Core Conditions

Question 1

Acute Coronary Syndrome

Answer 1

Definition: ACS is ischaemia of the myocardium and includes STEMI, NSTEMI and angina Aetiology: It is usually due to atherosclerotic disease of the coronary vessels Clinical Features: Chest Pain - severe, sudden, at rest, >30mins Not relieved by GTN Sweating, SoB, N&V, Pale / grey, Tachy, HF, Hypotension, ‘Silent’ in 20% Investigations: Simple - ECG Bloods - FBC, U&Es, Trop T/I, Lipids Radiology - ?Angiography (see below) Management: O2 if hypoxic Morphine + antiemetic GTN Aspirin 300mg and continue indefinitely Fondaparinux if low bleeding risk & angio > 24 hours or LMWH if angio NSTEMI & Unstable Angina GRACE score: Lowest Risk - Conservative Low Risk - 300mg loading then 12 months Clopidogrel Intermediate to Highest Risk - As above but also consider GPI (Tirofiban) or Bivalirudin plus Angiography +/- PCI within 96 hours STEMI Cath lab for immediate PCI Long-Term Drugs Aspirin indefinitely Clopidogrel 300mg for 12 months ACEi ß-blocker Statins Admin Assess LVF Follow -up clinic Education Cardiac Rehab Lifestyle Modification

Question 2

Angina

Answer 2

Definition: Transient symptoms of myocardial ischaemia due to exertion which is relieved by rest. Risk Factors: Age, Male Sex, FH, Hyperlipidaemia, Smoking, HPT, DM, COX 2 inhibitors (celecoxib) Clinical Features: Central Chest Pain - heavy, tight, gripping, radiation to arms and jaw May be silent Investigations: Simple - ECG (normal or previous MI) - Exercise ECG (ST depression >1mm which reverts to normal) Bloods - FBC, U&Es, TFTs Radiology - Angiogram - Thallium Scan Management: GTN ß-blocker or Ca-channel blocker, if not controlled…. Both ß-blocker & Ca-channel blocker (*Nicorandil if not tolerated or cantraindicated*) If not controlled….. Long-acting nitrate (isosorbide) or Nicorandil If not controlled…… Consider revascularisation

Question 3

Sinus Node Disease

Answer 3

Definition: Variable combinations of fast & slow supraventricular rhythms. Aetiology: Ischaemia Infarction Degenerative Disease Clinical Features: Variable combinations of fast & slow supraventricular rhythms. Investigations: ECG - long interval between P waves >2 seconds Management: Permanent Pacemaker Antiarrhythmics to reduce tachys Anticoagulation

Question 4

Heart Failure

Answer 4

Definition: Heart is unable to maintain sufficient tissue perfusion despite adequate venous filling pressures. Aetiology: Left HF - ischaemic heart disease, HPT, mitral / aortic valve disease, cardiomyopathy Right HF - lung disease (cor pulmonale), PE, pulmonary HPT, L-R shunt, tricuspid regurgitation Clinical Features: Left HF - fatigue, exersional SoB, orthopnoea, PND, pulmonary oedema, tachy, enlarged heart, gallop rhythm, crackles Right HF - Tiredness, anorexia, nausea, GI upset, raised JVP, pitting oedema, pleural effusion, hepatomegaly, ascites, tricuspid regurgitation Investigations: BNP CXR ECG ECHO - LV ejection fraction Angiography Management: If ejection fraction preserved then control comorbidities. LV dysfunction: 1. ACEi (or ARB) + ß-blocker 2. Add in spironolactone or ARB or hydralazine 3. Consider CRT pacing and digoxin

Question 5

Orthostatic Hypotension

Answer 5

Definition: A fall in systolic blood pressure of at least 20mm Hg and diastolic blood pressure of at least 10 mm Hg when a person assumes a standing position. Aetiology: The symptom is caused by blood pooling in the lower extremities upon a change in body position and reduction in venous return causing reduced cardiac output. Hypovolaemia Addison’s Atherosclerosis Clinical Features: Dizziness Euphoria or dysphoria Bodily dissociation Distortions in hearing Lightheadedness Nausea Headache Blurred or dimmed vision Seizures Investigations: Management:

Question 6

Shock

Answer 6

Definition: Circulatory failure resulting in inadequate organ perfusion. Generally systolic BP Aetiology: Pump Failure Primary: Cardiogenic Shock Secondary: PE, tension pneumothorax, cardiac tamponade Peripheral Circulation Failure Hypovolaemia Bleeding: trauma, AAA, ruptured ectopic Fluid Loss: Vomiting, diarrhoea, burns, ‘third spacing’ Anaphylaxis Sepsis Neurogenic Endocrine Failure: Addison’s, Hypothyroidism Iatrogenic: Drugs e.g. anaesthetics, antiHPT Clinical Features: Pallor Inc. Pulse Red. Capillary Return Air Hunger Oliguria Investigations: ABC approach Simple: ECG, dipstix and culture, BM Bloods: FBC, CRP, U&Es, TFTs, LFTs and clotting, Glucose, ABG + lactate, Cultures, X-Match Radiology: CXR, ?echo, USS, abdo CT Management: ABC Raise Foot of Bed IV Access x2 Fluids Stat! Identify Cause Investigations as Above Catheterise

Question 7

Syncope

Answer 7

Definition: ‘Blackouts’ with multiple clinical pictures and causes. May or may not involve LOC Vasovagal Syncope: reflex bradycardia +/- vasodilation Cough Syncope: weakness + LOC after coughing Effort Syncope: on exercise, cardiac origin e.g. AS Micturition Syncope: mostly men, at night Carotid Sinus Syncope: carotid sinus hypersensitivity, headturning or shaving Epilepsy: most likely Grand Mal presenting with LOC Stokes-Adams Attacks: transient arrhythmias causing low cardiac output & LOC Others: hypoglycaemia, orthostatic hypotension, drop attacks, anxiety Clinical Features: LOC with possible associated symptoms e.g. nausea, pallor, sweating, visual disturbance Investigations: Collateral History CVS with sitting / standing BP Neuro BM ? 24hr ECG Management: Cause dependent

Question 8

Mitral Stenosis

Answer 8

Aetiology: Rheumatic Fever Clinical Features: Secondary to Pulmonary HPT Progressive SoB PND Orthopnoea Haemoptosis Recurrent Bronchitis Others Malar Flush ⇓Pulse Volume AF Heart Sounds Tapping Apex Beat Loud 1st Heart Sound Opening Snap Rumbling Mid-diastolic Murmur @ Apex Signs of RVF Investigations: CXR – large L atrium, convex L heart border ECG – bifid ‘P’ wave, AF, R ventricular hypertrophy, R axis deviation Echocardiogram – Management: Medical: Diruretics Rate control for AF (β-blockers, Ca2+-blockers, Digoxin) Anticoagulation Endocarditis Prophylaxis Surgical: Balloon Valvotomy Closed Valvotomy Open Valvotomy Replacement Complications AF Emboli Pulmonary HPT Pulmonary Infarction Chest Infections Tricuspid Regurgitation RVF

Question 9

Mitral Regurgitation

Answer 9

Aetiology: Mitral Valve Prolapse Rheumatic Fever IHD Dilated Cardiomyopathy Infective Endocarditis Clinical Features: Palpitations Exertional SoB Fatigue Cardiac Failure Apex – laterally displaced, hyperdynamic, systolic thrill Heart Sounds Soft 1st heart sound Loud pan-systolic @ apex with radiation to axilla 3rd heart sound Investigations: CXR Echo Cardiac Catheterisation Management: Medical: Symptom management (ACEi, Diruretics) Endocarditis Prophylaxis Surgical: Valve replacement

Question 10

Aortic Stenosis

Answer 10

Aetiology: Congenital Rheumatic Fever Clacific Clinical Features: Often None Exertional angina, syncope, SoB Small volume, slow-rising pulse Sustained apex beat Systolic Thrill in aortic region Sudden Death Heart Sounds Ejection systolic murmur @ aortic area Radiation to carotids Ejection Click Soft 2nd heart sound Investigations: CXR Echo Management: Conservative: Avoid strenuous exercise Avoid vasodilators Medical: β-blocker for angina Surgical: Valve replacement (mandatory in symptomatic patients)

Question 11

Aoritc Regurgitation

Answer 11

Aetiology: Rheumatic Fever Marfan’s Syphilis Connective Tissue Disorders Aortic Dissection HPT Clinical Features: Can be asymptomatic Palpitations Angina LVF Collapsing Pulse Pistol Shot Femorals Wide Pulse Pressure Heart Sounds Apex – displaced, diffuse, hyperdynamic Soft, high-pitched early diastolic Left sternal edge Possible systolic aortic flow murmur Visible Carotid or Head Nodding Investigations: Management: Medical: Nifedipine may prolong time before replacement Surgical: Valve replacement at the onset of ventricular dysfunction

Question 12

Tricuspid Regurgitation

Answer 12

Aetiology: Infective Endocarditis in IV drug users Chronic Lung Disease Pulmonary HPT Dilatation of Right Ventricle Carcinoid Syndrome Clinical Features: Exersional SoB GI upset due to congestion Elevated JVP with giant V wave Pulsatile Hepatomegaly Peripheral Oedema Ascites Pleural effusions Right Ventricular Impulse at Left Sternal Edge Heart Sounds Pansystolic Murmur at lower left sternal edge, louder in inspiration Investigations: Management: Medical: treat right ventricular failure Surgical: resection in infective EC valve repair or replacement

Question 13

Venous Thromboembolism (DVT)

Answer 13

Definition: Occur in 25-50% of surgical patients, and many none surgical patients. 65% of below knee DVTs are asymptomatic and rarely embolize to the lungs. Risk Factors: Age, pregnancy, synthetic oestrogen, surgery, prev. DVT, malignancy, obesity, immobility, thrombophillia Clinical Features: Calf warmth / swelling / tenderness / erythema Mild Fever Pitting Oedema Investigations: Wells Score >3 - High probability, treat as suspected DVT & USS 1-2 - Intermediate probability, treat as suspected DVT & USS 0 - Low probability, perform D-dimer…. If +ve treat as suspected DVT & USS If -ve DVT is reliably excluded Management: Enoxaparin and Warfarin for ~48 hours and stop Enoxaparin when INR = 2-3 Continue Warfarin for 3/12 post-op, 6/12 if no cause, lifelong if recurrent DVTs IVC filters may be considered later

Question 14

BCC

Answer 14

Incidence: 1 / 1000 per year M:F 1.3:1.0 Risk Factors: Skin Types 1&2 Sunburn in childhood Immunosuppression Old Age Site: Upper 2/3 of face Features: Pearly papule with telangectasia Eroded centre Slowly increasing in size Management: Surgical Excision Mohs Curettage & Cautery Cryotherapy Photodynamic Therapy Topical 5-fluouracil Superficial Radiotherapy Prognosis: Excellent - rarely local recurrence 50% 2nd BCC at 5 years Does not metastasize

Question 15

Cellulitis

Answer 15

Clinical Features: Hot, tender area of confluent erythema Often on lower leg Can affect face Caused by streptococci Risk Factors: DM Management: Oral / IV Abx

Question 16

Eczema

Answer 16

Definition: Acute – inflamed weeping skin with vesicles Subacute – erythema, dry / flaky skin, crusted Chronic – lichinified skin Aetiology: 40% of population have an episode associated with atopy Atopic Individuals have a tendency to: Asthma Eczema Hay Fever Allergic Rhinitis Genetic Environmental – detergents, chemicals, infection, stress, animal fur, food Clinical Features: Itchy erythematous scaly patches Often flexural May be associated with nail pitting Investigations: May have raise IgE or eosinophils Patch Testing Management: Education & Explanation Avoid irritants Emollients Topical Steroids Abx Antihistamines Second-line Agents: UV Oral Steroids Ciclosporin / Azathioprine

Question 17

Melanoma

Answer 17

Incidence: 1 / 10000 per year Median Age at Presentation 50 Risk Factors: M:F = 1:2 FH Acute Sunburn, esp. childhood Number of pigmented moles Previous Melanoma Features: Irregular pigment and edge Increasing size in adult life Occurs in young adults Types: Superficial Spreading Nodular Sites: Males - back Females - leg Can occur anywhere on the body Management: Excise with wide margins - >1cm

Question 18

Psoriasis

Answer 18

Definition: Common disorder characterized by red, scaly plaques. 2% of the population. M=F Aetiology: T-cell driven Genetic Environmental Triggers: Infection Drugs e.g. Lithium UV light Alcohol Stress Clinical Features: Chronic Plaque Psoriasis: Purplish / red scaly plaques, particularly on extensor surfaces Scalp Involvement Can occur in areas of skin trauma (Köbner Phenomenon) 50% Associated with nail changes Flexural Psoriasis: Occurs in older patients Patches in groin, natal cleft, submammary Guttate Psoriasis: Raindrop lesions on trunk Occurs in children / young adults 2 weeks post strep sore throat Management: Education & Explanation Avoid irritants Topical steroids Calcipotriol (vit D analogue) Coal tar Phototherapy (PUVA) Methotrexate if severe

Question 19

SCC

Answer 19

Incidence: 1 / 4000 per year Risk Factors: Skin Type 1&2 Chronic Sun Exposure Outdoor Work & Leisure Activities Immunosuppression Old Age Chronic Skin Ulceration Defects in DNA repair - xeroderma pigmentosum Features: Painful, firm, keratotic / eroded, indurated nodule Increasing size over months Sun exposed sites - scalp, ears, dorsa of hands, lower legs Management: Surgical Excision with 4mm margin Prognosis: More likely than BCC to recur or metastisize Worse: ear, lip, ulcers size >2mm depth >4mm poorly differentiated immunosuppressed

Question 20

Adrenal Insufficiency

Answer 20

Definition: Primary Hypoadrenalism (Addison’s) Destruction of adrenal cortex causing reduced production of glucocorticoid, mineralocorticoid and sex steroids. Aetiology: Common: Autoimmune disease ~90% TB Surgical removal Uncommon: Haemorrhage / infarction Meningococcal septicaemia Venography Malignancy Amyloid Clinical Features: Tiredness Debility N&V Anorexia / weight loss Abdo pain Diarrhoea Depression Menstrual disturbance Pigmentation – mouth, palmar creases Postural hypotension Dehydration Loss of body hair Investigations: Reduced 9am Cortisol Reduced Synacthen Test Management: Replacement of glucocorticoids and mineralocorticoids with oral hydrocortisone and fludrocortisone

Question 21

Diabetes

Answer 21

Definition: Syndrome characterized by chronic hyperglycaemia due to relative insulin deficiency or resistance or both. WHO Classification Type 1: β cell destruction usually leading to absolute insulin deficiency Autoimmune or idiopathic Type 2: Variable combination of insulin resistance and defects in insulin secretion Aetiology: Autoimmune Idiopathic Genetic Endocrine problems (e.g. Cushing’s) Pancreatic trauma or disease Drug-induced - corticosteroids, thiazides Clinical Features: Due to hyperglycaemia Thirst Polyuria Weight loss Ketoacidosis ⇓ Energy Visual Blurring Candida Infections Due to Complications Skin infections Retinopathy - haemorrhages, exudates etc… Polyneuropathy - ‘glove&stocking’, autonomic Erectile Dysfunction Arterial Disease - atheroma, stroke, MI, PVD Renal Disease - glomerular sclerosis, pyelonephritis Charcot’s Joints Diabetic Foot Investigations: WHO Criteria For Diagnosis: HbA1c >6.5% is diabetic HbA1c 6.0-6.4% is high risk of developing diabetes - lifestyle advice & yearly monitoring Management: Based on self-monitoring and management by the patient, helped and advised by specialists. Requires good education and understanding of disease by the patient, including: - Monitoring blood sugar - Self-injection of insulin - Managing hypoglycaemic events - How to recognize complications - When to contact specialists for help Type I Drugs Insulin - fast, intermediate, long acting (pumps) Type II Drugs Oral Hypoglycaemics: Biguanides - inc. insulin sensitivity (eg Metformin) Sulfonylureas - inc. insulin secretion (eg Gliclazide) Thiazolidinediones - inc. insuin sensitivity (eg Pioglitazone)

Question 22

Goitre

Answer 22

Definition: Swelling of the thyroid gland, may be associated with hypo / hyperthyroidism Aetiology: Aetiology in Euthyroid Patient: Simple non-toxic goitre - Iodine Deficiency - Treated Grave’s disease - Puberty Solitary Nodule - Thyroid adenoma - Thyroid cyst - Thyroid carcinoma Aetiology in a Hypothyroid Patient: Hashimoto’s Thyroiditis Radioiodine-treated Grave’s Aetiology in a Hyperthyroid Patient: Grave’s Disease Toxic Multinodular Goitre Clinical Features: Neck swelling and features of hyper / hypothyroidism Management: Treat cause

Question 23

Hypothyridism

Answer 23

Definition: A condition in which free T4 is reduced due to different potential causes. Aetiology: Hashimoto’s - autoimmune Thyroid destruction Radioiodine-treated hyperthyroidism Thyroidectomy Clinical Features: Weight gain Lethargy Depression Patient feels cold Constipation Poor appetite Menstrual disturbances Myxoedema facies; thickened skin Brittle hair Periorbital puffiness Bradycardia Slow relaxing reflexes Investigations: Biochemistry Haemotology – macrocytosis, anaemia Anti-thyroid antibodies Management: Thyroxine Caution in cardiac disease Monitor TSH

Question 24

Hyperthyroidism

Answer 24

Definition: Characterised by increased plasma concentration of free T4 Aetiology: Grave’s Disease Toxic multinodular goitre Single toxic nodule Gestational Clinical Features: Heat intolerance Weight loss Increased appetite Diarrhoea Irritability Sleepleessness, tiredness Exertional SoB Goitre Tachy / AF Tremor Hyperkinesia Proximal muscle wasting Cardiac failure Pretibial myxedema Eye Signs (Grave’s): Exopthalmos Lid lag Lid retraction Opthalmoplegia Investigations: T4 up TSH down Management: Carbimazole Propylthiouracil Radioiodine Surgical for: Malignancy Pressure symptoms Failure of medical treatment

Question 25

Acute Abdomen

Answer 25

Definition: Someone who becomes acutely ill and in whom symptoms and signs are chiefly related to the abdomen. Aetiology: Clinical Syndromes That Usually Require Laparotomy: Rupture of an organ – spleen, aorta, ectopic pregnancy Peritonitis – perforation of ulcer, diverticulum, appendix, bowel or gall bladder Syndromes That May Not Require Laparotomy: Local Peritonitis – diverticulitis, cholecystitis, salpingitis or appendicitis Colic - Clinical Features: Rupture of an organ – shock, swelling, trauma Peritonitis – prostration, shock, lying still, +ve cough test, tenderness +- rebound/percussion, rigid abdomen, guarding, absent bowel sounds Local Peritonitis – Colic – waxing & waning pain, restlessness Investigations: FBC U&Es Amylase LFTs CRP Urinalysis ABG (mesenteric ischaemia) CXR (gas under diaphragm) AbdoCT / USS Management: ABC approach Fluid Resus Pain relief Nil by mouth Find & treat cause

Question 26

Alcoholic Liver Disease

Answer 26

Definition: Steatosis \> Fibrosis \> Cirrhosis Degree of liver damage dependent on genetic factors and coexisting liver disease; women progress to cirrhosis faster Cage Questionnaire: Have you ever felt the need to cut down? Have you ever felt annoyed by criticism of your drinking? Have you ever felt guilty about your drinnking? Have you ever felt the need for an eye-opener? Clinical Features: lethargy, splenomegaly, jaundice, leuconychia, telangiectasia, spider naevi, gynaecomastia, xanthelasma/xanthoma, Dupuytren’s, clubbing, dilated chest/abdo wall veins, excoriations, fetor hepaticus (breath of the dead), palmar erythema Investigations: FBC - ⇑MCV, ⇓Platelets LFTs - ⇑GGT, ⇑bilirubin Coag - ⇑PT Others: ⇑Albumin, ⇑cholesterol Liver Screen: ⇑IgA U&Es to check kidney function & provide baseline USS +- biopsy Management: Abstinence Nutrition Vitamin replacement Laxatives Liver Tx

Question 27

Biliary Colic

Answer 27

Definition: Pain caused by gallbladder contraction against a gallstone stuck in the neck or the cystic duct Clinical Features: Pain in the RUQ / Epigastrium - with radiation around costal margins to back Sweaty Pale Tachycardia Nausea / Vomiting Patients often writhe around with pain, rather than sitting still Attacks lasts \< 6hrs Examination is otherwise normal Investigations: FCB, U&Es, LFTs CRP, Urine Dipstix USS gall bladder Management: Analgesia Nil by mouth Laprascopic Cholecystectomy

Question 28

Cholecystitis

Answer 28

Definition: Inflammation of the gall bladder Aetiology: Caused by chemical irritation within an obstructed gallbladder. Often begins with simple Biliary Colic Clinical Features: Severe RUQ pain Fever Tachycardia Nausea / Vomiting Murphy’s sign +ve - ask patient to take deep breath pressing RUQ under costal margin Patients tend to lay still & take shallow breaths as this is a local peritonitis Investigations: WCC - increased USS - Gallbladder - thickened gallbladder Plain Abdominal X-ray - only show 10% of stones Management: IV Fluid resuscitation IV Antibiotics - Cefuroxime Keep patient NBM Cholecystectomy Time frame is controversial Increasingly surgeons carry out procedure early in the acute phase Some say it’s better to wait until 6-8 weeks later 80-90% of cases of acute cholecystitis will spontaneously resolve over 24-48hrs

Question 29

Cholestasis

Answer 29

Definition: Obstructive jaundice arising in the biliary tree Aetiology: Main Gallstones Pancreatic Cancer Other Cholangiocarcinoma Chronic Pancreatitis Enlarged lymph nodes in the porta-hepatitis Clinical Features: Yellow appearance of skin + mucous membranes (above 50 micromol/l) Dark urine Pale stools Pruritis Weight loss - due to inability to absorb fat Investigations: FBC U&E LFT - increased alk phos Clotting USS - gallbladder/biliary tree - is a stone or a tumour causing obstruction? Chest X-ray Management: Gallstone Laproscopic cholycystectomy + Laproscopic common bile duct exploration or ERCP with stone extraction + Laproscopic Cholycystectomy Pancreatic Cancer CT should be carried out too assess resectability If it looks favourable then an endoscopic USS should be done: Allow a closer look at head of pancreas Allows cytology sample to be taken If the endoscopic USS also suggests favourobility then Whipple’s should be done If at surgery it’s decided the tumour is not removable, a biliary bypass should still be done If the tumour is not treatable then a stent should be fitted via ERCP to provide symptomatic relief

Question 30

Crohn's Disease

Answer 30

Definition: Inflammatory bowel disease which can affect anywhere from the mouth to the anus. It most commonly involves the terminal ileum, which can present as right iliac fossa pain. It affects patients between the ages of 18-30. Aetiology: Autoimmune attack against bowel wall. Causes full thickness infiltration and can therefore result in perforation, adhesions and fistula. It classically on colonscopy demonstrations skip lesions, which helps differentiate it from ulcerative colitis. Clinical Features: Fatigue Weight loss Fever Abdominal pain (classically RIF) Diarrhoea +/- blood Episcleritis Large joint arthropathy Tender abdomen Mass in RIF Episcleritis Erythema Nodosum Episcleritis Anal skin tags Extra-intestinal Manifestations Erythema Nodosum Episcleritis Large joint arthritis / Ankylosing spondylitis Renal stones Primary sclerosing cholangitis Investigations: FBC – Anaemia CRP Antibodies - Anti-S cerevisiae antibodies (more common in crohns than UC) Stool sample – culture & microscopy Ilieo-colonoscopy + Biopsy – skip lesions, deep ulceration Management: Severe abdo pain, diarrhoea, bowel obstruction, or systemically unwell = admit Mesalazine – prophylactic therapy Budesonide – Fewer side effects than prednisolone, but may be less effective Antibiotics for septic disease Immunomodulators Azothiaprine Methotrexate Biologics Infliximab Elemental diet Surgery Maintaining remission Mesalazine – after surgery Azothiaprine Infliximab

Question 31

Gallstones

Answer 31

Definition: Can be either: Cholesterol stone - 75% Pigment stone - Mixed 90% are Radio-lucent (unable to see on X-ray) Aetiology: Female - 3x more common Age - 10% of over 50’s have gall stones Obesity Hyperlipidaemia Haemolytic anaemia Crohn’s Disease Clinical Features: May Cause: Gallbladder Chronic cholecystitis Biliary colic Acute cholecystitis Mucocele Common bile duct Obstructive jaundice Cholangitis Pancreatitis Gut Gallstone ileus Investigations: Urinalysis, ECG, CXR to rule out other diseases FBC + CRP: infection LFTs: pattern of cholecystitis - ⇑ALP & ⇑GGT Amylase: pancreatitis U&Es: baseline USS to visualize stones ERCP Management: Usually surgical: cholecystectomy

Question 32

Gastroenteritis

Answer 32

Definition: Diarrhoea with N&V +/- abdo pain. Aetiology: Usually due to viruses (inc. Norovirus) but other infectious agent important - Shigella, Campylobacter Clinical Features: Diarrhoea, N&V, abdo pain, fever, sweating Investigations: Stool culture WCC inc. CRP inc. Management: Fluid replacement Antiemetics Discuss with Micro

Question 33

GORD

Answer 33

Definition: Decreased lower oesophageal sphincter; sustained or transient. Aetiology: Usually no obvious cause; secondary causes include smoking, pregnancy, scleroderma, drugs, trauma, alcohol, obesity Helicobacter Pylori is not associated with GORD Clinical Features: Heartburn, regurgitation Investigations: OGD, 24hr pH monitoring in difficult cases Management: Conservative: weight loss, avoidance of smoking and alcohol Medical: simple antacids, H2 blockers (Ranitadine), PPIs Surgery: Nissen fundoplication (fundus wrapped around distal oesophagus) Complications Reflux oesophagitis, peptic stricture, Barrett’s oesophagus

Question 34

Hernias

Answer 34

Definition: The protrusion of a viscus through the walls of it’s containing cavity into an abnormal position Aetiology: Congenital hernias Groin Hernias (most common 75%) Inguinal - direct, enter inguinal canal through transversalis and emerge at superficial inguinal ring - indirect, enter inguinal canal through deep ring and often protrude into scrotum Arise SUPERIOR & MEDIAL to pubic tubercle Femoral - emerge through femoral canal, normally contains only fat & lymph nodes. More prone to strangulation due to sharp edge of lacunar ligament Arise INFERIOR & LATERAL to pubic tubercle

Question 35

IBS

Answer 35

Definition: GI symptoms in the absence of structural pathology; abnormal autonomic reactivity, visceral hypersensitivity. Aetiology: Post-infective, stress, adverse life events, psychological problems: anxiety, depression. Clinical Features: Abdominal discomfort, relief with defaecation, alternating bowel habit, bloating Investigations: Patient Patient \>45, with short history or atypical symptoms – other pathologies should be ruled out Management: Supportive: explanation, reassurance, lifestyle advice Medical: Aimed at specific symptoms – antispasmodics (Mebeverine), antidepressants, anti-diarrhoeals, constipation treatments Dietary: Diary to discover causative foods & exclusion diet Psychological: CBT

Question 36

Liver Cirrhosis

Answer 36

Definition: Necrosis of hepatic parenchyma with connective tissue proliferation and nodular regeneration Aetiology: Alcoholism by far most common cause follwed by Hep c. Others - Hep B, PSC, PBC, Drugs, NAFLD, AA hep, Wilson's, Budd-Chiari Clinical Features: Related to underlying cause: lethargy, splenomegaly, jaundice, leuconychia, telangiectasia, spider naevi, gynaecomastia, xanthelasma/xanthoma, Dupuytren’s, clubbing, dilated chest/abdo wall veins, excoriations, fetor hepaticus (breath of the dead), palmar erythema Investigations: Aimed at finding cause: • LFTs • FBC • U&Es • Albumin • Coagulation • Biopsy Management: Treat underlying cause Complications of Cirrhosis: Malnutrition Hepatic Encephalopathy Ascites / Oedema Vitamin Deficiency Coagulopathy Impaired Immune System Varices Hepatorenal Syndrome Hepatocellular Carcinoma

Question 37

Ulcerative Colitis

Answer 37

Definition: Inflammatory bowel disease, affecting the colon only Aetiology: Mucosal inflammation of colon (transmural in crohn’s) Clinical Features: Weight loss Bloody diarrhoea Fever Colicky abdominal pain Tenesmus Constipation Tender abdomen Distension Abdominal mass Extra-gastrointestinal signs Erythema nodosum Pyoderma gangrenosum Ankylosing Spondylitis Episcleritis Primary Sclerosing Cholangitis Investigations: • Bloods o FBC – anaemia o CRP & ESR – disease severity o Antibodies – p Anca • Stool sample o Blood o Microscopy, Culture & Sensitivity • Abdominal X-ray – signs of toxic megacolon • Colonoscopy + Biopsy - diagnosis Management: Local – topical steroids in proctitis Systemic o Corticosteroids – Budesonide (induction of remission) o Mesalazine – induction & maintinence of remission o Azothiaprine – no response to steroids or \>2 use of steroids in 1yr o Infliximab – use when no response to azothiaprine (induction of remission) Surgery o Ileal pouch anal anastomoses (removal of colon)

Question 38

GI Malignancy

Answer 38

Definition: Aetiology: Clinical Features: Investigations: Management:

Question 39

Nephrotic Syndrome

Answer 39

Definition: A triad of: Proteinuria (\>3g/24h) Hypoalbuminaemia ( Oedema Aetiology: 80% due to glomerulonephritis membranous GN most common in adults minimal change GN most common in children Others: DM, amyloidosis, SLE, drugs and allergies Clinical Features: Oedema - peri-orbital, face, arms Frothy urine Ascites Normal JVP Investigations: Simple: 24hour urine, throat swab, Bloods: Albumin, U&Es (urea & Cr), Antibodies Others: CXR (pulmonary oedema) Renal imaging (USS) +- biopsy Management: Sodium restriction Diuretics ACEi Steroids Cyclophosphamide Complications: DVT Sepsis Oliguric Renal Failure Lipid Abnormalities

Question 40

Oesophageal Disease

Answer 40

Definition: Barrett's Oesophagus - columnar epithelium with intestinal metaplasia replaces normal squamous mucosa Oesophageal Carcinoma - 40% squamous, 60% adenocarcinoma Achalasia - failure of relaxation of lower oesophageal sphincter Aetiology: Barrett's Oesophagus - GORD Oesophageal Carcinoma - Barrett's, smoking Achalasia - Clinical Features: Barrett's Oesophagus - Oesophageal Carcinoma - dysphagia (solids-liquids), weight loss, anorexia, Virchow's Achalasia - dysphagia (solids-liquids) Investigations: Barrett's Oesophagus - Endoscopy Oesophageal Carcinoma - Endoscopy, USS, CT Achalasia - Barium Swallow (Rat's tail), endoscopy, manometry Management: Barrett's Oesophagus - watchful waiting Oesophageal Carcinoma - 10% 5 year survival, SCC (radio/chemo, surgery), Adeno (surgery, palliative, ablation, radio) Achalasia - balloon dilatation, botox, Heller's sphinctotomy

Question 41

Pancreatitis

Answer 41

Definition: Inflammation of the pancreas, acute or chronic Aetiology: Alcohol Gall Stones Trauma ERCP Drugs - azathioprine, steroids, oral contraceptive Infection - mumos, coxsackie, klebsiella Metabolic - hypercalcaemia, hyperlipidaemia, renal failure Other - hypothermia, malnutrition, scorpion bite Clinical Features: abdo pain radiating to back, N&V, anorexia, abdo tenderness & guarding, Grey-Turner sign, basal crackles Investigations: Abdo Xray inc. neutrophils U&Es - renal failure Calcium & glucose Amylase elevated ABG - hypoxia & acidosis LFTs USS - gallstones CT Management: GLASCOW SCORE ABC Analgesia ERCP HDU

Question 42

Peptic Ulcer Disease

Answer 42

Definition: Break in the mucosal surface of the stomach or duodenum \>5mm Aetiology: 95% of duodenal ulcers & 70% of gastric ulcers are associated with H-pylori. Other associations are NSAIDs, smoking and alcohol. Clinical Features: Dyspepsia Heartburn Anorexia Epigastric tenderness Investigations: OGD if \>55 or red flag symptoms Breath test if Stool antigen test Management: PPI, amoxicillin, clarithromycin 500mg or a PPI, metronidazole, clarithromycin 250 mg

Question 43

Peritonitis

Answer 43

Definition: Inflammation of the peritoneum, locally (eg appendicitis) or generalised. Aetiology: Rupture of abdominal viscus eg perforated duodenal ulcer, perforated appendix. Clinical Features: Sudden onset abdominal pain Shock Still patient Investigations: AXR - air under diaphragm Check amylase Management: Analgesia Surgery

Question 44

Anaemia

Answer 44

Definition: Reduced Hb concentration (Normal Range 13M, 11.5F) Aetiology: Reduced production - aplastic, pernicious, iron deficiency Increased destruction - congenital, sickle cell, AA, DIC RBC loss - haemorrhage, menstruation Clinical Features: Fatigue SoB Exertional angina Palpitations Pallor Tachy Koilonychia Angular stomatits / glossitis Investigations: WCC may be low in bone marrow failure Reticulocytes - measures bone marrow activity Blood film - shows erythrocyte morphology Management: Treat underlying cause eg iron supplements

Question 45

Leukaemia

Answer 45

Definition: Malignancy of the blood or bone marrow resulting in an abnormal increase of immature WBCs. Acute - Rare (5 in 100 000) AML & ALL Chronic - Usually older patients, changes to acute with a high 5-yr mortality CML & CLL Aetiology: Mostly unknown Some genetic & environmental factors Clinical Features: Acute: Bone marrow failure Weakness and tiredness due to anaemia Bruising due to thrombocytopenia Repeated infections Chronic Myeloid: Anaemia Night sweats & fever Weight loss Splenomegaly & pain Chronic Lymphocytic: Often incidental Infections due to neutropenia Anaemia Lymphadenopathy Hepatospenomegaly Investigations: Acute: Blood count Blood film - leukaemic blast cells Bone marrow - blast cells Chronic Myeloid: Blood count - raised WCC Multiple myeloid precursors Bone marrow biopsy Genetic testing for Philadelphia Chromosome 9:22 trans. Chronic Lymphocytic: Hb - low or normal WCC - raised 40% lymphocytes Plt - low or normal Serum IG - low Management: Acute: Correct anaemia & thrombocytopenia Treat infections Chemo to achieve remission Bone marrow ablation Chronic Myeloid: Interferons - remission in 10% Hydroxyurea reduced WCC Myeloablation with BM Tx Chronic Lymphocytic: Nothing if asymptomatic Steroids for haemolysis Fludarabine or Chlorambucil

Question 46

Anorexia

Answer 46

Definition: Reduced nutritional intake and an irrational fear of gaining weight due to distorted fears of body image Aetiology: Genetic Childhood sexual abuse Dietary problems in early life Social - higher class, ballet dancers, medical students Clinical Features: BMI Intense wish to be thin & morbid fear of fattness Amenorrhoea F\>\>M with adolescent onset Previously fat or chubby Avoids carbs Vomiting / excess exercise / purging Loss of libido Investigations: Clinical diagnosis Management: CBT - goal setting with rewards Psychotherapy Family therapy

Question 47

Anxiety

Answer 47

Definition: A displeasing feeling of fear and concern Aetiology: "biological vunerability" Clinical Features: GI - dry mouth, dysphagia, epigastric pain, diarrhoea Resp - chest constriction, difficulty inhaling, overbreathing CVS - palpitations, chest pain GU - frequency, erection failure, reduced libido Neuro - fatigue, blurred vision, dizziness, headache, poor sleep Psychological - Apprehension & fear, irritability, poor concentration, distractibility, restlessness, sensitivity to noise, depression, depersonalisation, derealisation Investigations: Clinical diagnosis Management: Reassurance, relaxation techniques, anxiety management, CBT SSRIs - citalopram, fluoxetine, sertraline ß-blockers for physical symptoms Short course of benzodiazepines - diazepam, temazepam

Question 48

Dementia

Answer 48

Definition: Progressive decline of cognitive function in the absence of clouded consciousness Alzheimer's - Neuronal loss, neurofibrillary tangles, senile plaques, amyloid deposition Lewy Bodies shown on CT Aetiology: Alzheimer's (65%) - may be familial Lewy Body (25%) CVD Clinical Features: Alzheimer's - Inability to learn new or recall old information, decline in language (names), apraxia, impaired organizing / sequencing, behavioural change, paranoia & loss of insight Lew Body - Fluctuating cognition with pronounced variation in attention / alertness, memory loss uncommon early on, sleep disorders, visual hallucinations, delusions & transient LOC Vascular - Hx of stroke Investigations: Rule out delerium: FBC, U&Es, ABG, BM, cultures, LFTs, TFTs, ECG, CXR ?CT / MRI, LP MMSE Management: Alzheimer's - cholinesterase inhibitors (eg rivastigmine, galantamine), NMDA (eg Memantine) Lewy Body - avoid neuroleptics (antipsychotics) Vascular - Stroke prevention

Question 49

Depression

Answer 49

Definition: Persistent low mood Aetiology: Physical - genetic, reduced 5HT, hormonal, CNS abnormalities Psychological - maternal deprivation, learned helplessness Social - stressful life events, sexual abuse in childhood Clinical Features: As you would expect plus hallucinations Investigations: Aimed at finding organic cause, endocrine, drugs etc Management: Stop depressing drugs Exercise SSRIs Venlafaxine ?TCAs, MAOIs, ECT Psychotherapy CBT Group / family support

Question 50

Mania

Answer 50

Definition: A state of abnormally elevated or agitated mood Aetiology: Physical - genetic, reduced 5HT, hormonal, CNS abnormalities Psychological - maternal deprivation, learned helplessness Social - stressful life events, sexual abuse in childhood Clinical Features: Elevated mood, fast, pressured speech, flight of ideas, grandiose ideation, insomnia, disinhibition, increased libido, excessive drinking / spending Investigations: Rule out intoxication Management: Acute - Lithium, Neuroleptics (eg Haloperidol) Prophylaxis - Lithium (monitor closely U&Es, TFTs), Carbamazepine, Valproate Psychotherapy / CBT Social

Question 51

Psychosis

Answer 51

Definition: Abnormal condition of the mind resulting in a loss of touch with reality Aetiology: Schizophrenia Schizoaffective disorder Bi-polar PTSD Drugs - alcohol, cannibis, meth Clinical Features: Schizophrenia: First Rank Symptoms - auditory hallucinations, thought withdrawal, thought insertion, thought broadcasting, delusions, externally controlled emotions, somatic passivity and feelings Investigations: Clinical based on first rank symptoms Management: Neuroleptics - (SE) Dopamine Antagonists (eg. Chlorpromazine, Haloperidol) Atypical (eg. clozaoine, risperidone, olanzaoine) less extrapyramidal SE Psychosocial suppport and education

Question 52

Mechanical Back Pain

Answer 52

Definition: Chronic back pain caused by a small injury leading to spasm of the back muscles and pain. Aetiology: Disc rupture - young Vertebral # - old Soft tissue tear - low back strain Clinical Features: Pain, usually self limiting Red Flags - 50 years, trauma, CNS symptoms, infective symptoms, steroid use, bony tenderness Investigations: \>3/52 - routine bloods to find cause \>4/52 &/or trauma &/or Red Flag - imaging Management: Get on with your life within limits of pain Physio Analgesia Treat depression Education

Question 53

Osteoarthritis

Answer 53

Definition: Pain & disability associated with joint space narrowing and altered cartilage osteophyte formation. Aetiology: Primary - Idiopathic Secondary - trauma, chondrocalcinosis, haemochromatosis, acromegaly, haemophillia, AVN, sickle cell Clinical Features: Joint pain / swelling / instability Morning Stiffness Joint effusion & crepitus Bony Swelling Muscle Wasting Limitation of movement & loss of function Investigations: Inflammatory markers not elevated No autoantibodies Xrays abnormal if severe damage MRI can show early cartilage changes Arthroscopy – early fissuring and cartilage surface erosion Management: Treat symptoms and disability, not xrays! Explain diagnosis and reassure Weight loss and exercise Hydrotherapy Heat / massage Analgesia Patients often use complimentary medicine Joint replacements / other surgery Clinical Subsets: Nodal OA Familial F \>\> M Develops in late middle age Poly articular involvement of the hand Heberden’s Nodes Generally good long-term functional outcome Predisposes to OA of the knee, hip and spine Xray – marginal osteophyte & joint space loss Erosive OA Rare DIP & PIP joints Poor functional outcome Xray – marked subchondral cysts May develop in to rheumatoid arthritis Generalised OA May occur in combination with nodal OA Hands, knees, first MTP joints and hips Familial F \> M May be autoimmune Large joint OA Knees & Hips Crystal-associated OA (Chondrocalcinosis) Calcium Phosphate Crystal Deposition Knees and wrists commonly affected Xray – may show calcification in the cartilage

Question 54

Rheumatoid Arthritis

Answer 54

Definition: Systematic disease with chronic, symmetrical polyarthritis, synovitis and non-articular features 1-3% of population Presents at all ages Commonly presents 30-50 years F \> M before menopause Familial or sporadic HLA-DR4 in 50-70% Aetiology: Unexplained T Cell Activation Presence of rheumatoid factors Clinical Features: Slow onset but progressive Symmetrical peripheral polyarthritis Joint pain & morning stiffness Eased by gentle activity Joints warm and tender Limitation of movement and deformity Joint effusion Muscle-wasting Lethargy, malaise Non-articular features Investigations: Anaemia ⇑ inflammatory markers Rh factors in 70% Xray – erosions Management: Explain diagnosis and reassure MDT approach NSAIDs & Analgesics DMARDs Sulphasalazine Methotrexate Leflunomide Anti-TNF Drugs: Entanercept Infliximab Adalimumab Corticosteroids Less commonly used: Gold Penicillamine Hydroxychloroquine Azathioprine Ciclosporin Anikinra Joint Replacment / other surgery Non-articular Manifestations of RA: Hands: Nail fold lesions of vasculitis Tenosynovitis Tendon sheath swelling Carpal tunnel syndrome Arms: Bursitis / nodules Eyes: Scleritis Scleromalacia Dry - Sjögren’s Syndrome Mouth: Dry – Sjögren’s Syndrome Neck: Lymphadenopathy Atlanto-axial subluxation Rarely causing cervical cord compression Lungs: Pleural Effusion Fibrosing Alviolitis Caplan’s Syndrome Small Airway Disease Nodules Heart: Pericarditis Splenomegaly Renal: Amyloidosis Lower Limb: Ulcers Oedema Sensorimotor Polyneuropathy Anaemia

Question 55

Osteoporosis

Answer 55

Definition: Low bone mass & micro-architectural deterioration of bone. Mineralised normally but deficient in quantity & quality including structural integrity. Aetiology: Female, age, early menopause, smoking, FH, excess alcohol, nutrition, steroids, immunosuppression, endocrine disorders, RA, renal / liver failure Clinical Features: Back pain Weight loss Kyphosis Colles' # #NOF Investigations: Ca - ++, PO4 & alk phos normal XRAYs DXA - Management: Prevention Identification & monitoring patients at risk Diet rich in Ca & Vit D Exercise Stop smoking Reduce risk of falls Ca & Vit Supplements Bisphosphonates Raloxifene Parathyroid hormone Strontium Androgens in hypogonadal men

Question 56

Achalasia

Answer 56

Definition: Aperistalsis in the oesophagus and failure of relaxation on the lower oesophageal sphincter. Aetiology: Unknown Clinical Features: Long history of dysphagia for both solids and liquids Regurgitation Severe retrosternal pain, particularly in younger patients Investigations: Barium Swallow - dilatation, aperistalsis, beak deformity Gastroscopy to exclude malignancy Oesophageal monometry - aperistalsis & failure of LOS to relax CXR - dilated oesophagus with fluid level behind heart and no fundal gas shadow Management: Symptom relief Dilatation or division of LOS Botox or Ca-blockers also used

Question 57

Carpal Tunnel

Answer 57

Aetiology: Compression of the median nerve as it passes depp to the flexor retinaculum. F\>M Idiopathic DM Hypothyroidism Pregnancy RA Obesity Clinical Features: Tingling or pain in thumb, index & middle fingers Worse at night Shake or flick wrist for relief Later: wasting of thenar eminence Investigations: Phalen's (prayer for 1-2mins) Tinel's (tapping over tunnel) USS Management: Pain relief Splints at night Retinaculum division

Question 58

Delirium

Answer 58

Definition: Impairment of consciousness associated with abnormalities of perception and mood Aetiology: Infection Metabolic Disturbance Hypoglycaemia Intracranial - trauma, malig, abscess, haemorrhage Drugs - anticonvulsants, anxiolytics, opiates, digoxin Drug / alcohol withdrawal Post-op Vit Deficiency - Thiamine (wernicke-karsakoff), B12 Clinical Features: Acute clears within days Fluctuant with lucid periods Worse at night Visual hallucinations Frightened, suspicious, restless & uncooperative Investigations: FBC, CRP, U&Es, LFTs, TFTs, B12 Cultures ECG CXR CT Head Management: Treat underlying cause Good nursing in well-lit environment Good comms, include family Hydration Review drugs Emergency Rx - Haloperidol 5mg IM, Lorazepam in withdrawal

Question 59

Epilepsy

Answer 59

Definition: A continuing tendency to suffer epileptic seizures, a seizure being an abnormal event resulting from paroxysmal discharge or cerebral neurons. 2% of the population has two or more seizures Aetiology: Genetic, Developmental, Trauma, Surgery, Pyrexia, Intracranial Mass, Infarction, Alcohol / Drug Withdrawal, Encephalitis, Metabolic Abnormalities (hyponatraemia/hypoglycaemia) Clinical Features: Classification Generalised: Absence (Petit Mal) Myoclonic Tonic-Clonic (Grand Mal) Tonic Akinetic Partial: Simple (Jacksonian - motor. No impairment of consciousness) Complex (impairment of consciousness) Investigations: EEG – normal between seizures CT/MRI Head Serum Biochemistry CXR - checking aspiration pneumonia Management: During Seizure: ABCDEFG Approach Maintain Airway & Physical Safety Rectal or IV Diazepam 5-10mg if seizure doesn’t cease spontaneously Prophylactic: First-Line: Generalised Tonic-Clonic – Phenytoin, Carbamazepine, Sodium Valproate Generalized Absence – Sodium Valproate, Ethosuximide Partial Seizures – Carbamazepine, Phenytoin, Sodium Valproate Common SE: Phenytoin – Rash, blood dyscasias, lymphadenopathy Carbamazepine – Rash, leucopenia Sodium Valproate – Anorexia, hair loss, liver damage Ethosuximide – Rash, blood dyscrasias, night terrors Other Drugs: Felbamate Gabaentin Lamotragine Levetiracetam Oxcarbazapine Tiagabine Topiramate Vigabatrin Driving It is illegal to drive for 12 months post any form of seizure or unexplained LoC. It is the responsibility of the doctor to inform the patient, but patient’s responsibility to inform DVLA.

Question 60

Giant Cell Arteritis

Answer 60

Definition: Inflammatory disease of the blood vessel Aetiology: Vasculitis Clinical Features: Headache Pain on eating Visual disturbance Aching muscles Tenderness Pulseless or nodular vessel Investigations: ESR, CRP & Plts - raised Hb - low Biopsy diagnostic Management: Prednisolone Analgesia Urgent biopsy Speak to opthalmology

Question 61

Guillian-Barre

Answer 61

Definition: Acute inflammatory post-infective polyneuropathy Aetiology: Follows 1-3 weeks after infection (often trivial or campylobacter) 3 in 100 000 / year Clinical Features: Weakness of distal limbs +/- numbness Weakness ascends over days for up to 3 weeks Can affect respiratory and facial muscles in 30% Investigations: Clinical diagnosis Nerve conduction studies CSF - cell count normal, protein raised Management: Record respiratory function - ABG, vital capacity, FEV Ventilate if required High dose IV gamma-globulin Plasmapharesis SC heparin - prophylaxis Prognosis: Spontaneous gradual recovery 15% disability or death

Question 62

Migraine

Answer 62

Definition: Recurrent headaches associated with visual and GI disturbance. Aetiology: Caused by the vasodilation and oedema of blood vessels and the release of vasoactive substances. Clinical Features: Prodrome: Teichopsia (flashes) Jagged Lines Unilateral Patchy Scotoma Lasts 15-60 mins Headache (hemicranial or generalized) N&V Irritable Preferance for the dark Sleeping Other Patterns: Migraine without aura Hemiplegic Migraine Investigations: Clinical Management: Avoid Precipitating Factors During Attack: Paracetamol Antiemetics Sumatripan (5HT agonist) Ergotamine Prophylaxis: Pizotifen, Methylsergitide (5HT antagonist) Propanolol Amitriptyline (low-dose)

Question 63

Motor Neurone Disease

Answer 63

Definition: Progressive degeneration of lower motor neurons and upper motor neurons of the cortex, cranial nerve nuclei and spinal cord. 2:100 000 pa Slight Male predominance Clinical Patterns: Progressive muscular atrophy – progressive weakness and wasting of arm and hand muscles Amyotrophic Lateral Sclerosis – progressive spastic tetraparesis or paraparesis with wasting and fasciculation Progressive Bulbar Palsy – degeneration of lower cranial nerve nuclei Clinical Features: Muscle Wasting Fasciculation Areflexia or hypereflexia Dysarthria Dysphagia Nasal Regurgitation of fluids Choking Bulbar & Pseudobulbar palsy Occular Movements not affected Cerebellar or extrapyramidal signs do not occur Dementia is unusual Sphincter function is usually preserved No sensory signs Investigations: Clinical diagnosis Electromyography (EMG) – denervation of muscles with preserved motor conduction velocity Management: Riluzole – sodium channel blocker slows progress Nothing affects outcome Relentlessly Progressive with death in 3 years

Question 64

Multiple Sclerosis

Answer 64

Definition: Multiple plaques of demyelination in the brain and spinal cord disseminated in time and place 60-100 in 100 000 UK Aetiology: HLA linked ?viral infection ?dietary antigens Clinical Features: Optic - unilateral blurred vision, occular pain, optic neuritis, optic atrophy Brainstem - double vision, vertigo, facial numbness, weakness, dysphagia, pyramidal, nystagmus, ataxia, CN defects, internuclear opthalmoplegia Spinal Cord - difficult walking, sensory, Lhermitte's Sign, GU, spastic paraparesis, inc tone, weakness, brisk reflexes, up-going plantars, sensory level Others - epilepsy, trigeminal neuralgia, tonic spasms of hand, organic psychosis, dementia Investigations: Clinical diagnosis two neurological events separated in time and neurological location MRI brain & spinal cord - plaques CSF - oligoclonal bands in 80% & raised mononuclear cell count Management: Aimed at reducing frequency & intensity of relapses, long-term not affected. Corticosteroids ß interferon Physio Occupational Therapy SALT Counselling Prognosis: From grave disability to mild & benign

Question 65

Myelopathy - Myasthenia Gravis

Answer 65

Definition: Disorder of the neuromuscular junction Aetiology: Unknown - IgG antibodies to ACTH receptor leading to destruction. Thymic hyperplasia in 70%. Associated with: Thyroid disease RA Pernicious anaemia SLE Clinical Features: Weakness and fatigability of muscles: Proximal limb Extraoccular Speech Facial expression Mastication Ptosis Reflexes preserved but fatigable Investigations: Tensilon test Serum ACTH receptor antibodies (+ve in 90%) Mediastinal imaging for thymoma (CXR, CT, MRI) Management: Oral anticholinesterase eg. pyridostigmine Thymectomy (improves prognosis) Corticosteroids Azathioprine Plasmapheresis

Question 66

Parkinson's / Parkinsonism

Answer 66

Definition: Cell degeneration in the substantia nigra. Loss of dopamine in the extrapyramidal nuclei Combination of tremor, rigidity and akinesia Increases with age, 1:200 over 70 Less prevalent in smokers Aetiology: Idiopathic Drug-induced eg. phenothiazides (chlorpromazine), antipsychotics MPTP (illegal synthetic opiate) Encephalitis lethargica Clinical Features: Tremor (pill-rolling) Micrographia Rigidity Cogwheeling Bradykinesia Falls Mask-like face Reduced blinking Festinant Poor arm swing Monotonous speech Normal power Brisk reflexes Downgoing plantars Cognitive function initially preserved, late dementia sometimes occurs Investigations: Clinical diagnosis Management: Levodopa plus decarboxylase inhibitor eg. Sinemet or Madopar (slow to reduce SE) Dopaminergic agonists eg. bromocriptine Selegeline - monoamine oxidase B inhibitor Neurosurgery (occasional for intractable tremor) Physiotherapy Physical aids SE of levodopa: short - term: N&V Confusion Visual hallucinations Chorea long-term: End-of-dose dyskinesia On-off syndrome Chorea Dystonic movements

Question 67

Neuropathy / Radiculopathy

Answer 67

Definition: A pathological process that affects peripheral nerves (neuropathy) or roots (radiculopathy) Pathology: Demyelination Axonal degeneration Wallerian degeneration (after nerve section) Compression Infarction Infiltration Aetiology: Mononeuropathies Carpal tunnel syndrome Ulnar nerve compression Radial nerve compression (sat night palsy) Mononeuritis multiplex Polyneuropathies Guillian-Barré syndrome Wernicke-Korsakoff syndrome (Thiamin deficiency) Vit B12 deficiency (subacute combined degeneration of the cord) Peroneal Muscular Atrophy (Charcot - Marie - Tooth disease) Autonomic Neuropathy Caused by DM, G-B, Amyloidosis Clinical Features: Depends on cause Investigations: Depends on cause Management: Depends on cause

Question 68

Stroke

Answer 68

Definition: Stroke - a focal neurological deficit due to a vascular lesion lasting \>24 hours (if the patient survives) TIA - a focal neurological deficit lasting Risk Factors: HPT Smoking FH Hyperlipidaemia Afro-Caribbean High-dose OCP Clinical Features: TIA Carotid System - visual loss, asphasia, hemiparesis, hemianopic visual loss Vertebrobasilar - diplopia, vertigo, vomiting, dysarthria, choking, ataxia, transient global ischaemia Evidence of embolic source - AF, carotid bruit, valvular heart disease, subclavian stenosis Cerebral Infarction Initially flaccid, areflexic weakness followed by spastic tone, brisk reflexes and extensor plantars Dysphasia - most probably left hemisphere, expressive - Broca's area in frontal. Receptive - Wernicke's area in temporal-parietal Middle cerebral / internal carotid - hemiparesis, aphasia, hemianopic visual loss, dysarthria Posterior inf cerebellar - coma, vertigo, vomiting, dysphagia, choking, ataxia, contralateral loss of pain on face Management: Acute: CT Head to rule out haemorrhage ?Alteplase Aspirin Stroke unit ABCD2 - risk of stroke following TIA Find underlying cause - bloods, lipids, ECG, CXR, echo Chronic: SALT - swallowing assessment Physio - OT - Risk Factor Modification Anti HPT Aspirin (300mg initially) / Clopidogrel Anticoagulation - AF Surgery (internal carotid) Prognosis: 30-40% survival at 3 years 10% risk of further stroke within one year

Question 69

Syncope / Dizziness / Falls

Answer 69

Definition: Aetiology: Clinical Features: Investigations: Management:

Question 70

Ectopic Pregnancy

Answer 70

Definition: The fertilised ovum implants outside the uterine cavity Aetiology: 2° to salpingitis, tubal surgery, prev ectopic, endometriosis, older IUCD, PoP Clinical Features: Abdo pain PV bleeding (prune juice) ~8 weeks amenorrhoea Rupture - severe pain, shock, peritonism Investigations: Pregnancy test - +ve, ßHCG lower than normal USS - TV probably better than abdo Management: Resus x-match 6 units Rhesus status - anti-D Refer Gynae

Question 71

Endometriosis

Answer 71

Definition: Endometrial glandular tissue beyond the uterine cavity Aetiology: Long-term IUCD or tampon use Retrograde menstrual flow Clinical Features: Pelvic pain at time of period Dysmenorrhoea Dyspareunia Investigations: PV exam MRI Laproscopy Management: Analgesia COCP or IUCD to stop ovulation so patches atrophy Excision

Question 72

Gynaecological Malignancy

Answer 72

Definition: Aetiology: Clinical Features: Investigations: Management:

Question 73

Menorrhagia

Answer 73

Definition: Increased menstrual blood loss for individual or change such as flooding, clots. Aetiology: IUCD Fibroids Endometriosis / Adenomyosis PID Polyps Hypothyroidism Dysfunctional Uterine Bleeding Clinical Features: As above Investigations: FBC TFTs Clotting USS Hysteroscopy Laproscopy Management: Antifibrinolytics Antiprostaglandins COCP Mirena Ablation (if family complete)

Question 74

Ovarian Cyst

Answer 74

Definition: A collection of fluid within the ovary, usually during childbearing age. Functional Cysts - follicular & corpus luteum (benign) Non-functional - chocolate (endometreosis), dermoid Aetiology: Idiopathic Clinical Features: Fullness / aching in lower abdo Urinary symptoms Systemic symptoms Disorders in menstruation Investigations: USS Management: 95% benign so analgesia Surgical excision

Question 75

PID

Answer 75

Definition: Inflammation of the fallopian tubes or uterus, ovaries caused by infection. It may lead to adhesions and potentially infertility. Aetiology: 90% STI - usually chlamydia Clinical Features: Pain Fever Lower abdo muscle spasm Cervicitis with purulent, bloody discharge Investigations: Endocervical & urethral swabs Blood cultures Management: IV Abx (cefriaxone & doxycycline) Contact tracing

Question 76

Pregnancy

Answer 76

Definition: Aetiology: Clinical Features: Investigations: Management:

Question 77

Cataract

Answer 77

Definition: Opacification of the lens by lens proteins Aetiology: Age Trauma Radiation Genetics Skin diseases Drug use Medications Clinical Features: Blurred vision Investigations: Management: Surgery

Question 78

Glaucoma

Answer 78

Definition: Raised intraoccular pressure Disease of middle to late years and unioccular Aetiology: Blockage of drainage of aqueous from the anterior chamber via the canal of Schlemm Clinical Features: Pain N&V Corneal oedema Fixed, dilated pupil Investigations: Opthalmoscopy Management: Refer to eye unit Pilocarpine 2-4% drops hourly Acetazolamide 500mg PO stat Surgical - peripheral iridectomy

Question 79

Macular Degeneration

Answer 79

Definition: Wet or Dry subtypes which are retinal damage causing blindness in the centre of the visual field. Aetiology: Dry (nonexudative) form, cellular debris called drusen accumulates between the retina and the choroid, and the retina can become detached Wet (exudative) form, which is more severe, blood vessels grow up from the choroid behind the retina, and the retina can also become detached Clinical Features: Deterioration of central vision, loss of acuity but fields intact Pigment, fine exudate and bleeding at the macula Drusen Investigations: Opthalmoscopy Management: Laser photocoagulation Screenin initiated if Drusen are seen

Question 80

Red Eye

Answer 80

Definition: Acute painful red eye Aetiology: Danger to vision - acute glaucoma, acute iritis, corneal ulcers) Others - episcleritis, conjunctivitis, spontaneous conjunctival haemorrhage Clinical Features: Depends on location of irritation Investigations: Opthalmoscopy Management: Variable

Question 81

Hypokalaemia

Answer 81

Definition: Normal Range 3.5-5.3 mmol/L Determined by cellualr uptake, renal excretion and extra renal losses (GI) Aetiology: Renal - diuretics (thiazide & loop) Increased aldosterone - liver / heart failure, nephrotic syndrome, Cushing's, Conn's, ACTH tumours Steroids Renal Disease Dietary Deficiency GI Losses Clinical Features: Muscle paralysis if severe Arrhythmias in abnormal hearts Potentiation of Digoxin toxicity Investigations: ECG Management: K+ supplements K+- sparing drugs Treat underlying cause

Question 82

Hyperkalaemia

Answer 82

Definition: Normal Range 3.5-5.3 mmol/L Aetiology: Decreased Excretion: Renal Failure Drugs - spironolactone, ACEi, NSAIDs, Heparin Addison's Acidosis Increased Intake: KCl administration Blood Transfusion Clinical Features: Arrhythmias Hypotension / bradycardia if severe Kussmaul breathing (associated acidosis) Widened QRS / tented T waves Investigations: ECG monitoring Management: Calcium Resonium Dialysis Treat Cause

Question 83

Hyponatraemia

Answer 83

Definition: Normal range 135-145 mmols/L May be associated with normal extracellular volume and body Na+ content, salt deficiency or water excess. Aetiology: Abnormal ADH release - SIADH, Addison's, Hypothyroid Psychiatric Illness - psychogenic polydipsia, TCAs Drugs - Oxytocin GI Loss - D&V, haemorrhage Renal Loss - hyperglycaemia, diuretics Clinical Features: Normovolaemia & signs of underlying disease Hypovolaemia in GI / Renal losses Investigations: Determine cause if unknown Management: Replace lost fluids & electrolytes Treat underlying cause

Question 84

Hypernatraemia

Answer 84

Definition: Normal Range 135-145 mmol/L Nearly always due to inadequate water intake Aetiology: Inadequate water intake plus: ADH deficiency (diabetes insipidus) Insensitivity to ADH (drugs, ATN) Osmotic Diuresis (diabetic coma, TPN) Clinical Features: Volume depletion Confusion / convulsions Fever Features of underlying cause Investigations: Plasma osmolality high Low urine osmolality indicates diabetes insipidus Management: Replace fluid Treat underlying cause

Question 85

Hypocalcaemia

Answer 85

Definition: Normal Range 2.12-2.65 mmol/L Always check corrected calcium as hypoalbuminaemia may give falsely low serum calcium. Aetiology: Vit D deficiency Hypoparathyroid Acute pancreatitis Alkalosis Alcoholism Clinical Features: spasm of hands and feet, twitching, tingling perioral, fatigue, depression, dry skin, coarse hair Hyperreflexia, tetany, Trosseau's, Chvosek's Worrying Features Reduced GCS, chest pain, palpitations, low BP, abnormal ECG Investigations: ECG - prolonged QT, ST abnormalities, arrhythmias Management: Calcium Gluconate ?Vit D

Question 86

Hypercalcaemia

Answer 86

Definition: Normal Range 2.12-2.65 mmol/L Aetiology: Hyperparathyroidism, malignancy, excess Vit D Clinical Features: Bones (pain / #), Stones (renal), Moans (depressed), Groans (abdo pain). Also: vomiting, const, weakness, thirst, polyuria, weight loss hypertension, arrhythmias, dehydrated, cachexia, bony tenderness Worrying Features Reduced GCS, chest pain, palpitations, inc HR, low BP, abnormal ECG Investigations: ECG - short QT, arrhythmias CXR; Bone scan Management: Correct fluid deficit Furosemide Catheterisation Bisphosphonates

Question 87

Sepsis

Answer 87

Definition: SIRS + suspected infection Severe Sepsis - sepsis + signs or organ hypoperfusion Septic Shock - persistant hypotension despite fluid challenge Aetiology: Pneumonia, cellulitis, gangrene, endocarditis, perforation, UTI, pyelonephritis, wound infection, bowel leak Clinical Features: Symptoms of infection plus low BP, tachy, warm peripheries, low JVP, reduced GCS, oliguria Investigations: Determine severity using 'sepsis 6' protocol Management: Follow algorithm Briefly: 1. Give 15LO2 2. Take blood cultures 3. Give IV Abx (according to suspected source) 4. Give IV fluids 5. Take lactate & Hb 6. Take urine for fluid balance (catherterise)

Question 88

Lymphadenopathy

Answer 88

Definition: Palpable lymph nodes Aetiology: Isolated infection - EBV, CMV, hepatitis, HIV, TB Malignancy - lymphoma, leukaemia, mets Autoimmune - SLE, rheumatoid Others - sarcoidosis, amyloidosis, drugs Clinical Features: Lump, usually in neck, axilla, groin Worrying Features - non-tender, \>3/52, \>1cm, hard, irregular, tethering, weight loss, night sweats, fatigue, absence of infection Investigations: Determine infective cause if possible, or biopsy if concerned. Management: Watchful waiting or biopsy

Question 89

Paediatric Congenital Defects

Answer 89

Definition: Aetiology: Clinical Features: Investigations: Management:

Question 90

Paediatric Asthma

Answer 90

Definition: Reversible airway obstruction +/- wheeze, dyspnoea & cough. Leading chronic disease of childhood. Aetiology: FH, bottle fed, atopy, pollution Triggers - dust, pollen, animals, exercise, smoke Clinical Features: Wheeze SoB Cough Investigations: PEFR CXR Management: Chronic- Step 1 - occasional ß2-agonist via spacer Step 2 - regular inhaled steroid Step 3 - review diagnosis, check inhaler technique. Add LABA or aminophylline Step 4 - refer to specialist & increase inhaled steroid Step 5 - Prednisolone

Question 91

Common Paediatric Infections Five to Name & Briefly Describe

Answer 91

Measles Maculopapular rash - spreading from behind ears to face/trunk becomes confluent Child is ill with fever, red eyes & a harsh cough Koplik spot’s inside cheek are specific - day 3 or 4 of illness Incubation period - 10 days - infectious until day 5 of rash Complications - more likely if immunosuppressed - pneumonia, encephalitis Mumps Fever for a few days with unilateral parotitis - often becomes bilateral Infectious from seven days from onset of parotid swelling Long incubation period - 2-3 weeks Complications - viral meningitis, orchitis Rubella Well child with low grade fever & erythematous rash all over body Lymphadenopathy - posterior auricular & occipital nodes Risk to fetus - congenital rubella syndrome - cataract’s. deafness Chickenpox Papules - Vesicles - Pustules - Crusts Infectious for 7 days from start of rash Long incubation period - 2-3 weeks Rare complications - secondary bacterial skin infection & pneumonia Very rarely - varicella cerebellitis Slapped cheek disease / erythema infectiosum Due to Parvo-virus B19 Can affect erythroblasts in bone marrow Child has low grade fever for a few days prior to developing red cheeks Fine lace like rash may spread onto trunk & limbs Can cause Aplastic Crisis in Sickle Cell Disease Infection in pregnancy can cause fetal anaemia, heart failure & death

Question 92

Asthma

Answer 92

Definition: Chronic inflammatory disease of the airways Reversible airflow limitation Hyperesponsiveness to stimuli Inflammation of the bronchi Aetiology and Precipitatin Factors: Atopy & allergy Increased airway responsiveness Cold air, exercise, pollution Occupational (paint sprayers) Drugs eg NSAIDs, Beta-blockers Clinical Features: Cough Wheeze SoB Chest tightness Investigations: CXR Spirometry Peak flow charts Skin testing for allergies Management: BTS guidelines

Question 93

Bronchiectasis

Answer 93

Definition: Abnormal & permanently dilated airways Aetiology: Congenital Mechanical obstruction Post-infective damage Granuloma & fibrosis Immunocological Mucociliary clearence defects Clinical Features: Cough & excessive sputum Recurrent chest infections Halitosis Haemoptysis Clubbing Coarse crackles Hyperinflation Investigations: CXR - hyperinflation CT Sputum C&S Immunoglobulins Sweat electrolytes for CF Mucociliary clearance Management: Postural drainage Abx Bronchodilators Steroids Tx

Question 94

Bronchitis

Answer 94

Definition: LRTI worse in smokers & COPD Aetiology: Viral but may be complicated by bacterial infection Clinical Features: Cough Wheeze Retrosternal discomfort Chest tightness Investigations: Rule out other or serious causes Management: Self limiting so supportive only 4-8 days

Question 95

COPD

Answer 95

Definition: Non-reversible progressive airflow limitation Aetiology: Smoking 90% of cases Rarely alpha1-antitrypsin deficiency Clinical Features: Cough & sputum Wheeze SoB Exacerbating factors - URTI, cold weather, pollution Tachypnoea Signs respiratory compromise or RHF Investigations: Spirometry CXR - hyperinflation, flat diaphragm ABG ECG - P pulmonale, RBBB, RV hypertrophy FBC - Management: Stop Smoking Flu & pneumococcal vaccines ß2 agonists Antimuscarinics Corticosteroids Abx if required

Question 96

Cor Pulmonale

Answer 96

Definition: Right heart failure resulting from chronic pulmonary hypertension. Aetiology: COPD in most cases Pulmonary Fibrosis Recurrent PE Clinical Features: SoB Wheeze Chronic wet cough Ascites Peripheral oedema Prominent neck and facial veins Raised JVP Hepatomegaly Investigations: Find cause Management: Treat cause

Question 97

Pleural Effusion

Answer 97

Definition: Excessive liquid in the pleural space Aetiology: Transudates ( Exudates (\>35g/l protein) - malignancy, infection, vasculitidies, rheumatoid. If purulent and pH Clinical Features: SoB Pleuritic Chest Pain Investigations: CXR - loss of costophrenic angle with a meniscus Management: o2 Investigate cause ? aspiration

Question 98

Fibrosing Alviolitis

Answer 98

Definition: Progressive idiopathic pulmonary fibrosis Aetiology: Idiopathic Associations: Autoimmune Coeliac Disease Ulcerative Colitis Renal Tubular Acidosis Clinical Features: SoB Cyanosis Clubbing Bilateral fine inspiratory crackles Signs of respiratory failure, pulmonary HPT, RHF Investigations: CXR - reticulonodular shadowing HiRes CT Spirometry - restrictive pattern with reduced gas transfer Bronchoalveolar lavage - hypercellular Transbronchial biopsy Management: O2 Steroids Immunosuppression Single lung transplant Complications: Respiratory Failure Median survival 5 years

Question 99

Respiratory Malignancy

Answer 99

Definition: Bronchial carcinoma, malignant tumour of the bronchial tree. Most common malignancy and third most common cause of death in UK Types: Small Cell 20-30% Non-small cell Squamous 40% Large Cell 25% Adenocarcinoma 10% Bronchoalveolar 1-2% Aetiology: Smoking (including passive) - squamous Urban\>rural Occupational - adeno (asbestos, coal, chromium, aresenic, petroleum products and oils, radiation Clinical Features: Cough 41% Chest Pain 22% Cough & Pain 15% Haemoptysis 7% Chest Infection Others (SoB, malaise) Investigations: CXR Bloods - hyponatraemia, polycythaemia, anaemia CT & PET for staging Bronchoscopy biopsy Management: MDT Surgery - 5-10% of cases suitable. Non-small cell only Radiotherapy - squamous, symptom control, SVC obstr. Chemotherapy - combination therapy Prognosis: 55-67% 5-year survival with local disease 23-40% 5-year survival with locally advanced 1-3% 5-year survival with advanced disease

Question 100

Pulmonary Oedema

Answer 100

Definition: Fluid accumulation in the air spaces and paranchyma of the lungs. Aetiology: Cardiogenic - LVF, IHD Non-cadiogenic - HPT crisis, upper airway obstruction Clinical Features: dyspnoea, orthopnoea, PND, frothy sputum raised JVP, tachypnoea, fine crackles, wheeze, pitting, cold hands & feet Investigations: FBC - anaemia, infection, MI CRP - infection U&Es - BNP ?ABG ECG - exclude arrhythmias, STEMI, may show prev IHD CXR - cardiomegaly, oedema Echo - poor LVF Management: O2 Furosemide Analgesia ?nitrates

Question 101

Pulmonary Embolism

Answer 101

Definition: Embolus causing partial or total occulsion of the pulmonary artery or its tributaries. Aetiology: Usually arise from a venous thrombus in the pelvis or leg which gives of a clot whch travel through the right heart. Risk Factors: Recent surgery or prolonged bedrest Recent stroke / MI Disseminated malignancy Thrombophillia / antiphospholipid syndrome Pregnancy / post-partum / ?OCP/HRT Clinical Features: SoB, pleuritic chest pain, haemoptysis, dizziness, syncope COULD BE NO SYMPTOMS Tachy, hypotension, cyanosis, tachypnoea, raised JVP, pleural rub, pleural effusion Investigations: FBC - infection (WCC), Anaemia (Hb), Platelets U&Es – Electrolyte disturbances, renal function Clotting Screen – baseline \*D-Dimer – only if no other explaination for clinical features ABG – May show ¬⇓Pa02 and ⇓PaC02 (hyperventilation) CXR – May be normal, or show oligaemia, dilated pulmonary artery, effusion, wedge-shaped opacities. ECG – May be normal, or show tachy, RBBB, R vent. Strain (inverted T in V1 – V4). \*(S1, Q3, T3 pattern is rare)\* Management: WELLS SCORE FOR PE (gives probability) Sit up and 15L O2 Analgesia Fluids if low BP Senior Help CTPA +/- echo urgently Consider thrombolysis Enoxaparin 1.5mg/kg/24hr

Question 102

Pneumonia

Answer 102

Definition: Lung infection classified by site (lobar or bronchopneumonia) or by aetiology Aetiology: Bacterial - strep pneumoniae, mycoplasma pneumoniae Viral - Influenza A, Haemophilus Influenzae Opportunistic Infections Chemical (eg aspiration of vomit) Radiotherapy Allergic Clinical Features: Cough +/- purulent sputum Fever Pleuritic chest pain SoB Investigations: CURB65 CXR ABG Blood & Sputum Culture Microbiology Management: MIld - amoxicillin 500mg TDS (or Clarythromycin) Moderate - IV amoxicillin 500mg TDS (or Claryth) Severe - IV cefuroxime 1.5g QDS & Clarythromycin Adjust according to C&S O2 Supportive - fluids etc Complications: Respiratory Failure - type 1 (low paO2, low/norm. PaCO2) Lung Abscess Empyema

Question 103

Pneumothorax

Answer 103

Definition: Air in the pleural space leading to lung deflation Aetiology: Spontaneous (primary or secondary to lung disease) Chest trauma Ventilation Clinical Features: Pleuritic Chest Pain SoB Investigations: CXR - lung markings not extending to the peripheries Management: If bilateral or haemodynamically unstable - chest drain Primary + \>2cm &/or SoB - aspirate (drain & admit if fails) Primary with no SoB or Secondary + \>2cm - chest drain & admit Secondary

Question 104

Respiratory Syncytial Virus

Answer 104

Definition: Major cause of LRTI in children, most will have been infected by 2-3 years. Causes bronchiolitis Aetiology: Clinical Features: Flu-like illness, may lead to severe respiratory symptoms in some cases. Investigations: May do fluoroscopy Management: Supportive - fluids, O2, nebulsed saline

Question 105

Stridor

Answer 105

Definition: Upper airway obstruction which produces a high-pitched wheeze Aetiology: Infection (epiglottitis, abscess) Tumour Foreign Body Trauma Post-op Analphylaxis Management: ABC approach Anaesthetic & ENT urgently DO NOT LOOK IN MOUTH O2 Adrenaline Nebs (5mL of 1:1000) Look for signs of anaphylaxis Urgent portable CXR

Question 106

TB

Answer 106

Definition: Caseating granulomatous infection due to Mycobacterium tuberculosis in the lung TB is a notifiable disease and contact tracing is important Patients at Risk: Those from developing countries Immunosuppressed HIV / Steroids / malignancy Alcoholics / homeless / overcrowding Clinical Features: May be none Malaise & Lethargy Anorexia / Weight Loss Fever Cough Haemoptysis Pleural Effusion / Pneumonia / Fibrosis Investigations: CXR - affects upper zones mostly, +- calcification or cavitation Sputum Microscopy - Ziehl-Nielsen and culture Bronchial Lavarge / pleural biopsy Management: 6/12 of combination Abx, usually: Rifampicin & Isoniazaid + Pyrazinamide for 1st 2/12 Add Ethambutol if risk of resistance Compliance Vital

Question 107

AV Block First Degree Second Degree Mobitz Type 1 - Wenckebach or Mobitz Type 2 2:1 or 3:1 Block Third Degree (Complete Heart Block)

Answer 107

Definition: 1st - Prolonged PR interval Mobitz 1 - Progressive elongation of PR until missed Mobitz 2- Missed QRS without PR elongation 2:1 or 3:1 - Every 2nd or 3rd P conducts 3rd - No association of P waves & QRS Aetiology: IHD Cardiac Surgery Dilated Cardiomyopathy Drugs Clinical Features: 1st - Usually asymptomatic Mobitz 1 - Usually asymptomatic Mobitz 2 - Usually asymptomatic 2:1 or 3:1 - Asymptomatic or syncope, dizziness, HF, fatigue, lethargy 3rd - Asymptomatic or syncope, dizziness, HF, fatigue, lethargy Investigations: Management: 1st - Surveillance and v.rarely pacing Mobitz 1 - Pacing if symptomatic (v.rare) Mobitz 2- Pacing if symptomatic (v.rare) 2:1 or 3:1 - Pacing if symptomatic and consider without symptoms as can progress to 3rd degree 3rd - Rule out reversible causes (K, Mg, Ca), sepsis, other illness and bradycardic drugs

Question 108

Bundle Branch Block

Answer 108

Definition: A disruption of conduction in the His / Purkinje system, either left or right. This causes the 'blocked' ventricle to receive the conduction impulse later. Aetiology: RBBB - congenital heart disease, cor pulmonale, PE, MI, cardiomyopathy, hyperkalaemia, normal LBBB - AS, HPT, acute MI, severe coronary disease, cardiomyopathy Clinical Features: Investigations: RBBB ECG - 'RSR' in v2 & slurred S in v5, v6 LBBB ECG - 'RSR' in I, AVL, v4-v6 & slurred S in v1, v2 Management: Pacing in symptomatic patients

Question 109

Atrial Flutter

Answer 109

Definition: caused by a reentrant rhythm in either the right or left atrium. Typically initiated by a premature electrical impulse arising in the atria. Aetiology: IHD, Rheumatic heart disease, Thyrotoxicosis, Cardiomyopathy, W-P-W Syndrome, Pneumonia, ASD, Pericarditis, PE Clinical Features: Asymptomatic, reduced exercise tolerance, palpitations, HF, embolic events, completely irregular pulse Investigations: ECG - Sawtooth flutter waves between QRSs Management: Electrical Cardioversion Class III Antiarrythmics (K) - Amioderone, Sotalol

Question 110

Atrial Fibrillation

Answer 110

Definition: Uncoordinated rapid continuous activation of atria from multiple foci. Fortunately only some of these are conducted to the ventricles due to the AV node. Three Types Paroxysmal Persistent \>48 hours Permanent Aetiology: IHD, Rheumatic heart disease, Thyrotoxicosis, Cardiomyopathy, W-P-W Syndrome, Pneumonia, ASD, Pericarditis, PE Clinical Features: Spectrum - Asymptomatic \> Palpitations \> Dyspnoea \> Chest Pain \> Heart Failure \> Syncope Investigations: ECG - irregularly irregular QRS, no P waves, irregular baseline Rate may be fast, normal or slow Management: (three principles) Rate Control (if fast) - ß-blockers, Ca-blockers, Digoxin Rhythm Control - ß-blockers, Flecanide (Na), Amioderone (K) Stroke Prevention - Warfarin or Dabigatran/Rivaroxaban CHA2Ds2VASc risk stratification for use of anti-coagulation Consider DC Cardioversion

Question 111

SVT

Answer 111

Definition: Two abnormal circuits produce this arrythmia, both passing through the AV node. AVNRT - atrio-ventricular node re-entrant tachycardia (passes through and near to AV node) AVRT - atrio-ventricular re-entrant tachycardia (electrical 'hole' in AV septum. This conducts the signal more rapidly - pre-excitation and shows as a delta wave on ECG Aetiology: Exertion Caffeine Alcohol ß2-agonists Congenital - W-P-W Clinical Features: Palpitations Chest Pain SoB Syncope Polyuria Rapid Regular Pulse 140-280bpm Investigations: ECG - narrow complex tachycardia, P waves may be within or after the QRS Management: Vagotonic Manoeuvres Carotid Sinus Massage Occular Pressure Valsalva Manoeuvre Adenoseine (avoid in asthma) Prophylaxis Accessory Pathway Ablation

Question 112

Ventricular Tachyarrythmias

Answer 112

Definition: Ventricular Fibrillation - Irregular rhythm with irregular QRS voltage and width. Not compatible with life. Broad Complex Tachycardia - VT until proven otherwise Aetiology: Shock MI Clinical Features: VF - LOC BCT - Palpitations, dizziness, syncope, angina Investigations: ECG VT - Irregular rhythm with irregular QRS voltage and width ECG BCT - wide QRS, usually rapid \>180bpm Management: VF - DC shock immediately BCT - If haemodynamically stable try amioderone / lignocaine If unstable DC shock as can progress to VF

Question 113

Hypertension

Answer 113

Definition: Chronically high BP Stage 1 - \>140/90 in clinic & ABPM average \>135/85 Stage 2 - \>160/100 in clinic & ABPM average \>150/95 Severe - \>180 systolic or \>110 diasolic in clinic Aetiology: Primary - genetic, obesity, alcohol, sodium intake, stress Secondary Renal - diabetic nephropathy, renovascular disease, adult polycystic disease, chronic glomerulonephritis Secondary Endo - Conn's, adrenal hyperplasia, phaeochromocytoma, Cushing's, acromegaly Secondary CVS - coaectation of aorta Secondary Drugs - OCP, steroids, NSAIDs Secondary Pregnancy - 2nd half of pregnancy, pre-eclampsia Clinical Features: Usually asymptomatic Features of underlying cause Headaches Nose Bleeds Nocturia Elevated BP Renal Artery Bruit Radiofemoral Delay (coarctation) Left Ventricular Hypertrophy Retinal Changes Grade 1 - tortuosity of retinal arteries & 'silver wiring' Grade 2 - G1 + arteriovenous nipping Grade 3 - G2 + flame haemorrhages & soft "cotton wool" exudates Grade 4 - G3 + papilloedema Investigations: Simple - Urinalysis - casts, protein & red cells - ECG - LV hypertrophy & strain Bloods - Fasting BM & lipids - U&Es Radiology - CXR - Echo - LV hyoertrophy Management: Step 1 - ACEi (or ARB) Step 2 - Step 1 + Ca-channel Blocker Step 3 - Step 2 + Diuretic (thiazide-like) Step 4 - Consider Spironolactone or alpha-blocker or ß-blocker \>55 years or black As above but start with Ca-channel Blocker Lifestyle - weight loss, alcohol reduction, salt restriction, exercise, low fat diet Complications: Cerebrovascular Disease Coronary Artery Disease Retinopathy Renal Disease

Question 114

Hepatic Failure

Answer 114

Definition: Acute necrotizing hepatitis leading to cell destruction; There are three types of acute liver failure: 1. Hyperacute or fulminant liver failure – encephalopathy develops 2. Acute liver failure – encephalopathy develops 2-4/52 3. Subacute liver failure – encephalopathy develops 4-8/52 Aetiology: viral hepatitis, infection, drugs, toxins, alcohol, ischaemia, complications of pregnancy, malignancy Clinical Features: Lethargy, weakness, nausea, anorexia, sleep disturbance, Jaundice, fever, fetor hepaticus, encephalopathy, cerebral oedema leading to bradycardia, hypertension, tachypnea Investigations: Liver Screen to identify cause Poor prognostic indicators include: ⇑bilirubin, severe hyponatraemia, rising lactate, acidosis, rapid ⇓ transaminases, renal failure Management: Supportive in ITU, Liver Tx Complications: Renal failure, coagulopathy, respiratory failure, sepsis, circulatory failure, hypoglycaemia, pancreatitis

Question 115

Childhood UTI

Answer 115

Definition: Commonest condition in childhood with E. Coli causing 95% of cases. Clinical Features: Fever Poor Feeding Irritability Offensive Urine Vomiting Investigations: Dipstix - leukocytes, blood, protein, nitrites Clean Catch Sample - microscopy & culture Management: \>3 months and not systemically unwell - treat at home with 3/7 Trimethoprim PO Recurrent UTI - Trimethoprim low dose OD Further Investigations: Performed if UTI \< 6months or recurrent \>6months UUS - to detect structural abnormalities of kidneys or obstruction DMSA - radio-isotope to give detailed anatomy of kidneys, shows renal scarring. Should be delayed by 2-3 months as recent infection affects validity. Micturating Cysto-urethragram - detects reflux from bladder to ureters (vesico-ureteric reflux VUR)