Core Conditions Flashcards
Contents of spermatic cord in males?
Vas deferens, obliterated processus vaginalis and lymphatics Arteries to vas, cremaster and testis Pampiniform plexus and venous equivalent of above Genital branch of genitofemoral nerve and sympathetic nerve (in females, round ligament)
Treatment for hyperT?
Drugs - B-blockers for rapid symptom control. Anti-thyroid medication = carbimazole. Giving thyroxine and carbimazole together reduces risk of iatrogenic hypoT
Radioiodine - most become hypoT after treatment. Contraindicated in prego and breastfeeding.
Thyroidectomy - risk of damage to recurrent laryngeal nerve and hypoparathyroidism.
Common causative organisms of septic arthritis?
Staph Aureus, streptococci, Neisseria gonococcus and gram -ve bacilli
Where do pancreatic cancers arise?
60% pancreas head, 25% body, 15% tail
Risk factors for malnutrition in children?
Young age, co-existing chronic illness or developmental delay, neglect by care givers, poverty.
Mnemonic for worrying peptic ulcer symptoms?
ALARM Symptoms Anaemia (iron deficiency) Loss of weight Anorexia Recent onset/progressive symptoms Melena/haematemesis Swallowing difficulty
Causes of SAH?
Rupture of saccular aneurysm
Ateriovenous malformation
No cause (
Signs of motor neuropathy?
Often progressive (may be rapid); weak or clumsy hands; difficulty in walking (falls); difficulty in breathing.
Signs of LMN lesion: wasting and weakness most marked in distal muscles of hands and feet (foot/wrist drop). Reflexes reduced or absent.
Treatment of pulmonary fibrosis?
Immunosuppressive therapy, lung transplantation, oxygen therapy, smoking cessation, pulmonary rehabilitation
Enzymes for MI?
Troponins T and I, Creatine kinase
Biggest risk factor for lung cancer?
Cigarette smoking
Complications of gallstones in bile ducts?
Obstructive jaundice, cholangitis, pancreatitis
What is a direct inguinal hernia?
Push their way directly through the posterior wall of the inguinal canal, into a defect in the abdominal wall (meadial to inferior eigastric vessels and lateral to rectus abdominus)
What is a primay generalised seizure?
Simultaneous onset of electrical discharge throughout cortex, with no localising features referable to only one hemisphere.
Signs of varicose veins?
Oedema; eczema; ulcers; haemosiderin; haemorrhage; phelbitis; atrophie blanche (white scarring at site of previous healed ulcer); lipodermatosclerosis (skin hardness from subcutaneous fibrosis caused by chronic inflammation and fat necrosis)
Treatment of acute asthma?
Salbuatamol 5mg nebulised with O2 Hydrocortisone 100mg IV or prednisolone 40-50mg PO or both if very ill O2 if sats
Risk factors for depression?
Female sex - pregnancy and postnatal period
Significant physical illness
Other mental health problems - i.e. dementia
African-caribbean, aisan, refugee and asylum seeker communities
Family history of mental illness
Risk factors for dementia?
Age, FH, genetics
Specific causes of AAA?
Trauma, infection, inflammatory diseases, connective tissue disorders
Presentation of parathyroid adenoma?
First signs = bone fractures and urinary calculi.
Can experience common symptoms that can range from joint, muscle and abdominal pain to slight discomfort. Constipation and exhaustion can also be experienced as a result of irregularity in the bloodstream. Kidney damage could also occur.
What are blue bloaters?
Reduced alveolar ventilation, with low PaO2 and high PaCO2. Cyanosed but not breathless and may go on to develop cor pulmonale. Respiratory centres are relatively insensitive to CO2 and they rely on hypoxic drive to maintain respiratory effort. EMPHYSEMA
Causes of GORD?
Lower oesophageal sphincter hypotension Hiatus hernia Loss of oesophageal peristaltic function Abdominal obesity Gastric acid hypersecretion Slow gastric emptying Overeating Smoking Alcohol Pregnancy Drugs Systemic sclerosis H.pylori
Sinister complication of GORD?
Barrett’s oesophagus - distal oesophafeal epithelium metaplasia (sqaumous to columnar) - 0.6-1.6% will progress to cancer
Cardinal signs of dementia?
Behaviour, speech, thinking, perception, mood
Global intellectual deterioration without impairment of consciousness - plus memory loss.
Behaviour - restless, no initiative, repetitive, purposeless activity, sexual disinhibition, social gaffes, shoplifting, rigid routines.
Speech - syntax errors, dysphasia, mutism
Thinking - slow, muddled, delusions. Poor memory. No insight.
Perception - illusions, hallucinations (often visual).
Mood - irritable, depressed, affect blunt, emotional incontinence
Risk factors for gastric cancer?
Age, male gender, strong association with poor socio-economic status, H.pylori, diet, smoking, familial risk, atrophic gastritis, pernicious anaemia, post-gastrectomy
Valves most commonly affected by infective endocarditis?
In descending order: mitral, aortic, combined, tricuspid, pulmonary.
Common features of MS?
Visual
Eye movements - symmetrical horizontal jerking nystagmus, lateral rectus weakness
Facial weakness
Hearing and balance deficiencies
Unpleasant sensations
Loss of sensation in legs ascending to trunk
Transverse myelitis - acute episode of weakness or paralysis in both legs, with sensory loss and control of bowels and bladder
Autonomic - faecal incontinence, loss of inhibition of reflex bladder emptying, sexual problems, loss of thermoregulation.
Definition of AKI? (numbers)
Rise in creatinine >2umol/L in 48 hrs Rise in creatinine 1.5x baseline Urine output 6 consecutive hours
Risk factors for acute pyelonephritis?
Structural renal abnormalitieis, calculi, urinary tract catheterisation, stents, drainage procedures, pregnancy, diabetes, primary biliary cirrhosis, immunocompromised patients
Causes of somatisation?
- Patient seems to seek sick role, which affords relief from stressful or impossible interpersonal expectations (primary gain)
- Association between somatisation and history of sexual or physical abuse
- Often associated with the interpersonal representation of the unmet need for closeness with others.
Causes of mitral stenosis?
Rheumatic, congenital, mucopolysaccharides, enocardial fibroelastosis, malignany carcinoid, prosthetic valve.
Symptoms and signs of macrocytic anaemia?
General symptoms of anaemia
Lemon tinge to skin due to combination of pallor (anaemia) and jaundice (haemolysis), glossitis, angular stomatitis.
Causes of femoral embolism?
Left atrial thrombus in AF, mural thrombus after MI, prosthetic and normal heart valves, aneurysm, proximal atheromatous stenosis, malignant tumour, or foreign body
Typical age of SAH?
35-65
Prostate cancer metastasis
liver, bone, lung
Risk factors for oesophageal cancer?
Smoking, alcohol, Barret’s oesophagus, chronic inflammation, obesity, family history of hiatus hernia
Classical triad of aortic stenosis?
Angina, syncope and heart failure (usually after 60)
Two types of Addison’s disease?
Primary insufficiency (Addison’s) - inability of adrenal glands to produce enough steroid hormones. Most common cause is autoimmune.
Secondary insufficiency - inadequate pituitary or hypothalamic stimulation of adrenal glands.
B symptoms in Hodgkin’s lymphoma?
Drenching night sweats, unexplained fever >38, weight loss >10% over 6 months.
Alcohol induced pain at sites of nodal disease.
Seizure history?
Is it actually a seizure? (witness history) What type is it? Any triggers?
What is coeliac disease?
An immune mediated inflammatory systemic disorder provoked by gluten and related prolamines in genetically susceptible individuals.
Curative treatment for bladder cancer?
Radical cystectomy
Treatment for cholecystitis?
Laproscopic cholecystectomy is treatment of choice
Investigations in chronic liver failure?
Thrombocytopenia.
INR raised.
Trasaminases through the rooooooofffff, alkaline phosphatase may be slightly raised. Bilirubin raised, ammonia high.
What is the prevalence of coeliac and when can it present?
1 in 100. Can present at any age.
Causes of large bowel obstruction?
Colon cancer, constipation, diverticular stricture, volvulus (sigmoid/caecal)
Symptoms of prostatitis?
Flu-like symptoms, low backache, few urinary symptoms, swollen or tender prostate on PR.
Management of self harm?
Referral to secondary mental health services
Activated charcoal should be given as early as possible in overdose to prevent or reduce absorption of the drug
Psychological intervention and stuff, care plans
How does COPD differ from asthma?
Age of onset >35 years Smoking involved Chronic dyspnoea Sputum production Minimal diurnal variation in FEV1
AXR in Small bowel obstruction?
AXR shows central gas shadows with valvulae coniventes that completely cross the lumen and no gas in the large bowel
Most common type of renal carcinoma in adults and children?
RCC in adults.
Wilms’ tumour in children.
Presentation of an AUGIB?
Haematemasis or malena, dizziness, fainting, abdo pain, ?dysphagia Hypotension, tachycardia, decreased JVP, decreased urine output, cool and clammy
Main causative organism of UTI?
E.coli
Causes of B12 deficiency?
Dietary
Malabsorption - stomach (lack of intrinsic factor - pernicious anaemia), terminal ileum (ileal resection, crohn’s)
Congenital metabolic errors
Cardinal features of critical ischaemia?
Ulceration, gangrene a foot pain at rest (e.g. burning pain at night relieved by hanging legs over side of bed)
Risk factors for OA?
Genetic factors
Constitutional factors - ageing, female sex, obesity, high bone density (risk for development of OA), low bone density (RF for progression of knee and hip OA)
Biomechanical factors - joint injury, occupational and recreational stresses on joints, reduced muscle strength, joint laxity, joint malalignment
Risk factors for anxiety?
Being aged between 35 and 54
Being divorced or separated
Living alone or as a lone parent
Types of benign salivary gland neoplasms?
Pleomorphic adenoma (benign mixed tumour) is most common tumour of parotid gland - slow growing and asymptomatic.
Warthin’s tumour - second most common benign salivary gland neoplasm. 6th decade in women, 7th in men.
Most common sites of metastasis for lung cancer?
brain, bone, liver, adrenals
Risk factors for Parkinsons?
Men, age
Presentation of mitral stenosis?
Symptoms, signs, ECG, CXR
Symptoms - dyspnoea, fatigue, palpitations, chest pain, systemic emboli, haemoptysis, chronic bronchitis like picture.
Signs - malar flush (low cardiac output), low volume pulse, AF common, tapping non-displaced apex beat.
On auscultation - loud S1, opening snap, rumbling mid-diastolic murmur (expiration with patient on left side).
ECG - AF; P mitrale if in sinus rhythm (bifid P waves); RVH; progressive RAD.
CXR - left atrial enlargement, pulmonary oedema, mitral valve calcification
Symptoms of right heart failure?
Peripheral oedema, ascites, nausea, anorexia, facial engorgement, pulsation in face and neck, epistaxis.
CXR features of LVF?
Alveolar oedema (bats wings) Kerley B lines (interstitial oedema) Cardiomegaly Dilated prominent upper lobe vessels Pleural effusion
Management of acute pancreatitis?
NBM Analgesia Continuous observations ERCP + gallstone removal may be needed Repeat imaging (CT) to monitor progress
Ulnar nerve palsy signs?
weakness/wasting of ulnar side wrist flexors, interossei (can’t cross fingers), medial 2 lumbricals (claw hand), hypothenar eminence wasting, sensory loss over medial 1 1/2 fingers
M:F ratio and peak onset of RA?
F:M 2:1 - 5th-6th decade
Symptoms of appendicits?
Classically umbilical pain that moves to RIF (McBurney’s point) Anorexia and important feature Vomiting rarely prominent - pain normally precedes pain in surgical abdomen Constipation normal, diarrhoea may occur
Oesophageal symptoms of GORD?
Heartburn (retrosternal burning discomfort after meals, stooping or straining, relieved by antacids) Belching Acid brash (acid/bile regurgitation) Waterbrash (mouth filling with saliva) Odynophagia (painful swallowing)
Management of aortic regurgitation?
Aim to reduce systolic hypertension - ACE-i helpful. Aim to replace valve before significant LV dysfunction occurs.
Treatment of tension pneumothorax?
Large bore cannula in 2nd intercostal space mid clavicular line on side of suspected PT, then a chest drain
Risk factors for RA?
Smoking, HLA DR4/DR1 linked
M:F ratio of OA and typical age of onset?
M:F 1:3 - >50 yrs
Secondary prevention of MI?
aspirin, clopidogrel, beta blockers, statins, ACE-i, ARBs
What are pink puffers?
Have increased alveolar ventilation, a near normal PaO2 and a normal or low PaCO2. Breathless but not cyanosed, may progress to type 1 resp failure (V/Q mismatch) CHRONIC BRONCHITIS
Most common causative organisms of bacterial gastroenteritis?
Salmonella, campylobacter, shigella
When should someone be admitted for AUGIB?
Aged >60 yeas Witness haematemesis Haemodynamic disturbance (BP 100) Liver disease or known varices Other significant comorbiditiy
Management of somatisation?
General advice/explanation, psychotherapy, pharmacological (for underlying mood disorders)
Extra-oesophageal symptoms of GORD?
Nocturnal asthma Chronic cough Laryngitis (hoarseness, throat clearing) Sinusitis
Commonest cause of CAP?
Streptococcus pneumoniae
Surgery for GORD?
Aims to increase resting lower oesophageal sphincter pressure Nissen fundoplication; HALO or Stretta radiofrequency ablation of GOJ if high grade dysplasia
How to distinguish between indirect and direct hernias clinically?
Occlude deep inguinal ring and ask patient to cough - if hernia restrained it is direct, if not, it is indirect.
Classifications of anxiety?
GAD - anxiety and 3 somatic symptoms for >6 months
Panic disorder
Phobia
PTSD
Social anxiety disorder
Obsessive-compulsive disorder
What is the treatment of choice for non-small cell tumours?
Excision, then chemo/radiotherapy
Ohter causes of primary hypoT?
Iodine deficiency
Post thyroidectomy or radioiodine treatment
Drug induced
Subacute thyroiditis
What antigens are associated with coeliac disease?
HLA-DQ2 or HLA-DQ8
Signs of stroke?
Sudden onset, maybe with further progression over hours.
Pointers to bleed = meningism, severe headache and coma.
Pointers to ischaemia = carotid bruit, AF, past TIA, IHD
Risk factors for UTI?
Female Sex Pregnancy or menopause Urinary tract: obstruction, stones, catheter, malformation decreased host defence (DM)
Treatment of RA?
Early use of DMARDs and biological agents.
Steroids rapidly reduce symptoms, useful for treating acute exacerbations.
NSAIDs good for symptom relief but no effect on disease progression.
Surgery may relieve pain, improve function and prevent deformity.
Who is anxiety more common in?
Women
Left colon cancers presentation?
Often colicky pain, rectal bleeding, bowel obstruction, tenesmus, mass in LIF, early change in bowel habit, less advanced at presentation
Types of partial seizure?
Simple - awareness unimpared, focal motor, sensory, autonomic or psychic symptoms. No post-ictal symptoms.
Complex - awareness impaired. May have aura or impaired awareness at onset. Most commonly arise from temporal lobe. Post-ictal confusion common with seizures from temporal lobe, recovery rapid in seizures from frontal lobe.
with secondary generalisation - typically convulsive
When does pancreatic ca usually present?
>60yrs
Treatment for AAA rupture?
IT’S A FUCKING SURGICAL EMERGENCY AGHHHHHHHHHHHHH
Risk factors for T2DM?
Obesity, lack of exercise, calorie and alcohol excess.
High prevalence in asian men and the elderly.
Signs of hypoT?
BRADYCARDIC
Bradycardia, reflexes relax slowly, ataxia (cerebellar), dry thin hair/skin, yawning/drowsy, cold hands, ascites, round puffy face/double chin, defeated demeanour, immobile + ileus, CCF
Causes of iron deficiency anaemia?
Blood loss (menorrhagia, GI bleeding)
Poor diet (in children)
Hookworm (GI bleeding, commonest cause in tropics)
Risk factors for varicose veins?
Prolonged standing, obesity, pregnancy, family history, OCP
Plain radiographs show what in OA?
LOSS
Loss of joint space
Osteophytes
Subarticular sclerosis
Subchondral cysts
Symptoms of a polyneuropathy?
Numbness, pins and needles, ‘feels funny’ or ‘burning’. Affects extremities first (glove and stocking). May be difficulty holding small objects. Signs of trauma or deformation may indicate sensory loss.
Diabetic and alcoholic neuropathies particularly painful.
Duration and exacerbating factors of IBS?
Symptoms are chronic (>6 months) and exacerbated by stress, menstruation or gastroenteritis
Cases in which ruputre of AAA is more likely?
Hypertensive, smoker, female, strong FH
Presentation of right colon cancers?
Weight loss, anaemia, occult bleeding, mass in RIF, disease more likely to be advanced at presentation
When is pneumonia classed as hospital acquired?
>48h after hospital admission
How common is AKI?
15% of adults admitted to hospital
When should you consider septic arthritis?
in any acutely inflamed joint, as it can destroy a joint in under 24h
What is Cushing’s syndrome?
Clinical state produced by chronic glucocorticoid excess and loss of normal feedback mechanisms of hypothalamo-pituitary adrenal axis and loss of circadianrhythm of cortisol secretion
What is most common surgical emergency?
Acute appendicits
ABPI - normal, PVD, critical ischaemia?
Normal = 1-1.2
PAD = 0.5-0.9
Critical ischaemia =
Investigation and treatment of gastric cancer?
Rapid access flexible endoscopy is investigation of choice.
Distal tumours treated by subtotal gastrectomy and proximal tumours by total gastrectomy.
Risk factors for DVT?
Biggest = prior history of DVT age over 60 yrs, surgery, obesity, prolonged travel, acute medical illness, cancer, immobility, thrombophilia, pregnancy, COP, HRT therapy
Where do majority of salivary gland neoplasms arise?
Parotid glands (80%)
10-15% submandibular, remainder in sublingual and minor salivary glands.
Signs of cerebral infarct?
Contralateral sensory loss or hemiplegia - initially flaccid (floppy limb), spasticity (UMN), dysphasia, homonomous hemianopia, visuo-spatial deficit.
Presentation of delerium?
Patient disorientated in time and with greater impairment, in place.
Sometimes quiet or drowsy, sometimes adgitated.
May be deluded or hallucinating.
Definition of macrocytosis?
MCV > 96fL
RVF + LVF = ?
CCF
Signs of acute cholecystitis?
Local peritonism, possible GB mass - main difference from biliary colic is inflammatory component (local peritonism, increased WCC) If stone moves to common bile duct obstructive jaundice and cholangitis may occur. Murphy’s sign
Causes of prerenal AKI?
Renal hypoperfusion. Hypotension (any cause, hypovolaemia, sepsis) Renal artery stenosis, ACEi
Causes of a diffuse smooth goitre?
Grave’s disease
Thyroiditis
Iodine deficiency
Drugs
Hereditary factors
What causes peripheral vascular disease?
Atherosclerosis causing stenosis of arteries via a multifactorial process involving modifiable and non-modifiable risk factors
Differences in presentation between small and large bowel obstruction?
SBO - vomiting occurs earlier, distension is less, pain higher in abdomen. LBO - pain more constant
Causes of anxiety?
Genetic predisposition
Stress
Events
Faulty learning or secondary gain
What is chronic bronchitis?
Cough, sputum production on most days for 3 months of 2 successive years
When would you do a LP in meningitis?
When meningitic signs predominate and so signs of shock or raised ICP
What are worse; non-small cell or small cell carcinomas?
Small cell - almost always disseminated at presentation
Risk factors for cholecystitis?
Gallstones Hospitalisation for trauma or acute billiary illness Female gender Increasing age Obesity Rapid weight loss Pregnancy Crohns disease Hyperlipidaemia
Two groups of Non-Hodgkin’s?
Low grade - relatively good prognosis, but usually not curable in advanced clinical stages.
High grade - shorter natural history but significant number can be cured with intensive chemo
Who does epilepsy affect?
Can develop in anyone at any age. Seizures more common in young children and old people
Treatment for CAP?
Oral amoxicillin or clarithromycin or doxycycline Severe - co-amoxiclav or cephalosporin in IV and clarithromycin
Types of duct papilloma?
Central type - near nipple, solitary, nearing menopause Peripheral type - multiple, peripheries, younger women (higher risk of malignancy)
What does a parathyroid adenoma generally casuse?
more PTH to be secreted, causing hypercalcaemia
Presentation of low-grade non-Hodgkins lymphoma?
Painless, slowly progressive peripheral lymphadenopathy. Systemic symptoms not common at presentation but common in advanced disease. Bone marrow frequently involved, cytopenia. Splenomegaly, hepatomegaly.
Management of mitral stenosis?
Control rate if fast AF. Anticoagulate. Diuretics improve symptoms - aim to replace valve before LV irreversibly impaired.
Complications of GORD?
Oesophagitis Ulcers Benign stricture Iron-deficiency
Treatment of PAD?
Risk factor modification - smoking, treat HT and cholesterol, antiplatelet agent
Management of claudication - supervised exercise programmes, encourage them to exercise to point of maximal pain, vasoactive drugs (noftidrofuryl oxalate)
Age of onset of IBS
Test for ACTH dependent cushing’s?
Dexamethasone suppression test
Risk factors for septic arthritis?
Pre-existing joint disease (esp RA)
DM
Immunosuppression
CKD
Recent joint surgery
Prosthetic joints
IV drug abuse
Age >80 years
Signs of pneumothorax?
Reduced expansion, hyper-resonance to percussion and diminished breath sounds on affected side. Tension pneumothorax - trachea deviated away from affected side
Features of hyperparathyroidism?
Osteopenia (bone pain and pathological fractures), renal calculi (from excessive renal calcium absorption)
Muscle weakness, proximal myopathy, fatigue
Anorexia, nausea, vomiting, constipation, abdo pain, peptic ulcer disease, acute pancreatitis
Neruopsychiatric manifestations
MF ratio of IBS?
M:F 1:2
Where do most AAAs arise?
Infra-renally
What causes gout?
Deposition of monosodium urate crystals in and near joints, precipitated for example, by trauma, surgery, starvation, infection or diuretics.
Commonest sites of mets of renal cancer?
Lungs - classical picture of cannonball secondaries is almost diagnostic.
Adrenal glands, liver, spleen, colon, pancreas.
What are mononeuropathies?
Lesions of individual peripheral nerves or cranial nerves. Causes usually local, such as trauma or entrapment.
Management of AF?
Control of arrythmia and thromboprophylaxis, plus treatment of underlying cause and HF. Rhythm control - flecainide, beta blockers, amiodarone, dronedarone
Presentation of rheumatic heart disease?
Symptoms, signs, ECG, CXR
Symptoms - elderly person with chest pain, exertional dyspnoea, syncope. Dyspnoea, dizziness, faints, systemic emboli if infective endocarditis, sudden death.
Signs - slow rising pulse with narrow pulse pressure; heaving non displaced apex beat, LV heave, aortic thrill, ejection systolic murmur (left sternal edge, base, radiates to carotids)
ECG - P-mitrale, LVH with strain patter, LAD, poor R wave progression, LBBB or complete AV block (calcified ring)
CXR - LVH, calcified aortic valve, post-stenotic dilatation of ascending aorta.
AD more common in men or women?
Women
Patterns of MS?
Relapsing/remitting
Secondary progressive
Primary progressive
Investigations for gout?
Polarised light microscopy of synovial fluid shows negatively birefringent urate crystals.
Serum urate usually raised but may be normal.
Radiographs show only soft-tissue swelling in early stages. Later, well defined ‘punched out’ erosions seen in juxta-articular bone.
M:F ratio of UC?
1:1
Treatment of breast ca?
Wide local excision or mastectomy, axillary node clearance or sentinel node biopsy. Radiotherapy recommended for all breast ca. Chemo improves survivial in most groups. Endocine agents - Aim to reduce oestrogen activity (ER/PR blockers) ER blocker = tamoxifen (5 yrs after surgery) Aromatase inhibitors (anastrazole) - target peripheral oestrogen synthesis
Who does meningitis affect?
All groups, mainy infants, young children and the elderly
Presentation of Addison’s disease?
Persistent non-specific symptoms
Fatigue/weakness, nausea, vomiting, weight loss, abdo pain, diarrhoea, constipation, cravings for salt, muscle cramps/joint pains, syncope/dizziness, confusion, personality change, irritability, loss of pubic or axillary hair in women.
Signs - hyperpigmentation (buccal mucosa, lips, palmar creases, pressure areas), hypotension, postural hypotension.
Extra intestinal signs of UC?
May be none. In acute severe UC: clubbing, apthous oral ulcers, erythema nodosum, pyoderma gangrenosum, conjunctivitis, episcleritis, iritis… loads more
What causes depression?
Genetics
Biochemistry (excess 5HT2 receptors in frontal cortex of suicide victimes)
Endocrinology
Stressful events
Learned helplessness
Vulnerability factors - physical illness, pain, lack of intimate relationships
Investigations in hypoT?
High TSH, low T4
Signs of RA?
Early - swollen MCP, PIP, wrist or MTP joints (often symmetrical)
Late - ulnar deviation of fingers and dorsal wrist subluxation. Boutonniere and swan neck deformities of fingers or z-deformity of thumbs occur. Hand extensor tendons may rupture. Foot changes similar.
Extra-articular - nodules on elbows and lungs, lymphadenopathy, vasculitis, fibrosing alveolitis, eye shit, bone shit…
what are varicose veins?
Long tortuous and dilated veins of the superficial venous system
Treatment of migraine?
Analgesia (NSAIDs)
Anti-migraine drugs and anti-emetics
Identify possible trigger factors and remove
95% of pancreatic cas have mutations in what gene?
KRAS2 gene
Highest period of incidence of RCC?
Incidence rises after age 40 and is highest between 60 and 70.
Where does Crohn’s affect?
Anywhere from mouth to anus (especially terminal ileum and proximal colon) Characterised by skip lesions
When does MS usually start? Who gets it? Prevalence?
Early adult life
F:M 3:2, caucasians, strong familial inheritance
1:1000
Types of AKI?
Pre-renal, renal and post-renal
What is the most important risk factor for illness and dealth globally?
Manutrition
Risk factors for epilepsy?
Fucked up babies, bleeding in brain, abnormal cerebral vasculature, serious brain injury, brain tumours, infections in the brain, stroke, cerebral palsy, conditions with intellectual and developmental disabilities, family history, use of illegal drugs
UTI commoner in?
Women
What causes varicose veins?
Valves prevent blood from passing from deep to superifical veins - if they become incompetent there is venous hypertension and dilatation of the superficial veins occurs.
Risk factors for an acute upper GI bleed?
Alcohol abuse Chronic renal failure NSAID use Age Low socio-economic class
Result of high levels of PTH?
Serum calcium levels increase, serum phosphate levels decrease
Peak age and gender for urinary tract stones?
30-50, M:F 3:1
Causes of epilepsy/seizures?
2/3 idiopathic (often familial)
Cortical scarring, developmental, space occupying lesion, stroke…
Prevalence of parkinson’s?
- 6% at 60-64
- 5% at 85-89
What is Addison’s disease?
Adrenal insufficiency - destruction of adrenal cortex and subsequent reduction in output of adrenal hormones (glucocorticoids and/or mineralocorticoids)
2 ACTH dependent causes of Cushing’s?
Cushing’s disease
Ectopic ACTH production (small cell lung cancer and carcinoid tumours)
Causes of Renal AKI?
Tubular (ATN) Glomerular (autoimmune, glomerulonephritis) Interstitial (drugs, etc) Vascular (vasculitis)
Investigation of DVT?
WELL’S SCORE Either: a proximal leg ultrasound scan and a D-dimer test OR a D-dimer test and an interim 24 hour dose of a parenteral anticoagulant Venography Standard CXR, bloods, urinalysis etc
Definition of AKI? (wordy)
rapid deterioration of renal function, resulting in an inability to maintain fluid, electrolyte and acid-base balance
Presentation of hereditary renal cancers?
Tend to be multiple, bilateral and occur at an earlier age
Investigations in Addison’s disease?
High sodium, low potassium, high calcium, cortisol usually reduced.
ACTH levels raised in primary insufficiency - Synacthen test required to confirm diagnosis
Renin high and aldosterone low in Addison’s
Most common causes of HF?
hypertension and CHD
Risk factors for Non-Hodgkin’s?
Chromosomal translocations, some viruses, environment factors (pesticides, solvents, chemicals, preservatives, chemo, radiation), congenital and acquired immunodeficiency states. Autoimmune disorders.
What is RA?
Chronic systemic inflammatory disease characterised by a symmetrical, deforming, peripheral polyarthritis.
Presentation of pleural effusion on CXR?
Small effusions blunt the costophrenic angles, larger ones seen as water dense shadows with concave upper borders. A completely flat horizontal upper border implies that there is also a pneumothorax
Symptoms/signs of ruptured AAA?
Intermittent or continuous abdo pain (radiating to back, iliac fossae or groins), collapse, an expansile abdominal mass and shock.
Should be considered in any patient with hypotension and atypical abdominal symptoms.
How long do you have to stop driving for after a seizure?
1 year, they have to contact DVLA
Risk factors for PVD?
Smoking, DM, hypertension, hyperlipidaemia, physical inactivity, obesity
Empirical treatment for acute pyelonephritis?
Ciprofloxacin - third gen cephalosporin is alternative
Chief cause of Cushing’s syndrome?
Oral steroids
Symptoms of acute pyelonephritis?
High frequency, rigors, vomiting, loin pain/tenderness, oliguria
Investigations in RA?
Rheumatoid factor positive in about 70%.
Inflammation causes increased platelets, increased ESR, increased CRP.
X-rays show soft tissues swelling, juxta-articular osteopenia and reduced joint space. Later there may be bony erosions, subluxation or complete carpal destruction.
Hallmarks of chronic liver failure?
Hepatic encephalopathy, abnormal bleeding, ascites, jaundice
Symptoms of acute cholecystitis?
Continuous epigastric or RUQ pain (referred to right shoulder), vomiting, fever
Other causes of peptic ulcer?
NSAID use, pepsin, smoking, alcohol, bile acids, steroids, stress
Causes of meningitis in neonates?
Group B streptococci, listeria monocytogenes, E.coli
Where in the bowel does UC affect?
Never spreads proximal to ileocaecal valve - may just affect rectum or extend to affect some or all of colon
Treatments for alcohol dependence?
Abstinence/controlled intake
Refer to specialists - self-help/group therapy
Disufiram - produces nasty reaction if taken with alcohol
Education and counselling
Homelessness common - sort this out
Risk factors for stroke?
Hypertension, smoking, DM, heart disease, peripheral vascular disease, past TIA, carotid bruit, OCP, hyperlipidaemia, alcohol excess, clotting disorders
Risk factors for prostate cancer?
+ve family history, increased testosterone
Symptoms/signs of T1DM?
Polydipsia, polyuria, lethargy, boils, pruritis vulvulae
Weight loss, dehydration, ketonuria, hyperventilation
Increased risk of what in RA?
Cardiovascular disease - atherosclerosis accelerated in RA
Management of pancreatic ca?
Pancreaticoduodenectomy (Whipple’s procedure) if fit and no mets. Post op mortality high.
Investigations in macrocytic anaemia?
Low Hb, high MCV, WCC and platelets
low serum b12
low reticulocytes
What is a Mallory-Weiss tear?
bleeding from a tear in the mucosa at the junction of the stomach and esophagus, usually caused by severe alcoholism, retching, coughing, or vomiting.
Risk factors for bladder carcinoma?
Main = increasing age.
Smoking (aromatic amines and polycyclic aromatic hydrocarbons)
Occupational exposure to AAs and PAHs (dyes, paints, metal, petrol)
Radiation to pelvis
Chronic inflammation from stones or catheters
Schistosomiasis - 80% bladder cancers in developing world
Causes of polyneuropathy?
Diabetic neuropathy
Nutritional - alcohol, B12 deficiency
Heavy metal poisoning
Infection
Metabolic
Chronic vascular disease
Chronic inflammtory demyelinative polyneuropathy
Postinfective polyeneuriti (Guillain-Barré)
Sarcoidosis
Drugs
Congenital
Signs of pleural effusion?
Decreased expansion, stony dull percussion note, diminished breath sounds occur on affected side, tactile vocal fremitus/vocal resonance decreased
Local complications of lung cancer?
Recurrent laryngeal nerve palsy, phrenic nerve palsy, SVC obstruction, Horner’s syndrome, rib erosion, pericarditis, AF
Commonest age of onset for appendicits?
10-20
Abx for meningitis?
Cefotaxime
Ampicillin too for Listeria, also if >55 yrs old
Causes of mononeuropathy?
Mechanical (trauma, compression)
Entrapment
DM
Hypothyroidism
Rheumatoid arthritis
Vitamin deficiencies
Vasculitis
Sarcoidosis
Amyloidosis
Pregnancy - carpal tunnel syndrome
Two things associated with prognosis in breast ca?
Oestrogen receptor +ve = better prognosis HER2 positivity = poorer prognosis
Severity scoring system for pneumonia?
CURB-65 Confuson - AMTS 7mmol/L RR >30 BP 65 0-1 = home 2 = hospital therapy >3 = severe pneumonia, mortality 15-40%
Presentation of bladder cancer?
Painless haematuria is bladder cancer until proven otherwise.
Advanced disease may cause voiding symptoms. Muscle invasive disease.
Symptoms of IBS?
Abdo pain (or discomfort) relieved by defecation or associated with altered stool form or bowel frequency (constipation and diarrhoea may alternate) >2 or: urgency, incomplete evacuation, abdominal bloating/distension, mucous PR, worsening of symptoms after food.
Complications of hyperT?
Heart failure (thyrotoxic cardiomyopathy), angina, AF, osteoporosis, opthalmopathy, gynaecomastia.
Symptoms of Crohn’s?
Diarrhoea/urgency, abdo pain, weight loss/failure to thrive Fever, malaise, anorexia
Sign of common peroneal nerve damage and where is it vulnerable?
Foot drop
As it winds around the fibular head
Presentation of gout?
Acute monoarthropathy with severe joint inflammation.
>50% occur at MTP joint of big toe. Other joints affected = ankle, foot, small joints of hand, wrist, elbow or knee.
Management of UTI?
Drinking plenty and urinating often Empirical treatment - trimethoprim/nitrofurantoin Alternative - amoxicillin, cefalexin, co-amoxiclav In men, refer to urology
Endogenous cause of Cushing’s?
80% due to increased ACTH - pituitary adenoma (cushing’s disease) is commonest cause
Treatment of tension headache?
Attention to stress, anxiety, depression. Adviceon exercise, physiotherapy and posture, lifestyle changes.
Simple anlgesics. If not working, tricyclic antidepressants (amitryptiline)
What is an indirect inguinal hernia?
Pass through internal inguinal ring, and, if large, out through the external ring.
What drugs would you want to stop in AKI?
NSAIDs, ACE-i, gentamicin, amphotericin
Features of bowel obstruction?
Fermentation of intestinal contents causes ‘faeculent’ vomiting. Constipation need not be absolute if obstruction is high, though in distal obstruction nothing will be passed. Abdominal distension is marked as obstruction progresses Active, tinkling bowel sounds
Viruses causing gastroenteritis?
Rotavirus, norovirus, adenovirus, astrovirus
Signs of PVD?
Absent femoral, popliteal or foot pulses
Cold white legs, atrophic skin, punched out ulcers, postural/dependent colour change, Buerger’s angle 15s
How to distinguish between indirect and direct hernias in surgery?
Direct hernias arise lateral to inferior epigastric vessels, indirect hernias are medial
WHO criteria for manutrition in children?
Bipedal oedema, visible severe wasting, weight for height more than 3 SDs below the median of international reference population.
What is pulmonary fibrosis?
Group of diseases which produce interstitial lung damage and ultimately fibrosis and loss of elasticity of the lungs
Functions of PTH? (4)
Increases release of calcium from bone matrix
Increases calcium reabsorption by kidney
Increases phosphate excretion
Increases renal production of calcitrol, which increases intestinal absorption of calcium
Prevalence of breast ca?
1 in 9 women, rare in men
Cardiac causes of stroke?
Non-valvular AF, external cardioversion, prosthetic valves, acute MI, paradoxical systemic emboli (via venous circulation), cardiac surgery, valve vegetations from SBE/IE
Prevalence of depression?
20% each year
Presentation of somatisation?
Cardiac - sob, palpitations, chest pain
GI - vomiting, abdo pain, dysphagia, nausea, bloating, diarrhoea
MSK - pain in limbs, back pain, joint pain
Neuro - headahces, dizziness, amnesia, vision changes, paralysis, muscle weakness
Urogenital - dysuria, low libido, dyspareunia, impotence, dysmenorrhoea
What is the commonest joint condition?
OA
How does femoral hernia present?
Bowel enters femoral canal, presenting as mass in upper medial thigh or above the inguinal ligament where it points down the leg, unlike inguinal which points to the groin
Presentation of infective endocarditis?
Majority = fever, associated with systemic symptoms of chills, poor appetite and weight loss.
Heart murmurs in up to 85%
Splinter haemorrhages, osler’s nodes, clubbing, Roth’s spots, Janeway’s lesions, arthritis, splenomegaly, meningism.
Peak age of incidence of pulmonary fibrosis?
50-70
Cause of parkinsons?
Mitochondrial DNA dysfunction causes degeneration of dopaminergic neurons in the substantia nigra pars compacta
Treatment of acute stroke?
Thrombolysis - if onset
NBM - swallowing may lead to choking.
Antiplatelet agent - once haemorrhagic stroke exlcuded, give aspirin 300mg.
Types of malignant salivary gland neoplasm?
Mucoepidermoid carcinoma - most common malignany of parotid gland (2nd of submandibular after adenoid cystic)
Adenocarcinoma - poorly differentiated and anaplastic
SCC, malignant mixed tumours, adenoid cystic carcinoma
AXR in large bowel obstruction?
AXR shows peripheral gas shadows proximal to blockage but not in rectum, unless PR has been done. Large bowel haustra do not cross all the lumen’s width.
Presentation of renal carcinoma?
- Classic triad = haematuria, loin pain, loin mass (not often seen now)
- Fatigue, weight loss, macroscopic haematuria, palpable mass, varicocele, bilateral ankle oedema, pyrexia of unknown origin and hypertension.
- 25-30% present with symptoms of metastatic disease - haemoptysis, bone pain and pathological fracture.
Treatment for prostate ca?
Radical prostatectomy Radical radiotherapy Hormone therapy Active surveillance
Risk factors for alcohol dependence?
Steady drinking over time
Age
FH
Depression/other mental health problems
Social/cultural factors
Mixing medication and alcohol
Symptoms of hypoT?
Tired, sleepy, lethargic, low mood, cold-disliking, weight gain, constipation, menorrhagia, hoarse voice, reduced memory/cognition, dementia, myalgia, cramps, weakness
Other causes of CAP?
Haemophilus influenzae, mycoplasma pneumoniae, Staph aureus, legionella species, moraxella catarrhalis and chlamydia.
Treatment for PE?
Anticoagulate with LMWH Start warfarin Stop heparin when INR >2 and continue warfarin for a minimum of 3 months Thrombolysis for massive PE Consider placement of veno caval filter in patients who develop emboli despite adequte coagulation
Signs of Iron deficiency anaemia?
Pallor (e.g. conjunctival)
Signs of hyperdynamic circulation (tachycardia, flow murmurs, cardiac enlargement)
Chronic IDA signs - koilonychia, atrophic glossitis, angular stomatitis, post-cricoid webs
Smoking and UC?
Protective - 3 times as common in non-smokers, symptoms may relapse on stopping smoking
Symptoms of hyperT?
Diarrhoea, weight loss, increased appetite, overactive, sweats, heat intolerance, palpitations, tremor, irritability, liable emotions, oligomenorrhoea +/- infertility.
Where might the radial nerve be damaged?
Compression against the humerus
Secondary hypoT?
Very rare - hypopituitarism
Other causes of LVF?
Valve disease, secondary to myocardial disease, high output failure (anaemia, pregnancy, hyperthyroid)
Age relation to peripheral neuropathy?
More common as you get older
Symptoms of prostate cancer?
Lower urinary tract symptoms - nocturia, hesitancy, poor stream, terminal dribbling, obstruction
Symptoms of PVD?
Cramping pain felt in calf, thigh or buttock after walking a given distance and relieved by rest.
Sign of brachial plexus injury?
Pain/paraesthesia and weakness in the affected arm in a variable distribution
Symptoms of UC?
episodic or chronic diarrhoea (with or without blood/mucus); crampy abdominal discomfort; bowel frequency relates to severity Urgency/tenesmus indicates rectal UC. Systemic symptoms in acute attacks - fever, malaise, anorexia, weight loss
Specific features of ectopic ACTH production?
pigmentation, hypokalaemic metabolic acidosis, weight loss, hyperglycaemia
What would you see on colonoscopy in UC?
Inflammatory infiltrate, goblet cell depletion, glandular distortion, mucosal ulcers, crypt abscesses
Complications of macrocytic anaemia?
Neuropsychiatric
Neurological - paraesthesiae, peripheral neuropathy
Subacute combined degeneration of spinal cord
Median age at diagnosis of Non-Hodgkin’s lymphoma?
Older than 50
Prostate cancer PR?
Hard, irregular prostate
Causes of hyperT?
Grave’s disease
Toxic multinodular goitre - elderly and iodine deficient areas.
Toxic adenoma
Ectopic thyroid tissue
Exogeneous - iodine excess
Causes of aortic stenosis?
Senile calcification is commonest. Others = congenital and rheumatic heart disease.
How does alcohol dependence present?
Difficulty or failure of abstinence
Narrowing of drinking repertoire
Increased tolerance to alcohol
Often aware of compulsion to drink
Priority is to maintain alcohol intake
Sweats, nausea or tremor on withdrawal
social problems, mental health problems, law problems, physical problems spanning all systems
Treatment for hypoT?
Levothyroxine (t4) - once normal check TSH yearly
Management of delerium?
Find the cause. Optimise surroundings and nursing care. Monitor BP often. If adgitation distressing patient, consider haloperidol or risperidone.
Treatment of acute gout?
Use high dose NSAID or coxib. Symptoms should subside in 3-5 days.
Steroids may also be used. Rest and elevate affected joint. Ice packs can be effective.
Causes of RHF?
LVF, pulmonary stenosis, lung disease
Definition of AAA?
Aortic diameter exceeding 3cm
Who does bladder carcinoma occur in?
Mostly patients over 60 years. M:F 3:1 but women have poorer prognosis.
Presentation of breast abscess?
>1 week postpartum Only one breast affected, only one quadrant or lobule painful to touch, inflamed, swollen, hot.
What causes urinary tract stones?
Renal calculi formed when urine supersaturated with salt and minerals such as oxalate, struvite, uric acid and cytseine.
Who is at risk of aspiration pneumonia?
Stroke patients, myasthenia, bulbar palsies, those with decreased consciousness
Symptoms of fibrocystic change?
Pain or discomfort in both breasts Pain that commonly comes and goes with the period but may last the whole month Breasts that feel full, swollen and heavy Pain or discomfort under the arms Thick or lumpy breasts
Causes of delerium?
Infection, drugs, deranged electrolytes, hypoglycaemia, weird blood gases, epilepsy, alcohol withdrawal, trauma, surgery
Treatment for T1DM?
Insulin
Risk factors for goitre?
Women, age, iodine deficiency, pregnancy/menopause, medication, exposure to radiation
Risk factors for pulmonary fibrosis?
Occupational hazards
Smoking
GORD
Infectious agents
Genetic factors
What proportion of parotid neoplasms are benign?
80%
Investigation for fibrocystic disease?
Triple assessment if lump found Under 35 - USS, over 40 - mammogram
Main aetiological factor in peptic ulcers?
H.pylori - 95% of duodenal ulcers, 80% of gastric ulcers
Smoking and Crohn’s?
Increases risk by 3-4x
Symptoms of lung cancer?
Cough (80%), haemoptysis (70%), dyspnoea (60%), chest pain (40%), recurrent or slowly resolving pneumonia, lethargy, anorexia, weight loss
Most common sites of mets of colorectal cancer?
Liver, lung, peritoneum
What is a parathyroid adenoma?
Benign tumour of parathyroid gland
AF signs?
irregularly irregular ventricular pulse and loss of association between cardiac apex beat and radial pulsation
Signs illicted in RIF in appendicitis?
Guarding Rebound and percussion tenderness PR painful on right (sign of low lying pelvic appendix)
Types of generalised seizure?
Absence - brief, pauses, then carries on where left off. Presents in childhood.
Tonic-clonic - loss of consciousness, limbs stiffen then jerk. Post ictal confusion and drowsiness.
Myoclonic seizures - sudden jerk of a limb face or trunk. Patient may be thrown to the ground or have a very disobedient limb.
Atonic (akinetic) seizures - sudden loss of muscle tone causing a fall, no LOC
Joints most commonly affected in septic arthritis?
Knee (50%)
Hip (20%)
Shoulder (8%)
Ankle (7%)
Wrists (7%)
Causes of a single nodule in the thyroid?
Cyst, adenoma, carcinoma
Investigation of choice in coeliac disease?
IgA anti-tissue transglutaminase antibodies (tTGAs)
What do you want to do with a pleural effusion?
Diagnostic aspiration - clinical chemistry, bacteriology, cytology, immunology. Drainage Pleurodesis - with tetracycline, bleomycin or talc - may be useful in recurrent effusions Surgery required if persistent collections and increasing pleural thickness
Drugs for epilepsy?
Sodium valproate or lamotrigine are 1st line, then carbameazepine or topiramate (for tonic clonic)
Investigations in hyperparathyroidism?
Hypercalcaemia, raised PTH, hypophosphataemia, increase in 24 hour urinary calcium excretion
Causes/risk factors for pleural effusion?
CCF, kidney failure, malignancy, infection, PE, hypoalbuminaemia, cirrhosis, trauma
Who does somatisation affect?
Higher percentages in people with IBS and chronic pain patients, patients with PTSD.
Antiosocial personality disorder is associated with risk.
Usually begins before age 30 and occurs more commonly in women than men.
Investigations in somatisation?
Diagnostic tests used to rule out physical causes
Psychological evaluation
Presentation of oesophageal carcinoma?
Dysphagia, vomiting, anorexia/weight loss, symptoms of GI bleeding
Prevalence of alcohol dependence?
9% men, 4% women
Risk factors for meningitis?
CSF shunts or dural defects
Spinal procedures
Bacterial endocarditis, DM, alcoholism and cirrhosis, IV drug abuse, renal/adrenal insufficiency, malignancy, hypoparathyroidism, thalassaemia major, CF
Splenectomy, sickle cell disease
Crowding
What does CSF look like after SAH?
Typically bloody early on and becomes xanthanchromic after several hours due to bilirubin
Presentation of breast ca?
Painless increasing mass, may be associated with nipple discharge, skin tethering, ulceration. In inflammatory cancers oedema and erythema may also be present (peau d’orange) Nipple inversion, blood-stained nipple discharge Disseminated disease - bone pain, pathological fracture, dyspnoea, pleural effusion, hepatomegaly, jaundice
Conditions associated with hypothyroidism?
Other AI disorder (T1 DM, addison’s, PA), Turner’s, down’s, CF, primary biliary cirrhosis, POEMS syndrome
Differential diagnosis of claudication pain?
Sciatica, spinal stenosis, entrapment syndromes, muscle/tendon injury
Most sublingual and minor salivary gland neoplasms are …?
Malignant
Signs of unruptured AAA on examination?
Pulsatile and expansile abdominal swelling
Presentation of coeliac disease?
Anaemia, non-specific symptoms of abdo discomfort, arthralgia, anaemia, fatigue and malaise.
Diarrhoea, steatorrhoea and malabsorption.
Mouth ulcers and angular stomatitis are common. Deficiencies of vit E and B12 can occur.
Signs suggesting incurable gastric cancer?
Epigastric mass, hepatomegaly, jaundice, ascites, Troiseir’s sign (virchows), acanthosis nigricans
Types of breast cancer?
Invasive ductal carcinoma (70%) Invasive lobular carcinoma (10-15%) Medullary (5%)
What is COPD?
Chronic bronchitis and emphysema
Most common cause of ruputre in the abdomen?
Perforated duodenal ulcer
When does UC usually present?
15-30 years
Symptoms of cystitis?
Frequency, dysuria, urgency, haematuria, suprapubic pain
Definition of neurosis?
Maladaptive psychological symptoms not due to organic causes or psychosis and usually precipitated by stress
Empirical abx therapy for IE?
Native valve, prosthetic valve, staph native valve, staph prosthetic valve
native valve = amoxicillin and (optional) gentamicin
Prosthetic valve = vancomycin AND gentamicin AND rifampicin
Staph, native valve = flucloxacillin IV, 6 weeks
Staph, prosthetic valve = flucloxacillin and rifampicin and gentamicin
Later signs of meningitis?
Meningism - neck stiffness, photophobia, kernig’s sign (pain/resistance on passive knee flexion with hip fully flexed)
Conscious level decreased, coma
Seizures
Petechial rash (non blanching)
Signs of galloping sepsis - slow cap refill, DIC, low BP, high temp and pulse
Presentation of mitral regurgitation?
Symptoms, signs, ECG, CXR
Symptoms - dyspnoea, fatigue, palpitations, infective endocarditis.
Signs - AF; displaced hyperdynamic apex; RV heave; pansystolic murmur at apex radiating to axilla.
ECG - AF; P mitrale if in sinus rhythm; LVH
CXR - big LA and LV, mitral valve calcification, pulmonary oedema.
Signs of Crohn’s?
Apthous ulcerations, abdo tenderness/mass, perianal abscess/fistulae/skin tags, anal strictures. Clubbing, skin joint and eye problems
Causes of mitral regurgitation?
Functional (LV dilatation), annular calcification, rheumatic fever, infective endocarditis, mitral valve prolapse, ruptured chordae tendinae, papillary muscle dysfunction/rupture, connective tissue disorders, cardiomyopathy, congenital.
Parkinson’s gait?
Gait - reduced arm swing, festinance, freezing at obstacles, expressionless face.
what is a pneumothorax?
Collection of air in pleural space surrounding lung
Presenting features of localised disease in OA?
Pain on movement and crepitus, worse at the end of the day
Background pain at rest
Joint gelling - stiffness at rest up to ~30 mins
Joint instability
Risk factors for SAH?
Smoking, alcohol misuse, high BP, bleeding disorders, mycotic aneurysm, post-menopausal decrease in oestrogen. Close relatives have 3-5 fold increase in risk
Diagnostic criteria for T1DM?
Symptoms of hyperglycaemia AND raised venous glucose once - fasting >7mmol/L or random >11.1 mmol/L
Or asymptomatic with rasied readings on two separate occasions.
Pharmacological management of T2DM?
Metformin (biguanide) - increased insulin sensitivity and helps weight
Sulfonylurea - increased insulin secretion (e.g. gliclazide)
Insulin may be needed
Glitazone - increased insulin sensitivity
Sulfonylurea receptor binders - increased beta-cell insulin resistance
Glucagon like peptide (GLP) analogues - augment insulin release
Alpha-glucosidase inhibitors (acarbose) - reduced breakdown of starch to sugar
Breast ca risk factors?
Family history, age, uninterrupted oestrogen exposure (early menarche, late menopause, 1st prego >30 yrs old, HRT, obesity), BRCA genes, not breastfeeding, past breast ca
Risk factors for delerium?
Age >65 years, male sex, pre-existing cognitive deficit, severity of dementia, severe comorbidity, previous episode of delerium, operative factors (frature repairs), certain conditions, current hip fracture or severe illness, drug use, substance misuse, extremities of sensory experience, visual or hearing problems, poor mobility, social isolation, stress, terminally ill, movement to new environment, ICU admission
Who does tension headache affect?
More common in women than men and most common in young adults.
Presentation of high-grade non-Hodgkin’s lymphoma?
Rapidly growing and bulky lymphadenopathy. Systemic symptoms and extranodal involvement more common. Hepatomegaly, splenomegaly. Obstructive hydronephrosis due to bulky retroperitoneal lymphadenopathy obstructing ureters. Testicular mass, skin lesions.
ECG signs in AF?
absence of P waves, irregular R-R intervals, QRS complexes narrow
Most common causes of hospital acquired pneumonia?
Gram negative enterobacteria or Staph Aureus
Symptoms of iron deficiency anaemia?
Fatigue, dyspnoea, faintness, palpitations, tinnitus, anorexia
Treatment of DVT?
LMWH or fondaparinux Compression stockings Temporary IVC filters for patients with proximal DVT or PE who can’t have anticoagulation treatment
Cardinal triad or parkinsonism?
Tremor - worse at rest, ‘pill rolling’
Rigidity/hypertonia - rigidity and tremor gives ‘cogwheel rigidity’
Bradykinesia/hypokinesia - slow to initiate movement and slow low amplitude excursions in repetitive action.
Reduced blink rate, monotonous monophonic speech, micrographia.
Signs of LVF?
tachypnoea, cool peripheries, central/peripheral cyanosis, tachycardia at rest, low systolic BP, displaced apex (LV dilatation), crackles in lung bases
Complications of acute pancreatitis?
Shock, ARDS, renal failure, DIC, hypocalcaemia, hyperglycaemia,. Pancreatic necrosis, psuedocyst, asbcesses, bleeding, thrombosis, fistulae, recurrent odematous pancreatitis.
Main type of bladder cancer?
90% = transitional cell carcinoma, rest = SCC
Risk factors for AF?
Hypertension, primary heart diseases (CHD, valvular), lung pathologies, excess alcohol consumption, hyperthyroidism, HF
Imaging modality of choice for urinary tract stones?
Non-enhanced CT scanning, USS
Typical symptoms of RA?
Symmetrically swollen, painful and stiff small joints of hands and feet, worse in the morning. Can fluctuate and larger joints may be involved.
Core treatments for OA?
Exercise to improve local muscle strength and general aerobic fitness. Weight loss if overweight.
Analgesia - regular paracetamol and topical NSAIDs. If ineffective use codeine or short term oral NSAID. Topical capsaicin. Infra-articular steroid injections temporarily improve symptoms, intra-articular hyaluronic acid injections. Glucosamine not recommended
Non-pharmacological - MDT approach. Heat or cold packs, walking
Surgery - joint replacement best way to deal with it
Difference between ileus and obstruction?
Ileus is functional obstruction from reduced peristalsis - no pain and bowel sounds absent.
Presentation of Hodgkin’s lymphoma?
Enlarged but otherwise asymptomatic lymph node, typically in lower neck or supraclavicular region.
Mediastinal masses frequent - may complain of chest discomfort with cough or dyspnoea.
B symptoms.
OE - lymphadenopathy, hepatomegaly, splenomegaly, SVC syndrome.
Risk factors for self-harm?
Psychiatric problems - borderline personality disorder, bipolar disorder, schizophrenia, drug/alcohol abuse
Domestic violence, socio-economic disadvantage, eating disorders, South Asian women
Signs of MI?
BP low, HR fast, pulmonary oedema
Complications of gastric ulcer?
Bleeding, perforation, malignancy, decreased gastric outflow
Cardinal features of bowel obstruction?
Vomiting, colicky pain, constipation, distension
Surgical treatment of breast abscess?
Incision and drainage
Premalignant breast conditions?
Non-invasvie ductal carcinoma in situ (DCIS) - premalignant and seen on mammography Non-invasive lobular CIS - rarer
Where is ulnar nerve vulnerable to damage?
At elbow
Joints most commonly affected by OA?
Knee and hip
Three things that make up asthma?
- Bronchial muscle contraction 2. Mucosal swelling/inflammation 3. Increased mucus production
Who does stroke affect?
People over 65, men more than women, black people at increased risk
Signs of sciatic nerve damage?
Damaged by pelvic tumours of fractures to pelvis or femur
Affects hamstrings and all muscles below the knees (foot drop) with loss of sensation below the knee laterally
Common cause of pneumothorax?
Spontaneous rupture of sub-pleural bulla
Definition of an aneurysm?
A permanent and irreversible dilatation of a blood vessel by at least 50% of the normal expected diameter.
Lifestyle changes to treat GORD?
Raising the bed head Weight loss Smoking cessation Small regular meals Avoid: hot drinks, alcohol, citrus, tomatoes, onions, fizzy drinks, spicy foods, chocolate and eating
Abx treatment for mastitis?
Flucloxacillin or erythromycin
TTH compared to migraine?
More gradual in onset
More variable in duration (usually shorter)
More constant in quality
Less severe
Usually responsive to over the counter medication
Pain is bilateral and occipitio-nuchal or bifrontal. Well between attacks.
MI treatment?
morphine, oxygen, aspirin, PCI
Causative organisms of UTI?
E.coli, proteus mirabilis, klebsiella pneumonia, staphylococcus saprophyticus
Classical pattern of PE in ECG?
sinus tachycardia, SI QIII TIII, RBBB, right ventricular strain (inverted T in V1 to V4)
Risk factors and associations for gout?
Hereditary, excess dietary purines, alcohol excess, diuretics, lukaemia, cytotoxics
Associations = CVD, hypertension, diabetes, CKD
Presentation of malnutrition in adults?
Lose weight often insidiously. Listlessness, increasing fatigue, cold sensitivity, non-healing wounds and severe decubitus ulcers.
Where does bladder cancer metastasise to?
LNs, lung, liver, bone, CNS
Treatment for hyperparathyroidism?
Parathyroidectomy
AF symptoms?
palpitations, tired and/or breathless on exertion, sometimes angina and ankle oedema
Symptoms of T2DM?
Polydipsia, polyuria, lethargy, boils, pruritis vulvulae, increased hunger/thirst
Causes of aortic regurgitation?
Acute - infective endocarditis, ascending aortic dissection, chest trauma.
Chronic - congenital, connective tissue disorders, rheumatic fever, RA, SLE, seronegative arthritides, hypertension, osteogenesis imperfecta, syphilitic aortitis.
Risk factors for Crohn’s?
Smoking NSAID use FH Age
Most common pancreatic ca?
Ductal adenocarcinoma - metastasise early, present late
Symptoms of Cushing’s syndrome?
Weight gain, mood change, proximal weakness, gonadal dysfunction, acne, recurrent achilles tendon rupture,
Claudication sites an where they suggest disease is?
Calf claudication = femoral disease
Buttock claudication = iliac disease
What is triple assessment?
- Clinical examination/history 2. Radiology - US for 35 3. Histology/cytology
Presentation of pancreatuc cancer?
Tumours in head of pancreas present with painless obstructive jaundice.
75% in body and tail present with epigastric pain (radiates to back and relieved by sitting forward)
May cause anorexia, weight loss, diabetes or acute pancreatitis
Presentation of depression?
- Anhedonia
- Poor appetite with weight loss
- Early waking (mood worse in mornings)
- Psychomotor retardation (sluggish)
- Decrease in sexual drive or other appetites
- Reduced ability to concentrate
- Ideas of worthlessness, inappropriate guilt or self-reproach
- Recurrent thoughts of death and suicide, or suicide attempts
Management of parathyroid adenoma?
Surgery is only cure
Signs of Grave’s disease?
Eye disease - exopthalmos, opthalmoplegia
Pretibial myxoedema - odematous swellings above lateral malleoli
Thyroid acropachy - extreme manifestation, with clubbing, painful finger and toe swelling and periosteal reaction in limb bones.
Most common cause of bloody nipple discharge in women 20-40?
Duct papilloma - biopsy needed to rule out malignany
Signs of pancreatic cancer?
Jaundice and palpable gallbladder, epigastric mass, hepatomegaly, splenomegaly, lymphadenopathy, ascites
Symptoms of SAH?
Sudden devastating typically occipital headache
Vomiting, collapse, seizures and coma often follow
M:F ratio for inguinal and femoral hernia?
Inguinal - M:F 8:1 Femoral - women
Rarer causes of bowel obstruction?
Crohn’s stricture, gallstone ileus, intussusception, TB, foreign body
Causes of chronic pancreatitis?
Alcohol (by far biggest cause) Familial CF Haemochromatosis Pancreatic duct obstruction High PTH levels Congenital
Age of onset, TIDM?
Adolescent usually
Treatment for varicose veins?
Treat any underlying cause, education (avoid prolonged standing, elevation, support stockings, lose weight, regular walks), endovascular treatment, surgery (stripping etc.)
Side effects of oral iron?
Nausea, abdo pain, diarrhoea/constipation, black stools
Signs of brainstem and lacunar infarcts?
Brainstem - quadriplegia, disturbances of gaze and vision, locked-in syndrome.
Lacunar - in basal ganglia, internal capsule, thalamus and pons. 5 syndromes -ataxic hemiparesis, pure motor, pure sensory, sensorimotor and dysarthria/clumsy hand.
Symptoms of LVF?
cough (frothy/blood tinged mucus), decreased urine production, orthopnoea, fatigue, weakness, faintness, irregular or rapid pulse, palpitations, SoB, PND, weight gain from fluid retention, wheeze, nocturia, cold peripheries
Endocrine complications of lung cancer?
Ectopic hormone secretion (SIADH and ACTH) by small cell tumours; PTH by squamous cell tumours
Types of hyperparathyroidism?
Primary - single PT adenoma producing excess PTH
Seconary - PT glands become hyperplastic in response to long term hypocalcaemia because of kidney, liver or bowel disease.
Tertiary - after prolonged secondary hyperparathyroidism, glands become autonomous, producing excess PTH even after cause of hypocalcaemia has been corrected. Renal disease = main cause
Age of fibrocystic disease?
Between 20 and 45 (rare in women after menopause unless on oestrogen)
Signs of pneumonia?
Pyrexia, cyanosis, confusion, tachypnoea, tachycardia, hypotension, signs of consolidation (diminished expansion, dull percussion note, increased TVF/VR, bronchial breathing and a pleural rub
Presentation of gastric cancer?
Nonspecific with dyspepsia, weight loss, vomiting, dysphagia and anaemia.
Early presentation of meningitis?
Headache, leg pains, cold hands and feet, abnormal skin colour
Treatment for depression?
Psychological treatment - in all depression
Antidepressants
Delusions or hallucinations require physical treatment
Lithium or valproate prophylaxis may be needed
Reasons to admit: social circumstances, high suicide drive, isolation
Signs of median nerve palsy?
No precision grip. Weakness of abductor policis brevis and sensory loss over radial 3 1/2 fingers and palm.
Who does gout affect?
M:F 4:1
Signs of mets from lung cancer?
Bone tenderness, hepatomegaly, confusion, fits, focal CNS signs, cerebellar syndrome, proximal myopathy, peripheral neuropathy
Presentation of BPH?
nocturia, frequency, urgency, post-micturation dribbling,, poor stream/flow, hesitancy, overflow incontinence, haematuria, bladder stones, UTI
When do MI enzymes appear?
Troponins - 3-12 hours, peak 24-48, baseline 5-14 days CK - 3-12 hours, peak 24, baseline 48-72
Signs of UTI?
Fever, adbo tenderness, foul-smelling urine,
Treatment of pneumothorax?
Always give oxygen Pneumothroax due to trauma or mechanical ventilation requires a chest drain Surgical treatment if bilateral pneumothoraces, lung fails to expand after intercostal drain insertion, 2 or more previous on the same side, or history of pneumothorax on opposite side
What is a partial seziure?
Focal onset, with features referable to part of one hemisphere, often seen with underlying structural disease.
How long does a urinary tract stone take to pass?
1-3 weeks
Organisms that cause acute pyelonephritis?
Same as UTI
Symptoms of migraine?
classically visual or other aura lasting 15-30 minutes followed by unilateral throbbing headache. Prodrome often precedes headache by hours/days.
When would you do an endoscopy for GORD?
Symptoms for >4 weeks Persistent vomiting GI bleeding/iron deficiency Palpable mass Age >55 Dysphagia Symptoms despite treatment Relapsing symptoms Weight loss
Signs of SAH?
Neck stiffness, retinal, subhyaloid and vitreous bleeds (=Terson’s syndrome, mortality 5x more likely)
Focal neuropathy at presentation may suggest site of aneurysm (e.g. pupil changes suggesting a IIIrd nerve palsy with a posterior communicating artery aneurysm.
Symptoms of pneumonia?
Fever, rigors, malaise, anorexia, dyspnoea, cough, purulent sputum, haemoptysis, pleuritic pain
Drugs for GORD?
Antacids or alginates PPI for oesophagitis (better than H2 antaganists)
Typical age of onset of Parkinson’s?
65
Signs of hyperT?
Pulse fast/irregular, warm moist skin, fine tremor, palmar erythema, thin hair, lid lag, lid retraction (exposure of sclera above iris).
Goitre, nodules or bruit.
Symptoms of chronic pancreatitis?
Epigastric pain ‘bores’ through to back, relieved by sitting forward or hot water bottle on epigastrium/back. Bloating, steatorrhoea, weight loss, brittle diabetes. Symptoms relapse and worsen.
ACTH independent causes of Cushing’s?
Adrenal adeonoma - dexamthasone does nothing because it is autonomous
Adrenal nodular hyperplasia - no dexamethasone suppression
Iatrogenic - drugs (steroids)
What valve disease can cause LVF?
aortic stenosis can cause LVH due to chronic excessive afterload. Aortic/mitral regurgitation, ASD/VSD and tricuspid incompetence can cause excessive preload
Definition of iron deficiency anaemia?
Men
Women
Causes of meningitis in adults and older children?
S pneumoniae, H influenzae B, N meningitidis, gram -ve bacilli, staph, strep, l.monocytogenes
Causes of chronic liver failure?
Toxins - chronic alcohol abuse, paracetamol poisoning, illicit drugs
Infections - viral hepatitis, adenovirus, EBV, cytomegalovirus, viral haemorrhagic fevers
Neoplastic - hepatocellular carcinoma or metastatic carcinoma
Metabolic - Wilson’s disease, alpha-1-antitrypsin deficiency, fructose intolerance, galactoseamia, tyrosinaemia
Vascular
Autoimmune liver disease
Management of coeliac disease?
Gluten free diet nigga
Signs suggest of salivary gland malignancy?
Hardness, fixation, tenderness, infiltration of surrounding structures, overlying skin ulceration.
Facial palsy + salivary gland mass = malignancy
Management of urinary tract stones?
NSAIDs to relieve colic, antiemetics and rehydration.
Conservative management up to 3 weeks, unless patient unable to manage pain, or if they develop signs of infection or obstruction.
Medical expulsive therapy - calcium channel blockers, alpha blockers, corticosteroids.
1 in 5 stones need surgery
Risk factors for renal cell carcinoma?
Smoking, obesity, hypertension, long term dialysis, von-Hippel-Lindau disease, renal transplant recipients, tuberous sclerosis, acquired renal cystic disease
Drugs used to treat LVF?
Loop diuretics ACE-i Beta blockers Spironolactone Digoxin Vasodilators (hydralazine and isosorbide dinitrate)
What do you have to be careful to avoid in management of malnutrition?
Refeeding syndrome
Risk factors for PE?
Recent surgery Thrombophilia Leg fracture Prolonged bed rest/reduced mobility Malignancy Pregnany; OCP; HRT Previous PE
Risk factors for Hodgkin’s lymphoma?
EBV, previous mononucleosis, HIV, immunosuppresion, tobacco smoking
Organisms responsible for infective endocarditis?
Staph aureus = most common overal, most common with prosthetic valves (coagulase negative)
Streptococci
Strep viridans = most common
Group D strep
Strep intermedius
Group A, C and G strep
Group B strep
M:F ratio and age of presentation of Crohn’s?
1:1, 20-40 years
What are polyneuropathies?
Disorders of peripheral or cranial nerves whose distribution is usually symmetrical and widespread, often with distal weakness and sensory loss (‘glove and stocking’)
Complications of gallstones in gut?
Gallstone ileus
Signs of tibial nerve damage?
Inability to tiptoe, invert the foot, flex the toes, sensory loss over sole
Causes of pneumothorax?
Asthma, COPD, TB, pneumonia, lung abscess, carcinoma, CF, lung fibrosis, sarcoidosis, CT disorders, trauma, iatrogenic, CPAP
Main causes of acute GI bleed?
Peptic ulcer disease (35-50%) Gastroduodenal erosions (8-15%) Oesophagitis (5-15%) Mallory-Weiss tear (15%) Varcies (5-10%) Upper GI malignancy
Treatment for SAH?
Refer to neurosurgery immediately
Maintain cerebral perfusion by keeping well hydrated
Nimodipine - Ca2+ antagonist reduces vasospasm and consequent mortality from cerebral ischaemia
Endovascular coiling preferable to surgical clipping
Causes of pneumonia in the immunocompromised patient?
Strep pneumoniae, H.influenzae, Staph Aureus, M.catarrhalis, M.pneumoniae, gram -ve bacilli, pneumocystis jiroveci Other fungi, viruses (CMV, HSV) and mycobacteria
Causes of meningitis in infants and younger children?
H influenzae B, Neisseria meningitidis, strep pneumoniae
Which is commoner Hodgkins or Non-Hodgkins?
Non-Hodgkins 5x more
Investigations in IDA?
Microcytic hypochromic anaemia with anisocytosis and poikilocytosis
Low MCV, low MCH, low MCHC, low ferritin, low serum iron with high TIBC (total iron binding capacity)
Less common symptoms of RA?
Sudden onset, widespread arthritis; recurring mono/polyarthritis of various joints (palindromic RA)
Persistent monoarthritis (often knee, shoulder or hip); systemic illness with extra-articular symptoms (eg. fever, fatigue, weight loss, pericarditis and pleurisy, but initially few joint problems)
Polymyalgic onset - vague limb girdle aches. Recurrent soft tissue problems - frozen shoulder, carpal tunnel.
Risk factors for breast abscess?
Nipple fissures, cracks and sores breast engorgement and poor milk drainage Maternal age over 30 years Women with history of mastitis Gestational age over 41 weeks Improper nursing technique
Who does malnutrition affect disproportionately?
Children and pregnant women
What is emphysema?
Defined histologically as enlarged air spaces distal to terminal bronchioles with destruction of alveolar walls
How are polyneuropathies classified?
Course - acute or chronic
Function - sensory, motor, autonomic, mixed
Pathology - demyelination, axonal degeneration or both
Presentation of aortic regurgitation?
Symptoms, signs, ECG, CXR
Symptoms - exertional dyspnoea, orthopnoea, PND. Palpitations, angina, syncope, CCF.
Signs - collapsing pulse, wide pulse pressure, displaced, hyperdynamic apex beat, high pitched early entry diastolic murmur (expiration, sitting forward)
ECG - LVH
CXR - cardiomegaly, dilated ascending aorta, pulmonary oedema
Treatment for iron deficiency anaemia?
Ferrous sulphate 200mg/8h PO
Causes of CKD?
Diabetes Hypertension Glomerulonephritis Unknown Pyelonephritis and reflux nephropathy
Treatment of UC?
Aminosalicylate (treatment of choice in induction and maintenance of remission) Corticosteroids Infliximab (moderate to severe) Surgery in 20% of cases
Risk factors for inguinal hernia?
Male gender Constipation Urinary obstruction Heavy lifting Ascites Past abdominal surgery
Most common types of lung carcinoma?
- Squamous cell (35%) 2. Adenocarcinoma (27%) 3. Small Cell (10%) 4. Large cell (10%) 5. Alveolar cell (rare)
Risk factors for colorectal ca?
Age, FH, past history, IBD
Polyposis syndromes
Hormonal factors - nullparity, late age at first prego, early menopause
Diet - rich in meat and fat, poor in fibre, folate and calcium
Sedentary lifestyle, obesity, smoking, alcohol, DM
Previous irradiation, occupational hazards
History of small bowel ca, endometrial ca, breast ca, ovarian ca
Risk factors for urinary tract stones?
Anatomical abnormalities in the kidney/urinary tract
Family history of renal stones
Hypertension
Gout
Hyperparathyroidism
Immobilisation
Metabolic disorders which increase excretion of solutes
Drugs - diuretics, calcium/vit D supplements
More common in hot climates and increased risk in higher socio-economic groups
Treatment of MS?
Disease modifying treatment - interferon beta, glatiramer, dimethyl fumarate
Acute attacks - IV infusion of methylprednisolone
Treat all other complications
Definition of self harm?
A behaviour which resulted in a nonfatal act which included one or more of the following:
- A behaviour intended to cause self-harm
- Ingesting a substance in excess of the prescribed or generally recognised therapeutic dose
- Ingesting a recreational or illicit drug that was an act the person regarded as self harm
- Ingesting a non-ingestible substance or object
Aortic aneurysms can be classified as what?
Abdominal (majority) or thoracic
Hodgkin’s lymphoma - peaks in incidence?
20-34 years, then over 70 years
What is raised in acute pancreatitis?
Serum amylase, serum lipase
Risk factors for pancreatic ca?
Smoking, alcohol, carcinogens, DM, chronic pancreatitis, high waist circumfrence
Management of AKI?
Aim for euvolaemia Treat underlying cause Manage complications STOP NEPHROTOXICS
Causes of small bowel obstruction?
Adhesions, hernias
Causes of dementia?
AD, vascular, lewy-body, frono-temporal, mixed dementia, parkinson’s disease
Who does pneumonia affect?
Very old and very young
Presentation of chronic liver failure?
Mental state - drowsiness and possible confusion. Jaundice, hyperdynamic circulation with multiple organ failure.
Abdominal distension and abdominal mass: possible massive ascites.
Cerebral oedema with raised ICP
Palms are red and hepatic flap may present
Hepatic encephalopathy
Signs of phrenic nerve palsy and possible causes?
Orthopnoea with raised hemidiaphragms on CXR
Lung cancer, myeloma, thyoma, cervical spndylosis/trauma, c3-5 zoster, HIV, big left atrium, phrenic muscle lesion
Buttock claudication and impotence imply what?
Leriche’s syndrome
Classical skin manifestation of coeliac disease?
Dermatitis herpetiformis
Symptoms of septic arthritis?
Single swollen joint with pain on active or passive movement
Fevers and rigors present in majority of cases
Bacteraemia a common finding, may cause prostration, vomiting or hypotension.
Presentation of peptic ulcer?
Epigastric pain related to hunger, specific foods or time of day - fullness after meals, heartburn, tender epigastrium
What causes stroke?
Ischaemic infarction or bleeding into part of the brain
What causes MS?
Autoimmune - repeated episodes of inflammation of the nervous tissue in the CNS, causing loss of the myelin sheath.
Cause of T2DM?
Reduced insulin secretion and/or increased insulin resistance, leading to increased blood glucose.
Risk factors for infective endocarditis?
Valvular heart disease with stenosis or regurgitation; valve replacement; structural congenital heart disease; previous IE; hypertrophic cardiomyopathy.
Presentation of anxiety?
Free floating anxiety and depression are main symptoms.
Fatigue, insomnia, irritability, worry.
Obsessions, compulsions, somatisation.
Trembling, sense of impending doom, poor concentration, ‘butterflies in stomach’, hyperventilation, headaches, sweating, palpitations, poor appetite, nausea, ‘lump in throat’ unrelated to swallowing
ALL MORE INTENSE THAN THE STRESS PRECIPITATING THEM WOULD WARRANT
Primary prevention of stroke?
Control risk factors - hypertension, DM, lipids, cardiac disease, do exercise
Folate supplements
Quit smoking
Lifelong anticoagulation if rheumatic or prosthetic heart valves on left side and consider in chronic non-rheuamtic AF.
Treatment of BPH?
Alpha-blockers - tamsulosin 5-alpha-reductase inhibitors - finasteride Surgery - TURP, TUIP, retropubic prostatectomy
Prognosis of Hodgkin’s lymphoma?
Can be cured in most. Five year survival 81%
Signs of radial nerve palsy?
Wrist and finger drop
Sensory loss most reliably in anatomical snuffboxes
BEST - brachioradialis, extensors, supinator, triceps.
Symptoms of acute pancreatitis?
Gradual or sudden epigastric or central abdominal pain (radiates to back, sitting forward may relieve); vomiting prominent
What is somatisation?
When mental factors such as stress cause physical symptoms. People often convinced that their symptoms have a physical cause.
What is delerium?
Impaired consciousness with onset over hours or days, usually reversible.
Signs of cushing’s syndrome?
Central obesity, plethoric moon face, buffalo neck hump, supraclavicular fat distributon, skin and muscle atrophy, bruises, purple abdominal striae, osteoporosis, increased BP, hyperglycaemia, infection-prone, poor healing
Who does migraine affect?
Adults and children - more common in women than men
Treatment of peptic ulcers?
Lifestyle - purge stress. Reduce alcohol and tobacco use, avoid aggravating foods H.pylori eradication via triple therapy Drugs to reduce acid - PPIs/H2 blockers
Treatment for septic arthritis?
If in doubt start IV abx:
Flucloxacillin (clindamycin if penicillin allergic)
Vancomycin if MRSA
Cefotaxime if gonococcal or gram -ve organism suspected.
Abx required for prolonged period.
Ask for orthopaedic advice for consideration of arthrocentesis, lavage and debridement, esp if prosthetic joint involved.
Risk factors for AKI?
Age > 75 CKD Cardiac failure Chronic liver failure Diabetes Drugs Sepsis Poor fluid intake/increased losses History of urinary symptoms
Treatment for hospital acquired pneumonia?
Aminoglycoside + antipseudomonal penicillin IV or 3rd gen cephalosporin IV
Incidence of delerium higher in whom?
Elderly, those with previous cognitive impairment, malignancy and HIV
Who does depression affect?
1 in 4 women, 1 in 10 men
What is epilepsy?
Recurrent tendency to spontaneous, intermittent abnormal electrical activity in part of the brain, manifesting as seizures.
Presentation of DVT?
Limb pain/tenderness along line of deep veins Swelling of calf or thigh (unilateral Distension of superficial veins increase in skin temperature Skin discoloration Palpable cord (hard, thickened palpable vein)
Management of aortic stenosis?
Aortic valve replacement, TAVI if not fit for surgery
In which groups is self-harm common?
Young people - 10% girls 3% boys aged 15-16
Treatment of Parkinsons?
Levodopa - late start may be wise due to SEs (dopamine-induced dyskinesias)
treatment for associated neuropsychiatric complications
Deep brain stimulation
Surgical ablation of overactive basal ganglia circuits
How to ilicit Murphy’s sign?
Lay 2 fingers over RUQ and ask patient breathe in - causes pain and arrest of inspiration as inflamed GB impinges on fingers. Only positive if same test doesn’t cause tenderness in LUQ
Causes of stroke?
Small vessel occlusion, cardiac emboli (AF), atherothromboembolism (carotids), CNS bleeds, sudden drop in BP (sepsis), carotid artery dissection, vasculitis, SAH, venous sinus thrombosis, antiphospholipid syndrome, thrombophilia, Farby’s disease
Investigations in hyperT?
Low TSH, high T3 and T4
ESR high, hypercalcaemia, high LFT
secondary prevention of stroke?
Risk factor control
Antiplatelet agents after stroke (if no haemorrhage) - clopidogrel
Anticoagulation after stroke from AF - warfarin 2 weeks after stroke, use antiplatelet therapy until anticoagulated.
Presentation of generalised disease in OA? (Primary OA)
Heberden’s nodes (commonly - DIPJs)
May be joint tenderness, derangement and bony swelling (heberden’s nodes DIP, bouchard’s nodes PIP), reduced ROM, mild synovitis.
Occupation, family duties, hobbies and lifestyle often affected.
Complications of gallstones in gallbladder and cystic duct?
Biliary colic, acute and chronic cholecystitis, mucocele, empyema, carcinoma
Cause of TIDM?
Insulin deficiency from autoimmune destruction of insuilin secreting beta cells
Risk factors for malnutrition in elderly people?
Living alone, institutionalisation, severe learning difficulties or mental health problems, diseases that affect appetite, eating/swallowing or GI function, catabolic states
Post-renal?
Urinary tract obstruction Luminal - stones, clots Mural - malignancy, BPH, stricutres Extrinsic compression - malignancy, retroperitoneal fibrosis
Other causes of hospital acquired pneumonia?
Pesudomonas, klebsiella bactriodes, clostridia
Causes of primary autoimmune hypoT?
Primary atrophic hypoT - 6:1 FM. Lymphocyte infiltration, atrophy. Not goitre.
Hashimoto’s thyroiditis - GOITRE
Causes of meningitis in elderly and immunocompromised?
S. pneumoniae, L.monocytogenes, TB, gram -ve organisms
What is OA characterised by?
Localised loss of cartilage, remodelling of adjacent bone and associated inflammation
Complications of pancreatic ca?
Hypercalcaemia, portal hypertension, nephrosis
Presentation of pulmonary fibrosis?
Gradual onset of dyspnoea and/or nonproductive cough. Wheezing, haemoptysis, chest pain.
Signs = central cyanosis, fine end-inspiratory crackles, finger clubbing. Signs of pulmonary hypertension and RHF occur late in disease.
CXR - reticular and/or nodular opacities. Honeycombing a late sign.
Presentation of Burkitt’s lymphoma?
Abdominal mass and symptoms of bowel obstruction
Treatment of femoral embolism?
EMERGENCY
Needs open surgery or angioplasty. Surgical embolectomy or local intra-arterial thrombolysis. After successful embolectomy, anticoagulation with heparin to prevent reoccurrence.
Where are berry aneurysms?
Junction of posterior communicating with the internal carotid, of the anterior communicating with the anterior cerebral artery or bifurcation of middle cerebral artery.
Associations - PKD, coarction of aorta, Ehlers-Danlos syndrome
Presentation of protein energy malnutrition in children?
Poor weight gain, slowed linear growth, behavioural changes (irritability, apathy, anxiety, attention deficit).
Classically apathetic and quiet when lying in bed but cry when picked up with a typical monotonous bleat or loud groan.
Treatment of Crohn’s?
Mild attacks - prednisolone Severe - IV steroids (hydrocortisone), then oral prednisolone
Management of mitral stenosis?
if in AF, rate control. Anticoagulate with warfarin. Diuretics reduce preload and pulmonary venous congestion. Balloon valvuloplasty.
Prevention of gout?
Lose weight, avoid prolonged fasts, alcohol excess, purine rich meats and low dose aspirin.
Presentation of salivary gland tumours?
Slowly enlarging painless mass.
Parotid - most commonly occur in tail as discrete mass in otherwise normal gland.
Submandibular - diffuse enlargement of gland.
Sublingual - palpable fullness in floor of mouth
Airway obstruction, dysphagia, hoarseness, nasal obstruction, sinusitis.
Causes of macrocytic anaemia?
B12/folate deficiency is the biggest
Megaloblastic - B12 deficiency, folate deficiency, cytotoxic drugs
Non-megaloblastic - alcohol, reticulocytosis, liver disease, hypothyroidism, pregnancy
Other haematological disease - myelodysplasia, myeloma, myeloproliferative disorders, aplastic anaemia
In whom does pneumothorax most commonly occur?
Healthy young adults with no lung disease - common in tall thin people, more common in men than women, rare in people over 40, more common in cigarette smokers
Common causative organisms for mastitis and breast abscess?
Staph aureus, E.coli, bacteeriodes, streptococci
management of anxiety?
Symptom control - reassurance about worries.
Regular exercise
Meditation
CBT
Behavioural therapy
Drugs - benzos, SSRIs, azapirones, old-style antihistamines, beta-blockers, pregabalin and venlafaxine
Symptoms of unruptured AAA?
Often none - may cause abdominal/back pain, often discovered incidentally on abdo exam
What are you looking for in a CXR of pneumothorax?
Areas devoid of lung markings, peripheral to edge of collapsed lung
Causes of acute pancreatitis?
I GET SMASHED Iatrogenic Gallstones Ethanol Trauma Steroids Mumps Autoimmune Scorpion venom Hyperlipidaemia, hypothermia, hypercalcaemia ERCP Drugs
Risk factors for AAA?
Severe atherosclerotic damage of the aortic wall;
Family history - strong genetic factors
Tobacco smoking, male sex, increasing age, hypertension, COPD, hyperlipidaemia
Three types of pulmonary fibrosis?
Replacement fibrosis secondary to lung damage - infarction, TB, pneumonia.
Focal fibrosis in response to irritants - coal dust and silica.
Diffuse parenchymal lung disease - occurs in fibrosing alveolitis and extrinsic allergic alveolitis.
How does perforated viscus present on CXR?
Air under diaphragm (pneumoperitoneum)
What is a SAH?
Spontaneous bleeding into the subarachnoid space
Presentation of tension headache?
Featureless, often generalised headache.
Described as pressure or tightness, like a tight band around head. Often relationship to neck. Lacks specific features and associated features of migraine.
Presentation of urinary tract stones?
Renal/ureteric colic - sudden severe pain. Pain starts in loin and moves to groin, with tenderness of renal angle, sometimes with haematuria.
Moving stone more painful than static stone. Radiation to testis, scrotum, labia or anterior thigh.
Pain of renal colic more constant than biliary or intestinal colic, but periods of relief or just a dull ache before it returns.
Rigors, fever, dysuria, haematuria, urinary retention, nausea, vomiting.
Writhing around in agony
Interventions in PAD?
Percutaneous transluminal angioplasty (PTA) - disease limited to a single arterial segment
Surgical reconstruction - femoral-popliteal bypass, femoral-femoral crossover, aorto-bifemoral bypass grafts
Amputation - (
Prevalence of PVD?
10%
Important investigation in LVF?
Echocardiogram
Three types of gallstones?
Pigment stones, cholesterol stones, mixed stones
Signs of acute pancreatitis?
Tachycardia, fever, jaundice, shock, ileus, rigid abdomen, local/general tenderness. Cullen’s/Grey Turner’s sign from blood vessel autodigestion or retroperitoneal haemorrhage.
6 Ps of critical ischaemia?
Pale, pulseless, painful, paralysed, paraesthetic and perishingly cold
