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
