood pressure, and distant heart sounds.
→ get US
Tx of cardiac tamponade
pericardiocentesis
Causes of acute pericarditis
viral infections (Coxsackie)
tuberculosis
uraemia (causes ‘fibrinous’ pericarditis)
trauma
post-myocardial infarction, Dressler’s syndrome
connective tissue disease
hypothyroidism
Signs of pancoast tumour
- Horners syndrome: miosis, anhidrosis, ptosis
- Thoracic outlet syndrome: pain + weakness of arm + hand
- Hoarse voice/ bovine cough - recurrent laryngeal nerve
Location of pancoast tumour
Lung apices - either side
DON’T MISS THIS ON A XRAY
Severe vomiting → retrosternal chest and upper abdominal pain - what condition are you worried about
oesophageal rupture - Boerhaave syndrome
In Boerhaave syndrome - what might be visible on CXR
pneumomediastinum + widened medistinaum
Causes of widened mediastinum on CXR
Most commonly patient is rotated
Causes of actual mediastinal widening include:
vascular problems: thoracic aortic aneurysm
lymphoma
retrosternal goitre
teratoma
tumours of the thymus
→ CT to diagnose
What condition is associated with Thymoma
MG - check antibodies to acetylcholine receptors - 15% get thymomas
What is the cause of charcot’s foot? What is seen on XR foot?
Autonomic neuropathy - commonly secondary to poorly controlled DM (used to be due to tabes dorsalis syphilis).
Extensive bone remodeling / fragmentation involving the midfoot
Causes of acanthosis nigrans
gastrointestinal cancer diabetes mellitus obesity polycystic ovarian syndrome acromegaly Cushing's disease hypothyroidism familial Prader-Willi syndrome drugs: oral contraceptive pill, nicotinic acid
Where can acanthosis nigrans be found?
neck, axilla and groin
Features of neurofibromatosis
AD condition Café-au-lait spots (>= 6, 15 mm in diameter) Axillary/groin freckles Peripheral neurofibromas Scoliosis Pheochromocytomas neurocutanous disorder
Causes of gum hypertrophy
Drugs: anticonvulsants e.g phenytoin
Inflammation
Systemic: Vit C def, leukemia, pregnancy
Causes of massive splenomegaly
myelofibrosis
chronic myeloid leukaemia
malaria
Causes of splenomegaly
portal hypertension e.g. secondary to cirrhosis
lymphoproliferative disease e.g. CLL, Hodgkin’s
haemolytic anaemia
infection: hepatitis, glandular fever
infective endocarditis
sickle-cell*, thalassaemia
rheumatoid arthritis (Felty’s syndrome)
Presentation of diverticular disease
- where in the colon are they most commonly found
painful diverticular disease: altered bowel habit, colicky left sided abdominal pain. A high fibre diet is usually recommended to minimise symptoms
Diverticulitis: left iliac fossa pain and tenderness
anorexia, nausea and vomiting
diarrhoea
features of infection (pyrexia, raised WBC and CRP)
sigmoid colon
what rash is associated with coeliac disease - how to TX
dermatitis hepatoformis - itchy rash on wrist
Dapsone
complications of coeliacs
anaemia: iron, folate and vitamin B12 deficiency (folate deficiency is more common than vitamin B12 deficiency in coeliac disease)
hyposplenism
osteoporosis, osteomalacia
lactose intolerance
enteropathy-associated T-cell lymphoma of small intestine
subfertility, unfavourable pregnancy outcomes
Causes of hepatomegaly + what it would feel like on palpation
- Early stages of cirrhosis. Later → shrinks - non-tender firm liver
- Malignancy - primary or met → hard + irregular
- RHF → firm, smooth, tender, may pulsate
others: viral hepatitis glandular fever malaria abscess: pyogenic, amoebic hydatid disease haematological malignancies haemochromatosis primary biliary cirrhosis sarcoidosis, amyloidosis
what examinations to do on ascites
shifting dullness, fluid thrill
Causes of ascites
Liver cirrhosis Malignancy HF Nephrotic syndrome pancreatitis TB
What complication are you worried about
spontaneous bacterial peritonitis
Main causes of pre-hepatic jaundice + how to inv
Excessive breakdown of Hb
Main causes of hepatic jaundice
- Hepatitis (alcohol, viral, autoimmune, drugs) cirrhosis (any), malignancy (primary or secondary)
Gilbert’s Sydrome: abnormality in bilirubin handling in liver
Crigler-Najjar Syndrome: liver cells have defect in enzyme that conjugates bilirubin.
Causes of post hepatic
Post-Hepatic (obstructive):
- Primary biliary sclerosis
- Gallstones
- Pancreatic
- Cholangicarcinoma
Hx for jaundice
History
• Duration • Speed of onset (acute/chronic), intermittent/persistent o Progressive: malignancy/CLD o Short hx: gallstones/ hepatitis o Fluctuating: bile duct stones
• stools/urine colour
o Pale stools/dark urine: obstructive
• Pain
o Colicky: gallstone
• Weight loss
o Caricoma/CLD
• Skin itchy
o Cholestasis disease
• Vomit
• Bruise easily
o Obstructive jaundice, decreased bile salts (emulsify fat), reduced absorbtion of Vit K (fat soluable vit), decreased CF II, VII. IX, X.
• Fever
PMH • Gallstones • Operations • Long term conditions (autoimmune) • Blood transfusions
DH • Paracetmol OD • Drugs affecting liver SH • Alcohol: CAGE • Smoking • Foreign Travel where o Hep B/C: Africa/asia • IV drugs, tattoos, injections o Hep B/C • Unprotected sex (homosexual/prostitution) • Occupation
Investigation for jaundice
Urine
• Bilirubin? Absent in pre-hepatic
• Urobilinogen? Absent in obstuctice (bilirubin reduction)
Haem • FBC • Clotting (raised PT) • Blood Film • Coomb’s Test (autoimmune haemolytic anaemia) • Viral markers o HbeAg o Anti-HCV
Biochem • U&E’s • LFT o Bilirubin: conjugated/unconjugated o ALT&AST: Indicate hepatocellular damage o ALP, gamma-GT: bilinary tract damage
ALP raised in bile duct blockage with normal aminotransferases, but also indicates osteoblast activity in paget’s disease.
US • Bile duct dilation (<6cm obstruction) • Gallstones • Hepatic masses • Pancreatic mets
ERCP/MRCP: relieve common bile duct stones
Liver Biopsy
Mgmt of benign oesophageal stricter
Bougie to dilate + PPI and stop anything causing oesophagitis
Complications of strep throat
Local: tonsilar abscess
Systemic: sepsis, glomerulneprhtisi, rheumatic fever
Mgmt of strep throat
phenoxymethylpenicillin 10 days + fluids + paracetamol
Complications of UC
Primary sclerosing colangitis
Colon cancer - annual surveillance
Anterior uveitis
Arthritis → can be before UC
what is courvoisir’s sign
Jaundice + palpable gallbladder → sign of carcinoma as if obstructed due to gallstones you would not feel the gallbladder.
Head of pancreas
Causes of ulcer on genitalia
HSV, syphilus, Lymphogranuloma venereum (LGV) (chlamydia), cancer
- ask if painful
Complications of symphilis (tertiary)
gummas (granulomatous lesions of the skin and bones) ascending aortic aneurysms general paralysis of the insane tabes dorsalis Argyll-Robertson pupil
How to diagnose amyloidosis
Congo red staining: apple-green birefringence
serum amyloid precursor (SAP) scan
biopsy of rectal tissue
What causes J waves after QRS complex on ECG
Hypothermia, ↑ Ca
reward slowly as risk of ventricular arrhythmia
Circinate balanitis
painless, shallow lesion associated with reiters syndrome
Where do atrial myxoma occur and risks?
75% occur in left atrium
Risk of emboli and AF
Good prognosis with exercise programme
Signs of aortic regurgitation
Collapsing pulse
Corrigans sign - bounding ‘watterhammer’ carotid pulse
deMusset’s sign: head pop with pulse
Causes of aortic regur
HTN!!
Causes (due to valve disease) rheumatic fever infective endocarditis connective tissue diseases e.g. RA/SLE bicuspid aortic valve
Causes (due to aortic root disease) aortic dissection spondylarthropathies (e.g. ankylosing spondylitis) hypertension syphilis Marfan's, Ehler-Danlos syndrome
LV hypertrophy on ECG
S wave in V1 + tallest R wave height in either V5 or V6 = > 35mm
- ST ischaemic changes
non-pulsatile JVP
superior vena cava obstruction
Kussmaul’s sign in JVP
paradoxical rise in JVP during inspiration seen in constrictive pericarditis
‘a’ wave on JVP
large if atrial pressure e.g. tricuspid stenosis or pulmonary stenosis
Cannon ‘a’ waves on JVP
caused by atrial contractions against a closed tricuspid valve are seen in complete heart block.
giant V waves
tricuspid regurgitation
What does supraventricular tachycardia look like on ECG? How treated?
Narrow complex regular tachycardia
Vagal manoeuvres, adenosine 6mg → 12mg → 12mg (not in asthma use CCB)
When the rate is slowed the rhythm shoes the AVRT wolfparkison white. What does this look like on ECG?
- Shorted PR
- Delta wave
- QRS prolongation
- ST segment and T wave discordant changes
What is the difference between cushing disease and cushing syndrome
Cushing disease - cause by pituitary tumour producing ACTH
Cushing syndrome from other causes: tumour of adrenal gland - excreting cortisol + suppressed ACTH (other adrenal shrinks), ectopic ACTH lung cancer, exogenous steroids
Investigation for diagnosis of cushings?
24 urinary cortisol
overnight oral dexamethasone suppression test - should cause cortisol to ↓
How to localise cushings?
The first-line localisation is 9am and midnight plasma ACTH (and cortisol) levels. If ACTH is suppressed then a non-ACTH dependent cause is likely such as an adrenal adenoma.
High-dose dexamethasone suppression test
if pituitary source then cortisol suppressed
if ectopic/adrenal then no change in cortisol
What condition do you see pretibial myxoedema?
Hypothyroidism
Features of thyroid eye disease. How many of those with graves disease are affect with this?
the patient may be eu-, hypo- or hyperthyroid at the time of presentation
exophthalmos
conjunctival oedema
optic disc swelling
ophthalmoplegia
inability to close the eye lids may lead to sore, dry eyes. If severe and untreated patients can be at risk of exposure keratopathy
25-50%
Mgmt thyroid eye disease
Rule out sight-threatening eye complications Stop smoking Achieve euthyroid state Ocular lubricants Oral steroids Orbital radiotherapy
Tx of thyrotoxicosis
propranolol: this is often used at the time of diagnosis to control thyrotoxic symptoms such as tremor
carbimazole: blocks thyroid peroxidase from coupling and iodinating the tyrosine residues on thyroglobulin → reducing thyroid hormone production. Agranulocytosis is an important adverse effect to be aware of
radioiodine treatment
Causes of hypothyroidism
Hashimotos thyroiditis
Subacute thyroiditis (De quervain’s) - associated with painful swelling of thyroid and ↑ ESR - NB maybe hyperthyroid at first.
Reidel’s Thyroiditis → fibrous tissue that replaces the thyroid parenchyma, painless
postpartum thyroiditis → occurs within 6 months and returns to normal within 12
Drugs: lithium + amiodarone
Iodine deficiency
Causes of hyperthyroidism
Graves
Toxinodular goitre
Drugs amiodarone
- the initial presentation of some of the thrypoditis that then cause hypothyroidism e.g. subacute thyroiditis
What antibody is common in graves
TSH receptor antibodies
Hashimoto’s thyroiditis
anti-TPO antibodies
Complications of thyroid removal
Early
• Bleeding
• Thyroid crisis (hyperthermia, fast AF, pulmonary oedema)
Damage to surround structures
Voice change
hypocalcaemia - hypoparathryroid
Late
Late hypothyroid
Recurrent hyperthyroid
ECG changes in PE
Sinus tachycardia
RBB
S1Q3T3
Erythema Nodsum
infection: streptococci, TB, brucellosis
systemic disease: sarcoidosis, inflammatory bowel disease,
malignancy/lymphoma
drugs: penicillins, combined oral contraceptive pill
pregnancy
→ do CXR to look for sarcoid
Describe the tremor in parksinsons disease
unilateral, pill rolling, resting - worse when distracted
What is levodopa normally given with?
Describe its effectiveness
Side effects of the medication
usually combined with a decarboxylase inhibitor (e.g. carbidopa or benserazide) to prevent peripheral metabolism of levodopa to dopamine
reduced effectiveness with time (usually by 2 years)
unwanted effects: dyskinesia (involuntary writhing movements), ‘on-off’ effect, dry mouth, anorexia, palpitations, postural hypotension, psychosis, drowsiness
Name Dopamine receptor agonists
Bromocriptine, ropinirole, cabergoline, apomorphine
Side effects of Dopamine receptor agonists
atients should be warned about the potential for dopamine receptor agonists to cause impulse control disorders and excessive daytime somnolence
hallucinations
Which neurocutanous disorder is associated with epilepsy and ash leaf spots
Tuberous sclerosis
What does DANISH stand for
D - Dysdiadochokinesia, Dysmetria (past-pointing)
A - Ataxia (limb, truncal)
N - Nystamus (horizontal = ipsilateral hemisphere)
I - Intention tremour
S - Slurred staccato speech, Scanning dysarthria
H - Hypotonia
Causes of cerebellar syndrome
Friedreich's ataxia, ataxic telangiectasia neoplastic: cerebellar haemangioma stroke alcohol multiple sclerosis hypothyroidism drugs: phenytoin, lead poisoning paraneoplastic e.g. secondary to lung cancer
CF of myasthenia gravis
Proximal muscle weakness - worse with repeated movement
ptosis
extraocualar muscle weakness → double vision
dysphagia
What is MG crisis
Affects breathing → requires mechanical ventilation
Investigations for MG
single fibre electromyography (EMG)
Autoantiaboedies (antibodies acetylcholine receptors)
CT chest - thymus
Tension test
Assessment acute stroke
NMB
CT head
Bloods: FBC, U&E, coagulation, HbA1c + cholesterol
Options for management of ischaemic stroke
Thrombolysis <4.5 hours
Mechanical thrombectomy
Aspirin 300mg for 2 weeks
Emboli - warfarin (don’t start for 2 weeks)
Thrombootic: Clopidogrel - after 2 weeks
Statin after 48 hours
SALT assessment
Tell DVLA
In next 24 hours do: ECHO, Cartoid doppler
Whats the 10% rule for phaechromocytoma
bilateral in 10%
malignant in 10%
extra-adrenal in 10% (most common site = organ of Zuckerkandl, adjacent to the bifurcation of the aorta)
CF phaechromocytoma
Palpitation Sweating Headache Sweating HTN in young
24hr metaneprhines
Causes of hyperaldosteronism
Primary
Idiopathic hyperaldosteronism (70%)
Conns syndrome
Secondary Low BP (CHF, cirrhosis)
CF of hyperaldosteronism
↓K - constipation, weakness, arrhythmia
↑BP
nocturia, polyrina
What conditions are associated to berry aneurysms?
adult polycystic kidney disease, Ehlers-Danlos syndrome and coarctation of the aorta
Investigation for myeloma
Serum/urine electrophoresis - bence jones protein
FBC - anaemia
U+E - renal fialaure
Calcium ↑
→ bone marrow aspiration, skeletal surgery
What is syrinomyelia
- what motor/sensory disturbance does it cause
- associated condition
development of cavity (syrinx) within the spinal cord
motor: wasting and weakness of arms
sensory: spinothalamic sensory loss (pain and temperature)
loss of reflexes, bilateral upgoing plantars
Arnold-Chiari malformation
Ring enhancing lesion on CT
Abscess - toxoplasmosis
Hydrocephalus causes
Brain trama (bleed)
Brain tumour blocking ventricles
Normal pressure hydrocephalus - incontinence, dementia, gait abnormality
→ shunt
What is the most common type of motor neurone disease?
Amyotrophic lateral sclerosis (50% of patients)
What are the clinical features of this?
typically LMN signs in arms and UMN signs in legs
No ataxia, no sensory signs, age > 40
What define a prolonged QT
> 440ms in men
>460ms in women
What are prolonged QT at risk of
Torsades de points
→ IV magnesium
Causes of prolonged QT
Congenital
Electrolytes: ↓Ca, ↓K, ↓Mg
Drugs: Antiarrythmics, TCA, antipsychotics
Causes of shorted QT and how to measure
QTc - on ECG
↑Ca, congenital
risk of sudden cardiac death
causes of ↑ lactate on ECG
Anaerobic respiration
Sepsis
mesenteric ischaemia
seizures - really high
Very severe metabolic acidosis on ABG
DKA
Causes of resp alkalosis
panic attacks
aspirin overdose
In COPD if you see HCO3 what are u worried about?
That they are a retained (↑CO2) - caution giving oxygen.
Mixed metabolic and resp acidosis
COPD + Sepsis
Complications of uraemia
uraemia encephalopthy
Pericarditis
Bleeding impairment
What are the acute phase proteins
+ve
-ve
+ve: CRP, ferritin, WCC, ESR, platelets
-ve: albumin
Summaise - stomach cancer Hx Examine Inv Tx
epigastric fullness/pain
anorexia wt loss
vomiting anaemia
Cachexia, virchows node (troisier’s sign) masses
Endoscopy + biopsy, Ba Meal, CT
Surgery - partial gastretomy
Summaise - pancreatic Hx Examine Inv Tx
Abdo pain - deep or to back, Wt loss, steatorrhoea, DM, vomiting
EX: Wt loss, big liver, ascites, obstructive jaundice + palpable gall bladder (couvoisieris law)
Inv: LFT (jaudoce), US, CT, ERCP
Tx
Usually palliative - analgesia + antiemetic
Stent for jaundice
Summaise - colon and rectal cancer Hx Examine Inv Tx
Colon F>M Rectal M>F
RF: Fhx, familial polyposis (AD), UC (with pseudo polyps), benign polyps, low fibre
Iron def anaemia + wt losss (caecal) Large bowel obstruction Perforation/peritonitis Fistula Change in bowel habit Tenesmus Rectal bleeding
TMN or Dukes
Tx
resection +_ adjuvant chemo (chemo? benefit)
Hep B, livedo reticularish rah sh + multifocal neuropathy mix of symptoms
Polyarteritis nodosa (PAN) - biopsy
