Core Cases Notes Flashcards
What is Dysarthria
Slurred Speech
What is Dysphasia
Problem generating / comprehending speech
What is the conus medullaris
End of spinal cord ~ L1-2, after which you have the cauda equina
Describe Guillian Barre syndrome
AI polyneuropathy
Occurs post-infection, commonly campylobacter / cytomegalovirus
Presents with mixed proximal / distal weakness which ascends in glove-stocking
Mx: IV Ig, may spontaneously recover
What saccadic eye movements would be typical for cerebellar disease
broken saccades, overshoot on lateral gaze
What neural fibres are carried in the internal capsule?
Corticospinal tract fibres
What is myeloradiculopathy?
Disease of spinal cord/ spinal roots
What is syringomyelia?
Formation of fluid-filled cyst in spinal cord
D
D
What autoantibodies might you investigate in peripheral neuropathy
ANCA / ANA
Describe trigeminal neuralgia
Unilateral pain,
Usually maxillary / mandibular
Precipitated by tactile stimulation e.g brushing teeth
Mx: Carbamazepine
Differentials for weakness / wasting of hands
MND, cervical rib, pancoast tumour, T1 root lesion, syringomyelia
What is cervical rib
Congenital abnormaility
Additional rib at C7
What is a pancoast tumour
Tumour of pulmonary apex
Usually non-small cell
Patient has peripheral motor neuropathy, gait?
High stepping gait due to foot drop
Patient has peripheral sensory (proprioceptive) neuropathy, gait?
Ataxic / stamping gait
Patient has a wide-based, staggering gait (ataxic), where is their likely problem?
cerebellum
Describe a hemispheric gait disturbance
contralateral hemiplegic gait and contralteral arm flexion
circumduction
Describe a parkinsonian gait
Shuffling gait, loss of arm swing, stooped posture
festinant- tendancy to hurry and turn slowly due to instability
What is apraxia
Inability to carry out complex tasks e.g walking
Causes of apraxia?
cortical disease, diffuse vascular disease, normal pressure hydrocephalus
Describe anterior spinal artery thrombosis
Acute onset flaccid paralysis
Reduced reflexes
Normal DCML sensation (vibration, fine touch, proprioception)
Respiratory differentials of breathlessness
(CC-AAA-PPP)
COPD, CA,
Asthma, ARDS, Anaphylaxis
Pulmonary Fibrosis, Pneumonia / RTIs, Pneumothorax,
Cardiovascular differentials of breathlessness
Heart Failure,
Cardiac Tamponade
PE
What is an air bronchogram
Air filled bronchi (dark) seen on CXR caused by opacity of surrounding alveoli. This is pathognomic of consolidation - an infective process
CXR interpretation. What should you look out for in the apex of the lung?
Tuberculosis
Lung CA
CXR interpretation. COPD patients show signs of hyperinflation, What are the features of hyperinflation?
Flattened diaphragm
Seeing increased posterior ribs from spinal cord (8-9 normal, >/=10 abnormal)
What are the signs of HF on CXR?
ABCDE Alveolar oedema Kerley B lines Cardiomegaly Dilated upper lobe vessels Pulmonary effusion
CXR interpretation. What is a normal cardio-thoracic ratio
Heart <50%
CXR interpretation. What are kerley B lines and when might you see them?
Fluid in lymphatics, short horizontal lines at lower outer lung fields
ABG interpretation. Low pH, low Co2. Diagnosis? Potential cause?
Metabolic acidosis.
DKA, severe diarrhoea / dehydration, prolonged lack of O2 from shock / HF
ABG interpretation. Low pH. High Co2. Diagnosis? Potential cause?
Respiratory acidosis
COPD, sedative drugs, atelectasis
Patient is having an asthma attack and is hyperventilating, what is likely to be seen on ABG?
Respiratory alkalosis
Raised pH, Low Co2
Patient has severe vomiting, what is acid base balance diagnosis?
Metabolic alkalosis
ABG interpretation. High pH. High Co2. Diagnosis? Potential cause?
Metabolic alkalosis
Vomiting
ABG interpretation. High pH. Low Co2. Diagnosis? Potential cause?
Respiratory alkalosis
Hyperventilation e.g asthma / panic attack
Koilonychia is a sign of what biochemistry deficiency?
Fe2+
Clubbing nails is a sign of what GI condition?
Crohn’s
Hydrogen breath test is used as an investigation for what?
hypolactasia
small bowel bacterial over-growth
What are 2 common causes of raised Ca2+?
Primary hyperparathyroidism,
Disseminated malignancy
Patient has raised Ca2+, which investigation should you do as a follow-up assists in distinguishing the differential diagnoses?
PTH
Normal/raised PTH- primary hyperparathyroidism
Low PTH- disseminated malignancy
Virchow’s node is found where and is a sign of what?
supraclavicular lymph node
intra-abdominal malignancy
Differential diagnoses for constipation: Common Metabolic Drugs Neoplasia
Common: functional (e.g IBS), depression, idiopathic, inadequate dietary fibre
Metabolic: hypothyroidism, hypercalcaemia
Drugs: opiates, antidepressants, CCBs
Neoplasia: colon/rectal CA
What is the management of giardia?
Tinidazole 2g
What is calcium resonium used in the management of?
High K+
What is a foecal occult blood test?
screening test for colorectal cancer
checks for non-visible blood in stools
Patient has multiple myeloma, what do you see on urine sample?
Bence-Jones protein
What is hypochlorhydia and what might be a consequence?
low production of stomach acid
may lead to malabsorption
What is chymotrypsin?
pancreatic enzyme, converted to trypsin which breaks down protein
Give some differential diagnoses of malabsorption
Common: coeliac, crohn’s, chronic pancreatitis
Uncommon: hypolactasia, small bowel bacterial overgrowth, giardiasis, HIV
How can you investigate and manage a small bowel bacterial overgrowth
Ix: lactulose test
Mx: Abx (metronidazole and tertracycline)
Loss of lactase from small intestinal brush border is called…
hypolactasia
Symptoms, investigations and management of hypolactasia?
S&S: bloating, nausea, wind, dirarhoea
Ix: Lactose breath test
Mx: Low lactose diet
Symptoms of Vit C deficiency
Bleeding gums
Tooth loosening
Corckscrew hair,
Perifollicular haemorrhages,
Symptoms of Vit D deficiency
Osteomalacia- proximal myopathy, bone pain, malaise
Symptoms of Vit K deficiency
Easy bruising
What is trulove and witt’s criteria for severe UC?
Bowel open >6 times /24hrs + 1 or more of:
HR> 90
Temp >37.5
ESR ? 30mm/hour
Hb<10.5
Pale stools are a hallmark of which overall GI pathology?
Malabsorption
Give 3 routine investigations for syncope?
ECG, Blood Glucose, Lying and Standing BP
What is syncope?
Sudden LOC
What is the pathophysiology of vasovagal syncope?
excessive activation of PNS in response to a specific stimuli e.g fear, stress, heat
causes vasodilation and bradycardia –> hypotension and cerebral hypoperfusion –> syncope
What are the ECG changes seen in wolf-parkinson-white syndrome?
Shortened PR, wide QRS, slurred upstroke of R (delta) wave
What is the definitive treatment of wolf-parkinson-white syndrome?
radio-ablation of accessory pathway
Which condition is characterised by an abnormal accessory conduction pathway between atria and ventricles?
Wolf-parkinson-white syndrome
First-dose hypotension is most commonly associated with which anti-hypertensive?
ACE
Give 2 ways in which we can minimise the risk of first-dose hypotension?
Low starting dose e.g 1.25 ramipril
Take first few doses at night time whilst in bed
What are some potential symptoms of a silent MI
epigastric pain, SOB, acute pulmonary oedema, collapse, death
What are the different types of bronchial cancers?
Squamous cell CA (35%)
Adenocarcinoma (30%)
Small cell (20%)
Large cell (15%)
What are the investigations for bronchial tumours?
Bronchoscopy, washing, biopsy, CT/CXR for spread
Mx: small cell lung CA?
Mx: non-small cell lung CA?
Small cell mx= chemo
Non-small cell mx= radio
What is mesothelioma?
Malignant tumour of pleura
Patient has chest pain, signs of pleural effusion and has blood-stained effusion, likely diagnosis?
Mesothelioma
CXR shows honeycombing and calcified pleural plaques ‘holly leaves’, diagnosis?
Asbestosis
Which type of asbestos commonly causes mesothelioma?
Blue
Which condition are ACEi CI for?
As a result you should regularly monitor ptx ______?
Bilateral renal stenosis
Regularly monitor ptx renal function
Give an example of a loop diuretic
Furosemide / Bumetanide
Mechanism of action of loop diuretic
Inhibits sodium / chloride channels in the ascending limb of the loop of henle
3 SEs of loop diuretics
Hyponatraemia, hypokalaemia, hypotension
Mechanism of action of spironalactone?
Aldosterone antagonist,
Increased excretion sodium, reduced excretion potassium
3 SEs of spironolactone?
Hyperkalaemia, hyponatraemia, hypotension gynaecomastia, menstrual disturbance
Patient is on spironolactone, what should we monitor regularly?
Potassium levels
How is mesothelioma diagnosed / managed?
Pleural biopsy
No cure, radio slows growth
Name and mechanism of action of thiazide diuretic
Bendroflumethiazide
Inhibit sodium/chloride reabsorption at DCT
SEs of Thiazide diurteics
Hypokalaemia, hyponatraemia, hypotension
Hyperuricaemia (can precipitate gout)
Which endocrine problem may cause a hoarse voice?
Thyroid CA
laryngeal nerve palsy
Which is the commonest type of thyroid CA?
Papillary (80%)
Others: follicular and anaplastic
Name a medication that can be iaetrogenic cause of hypothyroidism
Amiodarone
Phaeochromocytoma is a tumour of what?
Chromaffin cells of adrenal medulla
Phaeochromocytoma causes secretion of what?
Catecholamines (adrenaline and noradrenaline)
Eye signs of graves disease
Proptosis (exophthalmous), lid lag, dipolopia
What is carbimazole and what is its major SE we should monitor for?
Hyperthyroidism treatment
Agranulocytosis - monitor WBCs
S&S of thyroid storm
Substantial weight loss, AF, profuse sweating, previous thyroid surgery, enlarged heart, pleural effusion
Mx of thyroid storm
Fluids and electrolytes
Anti thyroid drugs and glucocorticoids
B Blockers
US thyroid reveals single hot nodule, differentials?
Thyroid adenoma /CA
US thyroid reveals multiple ‘patchy hot’ nodules, likely diagnosis?
Hashimoto’s thyroiditis
US thyroid reveals diffuse hot gland, likely diagnosis and explanation?
Graves disease, diffuse stimulation of whole gland by thyroid antibodies
Give an non-infective cause of a febrile patient
Multiple pulmonary emboli
Remember that not all febrile patients have infections!
What is ‘double pnemonia’?
Severe infections predispose patients to further infections e.,g px with flu more likely to get pneumonia
What defines an ‘atypical’ pneumonia
Prominent extra-pulmonary manifestations (in addition to main lung infection)
What does convalescent mean?
A person recovering from an illness
Give an example of a macrolide antibotic?
Erythromycin
Azithromycin
Clarithromycin
What is Sydenham’s chorea and in which condition would you see it?
Rapid purposeless movements of face / arm jerky movements
Rheumatic Fever
Describe erythema marginatum, what condition is this pathognomic?
rash starts on trunks / arms as maccules
spreads to form snake like ring with clear middle
worse with heat
rheumatic fever
Patient presents with suspected DVT, they have a family history of PE, give 2 tests that may be carried out as part of a thrombophilia screen
Genetic causes: factor V leiden, antibody protein C resistance
Acquired: anti-phospholipid syndrome, antibody protein C resistance
Give an investigation that may be carried out in a patient with suspected glomerulonephritis?
antistreptolysin O
detects antibodies against group A strep
Patient has a positive direct coombs test, diagnosis?
AI haemolytic anaemia
What is the mechanism / indication of an indirect coombs test?
measures antibodies against foreign RBCs in serum
prenatal testing / prior to blood transfusion
What is the causative organism of scarlet fever?
Strep pyogenes
Give a cause of haemolytic anaemia?
mycoplasma pneumoiae
Treatment of mycoplasma pneumoniae?
macrolides e.g erythromycin / clarithromycin
doxycycline
Give an example of a cardiac, neuro and haem extra-pulmonary manifestation of mycoplasma pneumoniae
Cardiac= myocard/pericarditis, conduction abnormality Neuro= GBS, peripheral neuropathy, encephalitis Haem= haemolyitic anaemia
What is the pathophysiology of rheumatic fever
hypersentivity reaction to group A strep
What are the major criteria for Rheumatic Fever?
Migrating polyarthritis, carditits, syndeham’s chorea, erythema marginatum, subcutaneous nodules
How is rheumatic fever diagnosed?
2 major / 1 maj + 2 minor criteria
Antistreptolysin O titre +
Echocardiogram
What is the difference between Staph Aureus bacteraemia / septicaemia
Staph aureus bacteraemia= positive blood cultures, no systemic features of sepsis
Staph aureus septicaemia= positive blood cultures with systemic features of sepsis
Name a group A strep
Strep pyogenes
Raised ALP is a reliable indicator of…
post-hepatic bile duct obstruction
What does indurated mean?
Increased fibrous element of tissue commonly associated with inflammation
What are red cell fragments on a blood film an indicator of?
haemolytic anaemia
Does an increase or a decrease of antithromin make you more likely to develop DVT?
Decreaseased antithrombin = more likely to develop DVT
Antithrombin is a mild blood-thinner
What is protein S?
a mild-blood thinner
deficiency of protein S increases the likelihood of blood clots
What is the relationship between HRT and DVT?
HRT increases your risk of developing DVT 2-fold
What is fluconazole?
Anti-fungal medication
Give 3 classes and examples of drugs that warfarin typical interacts with
antibiotics - macrolides e.g erythromycin
antifungals- e.g fluconazole
anticonvulsants e.g valproate
Describe warfarin’s therapeutic index
Low / narrow therapeutic index (small changes in metabolism of warfarin can cause bleeding / clotting)
Give a cause of flow murmur due to hyperdynamic circulation
severe anaemia
Bone marrow failure resulting in a low production of RBCs is known as…
anaplastic anaemia
Give a sign in the eyes which would indicate anaemia
pale conjunvtiva
What is fresh frozen plasma? Indications?
liquid portion of whole blood
treat conditions with low blood clotting factors (INR >1.5)
replace plasma in fluid exhange
replace low blood proteins
normal range for INR?
0.9-1.2
therapeutic range for INR?
2-3
high INR score indicates increased risk of…
haemorrhage
High=Haemorrhage
low INR score indicates an increased risk of …
clotting
LOw=cLOt
What constitutes prothrombin complex concentrate, when might you give it?
Clotting factors 2, 9 and 10
Given to prevent bleeding
Specifically in haemophilia B if pure clotting factor 9 not available
Note it does NOT contain clotting factors:
7- haemophilia A
8- the other vit k clotting factor
Which haemophilia type can be treated with prothrombin complex concentrate?
Haemophilia B because prothrombin complex concentrate contains clotting factor 9
Patient has DIC, what does this stand for?
PPh?
Disseminated Intravascular Coagulation
blood clots develop in small vessels around the body, this uses up platelets and clotting factors increasing the risk of excessive bleeding
Patient has DIC:
Describe their prothrombin time, activated partial thrombin time, fibrinogen levels and d-dimer levels
Prothrombin time = prolonged
Activated partial thrombin time= prolonged
Fibrinogen levels= low
D-dimer= raised
What is meant by polychromasia? Give an example of when this may be seen?
High levels of immature RBCs (reticulocytes)
Bone marrow stress e.g haemolytic anaemia
Haemophilia A is a genetic mutation resulting in deficiency of which clotting factor?
Haemophilia A= factor VIII
Haemophilia B is a genetic mutation resulting in deficiency of which clotting factor?
Haemophilia B= factor IX
What is the mechanism of action of aspirin?
Anti-platelet
Irreversibly inhibits COX enzyme reducing the production of thromboxane and arachiodonic acid therefore reducing platelet aggregation
Give an indication for aspirin
ACS, acute ischaemic stroke
2nd prevention of cardiac, cerebrovascular or peripheral artery disease
What are the vitamin K dependent clotting factors?
2,7,9,10
What is the relationship between COCP and DVT/PE?
COCP increases risk of developing DVT/PE
Give 2 causes of microcytic anaemia
iron deficiency
thalassaemia
Give 3 causes of normocytic anaemia
acute bleeding
mixed Fe2+ + Vit B12 / folate deficiency
aplastic
chronic disease
Give 3 causes of macrocytic anaemia
vit b12 / folate deficiency
haemolytic anaemia
low T4
Patient has an uncomplicated DVT and is treated with LMWH. They should be discharged on what medication and for what duration?
Warfarin
3-6months
Biochemistry reveals raised urea, indications?
urinary tract obstruction, congestive heart failure, dehydration, severe burns, shock, upper GI bleed
What is a seminoma
Germ cell tumour of testicles
What type of medication is demeclocycline?
Tetracycline abx, used in tx of acne
i
I
Where would you expect to find metastases in oestrogen receptor negative breast CA?
Negative= visceral mets (liver, lung, brain)
What is the commonest site for a malignancy causing hypercalcaemia?
Lung CA
In addition to an elevated PSA which feature seen on XR would be pathognmonic of prostate CA?
Elevated PSA and sclerotic bone mets
High levels of Ca2+ detected in blood.
Which hormone is released to reduce Ca2+ levels and from where?
Calcitonin released from parafollicular cells in thyroid gland
(when high Ca2+ detected)
What is the action of calcitonin?
Reduced Ca2+ levels
Inhibits gut absorption
Inhibits reabsorption in kidneys
Stimulates bone deposition (++osteoblasts, – osteoclasts)
Low levels of Ca2+ detected in blood. Which hormone is released to raise Ca2+ levels and from where?
PTH released from Paraythyroid gland
What is the action of parathyroid hormone?
Raises Ca2+ levels
Stimulates reabsorption at kidneys
Stimualtes conversion of Vit D to Calcitriol which increases absorption in gut
Stimulates bone resorption (–osteoblasts, ++osteoclasts)
Symptoms of hypercalcaemia
Bones= pain
Stones= urinary
Abdo Groans= N+V, constipation, indigestion
Psychic Moans= depression, psychosis, fatigue, memory loss
What is the purpose of doing a mediastinoscopy?
Assess the operability of a potentially curable lung CA
Male patient has high levels of B-hCG, what do you suspect?
Testicular CA (tumour marker)
Patient has high levels of lactate dehydrogenase, what might this indicate?
Tissue turnover, may indicate tumour burden
What is meant by flaccid paraplegia?
Weakness or paralysis due to decreased muscle tone
What is mean by spastic paraplegia?
Stiffness and increased tone
Give a cause of marked ptsosis?
CN3 palsy
Give a cause of partial ptosis
myaesthenia gravis
partial ptosis
a young patient presents with bilateral facial pain similar to trigeminal neuralgia. what must you work to exclude as a cause?
MS
Give a neurological presentation of vitamin B12 deficiency?
Positive Babinski sign
extensor platar reflexes
Balance requires 3 sensory inputs.. these are from…
vision
vestibular (head position)
proprioception (dorsal column)
Patient has a positive romberg’s test, what happens on examination, what is the cause?
Lose balance when closing eyes
Problem is in spinal cord (dorsal columns)- they cannot detect proprioception
Patient is ataxic but has a negative romberg’s test, what is seen on examination and what is that cause?
Maintain balance when closing eyes
Problem is in cerebellum
A lesion in the internal capsule would cause what symptoms?
Mid-moderate hemiplegia with predominant spasticity
What are the symptoms of CN3 palsy?
Muscles- down and out
Pupil- dilation
Lid- marked ptsosis
(CN3 does 3)
Why does a CN3 palsy present with down and out pupil?
Superior oblique- CN4 and lateral rectus- CN6 action are unopposed
Give 3 causes of anterior spinal artery thrombosis
Emboli
In-situ thrombosis
Decompression sickness
What sensations are spared in anterior spinal artery thrombosis?
fine touch, vibration, proprioception (dorsal column)
S&S of anterior spinal artery thrombosis?
Rapid evolution, Back pain, Dorsal column sensation sparing Flaccid paralysis Reduced reflexes
Pregnant mother 38wks goes into cardiac arrest, what changes to CPR would you suggest and why to maximise possibility of spontaneous circulation returning?
Position mother in left lateral position
This ensures the foetus is not compressing the IVC
Normal circulation doesn’t return for 5 mins consider emergency C section
In pregnancy what normal changes might be detected in:
ECG
Murmurs
Resp/Blood gases
ECG- left axis deviation
Murmur- innocent flow murmur
Resp= higher RR–> increased minute volume ventilation–> lower PaCO2
Give 4 complications of MI
Valve disease- acute mitral valve regurg due to papillary muscle rupture Arrythmias- ventricular arr / AF Pulomary oedema Pericarditis (2-10 wks post) vsd
What is the commonest cause of pre-hospital death as a result of MI?
Ventricular arrhythmia
What is orthostatic oedema
Leg swelling following a prolonged time sitting / standing that goes away when recumbent
What is thrombophlebitis
inflammatory process causing the formation of blood clots that block 1 or more vessels
superficial clots= superficial thrombophlebitis
deep clots= DVT
What is an IVC filter and what are the indications for one?
a mechanical filter surgically inserted into IVC to catch blood clots and prevent PEs
Indicated if anticoagulation is CI or if recurrent PEs despite anticoagulation
What is the most likely causative organism for IE in IVDU patients?
Staph aureus
Third heart sound (S3) What is it? When does it occur? Where is it heard best? How to hear it? Who has ut?
What- additional heart sound forming a gallop rhythm, lower pitched and fainter than normal sounds, cadence follows work KentuckY
When- mid-diastole after S2
Where- apex
How- bell of stethoscope, ptx. lateral left debicutus position
Who- heart failure
What are the indicators on pleural effusion biochemistry of malignancy?
Low pH <7.3
Blood
Exudate
Glucose <3.3mmol/L
Patient has blood in their pleural effusion, what might this indicate?
Malignancy, PE with infarction, trauma
What does a MET team stand for?
Medical Emergency Team
What is the commonest abnormal vital sign seen in critically ill patients?
Resp rate
What is flumezanil
Benzodiazepam antagonist, given IV
In what circumstances would you prescribe naloxone?
Opiate overdose
What type of poisoning is forced alkaline diuresis a treatment?
Salicylate poisoning
Give 4 examples of opiates
Heroin, morphine, plethadine, coedine (metabolised to morphone)
What are the scores for GCS (eyes)
Eyes / 4 Spontaneous (4) To speech (3) To pain (2) None (1)
What are the scores for GCS (best verbal response)
Best verbal response / 5 Orientated (5) Confused (4) Inappropriate words (3) Incomprehensible sounds (2) None (1)
What are the scores for GCS (best motor response)
Best motor response / 6 Obey commands (6) localises pain (5) withdraws to pain (4) Flexion to pain (3) Extension to pain (2) None (1)
What are the differentials for dullness on respiratory percussion?
Tumour
Collapse
Fluid, consolidation, pleural effusion
What is the cause of hyper-resonance on respiratory percussion?
Pneumothorax
What is pleurodiesis
Medical procedure that adheres 2 surfaces of pleura together
What may cause air under diaphragm on CXR
intestinal perforation
Which medication overdose causes
a) pupil consitriction
b) pupil dilation
constriction= opiate overdose dilation= tricyclic overdose
What is section 2 of MHA
28 day assessment
What drug should be given alongside activated charcoal and why?
laxative, activated charcoal (used for detoxification) causes constipation
What is the timeframe for when activated charcoal is an effective detoxification method?
If given within 2 hours of ingestion of toxin
What are the symptoms of a patient who has just been given IV naloxone?
sweaty, agitated, hyperventilating, pupil dilation
In what patients would non-invasive ventilation be indicated?
Type II respiratory failure
Bilateral hilar lympahdenopathy is usally a sign of…
sarcoidosis
Give 3 iatrogenic causes of lung collapse?
overrigorous bagging
high inspiratory pressures
inserting ET tube too far
What are the components of CURB 65
Confusion
Urea >7mmol/L
Resp Rate >30
BP < 90/60
Age >65
Pre-tibial myxoedema is a sign seen in what condition?
Graves’ disease
What is empyema?
When does it occur?
Pus in the pleural cavity
Complication of pneumonia or thoracic trauma
Are ptx with nephrotic syndrome hyper or hypocoagulable? What is the implication of this?
Hypercoagulable
Increased risk of DVT/PE
What are the risk factors and suspected trigger for SLE?
Female, child-bearing age
Afro-caribbean / asian
Trigger= EBV
Signs and symptoms of SLE
DUAL RASH FACE
Discoid rash, Ulcers (oral), ANA+, Light sensitive
Renal disorder, Anti-dsDNA, Serositis, Haem disorder
Flushed (malar rash), Arthritis, CNS disorder, ESR raised (crp normal!)
Which autoantibodies are abnormal in SLE?
ANA (antinuclear antibody)
anti-dsDNA
anti-smooth muscle
antiphospholipid
Give 3 investigations for SLE
ANA, anti-dsDNA
ESR= raised, CRP=normal
Complement C3/C4 depleted
Ptx is having a severe flare up of their SLE?
IV cyclophosphamide
High-dose prednisolone
What are the 2 rashes typically seen in SLE ptx?
Malar rash (butterfly) Discoid rash
What is cystinuria
Autosomal recessive condition
Proximal tubule does not reabsorb positively charged AAs (especially cysteine). These then pass into urine.
Acidic/neural pH urine causes crystallising of AA forming stones.
What is the treatment of cystinuria?
penicillamine
Give the treatment of each of these 3 causes of renal/bladder stones:
hypercalcuria
urate calculi
cystinuria
hypercalcuria- tx thiazide diuretics
urate calculi- tx allopurinol
cystinuria- tx penicillamine
What is the commonest composition of a kidney stone
calcium oxalate
Give 3 dietary components which increase your risk of kidney stones?
sodium, protein, oxalate
What simple measure can patients do to reduce their risk of getting kidney stones?
increase hydration to >3L/day
You suspect the patient has Wilson’s disease
You order a 24hr urine sample
What are the results?
Raised copper in urine
What acid-base balance complication can GBS cause?
Respiratory acidosis
Decreased ventilation causes TII respiratory failure
How is serum osmolality calculated?
(2 x Na) + (2 x K) + glucose + urea
What is a U wave (ECG)?
small deflection up after T wave
sign of hypokalaemia
What is a J wave / Osborne wave (ECG)?
immediate deflection up after QRS complex
sign of hypercalcaemia
Describe the QRS complex in ventricular tachycardia?
Wide QRS complex
Describe the ECG features of wolf-parkinson-white syndrome?
Short PR
Slurred upstroke of r wave (delta wave)
Wolf= short and slurred
What should be involved in a annual DM check
Retinopathy, foot check, ACR, U+E Cholesterol, weight, HbA1c, glucose Smoking status
Postural hypotension defined as…
Drop in BP >20mmHg from sitting to standing
Sx of hypoglycaemia
sweating, tachycardia, palpitations, tremor
Tinel’s sign and Phalen’s sign are present in carpal tunnel syndrome. What are they?
Tinel's= tapping causes paraesthesia Phalen'= flexion causes wrist symptoms
Give 4 indications for tetracyclines?
Acne vulgaris
Lyme disease
Chlamydia
Mycoplasma pneumoniae
Which class of antibiotics is associated with photosensitivity?
Tetracyclines
Patient has open-angle glaucoma. Prescribed beta blocker, how does this help?
Reduces aqueous secretion by ciliary body
Gliclazides are an example of which drug class?
Sulfonylurea
What is meant by moribound?
At the point of death (look like about to die)
What is the common cause of anterior shoulder dislocation?
Fall on outstretched hand (FOOSH)
What type of shoulder dislocation is associated with seizures/electric shock? What does it look like?
Posterior shoulder dislocation
Shoulder locked in internally rotated position
What is the karyotype of kleinfelter’s syndrome?
47XXY
A partial/missing X chromosome in females causes what syndrome? How do they present?
Turners syndrome
Short stature, webbed necked, AI hypothyroid,
Primary hypogonadism, primary amenorrhoea
Thyrotoxicosis.. AKA…
Hyperthyroidism
What are the TSH and T4 levels in sick euthyroid?
TSH low, T4 low (e.g in chronic illness)
Give causes of secondary hypertension
Renal artery stenosis, PKD
Conn’s, cushing’s
Phaeochromocytoma, Acromegaly
Aortic coarctation
What is the pharmacological mx of HTN caused by phaeochromocytoma?
Alpha blockers followed by beta blockers
Give the 3 things to do in mx of hypercalcaemia 2nd to CA?
IV fluids
Oral/ IV bisphosphonates
Referal to oncology
Testosterone is given by what route? what frequency? what should you monitor for?
IM , every 4 weeks
Monitor for BPH, prostate CA (PSA/DRE)
What cancers metastasise to bone?
BLT with kosher pickle
Breast, Lung, Thyroid, Kidney, Prostate
How can cancer effect levels of calcium?
bone mets cause ca2+ leakage paraneoplastic syndrome (produces protein similar to PTH)
Patients with T2DM are more likely to develop hyperosmolar hyperglycaemia state or DKA?
Hyperosmolar hyperglycaemic state
You are managing a patient with suspected DKA. Blood gas reveals metabolic acidosis. What pH level concerns you enough to call ICU?
pH<6.99 call ICU
What is the difference in onset between DKA and hyperosmolar hyperglycaemic state?
DKA= acute history. HHS= insidious history
Describe “sick day rules” and an example of a condition in which this applies?
If patient gets sick the patient is under increased stress so need to double their dose of steroids
E.g if low corticosteroid levels in body e.g adrenal insufficiency
Give 4 causes of hypocalcaemia
AI hypoparathyroidism
Pseudohypoparathyroidism
DiGeorge syndrome
Dexamethasone suppression test is used for diagnosing which condition?
Cushing’s
ACTH synacthen test is used for diagnosing which condition?
Adrenal insufficiency
“Adrenal I, ACTH”
What at the rotterdam criteria?
For diagnosing PCOS, 2/3 of….
Annovulation / oligomenorrhoea / amenorrhoea
Polycystic ovaries on TVUSS - 1 ovary >12 small follicles volume >10
Raised androgens
What is the managemnet of PCOS?
Weight loss, COCP, Metformin
Anti-androgens= cyproterone acetate
Ovulation induction= anti-oestrogen (clomifene citrate)
Gonadatrohpine (FSH, LH, GnRH analogues)
IVF
What is meant by virilization ?
Development of male physical characteristics (hair, deep voice, muscle bulk) due to excess androgen production
A female patient is diagnosed with an androgen-secreting tumour. How might a excess androgens effect them/
Virilisation- develop male physical characteristics e.g hair growth, deep voice, muscle bulk
A patient has dry mucous membranes, poor urine output, is thirsty. You suspect they are dehydrated. How do you calculate serum osmolality and do you expect it to be high or low in a dehydrated patient?
Serum osmolality= 2 (Na + K) + urea + glucose
Dehydration = high serum osmolality
What is the colour change of patients with raynauds?
White, Blue, Red
What is meant by obstructive sleep apnoea?
loss of airway patency despite constant breathing effort
Linked to obesity, hypothyroid, asthma
What is balantitis?
Inflammation of glans of penis due to infection
What bone condition can result in hearing loss?
Paget’s disease
Kleinfelter’s syndrome is associated with hypogonadism, what is the karyotype for this syndrome?
47XXY
Kleinfelter’s syndrome is a condition which only effects men, true or false?
True,
Men with an extra X chromosome (47 XXY)
Female patient presents with primary amenorrhoea, you notice they have a webbed neck, which syndrome could cause this?
Turners syndrome
missing / partially missing X chromosome
What are the non-operative tx options for renal stones in the following locations: Bladder Lower 1/3 ureter Middle 1/3 ureter Upper 1/3 ureter
Bladder= endoscopic retrieval
Lower 1/3= uretero rhinoscopy
Middle 1/3= shock wave lithotripsy
Upper 1/3= percutaneous nephrostomy
A patient presents with haematuria, give differentials which relate to the following structures: Renal Ureteral Bladder Urethral
Renal- glomerulonephritis, pyelonephritis, renal cell carcionma, trauma, renal cyst
Ureteral- transitional cell carcinoma, stone, trauma
Bladder- bladder CA, trauma
Urethral- prostate CA, stone, trauma
Patient presents to GP embarassed. He says he’s got what feels like a “bag of worms” in his scrotum. What is the diagnosis? What cause should you rule out?
Varicocele- dilated veins in scrotum, next to/above 1 or both testes
Rule out renal vein obstruction due to renal tumour
You’ve been asked to examine the next gentleman’s hydrocele, what is a hydrocele? how can you examine this?
fluid collection in front of testes, usually benign
A male patient comes in telling you they have a scrotal swelling, what are the differentials?
Testicular cancer
Hydrocele
Varicocele
Epididymal cyst
Sebaceous cyst on scrotum
Inguinal hernia
Which bedside test/examination would differentiate between a hydrocele and varicocele?
Transillumination
A distressed young woman comes to see you saying that she has gotten pregnant unintentionally and wants you to sign off for a termination of pregnancy. What is the criteria for ToP?
<24wks pregnant
ToP reduces risk to mothers life
Top reduces risk to mother mental / physical health
Top reduces risk to mental / physical health of existing children
Substantial risk of baby being born with severe mental/physical handicap
Give 3 symptoms of an ectopic pregnancy?
Abdo pain, amenorrhoea, vaginal bleeding
Give 3 differentials of antepartum haemorrhage?
Placental abruption, placenta praevia, vasa praevia
Patient has painless PV bleeding whilst pregnant, what is likely diagnosis?
Placenta praevia
What do acromegaly, conn’s syndrome, cushing’s syndrome and phaeochromocytoma all have in common?
All causes of secondary hypertension
What are the 5 geriatric giants?
falls, incontinence, confusion, impaired homeostasis, iatrogenic disorders
How is postural blood pressure measured?
Measure BP when lying down, immediately on standing, after 1 minute standing, after 3 minutes standing
What s the definition of postural hypotension?
sustained reduction of systolic BP at least 20, diastolic of at least 10 within 3 minutes of standing
Give 2 examples of pharmacological tx of postural hypotension?
midodrine
fludrocortisone
What is a fragility fracture?
fractures resulting from mechanical forces that would not ordinarily result in fracture equivalent to fall from standing height or less
(i.e. mechanical fracture from fall from standing height/less)
Primary prevention of osteoporosis?
Secondary prevention of osteoporosis?
Primary= FRAX score / DEXA scan Secondary= alendronate
What % on FRAX score warrants further assessment on DEXA scan?
> 10%
What is the management of osteoporosis?
Lifestyle- smoking, alcohol, exercise
Vit D
Bisphosphonates
Others:
Denosumab (inhibits receptors which when activated cause osteoclast maturation)
Strontium ranelate (reduce bone turnover, stimulate bone growth)
Raloxifene (binds to oestrogen receptors, same effect
HRT
Elderly patient falls on their face, what is the more likely cause of fall?
Cardiac
Patient falls, are you looking for on urine dipstick? what do you suspect as cause?
Protein, blood, nitrites, leukocytes (UTI)
Patient falls, why do bladder scan?
Urinary retention
Which painkiller lowers the seizure threshold and therefore should be avoided in patients with a history of epilepsy?
Tramadol
Patient is an ex-boxer with parkinsons’ and eplilepsy who has started fighting the staff. The nurses asks you to prescribe haloperiodol to calm him down, what do you do?
Don’t prescribe it.
Antipsychotics lower seizure threshold
Instead try a benzodiazepine
What is charles bonnet syndrome?
Visual hallucinations due to visual loss e.g cataracts / age-related macular degeneration. Patients are generally aware that hallucinations are not real
What is the route of administration for gentamycin?
IV only!
if question is GP scenario the answer is not going to be gentamicin
What is another name of augmentin?
Co-amoxiclav
Female patient presents with unilateral throbbing headaches, with flashing lights in vision beforehand.
Likeky diagnosis? Which medication might they be taking which is an absolute contraindication?
Diagnosis= migraine with aura
COCP CI with migraine with aura
CT head shows midline shift, this might indicate…
severe swelling, haemorrhage, space occupying lesion
CT head shows oedema / swelling, this might indicate…?
raised ICP
CT head shows crescent shaped dark shadow, what is this likely to be? Pathophysiology?
Sub-dural haemorrhage
Strethcing and breaking of bridging cortical veins
What colour are dense structures on CT scans?
Whiter
How can you tell the difference between acute and chronic brain haemorrhage?
Acute is brighter
Chronic is darker
What might indicate raised ICP on CT head?
If you see what should you do/not do?
Ventricles thin/squashed/absent
Loss of differentiation between grey and white matter due to oedema
Don’t lumbar puncture!
Patient has a headache, visual disturbance, jaw pain, raised ESR but normal WCC. Which investigation would you follow up with?
Temporal artery biopsy- ?GCA
What is the consequence of doing a LP in patient with raised ICP
Brain herniation and death
You suspect SAH, do a LP after what time?
> 12hours,
Raised protein on LP, indications?
Bacterial meningitis, GBS, TB
What are the findings on temporal artery biopsy in patient with GCA?
Vasculitis
Lymphocyte infiltration
Granulomatous inflammation
Multinucleated giant cells
What does papilloedema look like? What does this indicate?
Blurring optic disc margins
Raised ICP
Patient presents with bilateral pressing headache, history of stressful job and poor sleep. How can you manage this patient?
Non-pharm- avoid stressors, exercise, sleep etc.
Ibruprofen 400mg / Paracetamol
Aspirin
Tricyclic antidepressants
Amitryiptyline SE
Drowsiness, Dry mouth, Constipation
What is the pharmacological prophylaxis and management of a patient with migraine?
Prophylaxis- propanolol / amitriptyline
Acute-
1) simple analgesia +/- anti-emetic. 2) sumatriptan
Patient has very severe headache around the eye which comes on suddenly. They have had several in the past week and had a similar series of headaches a year ago. What is the diagnosis? What is the acute and prophylactic management?
Cluster headache
Acute:
Sumatriptan 6mg SC
100% O2 for 15 mins (12-15L)
Prophylaxis- verapamil
Patient complains of an electric shooting pain across their face which lasts a couple of seconds, what is the likely diagnosis and management?
Trigeminal neuralgia
Carbamazepine / Gabapentin
Surgery to decompress trigeminal nerve
Which headache is treated acutely with paracetamol/sumatriptan 50mg and prophylactically with pronaolol/amitriptyline?
Migraine
Your patients medical records show they are prescribed verapamil for prophylactic treatment for headaches. What is the likely diagnosis? They are worried about having an acute attack, what will you prescribe them to take during a headache?
Cluster headache (prophylaxis verapamil)
Acute at tack:
Sumatriptan, 100% O2 for 15 mins
How can you assess a patient with NAFLD for fibrosis?
Fibroscan (US scan of liver)
NAFLD Fibrosis Score calculator e.g BMI, LFTs, DM
Child presents with lethargy, fever, headache assoc. w/slapped cheek rash spread to proximal arms and extensor surfaces. Likely diagnosis?
Erthema infectiosum
Parvovirus
CT shows petechial haemorrhages in tempral lobe
Patient has fever, headache, confusion, aphasia. Likely diagnosis?
Herpes Simplex Encephalitis
Mx- aciclovir
Why might a patient with GCA complain of generalised myalgia?
Polymyalgia Rheumatica associated with GCA
Young man presents with acute headache associated with unilateral periorbital oedema, on examination there is a lateral gaze palsy. Likely diagnosis?
Cavernous sinus thrombosis
Intense pain around one eye associated with watery eye, redness and constricted pupil. Likely diagnosis?
Management?
Cluster headache
Mx- verapamil (proph), sumatriptan 6mg SC / 100% O2 (acute)
Frontal headache developed following URTI, worse on leaning forwards, likely diagnosis? usual cause?
Sinusitis - usually viral
Elderly man presents with severe pain around right eye, assoc. nausea, redness, misty vision, semi-dilated pupil. Likely diagnosis?
Acute narrow-angle glaucoma
Patient has a headache and nausea which is worse at the weekends, not bad when they are at work or on holiday, what do you need to suspect?
Carbon monoxide poisoning
What is the definition of domestic abuse?
Incident / pattern of incidents of controlling, coercive, threatening behaviour, violence of abuse between those aged 16 or over who are or have been, intimate partners or family members regardless of gender or sexuality.
Includes: psychosocial, physical, sexual, financial. emotional
What is definition paraesthesia?
abnormal sensation caused chiefly by pressure / damage to peripheral nerves
e.g tingling, burning, numbness, warmth, chills
What is the pmneumonic VITAMINN CDEF
Vascular Infectious/inflammatory Trauma AI Metabolic Iatrogenic Neoplasm/ Neurological
Congenital
Degenerative
Endocrine
Functional
Vascular differential of parasthesia?
Raynaud’s
Stroke/TIA
What is the pattern of colour change in raynaud’s?
White–> Blue –> Red
Inflammatory/infectious cause of parasthesia?
GBS, leprosy
HIV
Lime disease
Sarcoidosis
What is saturday night palsy?
Prolonged pressure on medial side of upper arm (e.g arm hung over back of bench)
Trauma differentials parasthesia?
saturday night syndrome
fracture
carpal tunnel syndrome
Metabolic differentials of parasthesia?
Diabetes
Thyroid disease
Renal failure
Hypocalcaemia
Hyper/hypoglycaemia
Hyperkalamaemia
Hypermagnasaemia
Iatrogenic differentials of parasthesia?
Anticonvulvants e.g topiramate
Chemo e.g cisplatin
Neurological differentials of parasthesia?
Spinal cord compression
Cauda equina syndrome
Aura of parasthesia e.g migraine
Epilepsy
Congenital / inherited differentials of parasthesia?
Hereditary neuropathy with pressure palsies
Charcot-marie-tooth disease
Degenerative differentials of parasthesia?
MS
Environmental differentials of parasthesia?
Alcohol Lead posioning Arsenic posioning Mercury poisoning Deficiencies in B1, B6, B12, E, Folate
Functional differentials of parasthesia?
Carpal tunnel syndrome
Who is carpal tunnel syndrome more common in?
Women (smaller wrists)
2 common antibiotics that cause parasthesia?
nitrofurantoin
metronidazole
Blood tests for parasthesia?
Glucose, hba1c- ?DM U+E- ?CKD WCC- ?infection TFTs- ?hyper or hypothyroidism Vit D- too much causes Vit B1, B6, B12, E deficiency Folate ESR
Patient presents with tingling in fingers, you perform nerve conduction studies, which condition are you trying to rule out?
carpal tunnel syndrome
Non-pharmacological measures for pain management
Wt loss- OA TENS machines Distraction techniques Acupuncture Capsaicinn
Step 1 of pain ladder
Non-opioid analgesics
Paracetamol- avoid in chronic excess alcphol
NSAIDs
Step 2 of pain ladder
Mild opioids e.g Co-codamol Coedine Dihydrocodeine Tramadol
SEs of opioids?
Constipation
N+V
Addiction
Neuro/respiratory depression
Step 3 of pain ladder + examples
Strong opioids e.g: Morphine, diamorphine Oxycodone Fentanyl Alfentanil Buprenorphoine Methadone
Step 4 pain ladder
nerve blocks
Epidurals
Pumps e.g syringe driver
Adjuvant pain management
Antidepressants e.g amitryiptylline
Antiepileptics e.g gabapentin / pregabalin
Steroids
Child presents with pain, what diagnosis should we always suspect and attempt to rule out?
NAI
What might indicate a child in pain?
Say- they say so
Do- behaviour changes e.g holding arm
React- vital sign changes
Streptococcus pneumoniae is a common cause of community acquired pneumonia. Describe the microbiology of strep pneumonia?
Strep pneumonia: Gram + chains Coagulase negative Alpha haemolytic (green) Optichin sensitive
Staph aureus is a common cause of hospital acquired pneumoinia. Describe the microbiology of staph aureus?
Staph aureus:
Gram + clusters
Catalase + (vs strep negative)
Coagulase + (vs staph epidermidis negative)
staph are always positive
Give several side effects of opiate use?
Constipation N+V Droswiness Dry mouth Histamine release (itchy / bronchoconstriction) Toxicity
What is a standard start dose of morphine?
20-30mg daily
e.g 5mg 4hrly / 10mg 12hrly
Give several factors that increase a patients pain tolerance?
Relief of sx Sleep / Rest Physiotherapy Empathy Social/psychological support
Give several factors that decrease a patients pain tolerance =?
Discomfort Anxiety Fear Poor sleep Fatigue
How can we manage a palliative patient who is experiencing dysponoea?
Optimise asthma/COPD/HF/Infection tx
Opiates e.g morphine
Anxiolytics (mx associated anxiety)- diazepam/TCA/SSRIs
O2 therapy (only if hypoxic)
Palliative patient is experiencing restlessness, give 2 examples of medications which can be used for sedating?
Haloperidol (less sedating)
Midazolam (quite sedating)
Palliative patient is experiencing restlessness, give 2 examples of medications which can be used for sedating?
Haloperidol (less sedating)
Midazolam (quite sedating)
Anorexia associated with palliative care patient, what medication can be used?
15-30mg prednisolone
2-4mg dexamethasone daily
Hyoscine butylbromide used for…
Hyoscine hydrobromide used for…
Hyoscine butylbromide used for respiratory secretion
Hyoscine hydrobromide used for travel sickness
What is the theory behind why anorexia nervosa patients develop hirsutis?
develop languno hairs to insulate the body
