core conditions Flashcards
what does an acute subdural haemorrhage and an extradural haemorrhage look like on a CT scan (i.e. how can you tell the difference between the 2)?
SDH: imaging will show a hyperdense (bright), crescenteric collection surrounding the brain that is not limited by suture lines EDH: imaging will show a hyperdense (bright), biconvex (or lentiform) collection around the surface of the brain that is limited by suture lines
generally speaking, what are some causes of aneurysms?
- Atherosclerosis. - Vasculitis (e.g. Kawasaki disease). - Syphilis. - Infective (may be due either to fungi or bacteria invading the vessel wall and may be due to distant spread from infective endocarditis or from localised spread from adjacent structures). - Penetrative or blunt trauma. - Congenital (e.g. berry aneurysm). - Cocaine use has been associated with cerebral, aortic, visceral and peripheral aneurysms
generally, how should delirium be managed?
- Investigate underlying cause and treat this (e.g. UTI, polypharmacy etc) - Supportive management: > Involve family and carers > Have clock in room > Have familiar items in room > Have consistent staff see the patient - Haloperidol or olanzapine may be used if the patient is a risk to themselves or others (but weigh up pros/cons of adding additional medications)
what drug class is tramadol?
opioid
how would you expect the CSF from a lumbar puncture to appear (look like) in: - a normal sample - bacterial meningitis - viral meningitis?
- normal: clear - bacterial meningitis: cloudy/turbid - viral meningitis: clear
very very briefly, how should infective endocarditis be managed?
Initiate empirical abx while awaiting blood culture results (use trust guidelines) Some may require surgery (there’s a number of possible indications).
if morning stiffness is present in OA, how long would you expect it to last?
<30 mins
what is the name of the fraction of gluten responsible for the immunological response seen in coeliac disease?
gliadin
what blood result is taken to indicate hepatotoxicity in the context of paracetamol overdose?
ALT >1000 IU/L
what are some of the possible causes of thrombophilia?
- Inherited: Factor V Leiden, Protein C/Protein S deficiency - Acquired: Antiphospholipid syndrome, malignancy, pregnancy, myeloproliferative disorders (e.g. polycythaemia vera, essential thrombocytosis), malignancy, acute inflammatory states (e.g. IBD, connective tissue diseases), nephrotic syndrome, DIC
how should superficial thrombophlebitis be managed?
General: - The affected extremity should be elevated if possible and large, warm compresses may be applied - exercise reduces pain and the possibility of DVT. Pharmacological: - Topical analgesia with non-steroidal anti-inflammatory creams applied locally to the superficial vein thrombosis/superficial thrombophlebitis area controls symptoms - LMWH heparin or fondaparinux may be prescribed (depending on trust guidelines)
if it is decided that compression stockings are to be used in the management of someone with varicose veins (note that NICE doesn’t recommend them unless interventional options are not appropriate), what must you first do?
rule out the possability of peripheral arterial disease (in which compression stockings would be contraindicated)
describe the pathophysiology involved in hyperosmolar hyperglycaemic state
- HHS is usually precipitated by a trigger e.g. infection, poor diabetes control etc - A relative insulin deficiency leads to a serum glucose that is usually higher than 33 mmol/L (600 mg/dL), and a resulting serum osmolarity that is greater than 320 mosmol/kg - This causes excessive urination, leading to volume depletion and hemoconcentration that causes a further increase in blood glucose level. - Ketosis is absent because the presence of some insulin inhibits hormone-sensitive lipase mediated fat tissue breakdown.
how is a ‘chronic migraine’ defined?
patients have headaches at least 15 days a month, with at least eight episodes where their headaches and associated symptoms meet diagnostic criteria for migraine
what is the most common feature of a focal seizure arising from the parietal lobe?
Contralateral paraesthesia
what is the antidote for opioid overdose?
naloxone (0.4-2mg IV/IM)
how should a patient be instructed to take a bisphosphonate and why?
They may cause oesophageal irritation and so should be taken by the patient on an empty stomach (so usually morning), sitting up with plenty of water. The patient should then stay sat upright and not eat or take other oral medication for at least 30 minutes afterward
how should septic arthritis be managed?
- IV abx (e.g. flucloxacillin or vancomycin) started empirically - Analgesia - Joint immobilisation (and begin to mobilise ~5 days later/ after infection has been treated) - Joint drainage considered if antibiotics not effective - Urgent referral to orthopaedics
what is the biggest concern with being on a DMARD?
People on DMARDs are more prone to infections and complications of infections due to myelosuppression
what are some of the causes/ contributing factors to orthostatic hypotension?
- Ageing: healthy ageing is associated with decreased autonomic buffering capacity - Medication: antihypertensive medication, alpha-blockers, diuretics, tricyclic antidepressants - Conditions causes autonomic dysfunction: diabetes (peripheral neuropathy), Parkinsons - Anaemia, dehydration, hypovolaemia (e.g. secondary to blood loss)
how should a DVT be managed?
Start low molecular weight heparin or fondaparinux in confirmed DVT and those with a strong clinical suspicion - the LMWH or fondaparinux should be continued for at least 5 days or until the international normalised ratio (INR) is 2.0 or above for at least 24 hours, whichever is longer Offer oral anticoagulant (warfarin or NOAC) within 24 hours of diagnosis and continue for 3 months
which clotting factors are deficient in haemophilia type A and B?
A: factor VIII B: factor IX
which medication is is most commonly associated with osteonecrosis of the jaw (although is nonetheless a rare complication)?
bisphosphonates
what is the most common ECG indication for a permanent pacemaker insertion?
complete (3rd degree) heart block
a patient in SVT is haemodynamically unstable, how should they be managed?
If haemodynamically unstable, the most effective and rapid means of terminating any tachycardia is direct current (DC) cardioversion
a patient is found to have a 4.3cm AAA on abdominal ultrasound, how should they be followed up?
should have an aortic ultrasound every year to monitor (3-4.4 cm = monitor yearly, 4.5-5.4 cm = monitor every 3 months, >5.5cm = surgery adviced)
once the defib arrives at a crash call, how should it be used (not including what drugs are given when, just the procedure with the defib)?
- Continue to give chest compressions and ventilation while defib pads are applied (one applied below the right clavicle, the other in the midaxillary line (V6 position)) - Pause CPR for rhythm analysis (this should be for no-longer than 5 seconds) > Shockable rhythms are ventricular fibrillation and pulseless ventricular tachycardia > Non-shockable rhythms are pulseless electrical activity and asystole - If shockable rhythm, resume chest compressions while the defib is charging. Everyone else should move away - When the defib is charged, stop chest compressions and have everyone stand away. When safe, give shock - Immediately resume compressions and ventilation following shock and continue for another 2 minutes - After 2 mins, do another rhythm check and follow steps as above (if rhythm was unshockable, continue CPR and do another rhythm analysis in 2 mins time)
what are some of the features of critical limb ischaemia?
features include: rest pain (which is not acute, and can often be eased by the patient hanging their leg out of bed at night), ulceration and gangrene remember: it is not the same as acute limb ischaemia (as it is a chronic condition) and is technically a sub-type of PAD (it’s basically just severe stage of PAD)
in which 3 leads is it normal to get T wave inversion?
aVR, III and V1
what are some causes of cardiogenic shock?
- Most common: MI (particularly anterior) - Other causes: arrythmias (e.g. AF, VT), chest trauma, acute valvular incompetence, myocardial contusion (usually due to hitting steering wheel in car accident), severe PE, suppression of myocardial contractility by drugs (e.g. beta-blockers)
who should be referred to a fast-track cancer list when found to have IDA, regardless of any other symptoms?
anyone over 60
what are some of the possible causes of a trigeminal nerve lesion?
Sensory lesion: trigeminal neuralgia, herpes zoster Motor lesion: acoustic neuroma
if an adult attends A&E after sustaining a head injury, what features would indicate that a CT head should be performed in less than an hour of arrival?
CT head should be conducted in <1 hour if any of the following are present: - GCS < 13 on initial assessment (or <14 for children) - GCS < 15 at 2 hours after injury on assessment in the emergency department - Suspected open or depressed skull fracture - Any sign of basal skull fracture - Post-traumatic seizure - Focal neurological deficit - More than one episode of vomiting since the head injury
what should you tell patients who are undergoing investigations for coeliac disease?
Any test for CD is accurate only if a gluten-containing diet is eaten during the diagnostic process.
what most commonly causes cholecystitis?
In most cases (90%), it is caused by complete cystic duct obstruction usually due to an impacted gallstone in the gallbladder neck or cystic duct, which leads to inflammation within the gallbladder wall.
what are the 2 non-shockable rhythms in a cardiac arrest?
pulseless electrical activity asystole
anti-CCP (anti-cyclic citrullinated peptide) is most commonly seen in which condition?
rheumatoid arthritis (positive in about 70% of patients)
how should DIC be managed?
- Treat underlying condition - A platelet transfusion should be considered when the platelet count is <20 x 10^9/L or <50 x 10^9/L with active bleeding - Fresh frozen plasma (FFP) is the preferred agent for replacement of coagulation factors and coagulation inhibitors when significant bleeding is present or when fibrinogen levels are <2.94 micromol/L
how is a pathological q wave usually defined and what do their presence indicate?
- usually defined as duration ≥ 0.04 s or ≥ 25% of R-wave amplitude, although exact criteria can vary - They are a sign of a previous MI. They are not an early sign of myocardial infarction, but generally take several hours to days to develop.
very briefly, what causes Parkinson’s disease (i.e. the pathophysiology)?
It is caused by degeneration of the dopaminergic pathways in the substantia nigra
what is Uhthoff’s phenomenon and in which condition is it most associated with?
the worsening of symptoms when the body is overheated (e.g. hot weather, exercise, saunas). it is most associated with MS
what degree of heart block is mobitz type 2 and what does it look like on an ECG?
second degree 2 or 3 P waves occur successively, without a QRS complex following each (e.g. 2:1 or 3:1 ratio of P waves to QRS complexes)
what investigations might you consider in someone with suspected reactive arthritis?
- ESR and CRP are usually very high. - FBC: normocytic normochromic anaemia, mild leukocytosis and thrombocytosis during the acute phase. - HLA-B27 is positive in the majority of those affected. Rheumatoid factor and antinuclear antibodies are absent. - Joint aspiration may be required to rule out septic or crystalline arthritis - Culture of stools, throat and urogenital tract samples in order to identify the causative organism
how does NICE define the different stages of hypertension?
Stage 1 hypertension: BP in surgery/clinic is ≥140/90 mm Hg and ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM) ranges from 135/85 mm Hg to 149/94 mm Hg. Stage 2 hypertension: BP in surgery/clinic is ≥160/100 mm Hg but less than 180/120 mm Hg and ABPM or HBPM is ≥150/95 mm Hg. Stage 3 or severe hypertension: systolic BP in surgery/clinic is 180 mm Hg or higher or diastolic BP is 120 mm Hg or higher.
where is B12 absorbed?
in the distal ileum (so certain conditions, such as Crohn’s, or an ileal resection can affect absorption)
how should a suspected PE be investigated?
if PE is suspected, use the two-level PE Wells’ score to estimate the clinical probability of PE: - If score 4 or more, PE is likely and immediate computed tomography pulmonary angiogram (CTPA) should be offered - If score is less than 4 but PE still suspected, conduct D-dimer test. If positive, offer immediate CTPA other investigations: O2, FBC, U&Es, LFTs, baseline clotting screen, ECG investigations to consider: ABG, CXR , echo
what is the most common cause of a pansystolic murmur, heard best at the apex and often described as ‘blowing’?
mitral regurg
which joint does gout usually affect?
50% of all attacks and 70% of first attacks affect the first MTP.
what medications are recommended to be used in the long-term after an MI?
- Aspirin should be given to all patients, unless contra-indicated. The addition of clopidogrel has been shown to reduce morbidity and mortality - Beta-blocker (a rate-limiting calcium channel blocker such as verapamil may be considered if beta-blockers are contraindicated) - ACE inhibitor - Nitrates for angina - Statins may help prevent a recurring cardiac event
what does the h.pylori eradication regime consist of?
2 abx + 1 PPI NICE currently recommend: - A PPI (e.g. omeprazole) and - Clarithromycin and - Amoxicillin or metronidazole
what is the most common type of atrioventricular re-entry tachycardia (AVRT)?
Wolff-Parkinson-White syndrome is the most common type of AVRT. (Possible ECG features include a short PR interval and wide QRS complexes with a slurred upstroke - ‘delta wave’)
what are the first-line medications used in partial and generalised seizures?
- partial: carbamazepine (followed by sodium valproate and lamotrigine) - generalised: sodium valproate (or lamotrigine in women of childbearing age)
what scoring system is used to determine the most appropriate initial investigation in suspected PE?
the two-level PE Wells’ score
what is the incidence of complications in diverticulitis and what kind of complications can occur?
One third of patients with diverticulitis will develop complications such as: - perforation, abscess, fistula, stricture/obstruction - diverticular bleeding is a common cause of lower GI bleeding and is painless for most. Will resolve spontaneously in 70-80% of people
what is the daily requirement of: 1. water 2. potassium, sodium, chloride 3. glucose for a healthy adult?
- 25-30ml/kg/day 2. 1mmol/kg/day 3. 50-100g/day
when should someone be offered an immediate CTPA is suspected PE?
if they have a Well’s score of 4 or more
toxicity of which medication puts you at increased risk of SVT?
digoxin toxicity
what nerve is most likely to be affected by an anterior shoulder dislocation and what are the most likely affects of this?
- axillary nerve may result in: - impaired arm abduction - flatted deltoid (muscle atrophy) - loss of sensation in regimental badge area
what are some of the possible features of a PE?
- Sudden onset of symptoms - Dyspnoea - Pleuritic and/or retrosternal chest pain - Cough/haemoptysis - Dizziness/syncope - Hypoxia - Tachycardia/tachypnoea - Signs of DVT
what is the function of the abducens nerve?
controls the lateral rectus muscle (which enables eye to look laterally)
what are some of the clinical features of polymyalgia rheumatica?
- Age over 50 years and duration of symptoms more than two weeks - Bilateral shoulder or pelvic girdle aching, or both (bilateral upper arm tenderness usually accompanies shoulder pain) - Shoulder/hip girdle stiffness lasting >1 hour. (note: shoulder stiffness may make it difficult to raise arms to brush hair, dress, brush teeth etc) - Evidence of an acute-phase response (raised ESR/CRP) and/or rapid response to steroids - may be flu-like features at the onset
what are some possible causes of third nerve palsy?
diabetes (note, is usually pupil sparing so pupil is not dilated) GCA subarachnoid haemorrhage
what is the investigation of choice in suspected acute mesenteric ischaemia?
CT
when do alcohol withdrawal symptoms usually start to present and when do they usually peak?
usually start around 8 hours after last alcoholic drink. Symptoms usually peak roughly by day 2
what is the most common clinical signs seen in individuals with chronic myeloid leukaemia?
splenomegaly
what is the blood loss (both in ml and %) in: 1. Class 1 2. Class 2 3. Class 3 4. Class 4 haemorrhagic shock?
- <750ml, 10-15% blood loss 2. 750-1500ml, 15-30% blood loss 3. 1500ml-2000ml, 30-40% blood loss 4. >2000ml, >40% blood loss
what condition is defined as a deficiency of factor IX?
haemophilia type B
what are some of the negative prognostic features for rheumatoid arthritis?
- rheumatoid factor positive - poor functional status at presentation - HLA DR4 - X-ray: early erosions (e.g. after < 2 years) - extra articular features e.g. nodules - insidious onset - anti-CCP antibodies
what are some causes of non-meglabolastic macrocytic anaemia?
- Alcohol abuse is a common cause. There may also be folate deficiency due to a poor diet although beer is a good source of folate. - Liver disease. - Severe hypothyroidism. - Reticulocytosis. - Other blood disorders including aplastic anaemia, red-cell aplasia, myelodysplastic syndromes, myeloid leukaemia. - Drugs that affect DNA synthesis, such as azathioprine
acetylcysteine is used in the management of the overdose of which medication?
paracetamol
how would you expect hydrocephalus to present (in both an adult and an infnat)?
Adult patients with hydrocephalus present with symptoms due to raised intracranial pressure, which include: - Headache (typically worse in the morning, when lying down and during valsalva) - Nausea and vomiting - Papilloedema - Coma (in severe cases) As infants have skull sutures that are not yet fused, the pathological rise in ICP causes: - Rapid increase in head circumference - The skull sutures separate, the anterior fontanelle bulges and the scalp veins become distended - An advanced sign is fixed downward gaze or ‘setting-sun’ sign
what is Kernig’s sign and what condition is it seen in?
with patient supine and hip fully flexed, there is resistance and pain on passive extension of knee seen in meningitis
generally speaking, what is the non-invasive ventilation of choice in: 1. type 1 respiratory failure patients 2. type 2 repspiratory failure patients
- CPAP 2. BiPAP
what causes the lub dub sound on auscultation?
lub= closing of mitral and tricuspid valves (signifying start of systole) dub= closing of aortic and pulmonary valves (signficying start of diastole)
what is the difference in the epidemiology between Hodgkins and Non-Hodgkins Lymphoma?
HL: there is a peak in incidence in young adults aged 20-34 years, with a further peak observed over 70 years NHL: Low-grade NHL is most commonly seen in >50s, but high-grade NHLs are one of the more common cancers seen in children and young adults
describe how you should perform chest compression on an adult patient?
- Give 30 chest compressions followed by 2 ventilations. - The correct hand position for chest compression is the middle of the lower half of the sternum - Depth of 5–6 cm - Rate of 100–120 compressions min-1 - Allow the chest to recoil completely after each compression
what condition is a third heart sound (S3) associated with?
heart failure (note that in young healthy people it can be a normal phenomena)
how is pancreatitis traditionally diagnosed?
Serum amylase 3x or more than the normal is traditional way of diagnosing (although lipase levels are more sensitive and specific)
what signs/symptoms would you expect a patient with a subdural haematoma to present with?
Symptoms: - Headache (progressively getting worse) - Nausea/vomiting (may be sign of increased ICP) - May be a sign of increased intracranial pressure or increasing midline shift Signs: - Evidence of head trauma - Decreased/loss of consciousness (a sign of midline shift and herniation) - Abnormal eye examination: Anisocoria (unequal pupil size) may be a sign of brainstem herniation. Papilloedema may indicate raised ICP - May develop seizures
what are some of the possible complications of GCA?
- Inflammation may affect blood supply to eye resulting in permanent visual damage (occurs in 20%) - Aneurysms, dissections and stenotic lesions of the aorta and its major branches. - Complications of long-term steroid use e.g. osteoporosis
what medications should be prescribed/considered in someone with newly diagnosed stable angina?
- Prescribe sublingual glyceryl trinitrate (GTN) for the rapid relief of symptoms of angina. Advice to people: - Offer either a beta blocker or a calcium channel blocker as first-line treatment for stable angina. Decide which drug to use based on comorbidities, contraindications and the person’s preference - Consider aspirin 75 mg daily for people with stable angina, taking into account the risk of bleeding and comorbidities - Offer statin
describe how an IV insulin infusion should be given in DKA management
soluble insulin should be diluted (and mixed thoroughly) with sodium chloride 0.9% intravenous infusion to a concentration of 1 unit/mL; infuse at a fixed rate of 0.1 units/kg/hour.
what does the T-score have to be on DEXA scan to diagnose osteopenia?
T score less than -1 but above -2.5= hip BMD between 1 and 2.5 SD below the young adult reference mean (note <2.5= osteoporosis)
If a palate rises asymmetrically when patient is asked to say ‘aaahh’, what cranial nerve is affected?
vagus nerve
what is the best imaging for gallstones?
ultrasound
briefly, how should a subdural haematoma be managed?
- Stabilise patient + urgent referral to neurology - Prophylactic antiepileptics - Stop/reverse (if possible) any anticoagulation - Manage raised ICP e.g. IV Mannitol - Surgery (such as burr hole craniotomy) is needed if there are focal signs, deterioration, a large haematoma, raised intracranial pressure or midline shift
what would you expect to see in a patient with a radial nerve injury?
-wrist drop - reduced sensation to the dorsal aspect of the hand (over the thumb and the proximal phalanx of the index, middle and the medial part of the ring finger)
what is Reiter’s triad and in with what condition is it associated with?
urethritis, conjunctivitis, and arthritis associated with reactive arthritis (but not all patients with reactive arthritis will have all 3 features of reiter’s triad) (also note: Reiter was a freakin NAZI so Reiter’s triad and Reiter’s syndrome (now reactive arthritis) or phrases which aren’t really used anymore)
what condition is the ‘waiter’s tip posture’ seen in?
Erb’s palsy
what are possible symptoms of AF?
chest pain/discomfort, palpitations, dyspnoea, dizziness, irregularly irregular pulse
what is the normal water requirement for a healthy adult?
25-30ml/kg/day
what are some of the possible complications of taking a bisphosphonate?
- GI upset (e.g. heartburn, oesophagitis) - Hypophosphataemia - Osteonecrosis of the jaw. - Atypical femoral fracture
what is the definition of a subarachnoid haemorrhage?
An abnormal collection of blood between the arachnoid and pia mater, which normally contains CSF
what are the Canadian C-Spine rules? (i.e. what is their use, not what specifically are the rules)
The Canadian C-Spine Rule is a decision making tool used to determine when radiography should be utilized in patients following trauma where cervical spine injury is a concern
what should be done in primary care to help manage a patient with peripheral arterial disease?
- lifestyle modifications e.g. smoking cessation, increased exercise - Control risk factors e.g. hypertension, hyperlipidaemia - Start on an antiplatelet (usually aspirin, can be clopidogrel)
briefly describe the pathophysiology involved in DKA
- A lack of insulin in the blood (which may be due to diabetes or in response to a starvation state) results in glucose not being taken up into the cells - This stimulates the hormone glucagon, which stimulates glycolysis (the breakdown of glycogen), as well as glucaneo-genesis - This lack of cellular glucose also stimulates lipolysis (breakdown of fat). This causes the release of free fatty acids. These fatty acids are broken down in the liver to produce ketone bodies
how can you look for dilated bowel loops on an abdo x-ray? (i.e. what ‘rule’ can you use to help look for dilation)
use the 3-6-9 rule: small bowel should be <3cm, large bowel <6cm, ceacum <9cm
what is the max dose of paracetamol that should be taken in 24hours, and what is generally considered to be a lethal dose?
max dose= 4g lethal dose= >12g
what would you expect to see on the ECG of someone with unstable angina?
In unstable angina, the ECG typically shows T-wave inversion or ST-segment depression’ however, the ECG may be normal if some time has elapsed since the last episode of pain
what is the epidemiology for hodgkins lymphoma?
there is a peak in incidence in young adults aged 20-34 years, with a further peak observed over 70 years
how should an acute ischaemic limb be managed?
- Urgent admission + inform vascular surgery - Heparinisation is needed immediately (this may double the limb salvage rate), and provide analgesia - If the occlusion is embolic, the options are surgical embolectomy or local thrombolysis e.g. tissue plasminogen activator - If the occlusion is due to thrombotic disease the options are intra-arterial thrombolysis, angioplasty or bypass surgery. If due to thrombosis of an arterial graft, then thrombolysis is the first step - If a limb is irreversibly ischaemic, amputation will be required
what are some of the clinical features septic arthritis?
- Joint is usually swollen, warm, tender and exquisitely painful on movement - Fever and rigors often present - Bacteraemia is common and may cause prostration, vomiting or hypotension - Effusion may be obvious
what are some of the most common features of a focal seizure arising from the frontal lobe?
- Head/leg movements - Dystonic posturing (‘fencing posture’) - Post-ictal weakness - usually last <60 seconds
briefly, how should chronic heart failure be managed?
- Lifestyle changes - First-line treatment for all patients is an ACE inhibitor and a beta-blocker (ideally start separately) - Diuretics should be given for fluid overload - Vaccines: > Annual flu vaccine > One-off pneumococcal vaccine
what are some of the possible causes of spinal cord compression?
- Trauma (including car accidents, falls and sports injuries) - Tumours, both benign or malignant - A prolapsed intervertebral disc - An epidural or subdural haematoma - Inflammatory disease, especially rheumatoid arthritis - infection - Cervical spondylitic myelopathy
what investigations should you consider in someone with suspected subarachnoid haemorrhage?
- CT detects >90% of SAH within the first 48 hours - CT angiography to determine source of bleed - Lumbar puncture if CT -ve but clinical suspicion (xanthochromia= bilirubin in CSF, diagnostic of SAH). Should be done at least 12 hours after onset of symptoms
what is the classical triad of signs/symptoms seen in someone with cardiac tamponade?
hypotension, muffled heart sounds, jugular venous distention
with what signs and symptoms does Alzheimer’s dementia present with (early, later and advanced stages)?
- Onset is insidious and usually progresses slowly over 7-10 years - In early stages: short-term memory loss, dysphasia (difficulty finding words), spatial disorientation - Later stages: confusion, personality disintegration (e.g. aggression, psychosis), apraxia (inability to perform particular purposive actions), agnosia (inability to recognise objects/people/sounds etc) - Advanced stages: apathy, wandering/immobility, incontinence, psychiatric symptoms (e.g. hallucinations, delusions)
how should a haemodynamically stable patient in VT be managed?
- IV amiodarone - Direct current cardioversion 2nd line
what antibodies should be checked when suspecting coeliac disease?
Total immunoglobulin A (IgA) and IgA tissue transglutaminase (tTG) as the first choice. Endomysial antibodies (EMA) if IgA-tTG is unavailable
simply put, what usually causes hyperuricaemia (which can lead to gout)?
Hyperuricaemia is due to renal under-excretion of urate in 90% of cases and to over-production in 10%, although there is often an overlap of both
what usually happens to blood pressure in TACO and TRALI?
TACO: often rapidly increases TRALI: often decreases (with tachycardia)
how common is it to get secondary generalisation in a partial seizure?
occurs in roughly 2/3rds of patients who have a partial seizure
how can a migraine be managed acutely?
Moderate symptoms: NSAIDs or aspirin +/- anti-emetic (e.g. metoclopramide or prochlorperazine) Severe symptoms: triptan (e.g. sumatriptan) +/- NSAID +/- anti-emetic
how should TRALI be managed?
seek senior advice but largely supportive management with fluids and oxygen (may require ventilation + ICU admission if severe)
what bloods should you consider ordering in a patient with confusion?
- FBC: look for markers of infection - B12 and folate: deficiency can cause confusion - TFTs: hypothyroidism can cause confusion - U&Es: renal failure may cause cognitive problems - LFTs: may indicate underlying pathology or alcohol problems - Calcium: hypo and hypercalcaemia can cause cognitive changes
what is the most common sign of trochlear nerve palsy/lesion?
diplopia (+ often head tilt to attempt to compensate)
what is the definition of: - cholelithiasis - cholecystitis - choledocholithiasis - cholangitis?
- Cholelithiasis= stones in the gallbladder (so get colicky pain) - Cholecystitis= inflammation of gallbladder (caused by cystic duct obstruction by stones) - Choledocholithiasis= common bile duct obstruction by stone (so get jaundice) - Cholangitis= infection of biliary tree (caused by choledocholithiasis)
what does the mnemonic CRABBI stand for in the context of the main features of myeloma?
- Calcium: Hypercalcaemia occurs as a result of increased osteoclast activity within the bones. This leads to constipation, nausea, anorexia and confusion - Renal: Monoclonal production of immunoglobulins results in light chain deposition within the renal tubules. This causes renal damage which presents as dehydration and increasing thirst - Anaemia: Bone marrow crowding suppresses erythropoiesis leading to anaemia. This causes fatigue and pallor - Bleeding: bone marrow crowding also results in thrombocytopenia which puts patients at increased risk of bleeding and bruising - Bones: Bone marrow infiltration by plasma cells and cytokine-mediated osteoclast overactivity creates lytic bone lesions. This may present as pain (especially in the back) and increases the risk of fragility fractures - Infection: a reduction in the production of normal immunoglobulins results in increased susceptibility to infection
what are the most important antibodies to test for in suspected rheumatoid arthritis?
Rheumatoid factor (RF) and anti-cyclic citrullinated peptide (anti-CCP) are the most important antibodies to test for. Anti-CCP is slightly more specific than RF
describe a typical aura which precedes a migraine
typical aura are visual, progressive, last 5-60 minutes and are characterised by transient hemianopic disturbance or a spreading scintillating scotoma (spot of flickering light near or in the centre of the visual field)
what are some of the features of an atonic seizure?
sudden, brief loss of muscle tone in the body causing person to become limp and collapse. There is usually no LOC and recovery is swift
what is a delta wave and what does it suggest if seen on an ECG?
The Delta wave is a slurred upstroke in the QRS complex often associated with a short PR interval This may be a sign that the ventricles are being activated earlier than normal from a point distant to the AV node. Associated with Wolff-Parkinson-White syndrome
a patient presents with chest pain and new onset LBBB, how should they be managed?
MI can present with new LBBB (without ST changes) so manage as MI
with what signs and symptoms would you expect small and large bowel obstructions to present with?
Small bowel: nausea, vomiting (associated more with proximal obstructions), faeculent vomiting (due to reverse peristalsis or fistula formation), constipation, crampy abdominal pain, fever, history of prior abdominal surgeries Large bowel: abdominal distension, severe or complete constipation, colicky abdominal pain, nausea and vomiting (not as severe or common as small bowel), tenesmus, palpable abdo mass Both: dehydration, active high-pitched ‘tinkling’ bowel sounds
how can hydrocepahlus be categorised and what are some of the causes of the 2 categories?
Obstructive (‘non-communicating’) hydrocephalus: this is due to a structural pathology blocking the flow of cerebrospinal fluid. Causes include: - Tumours - Acute haemorrhage (SAH or intraventricular haemorrhage) - Congenital malformations e.g. aqueduct stenosis, Chiari malformation Non-obstructive (‘communicating’) hydrocephalus: this is due to an imbalance of CSF production/absorption. Causes include: - Choroid plexus tumour (causes increased production of CSF- very rare however) - Failure or reabsorption at the arachnoid granulations, which may be due to meningitis or post-haemorrhage
besides from an early diastolic murmur, what other signs may be elicited on examination of someone with aortic regurgitation? (2)
- Collapsing pulse - Wide pulse pressure (wide gap between systolic and diastolic BP)
how should an acute attack of gout be managed?
- NSAIDs e.g. diclofenac, naproxen - If NSAIDs are not tolerated or are contraindicated, prescribe colchicine - If on allopurinol at the time of attack, do not stop taking, but do not start in acute attack (Note: will resolve spontaneously within 3-15 days but require treatment as extremely painful)
what are some of the possible risk factors for hyperuricaemia/gout?
- male, middle-aged/elderly - Diet: meat, seafood, alcohol - Diuretics, chemotherapy - Obesity, diabetes, hypertension, CKD
how might someone who has taken an opioid overdose present?
Opioid overdose triad: - Pinpoint pupils - Unconsciousness - Respiratory depression Other symptoms include: hypotension, tachycardia, nausea/vomiting
what are some causes of iron overload?
- Hereditary haemochromatosis: a genetic condition where individuals show increased iron absorption and organ deposition - Repeated red blood cell transfusions - Other causes: liver disease, excess iron intake
a pericardial friction rub is associated with what condition?
pericarditis
where abouts in the GI tract are diverticula most commonly seen?
Diverticula can occur throughout the gastrointestinal tract, but are seen most commonly in the sigmoid and descending colon
what is the prophylactic management of gout?
- Lifestyle advice: limit alcohol, reduce meat/seafood, weight reduction, avoid dehydration - Manage risk factors: e.g. review diuretics, manage hypertension - Allopurinol, to be started at least 1-2 weeks after acute attack and titrate up while monitoring serum uric acid level
what colour do gram negative vs gram positive bacteria stain?
gram positive: purple gram negative: pink
which condition is the Framingham criteria used to help diagnose?
congestive heart failure
what are the 2 main diagnostic tests for myeloma?
Bone marrow aspiration and trephine biopsy: confirms the diagnosis if the number of plasma cells is significantly raised
a patient’s ECG shows tachycardia and a broad complex QRS, what arrythmia are they in?
ventricular tachycardia
lip smacking is a common feature in which kind of focal seizure?
those arising from the temporal lobe
during what time frame do acute transfusion reactions occur?
within 24 hours of the transfusion
how should status epilepticus be managed in a community setting?
- Protect head + secure airway - Use buccal midazolam or rectal diazepam as first-line treatment for prolonged or repeated seizures in the community - Call for ambulance
what would you expect to see on the ECG of someone having an inferior STEMI and which artery is most likely to be involved?
ST elevation in leads II, III and aVF right coronary artery is the most likely occluded vessel
how would you expect someone with myasthenia gravis to present?
The key feature is muscle fatigability - muscles become progressively weaker during periods of activity and slowly improve after periods of rest: - extraocular muscle weakness: diplopia - proximal muscle weakness: face, neck, limb girdle - ptosis - dysphagia - may experience a myasthenic crisis: a complication of MG characterised by worsening muscle weakness resulting in respiratory failure that requires intubation and mechanical ventilation
what 2 enzyme defects most commonly cause haemolytic anaemia?
G6PD deficiency (most common), pyruvate kinase deficiency
what condition is the Philadelphia chromosome associated with?
chronic myeloid leukaemia (seen in 90% of cases)
what is the usual treatment regime in someone with newly diagnosed RA?
In people with newly diagnosed active RA, offer DMARD monotherapy (usually methotrexate but can be leflunomide or sulfasalazine), plus short-term glucocorticoids as first-line treatment as soon as possible, ideally within three months of the onset of persistent symptoms (note, used to be dual DMARD therapy but NICE guidelines recently changed)
what does the hypoglossal nerve control?
muscles of the tongue
what is the epidemiology for non-hodgkins lymphoma?
Low-grade NHL is most commonly seen in >50s, but high-grade NHLs are one of the more common cancers seen in children and young adults. White people have a greater risk than black or Asian.
which is more common, an anterior or posterior shoulder dislocation? and what is the most common mechanism of the injury?
anterior is far more common (~95%) most commonly caused by a FOOSH
how might a lesion of the trigeminal nerve present?
- Loss of sensation - Loss of corneal reflex - Weakness of jaw clenching or side-to-side movements (depending on site of lesion, may not have all these features)
what basic investigations could be done in primary care to look for evidence of end-organ damage in someone with hypertension?
- Urine dip for haematuria. - Arrange measurement of: > Urine albumin:creatinine ratio (to test for the presence of protein in the urine). > HbA1C (to test for diabetes). > Electrolytes, creatinine, and estimated glomerular filtration rate (to test for chronic kidney disease). - Examine the fundi (for the presence of hypertensive retinopathy). - Arrange for a 12-lead electrocardiograph to be performed (to assess cardiac function and detect left ventricular hypertrophy). - Consider the need for specialist investigations in people with signs and symptoms suggesting target organ damage or a secondary cause of hypertension.
what is the main diagnostic investigation for GCA?
temporal artery biopsy (characterised by a predominance of mononuclear cell infiltration or granulomatous inflammation, usually with multinucleated giant cells)
a patient describes experiencing an ‘aura’ before their seizure. Based on this alone, what is the most likely seizure that the patient has experienced?
a focal seizure from the temporal lobe (note: is often, but not always, from the temporal lobe)
what is Murphy’s sign and which condition is it used to help diagnose?
Murphy’s sign: lay two fingers over the RUQ. Ask the patient to breathe in. This causes pain and arrest of inspiration as the inflamed GB impinges on your fingers. The sign is only positive if a similar manoeuvre in the left upper quadrant does not cause pain Classically seen cholecystitis
what are some of the red flag features which may point towards malignancy in a patient with back pain?
- history of cancer (particularly breast, prostate, lung (most common cancers causing bone mets) or myeloma) - Pain that remains when lying down, aching night-time pain that disturbs sleep - Constitutional symptoms, such as fever, chills, or unexplained weight loss. - Point tenderness over the vertebral body
what is the aetiology of peptic ulcers?
- H.pylori (90% of duodenal ulcers, ~80% of gastric ulcers) - Drugs: NSAIDs, steroids, SSRIs - Lifestyle: alcohol, smoking, stress - Zollinger-Ellison syndrome: rare cause characterised by excessive levels of gastrin, usually from a gastrin secreting tumour
what would you expect to see on the CT head of a patient with a subdural haematoma (both acute and chronic)?
Acute SDH: imaging will show a hyperdense (bright), crescenteric collection surrounding the brain that is not limited by suture lines Chronic SDH: imaging will show a hypodense (dark), crescenteric collection around the surface of the brain that is not limited by suture lines
what investigations should be considered in suspected acute diverticulitis?
- Bloods (raised WBC and inflammatory markers) - CXR with the patient upright can aid detection of pneumoperitoneum. - Abdominal X-rays may demonstrate small or large bowel dilation or ileus, pneumoperitoneum, bowel obstruction, or soft tissue densities suggesting abscesses. - CT scanning with intravenous, oral or rectal contrast: sensitivities and specificities for CT are significantly better than for contrast enemas. (note: endoscopy is generally avoided in the initial assessment due to risk of perforation)
when should levodopa be offered in patients with Parkinson’s disease?
Levodopa should be offered to people in the early stages of Parkinson’s disease whose motor symptoms impact on their quality of life
what are some euvolaemic causes of hyponatraemia?
- Severe hypothyroidism - Normal physiological change of pregnancy - Syndrome of inappropriate antidiuretic hormone secretion (SIADH)
what criteria must be met for a stroke to be classified as a ‘partial anterior circulation stoke’ (PACS)?
Two of the following need to be present for a diagnosis of PACS: - Unilateral weakness (and/or sensory deficit) of the face, arm and leg - Homonymous hemianopia - Higher cerebral dysfunction (dysphasia, visuospatial disorder)
which autoantibody are vasculitides most commonly associated with?
ANCA (anti-neutrophilic cytoplasmic antibodies) note that ANCA is not specific to vasculitides however
with what features would you expect someone in acute left ventricular failure to present with?
- dyspnoea: > Exertional (ask about exercise tolerance) + at rest > Orthopnoea (ask about no. of pillows) and paroxysmal nocturnal dyspnoea - Cough (may be worse at night and associated with pink/frothy sputum) - Fatigue - Signs: cyanosis, tachycardia, displaced apex beat, bibasal crackles (classically- may also be heard as a wheeze)
what is the most important investigation for septic arthritis?
Urgent joint aspiration for synovial fluid microscopy and culture
what does injury to the long thoracic nerve classically cause?
winged scapula
what are some of the risk factors for stoke?
Age, hypertension, smoking, diabetes, heart disease, post-TIA, combined oral contraceptive, carotid bruit (carotid artery occlusion), hyperlipidaemia, excess alcohol, clotting disorders
what condition will basically all individuals with Down’s syndrome eventually develop?
Alzheimer’s dementia (usually beginning around the age of 40)
what are some of the possible causes of vestibulocochlear nerve palsy/lesion?
- Paget’s disease of the bone - Meniere’s disease - Herpes zoster - Acoustic neuroma - Aminoglycosides e.g. gentamicin
how long should a normal QRS complex be on an ECG?
roughly 0.12s (3 small squares)
into what 3 categories can causes of hyponatraemia be divided into and what are some causes which fall under each category?
Hypovolaemic: - Vomiting - Diarrhoea - Burns - Diuretic use - Prolonged exercise/sweating - Addison’s disease (insufficient production of cortisol and aldosterone) Euvolaemic: - Severe hypothyroidism - Normal physiological change of pregnancy - Syndrome of inappropriate antidiuretic hormone secretion (SIADH) Hypervolemic: - Cirrhosis - Nephrotic syndrome - Congestive heart failure
which is more common- non-hodgkins lymphoma or Hodgkins lymphoma?
NHL is 5 times more common than HL
what signs/symptoms would you expect to see in a patient with a AAA (both un-ruptured and ruptured)?
Unruptured AAA: - Most are asymptomatic - May be found incidentally on examination (expansile abdominal aorta- pulsatile is normal) or scan (ultrasound, CT, MRI, abdominal x-ray) - Pain in the back, abdomen, loin or groin Ruptured AAA: - Ruptured AAA presents with a classical triad of pain in the flank or back (may be sudden and severe), hypotension and a pulsatile abdominal mass; however, only about half have the full triad - Syncope, shock or collapse - Retroperitoneal haemorrhage may cause Grey Turner’s sign, i.e. flank bruising - Patient may feel cold, sweaty and faint
how is osteoporosis diagnosed using a DEXA scan? (i.e. how to interpret the score)
- Osteoporosis= hip BMD 2.5 SD or more below the young adult reference mean (T score ≤-2.5). - Severe osteoporosis= hip BMD 2.5 SD or more below the young adult reference mean in the presence of one or more fragility fractures (T score ≤-2.5 PLUS fracture) where BMD= bone mineral density
briefly, how should viral meningitis be managed?
Viral meningitis usually requires only supportive therapy (e.g. fluids, antiemetics etc)
what chromosome is chronic myeloid leukaemia associated with?
Philadelphia chromosome (shortened chromosome 22)
how should hyperkalaemia be managed?
Protect cardiac membrane: - Give 10 ml 10% calcium gluconate (calcium chloride is an alternative ideally given via central access) which will improve ECG changes within 1-3 minutes; however, this effect only has a transient effect of 30-60 minutes - This reduces risk of arrythmias Shift potassium into cells: - Insulin-glucose infusion: usually 10 units of soluble insulin are added to 25 g of glucose and administered by IV infusion (potassium moves with glucose, glucose therefore given to prevent hypoglycaemia). - Capillary blood glucose needs to be checked before, during and after. - Potassium will decrease (0.6-1.0 mmol/L) in 15 minutes and the reduction lasts for 60 minutes - 10-20mg nebulised salbutamol is often also given to promote the movement of potassium into cells (note that there are other methods to remove potassium from the body, unlike the methods above which move potassium from extracellular to intracellular, but these are slower acting methods so should only be used in mild-moderate hyperkalaemia)
what are some of the most common causes of AF?
The most common causes of AF are coronary heart disease, hypertension, valvular heart disease and hyperthyroidism
what condition would you expect to see a positive Phalen’s test and Tinel’s sign and how are these elicited?
seen in carpal tunnel syndrome Positive Phalen test: flexing the wrist for 60 seconds causes pain or paraesthesia in the median nerve distribution. Positive Tinel’s sign: tapping lightly over the median nerve at the wrist causes a distal paraesthesia in the median nerve distribution
which tumours most commonly metastasize to the brain?
- lung (most common) - breast - bowel - skin (namely melanoma) - kidney (note that brain metastases are the most common type of brain tumour)
what do the 4Hs and 4Ts refer to and what are they?
they refer to the reversible causes of cardiac arrest - 4 Hs: hypoxia, hypothermia, hypovolaemia, hyperkalaemia (+ hypokalaemia, hypoglycaemia, hypocalcaemia, acidaemia and other metabolic disorders) - 4 Ts: cardiac tamponade, tension pneumothorax, thrombosis (coronary or pulmonary), toxins
what should be prescribed in an acute attack of gout if NSAIDs are contraindicated?
colchicine
what are some causes of hyperkalaemia?
Renal causes: - AKI - CKD Excessive release from cells: - Acidosis e.g. DKA - Tissue damage (e.g. rhabdomyolysis, burns, trauma) Medication: - ACEi, ARBs, NSAIDs, potassium-sparing diuretics (e.g. spironolactone), beta-blockers, heparin, trimethoprim Iatrogenic: - Blood transfusion - Over-replacement of K+ with intravenous fluids Addison’s disease (lack of aldosterone causes more potassium to be retained in kidneys)
what is the cornerstone of treatment for ankylosing spondylitis?
NSAIDs
what are some of the genetic causes of haemolytic anaemia?
- Red cell membrane abnormalities: hereditary spherocytosis, elliptocytosis. - Haemoglobin abnormalities: sickle cell anaemia, thalassaemia. - Enzyme defects: G6PD deficiency, pyruvate kinase deficiency
what is the most common cancer in children?
acute lymphoblastic leukaemia
overdose of aspiring causes what? (i.e. what type of poisoning)
salicylate poisoning
how long should LMWH or fondaparinux be continued for in management of PE?
Start as soon as possible and continue for at least 5 days or until INR is 2 or above for at least 24 hours (note: this is the same as DVT)
what are the 2 most common causes of acute pancreatitis and at roughly what age do they present?
alcohol (average age of onset is 38) and gallstones (average age of onset is 69) point is that alcohol-related AP usually occurs in younger patients than gallstone-related AP
how should a PE be managed (in a haemodynamically stable patient)?
Initial resuscitation: - Oxygen 100% - Obtain IV access - Analgesia if necessary (e.g. morphine) Anticoagulation therapy: - Offer low molecular weight heparin or fondaparinux in confirmed cases unless contraindicated. Start as soon as possible and continue for at least 5 days or until INR is 2 or above for at least 24 hours - Rivaroxaban (or other NOAC/warfarin) is recommended for at least 3 months following in patients with risk factors
how is appendicitis diagnosed and what investigations should be considered?
appendicitis is usually a clinical diagnosis investigations should be conducted to rule out alternative diagnoses e.g. - urinalysis +/- pregnancy test - imaging (CT is generally preferred over ultrasound)
groin pain that is exacerbated by movement should make you think of what?
hip OA
what are some causes of lymphoedema?
Possible causes include: lymph node removal (e.g. in breast cancer or other cancers), radiotherapy, cellulitis, trauma, DVT, obesity etc
what are some of the common causative organisms of bacterial meningitis in: - neonates - children - adults
Neonates: group B streptococci, E.coli Young children: Neisseria meningitidis, streptococcus pneumoniae, haemophilus influenzae Adults: Neisseria meningitidis, streptococcus penumoniae
how does severe haemophilia classically present? (in terms of presenting symptoms)
Recurrent spontaneous bleeding into joints (haemarthroses) and muscles without history of significant trauma
during what time frame does TRALI usually occur?
within 6 hours of the transfusion
what drug does NICE recommend if acetcycholinesterase inhibitors are contraindicated/not tolerated or if the patient has advanced Alzheimer’s?
Memantine (a N-methyl-D-aspartate (NMDA) antagonist)
what is the definition of an aneurysm?
An aneurysm is a permanent and irreversible dilatation of a blood vessel by ≥50% of its normal expected diameter
how should peripheral arterial disease be managed (both in primary and secondary care)?
In primary care: - lifestyle modifications e.g. smoking cessation, increased exercise - Control risk factors e.g. hypertension, hyperlipidaemia - Start on an antiplatelet (usually aspirin, can be clopidogrel) Referral: deteriorating or uncontrolled symptoms or the presence of features resembling critical limb ischaemia should prompt a referral to secondary care Secondary care intervention (usually only done in CLI or near CLI): - Endovascular revascularisation options include stents and percutaneous transluminal angioplasty (PTA). These are usually the options of choice when lesions are short and proximal - Bypass surgery is usually the option of choice when lesions are longer or multi-segmental. (ideally use vein grafts rather than prosthetic)
what are some signs of a basal skull fracture? (4)
- haemotympanum (blood in tympanic cavity of middle ear) - ‘panda’ eyes (bruising around the eyes) - CSF leakage (ears or nose) - Battle’s sign (bruising which sometimes occurs behind the ear in cases of basal skull fracture).
why should you always examine the hip if someone presents with knee pain?
as knee pain may be referred pain from the hip (e.g. in OA)
how does gout usually present?
- Tender, swollen, erythematous joint, with pain which reaches its crescendo over a 6- to 12-hour period - May have joint stiffness which may limit function - 50% of all attacks and 70% of first attacks affect the first MTP. Other sites include: wrist, ankle, knee, midtarsal joints
between DKA and HHS, which is more commonly seen in: 1. type 1 diabetics 2. type 2 diabetics
- DKA 2. HHS
what are some of the signs and symptoms of hypovolaeic shock?
Symptoms: - The individual may feel cold, unwell, anxious, faint and short of breath. - There may be faintness on standing or even on sitting up, due to postural hypotension. - There may be symptoms related to the cause of the hypovolaemia, such as pain from a bleeding ulcer, dissecting aneurysm, ruptured ectopic pregnancy, trauma or burns. - Gut ischaemia can lead to nausea and vomiting but the significance is often overlooked. Signs: - The patient may look pale and sweaty. - There may be tachypnoea. - The periphery may be cold from poor perfusion, and capillary refill time may be prolonged. However, this can be a poor indicator of hypovolaemia. - There may be tachycardia and a fall in blood pressure or postural hypotension. Tachycardia and cold peripheries from vasoconstriction may occur before a fall in BP, especially in children and young adults. - Young people may show little rise in pulse rate and no fall in BP despite significant exsanguination. It is very easy to underestimate the severity of loss in a young person. - Late features include confusion or even coma.
what condition is dermatitis herpetiformis associated with?
it is the skin manifestation of coeliac disease, with 75% of individuals who have the rash having villous atrophy
what does ‘P Pulmonale’ refer to and what causes it?
P wave amplitude is >2.5mm due to right atrial enlargement (which is usually secondary to pulmonary valve stenosis or pulmonary hypertension)
what are some features on a resting ECG which may be indicative of coronary artery disease?
Changes on a resting 12-lead ECG that are consistent with CAD include: - Pathological Q waves. - Left bundle branch block (LBBB). - ST-segment and T-wave abnormalities (eg, flattening or inversion).
what are the features of a tension-type-headache?
- Typically described as a tightness/pressure in a band around the head. The headache is not pulsatile/throbbing - There may be an identifiable trigger e.g. stress - Not associated with photophobia, vomiting (may get mild nausea), not exacerbated by movement - Neurological examination is normal
what would you expect to see on the MRI of someone with MS? (hard q)
95% of patients have periventricular lesions and over 90% show discrete white matter abnormalities. Areas of focal demyelination can also be seen as plaques in the optic nerve, brainstem and spinal cord
what are some of the risk factors for DVT?
Age, past DVT, family history, cancer, immobilisation (long-distance travel, hospital stay, bed bound), smoking, obesity, male, thrombophilia, pregnancy, combined oral contraceptive, HRT
A patient presents with weakness on one side of their face. They are unable to use all muscles of facial expression on this side, including not being able to raise their eyebrows. Is this an UMN or LMN lesion of the facial nerve? And what is the most likely cause?
LMN lesion Bell’s palsy is the most common cause of LMN facial palsy (UMN lesions, seen in patients with strokes or tumours, are forehead sparing)
what constitutes Charcot’s triad and in what condition is it seen?
Charcot’s triad: fever, jaundice, RUQ pain Seen in cholangitis
how does pancytopenia present?
present with features of anaemia, thrombocytopenia and leukopenia: - Anaemia: fatigue, weakness, pallor, headaches etc - Thrombocytopenia: epistaxis, bleeding gums, petechiae, spontaneous bruising - leukopenia: fever, chills, frequent infections
what is pernicious anaemia and what kind of anaemia does it cause?
autoimmune condition in which the immune system attacks cells in stomach which produce intrinsic factor, meaning B12 cannot combine with intrinsic factor to be absorbed in the distal ileum It causes megaloblastic macrocytic anaemia
what are some of the possible symptoms you would expect to see in myeloma?
- Bone pain (particularly backache) - pathological fractures - spinal cord/nerve root compression - lethargy (due to anaemia) - anorexia, dehydration (due to proximal tubule dysfunction from light-chain precipitation) - recurrent bacterial infection - bleeding and/or bruising - features suggesting amyloidosis (e.g. cardiac failure, nephrotic syndrome) - signs and symptoms of hypercalcaemia (e.g. thirst, constipation, nausea, confusion).
what are some causes of RBBB?
- normal variant - more common with increasing age - right ventricular hypertrophy - chronically increased right ventricular pressure - e.g. cor pulmonale - pulmonary embolism - myocardial infarction - atrial septal defect (ostium secundum) - cardiomyopathy or myocarditis
what time-span does one small square and one large square on an ECG represent?
small square= 0.04s large square= 0.2 seconds
what are the 4 main mechanisms which cause iron deficiency anaemia?
1- blood loss 2- insufficient intake 3- insufficient absorption 4- excessive requirement
which tumour marker is most specific for pancreatic cancer?
CA 19-9
what is the epidemiology for acute myeloid leukaemia?
AML is the most common acute leukaemia in adults. Median age of onset is 67
what are some of the driving rules regarding seizures/epilepsy?
generally patients cannot drive for 6 months following a seizure. For patients with established epilepsy they must be fit free for 12 months before being able to drive
what is the definition of status epilepticus?
a convulsive seizure which continues for a prolonged period (longer than five minutes, note that it used to be 30 minutes), or when convulsive seizures occur one after the other with no return of consciousness between.
what are some risk factors associated with subarachnoid haemorrhage?
Hypertension, smoking, excess alcohol, cocaine, bleeding disorders, family history Conditions associated with berry aneurysms: polycystic kidneys, coarctation of the aorta, Ehlers-Danlos syndrome, neurofibromatosis type 1
what kind of anaemia would you expect to see in thalassaemia?
hypochromic microcytic anaemia
what drugs can be used in rate control of AF?
Either offer a beta-blocker or a rate-limiting calcium channel blocker (e.g. diltiazem, verapamil etc). Digoxin may also be used but is not first-line
what 2 investigations are most relevant/important in someone with suspected peripheral arterial disease?
- ABPI: normal =1, intermittent claudication = 0.6-0.9, rest pain = 0.3-0.6, impending gangrene = <0.3 - Duplex ultrasound is best way to confirm diagnosis (should also do bloods + ECG)
what does left and right axis deviation look like on an ECG?
Right axis deviation: lead III has the most positive deflection and lead I is negatively deflected. Commonly seen in right ventricular hypertrophy. Left axis deviation: lead I has the most positive deflection and leads II and III are negative. Seen in individuals with heart conduction defects, may also be caused by left ventricular hypertrophy.
a patient with severe renal impairment presents with symptoms highly suspicious of a PE (Well’s score >4), what investigation should be done?
V/Q scan (if patient has renal impairment and therefore cannot have contrast, investigation of choice is V/Q scan rather than CTPA)
what would the FBC and blood film of someone with sickle cell anaemia typically show?
the haemoglobin level is in the range 6-8 g/dL with a high reticulocyte count of 10-20%; the blood films may show sickled erythrocytes and features of hyposplenism. (remember, most people will be diagnosed by heal prick/Guthrie test, not FBC)
what blood test can be useful in confirming a diagnosis of gout but what is the caveat?
serum uric acid level BUT should be obtained at least 2 weeks after the attack resolves, as it may be falsely low or normal during the attack
what is the difference between stable and unstable angina?
stable= pain is precipitated by predictable factors, usually exercise unstable= pain occurs at any time/ is unpredictable. should be managed as an ACS
what is seen on an ECG of someone in first degree heart block?
PR interval >0.2s (1 large square)
what is GCA/temporal arteritis?
GCA is a systemic immune-mediated vasculitis affecting medium-sized and large-sized arteries, particularly the carotid artery and its extracranial branches
what investigations should you consider in someone you suspect to have an acute ischaemic limb?
- Bloods (FBC, ESR, glucose, lipids, thrombophilia screen) - Hand-held Doppler ultrasound scan may help demonstrate any residual arterial flow - ABPI: 1= normal, 0.6-0.9= claudication 0.3-0.6= rest pain, <0.3= impending gangrene - Investigations to find source of embolism e.g. ECG, echocardiogram - If diagnosis is in doubt, do an urgent arteriography
which coagulation test is most commonly abnormal in people with haemophilia?
Activated partial thromboplastin time (APTT) - usually prolonged but can be normal in mild disease
which cancer are people with Down’s syndrome particularly more likely to develop?
leukaemia
after being diagnosed with hypertension, what tool should be used to help determine their risk of a cardiovascular event?
QRISK2 (or 3 now?)
describe the pathophysiology behind varicose veins
VVs are due to incompetent valves that connect the deep and superficial venous systems. Leakage in a valve causes retrograde flow back into the vein. Unlike deep veins which are thick-walled and confined by fascia, superficial veins cannot withstand high pressure and eventually become dilated and tortuous. The failure of one valve puts pressure on its neighbours and may result in retrograde flow - and hence varicosity - of the entire local superficial venous network.
what might an x-ray of someone with RA show?
soft tissue swelling, periarticular osteopenia, loss of joint space, erosions and deformity (MUST know difference between RA and OA x-ray findings)
if there is a lesion of the hypoglossal nerve, which side will the tongue deviate towards?
towards the site of the lesion
when should medication be considered in someone experiencing seizures?
at least after the 2nd seizure
which type of antibodies are involved in anaphylaxis (type 1 hypersensitivity reactions)?
IgE antibodies
how would you expect a facial nerve lesion to present?
- Facial weakness: > In LMN lesion, forehead is paralysed > In UMN lesion, forehead is spared - Taste loss
how should salicylate poisoning be managed?
- Activated charcoal if ingested <1 hour ago - Aggressive rehydration - urinary alkalinization with intravenous sodium bicarbonate - enhances elimination of aspirin in the urine - haemodialysis in severe cases
what condition is Zollinger-Ellison syndrome most commonly associated with?
peptic ulcer disease
what does the Oxford/Bamford Classification System classify? And into what 4 groups does it classify them?
Ischaemic strokes Classified into: - Total Anterior Circulation Strokes (TACS) - Partial Anterior Circulation Strokes (PACS) - Posterior circulation syndrome (POCS) - Lacunar Syndrome (LACS)
what is Virchow’s triad (both its purpose and what it makes up)?
Virchow’s triad describes the three broad categories of factors that are thought to contribute to thrombosis. These categories are: - vessel wall damage (e.g. catheterisation, intravenous drugs, sclerotherapy, inflammatory vascular diseases) - stasis (e.g. varicose veins, immobilisation) - hypercoagulability (e.g. oral contraceptive medicines, inherited or acquired thrombophilia)
what are some of the common side effects of iron supplementation?
constipation, black stools, epigastric pain, nausea, diarrhoea (note, these often reduce with time and may be improved by taking iron supplements with food)
how should postural hypotension be managed?
General: - Review medication - Give advice on safe standing (e.g. go in to sitting position first, take time etc) - Encourage high-dietary salt Medication (only given if symptoms persist despite the above): - Fludrocortisone is recommended as first-line drug monotherapy
what are Cullen’s and Grey Turner’s sign?
Cullen’s sign= periumbilical bruising due to intraperitoneal hemorrhage Grey Turner’s sign= bruising of flanks due retroperitoneal hemorrhage Both can be seen in severe acute pancreatitis, as well as other conditions (such as ruptured ectopic)
what does the T-score have to be on a DEXA scan to diagnose osteoporosis?
T score ≤-2.5=. hip BMD 2.5 SD or more below the young adult reference mean
what is the maximum recommended alcohol units for men and women?
14 units
what is the QRISK2 tool used for?
used to estimate the likelihood of a patient having a cardiovascular event within the next 10 years (usually done after a patient is diagnosed with a risk factor e.g. hypertension) can also be used to help determine appropriate treatment. i.e. is risk is >10%, then offer a statin
briefly describe the pathophysiology behind anaphylaxis?
An anaphylactic reaction occurs when an allergen reacts with specific IgE antibodies (so the individual must be pre-sensitised so IgE antibodies have already developed) on mast cells and basophils (type 1 hypersensitivity reaction), triggering the rapid release of stored histamine and the rapid synthesis of newly formed mediators. These cause capillary leakage, mucosal oedema and ultimately shock and asphyxia
what are some of the possible causes of thrombocytopenia? (there are many)
- Decreased production (disorders of bone marrow): malignancy (e.g. leukaemia, lymphoma, myeloma), viral infections (e.g. EBV, CMV, herpes simplex, varicella zoster), chemotherapy, alcohol - Decreased platelet survival: idiopathic thrombocytopenia purpura (ITP), medication (e.g. heparin, carbamazepine, ibuprofen, quinidine, quinine, rifampin, sulfamethoxazole, trimethoprim and vancomycin), DIC, sepsis, rheumatological disorders (e.g. SLE, rheumatoid arthritis), antiphospholipid
what is the classical presentation of an extradural haematoma?
The classical presentation is of a patient who initially loses, briefly regains and then loses again consciousness after a low-impact head injury. The brief regain in consciousness is termed the ‘lucid interval’ and is lost eventually due to the expanding haematoma and brain herniation.
a positive Trendelenburg sign is seen in the injury of which nerve?
superior gluteal nerve
what are 2 important pieces of advice to give to patients on Parkinson’s medication?
May cause day-time sleepiness (so should inform DVLA) Must be advised to avoid abrupt withdrawal due to the risk of neuroleptic malignant syndrome
what signs/symptoms would you expect to see in a patient with cannula-related phlebitis?
The commonest symptoms of any form of phlebitis are erythema and swelling along the venous track, leading to hardened, cord -like veins. The area can feel warm and patients may experience pain or discomfort during drug administration (and administration itself may also be difficult). Other possible symptoms include pus/exudate, pyrexia and, if allowed to progress, may lead to sepsis
what are the two types of second degree heart block and what do they look like on an ECG?
Mobitz type 1: PR interval gets progressively bigger until there is a dropped QRS complex, at which point the cycle restarts Mobitz type 2: 2 or 3 P waves occur successively, without a QRS complex following each (e.g. 2:1 or 3:1 ratio of P waves to QRS complexes)
how would you expect someone with Lewy Body Dementia to present?
Core features: - Fluctuating cognition (attention & alertness) - Spontaneous motor features of Parkinsonism e.g. tremor, rigidity, poverty of facial expression, festinating gait. Occurs in roughly 70% - Visual hallucinations (~70%) Additional Features: - Sleep (REM) disorder - Neuroleptic (antipsychotic) sensitivity - systematised delusions (70%)
what are the 2 characteristic features of ventricular tachycardia on an ECG?
tachycardia + broad QRS complex (>0.12s)
what condition often precedes myeloma?
monoclonal gammopathy of undetermined significance (MGUS)
how should first degree heart block be managed?
if asymptomatic, just requires monitoring (at low risk of progressing to higher degrees in block). If symptomatic, review medications (e.g. beta blockers), or refer to cardiology is symptoms cannot be controlled
what rules can you use to help differentiate small from large bowel on an abdominal x-ray?
- small bowel usually lies more centrally, with the large bowel framing it around the periphery. - The small bowel’s mucosal folds are called valvulae conniventes and are seen across the full width of the bowel. - The large bowel wall features pouches or sacculation that protrude into the lumen that are known as haustra (in between which are the semilunar folds). The haustra are thicker than the valvulae conniventes of the small bowel. They also commonly do not appear to completely traverse the bowel.
roughly how long after the onset of acute ischaemic limb will necrosis begin to occur (i.e. how long do you have to salvage the limb)?
roughly 6 hours
what are some of the clinical features of acute myeloid leukaemia?
- anaemia: pallor, lethargy, weakness - neutropenia: whilst white cell counts may be very high, functioning neutrophil levels may be low leading to frequent infections etc - thrombocytopenia: bleeding and petechiae (usually on lower limbs) - splenomegaly - bone pain
simply speaking, what is the role of vitamin D in the regulation of calcium?
vitamin D helps with calcium absorption, so vitamin D deficiency can cause hypocalcaemia
what conditions are associated with myasthenia gravis?
- thymomas in 15% - autoimmune disorders: pernicious anaemia, autoimmune thyroid disorders, rheumatoid, SLE - thymic hyperplasia in 50-70%
which leads on a 12-lead ECG represent an anteroseptal of the heart?
V1, V2 (more septal view) + V3, V4, (more anterior view)
what are the 2 mechanisms by which haemolysis can occur?
- Extravascular (most common and occurs in the reticuloendothelial system): red cells are removed from the circulation by the mononuclear-phagocytic system either because they are intrinsically defective or because of the presence of bound immunoglobulins to their surfaces 2. Intravascular (in the circulation): due to complement fixation, trauma, or other extrinsic factors
what are some of the risk factors for gallstone formation?
Increasing age, female, family history, sudden weight loss (e.g. after obesity surgery), loss of bile salts (e.g. ileal resection, Crohn’s disease), diabetes, pregnancy, oral contraception
what would you expect to see in the CSF of someone with MS? (hard q)
oligoclonal bands and elevated CSF immunoglobulin G (IgG) and IgG synthesis rates are present in 80% of MS cases
what are partial/focal seizures and what are the 3 different types?
partial seizures= focal onset with features referable to a part of one hemisphere. Often seen with underlying structural disease types are: - simple partial seizure - complex partial seizure - partial seizure with secondary generalisation
how can heart rate be calculated using an ECG tracing?
If heart rate is regular, it can be calculated by counting the number of large squares in an R-R interval, and then dividing 300 by this number e.g. 4 squares in an R-R interval; 300/4= 75bpm If rhythm is irregular, count the number of QRS complexes on the rhythm strip (each is 10s long) and multiply by 6
what is the imaging of choice in suspected MS?
MRI brain and spine
what is the difference between de-novo acute heart failure and decompensated acute heart failure and what are some of the causes of each?
de-novo AHF: new-onset heart failure in people without known cardiac dysfunction acute decompensation: occurs in people with a background of heart failure and is more common than de-novo AHF de-novo causes: Usually as a result of ischaemia. Other causes include: viral myopathy, toxins and valve dysfunction decompensated causes: Acute coronary syndrome, hypertensive crisis, acute arrhythmia, valvular disease
what are the 2 most important investigations to consider when you suspect a patient of having peptic ulcer disease (or have suspicion of other differentials)?
Upper GI endoscopy to rule out malignancy if suspected (>55 with ALARMS symptoms) Test for H.pylori: carbon-13 urea breath test, stool antigen test, blood antibody test (less common)
what signs and symptoms might someone with infective endocarditis present with?
Symptoms: - Fever/chills - Weight loss/ loss of appetite - Fatigue, myalgia Signs: - Heart murmur: most commonly of aortic regurgitation - Splinter haemorrhages - Osler’s nodes: small tender red-to-purple nodules on the pulp of the terminal phalanges of the fingers and toes - Janeway lesions: irregular painless erythematous macules on the thenar and hypothenar eminence (usually with acute IE and S. aureus) - Clubbing: only 10% of cases and usually in long-standing subacute IE - Roth’s spots: retinal haemorrhages with pale centres - splenomegaly
ESR is a useful prognostic factor in which cancer?
Hodgkin’s lymphoma (>70= poor prognosis)
what is the name of the criteria used to help determine whether a tonsillitis case is due to a bacterial source and what do the criteria consist of?
centor criteria the criteria are: - temp >38 - tender anterior cervical lymphadenopathy - exudate present on tonsils - absence of cough a bacterial infection is likely if at least 3/4 features are present
which viral infection is particularly associated with lymphoma?
Ebstein-Barr virus (glandular fever)
what is the most common cause of sciatica?
90% are caused by spinal disc herniation pressing on lumbar or sacral nerve roots
what is Schober’s test (how is it done) and in when should it be done (what condition can it be used to help diagnose)?
Done if suspecting ankylosing spondylitis While the patient is in a standing position the examiner makes a mark approximately at the level of L5. Two points are marked: 5 cm below and 10 cm above this point (for a total of 15 cm distance). Then the patient is asked to touch his/her toes while keeping the knees straight. If the distance of the two points do not increase by at least 5 cm (with the total distance greater than 20 cm), then this is a sign of restriction in the lumbar flexion
when should direct current cardioversion be used first line inn a patient with VT?
when the patient is haemodynamically unstable
a 65 year old has been diagnosed with hypertension. He was started on ramipril and then amlodipine was added when this was insufficient to bring his BP down. His BP is still not controlled. What is the next medication you should consider?
thiazide-diuretic (e.g. indapamide or bendroflumethiazide)
what is the normal lifespan of RBCs?
roughly 120 days
what is an aplastic sickle cell crisis often precipitated by?
infection with parvovirus B19 (slapped cheek syndrome)
how does hyponatraemia usually present?
- Hyponatraemia is often asymptomatic if it is mild to moderate - possible symptoms include: confusion, lethargy, anorexia, nausea, agitation, dizziness, disorientation, headache, seizures, coma, raised ICP
what does ‘P Mitrale’ refer to and what causes it?
bifid P wave seen in lead II and enhanced negative deflection seen in V1 due to left atrial enlargement (which is usually secondary to mitral stenosis).
what are some of the features of an essential tremor?
- usually a distal symmetrical postural tremor of the upper limbs, usually of low amplitude with a fairly rapid frequency of 8-10 Hz - Present during actions and may be worse with arms outstretched - Commonly improved with rest and alcohol - Often strong family history
what kind of anaemia is G6PD deficiency associated with?
haemolytic anaemia
adenosine should be avoided in patients with which common condition?
asthma
what is the prognosis like for patients with reactive arthritis?
- Reactive arthritis is usually self-limiting with resolution of symptoms by 3-12 months, but symptoms may persist for 12 months or more - There is a high incidence of recurrence, especially in those who are HLA-B27-positive
what are the different sub-types of delirium?
- Hypoactive subtype: apathy and quiet confusion are present and easily missed. This type can be confused with depression. - Hyperactive subtype: agitation, delusions and disorientation are prominent and it can be confused with schizophrenia. - Mixed subtype: patients vary from hypoactive to hyperactive
what are some of the signs and symptoms of aortic stenosis?
Symptoms: dyspnoea on exertion, angina, dizziness, syncope Signs: - Murmur: ejection systolic crescendo-decrescendo murmur, heard loudest at the right upper sternal border, and often described as a rough, low-pitch sound. The murmur radiates to the carotids. - Narrow pulse pressure (small gap between systolic and diastolic BP) - Slow rising pulse - Soft/absent S2 - A fourth heart sound indicates left ventricular hypertrophy (LVH) in severe AS
how would you expect someone in anaphylaxis to present (early and later findings)?
- Initially, patients usually develop skin symptoms, including generalised itching, urticaria and erythema, rhinitis, conjunctivitis and angio-oedema - Signs that the airway is becoming involved include itching of the palate or external auditory meatus, dyspnoea, laryngeal oedema (stridor) and wheezing (bronchospasm). - General symptoms include palpitations and tachycardia, nausea, vomiting and abdominal pain, feeling faint - with a sense of impending doom; and, ultimately, collapse and loss of consciousness - Airway swelling, stridor, breathing difficulty, wheeze, cyanosis, hypotension, tachycardia and reduced capillary filling suggest impending severe reaction
in a community setting, if you suspected someone had bacterial meningitis, what should you give them?
IM benzylpenicillin (if doesn’t delay transfer to hospital) exact dose depends on age but in adults is 1.2g
what is the epidemiology like for GCA?
- more common in women - almost exclusively occurs in >50s - european descent (uncommon in people of African or Asian origin)
what degree of heart block is mobitz type 1 and what does it look like on an ECG?
second degree PR interval gets progressively bigger until there is a dropped QRS complex, at which point the cycle restarts
what is the definition of paroxysmal AF? (the paroxysmal part, not the AF part)
AF with spontaneous termination within seven days and most often within 48 hours.
what medications should be prescribed for long-term use after an MI?
- Aspirin should be given to all patients, unless contra-indicated. The addition of clopidogrel has been shown to reduce morbidity and mortality - Beta-blocker (a rate-limiting calcium channel blocker such as verapamil may be considered if beta-blockers are contraindicated) - ACE inhibitor - Nitrates for angina - Statins may help prevent a recurring cardiac event
what are some of the clinical features of acute lymphoblastic leukaemia?
- anaemia: lethargy and pallor - neutropaenia: frequent or severe infections - thrombocytopenia: easy bruising, petechiae - bone pain (secondary to bone marrow infiltration) - splenomegaly - hepatomegaly - fever is present in up to 50% of new cases (representing infection or constitutional symptom) - testicular swelling
what criteria must be met for a stoke to be classified as a ‘total anterior circulation stroke’ (TACS)?
All three of the following need to be present for a diagnosis of TACS: - Unilateral weakness (and/or sensory deficit) of the face, arm and leg - Homonymous hemianopia - Higher cerebral dysfunction (dysphasia, visuospatial disorder)
explain the pathophysiology involved in paracetamol overdose
- When taken in normal therapeutic doses, paracetamol is converted through conjugation into non-toxic metabolites: sulfate and glucuronide. - A small proportion (~5%) is oxidised by cytochrome P450 into N-acetyl-p-benzoquinone imine (NAPQI) which is toxic to the liver. However, this toxic metabolite is usually rapidly broken down by glutathione, preventing harm. - In overdose, the sulfate and glucuronide pathways become saturated and more NAPQI is produced. The supplies of glutathione become depleted and thus eventually there is widespread hepatocyte damage leading to liver necrosis - Toxicity is increased in patients with induction of the P450 system through drugs such as rifampicin, phenobarbital, phenytoin, carbamazepine and alcohol
which leads on a 12-lead ECG represent a lateral view of the heart?
lead I, aVL, V5, V6
what is the most common type of brain tumour in children?
astrocytomas
what is the epidemiology of acute lymphoclastic leukaemia?
most common cancer in children, usually presenting 2-4 years of age, rare in adults
when can adrenaline and amiodarone be given in a cardiac arrest and what doses?
in a shockable rhythm: - give 1mg IV adrenaline and 300mg IV amiodarone after the 3rd shock. The adrenaline can be repeated roughly every 3-5 mins (or after alternate shocks) in a non-shockable rhythm: - Give 1mg IV adrenaline as soon as IV access is achieved. This can be repeated roughly every 3-5 mins (or after alternate shocks)
what is the toxic metabolite involved in paracetamol overdose?
N-acetyl-p-benzoquinone imine (NAPQI)
what are the 2 most common causative organisms of bacterial meningitis in adults?
Neisseria meningitidis and streptococcus pneumoniae
what are the different types/classifications of a subdural haematoma?
- An acute SDH. - A subacute SDH (this phase begins 3-7 days after the initial injury). - A chronic SDH (this phase begins 2-3 weeks after the initial injury
what are some of the signs and symptoms someone with salicylate (aspirin) poisoning may present with?
Symptoms: nausea, vomiting, tinnitus, lethargy, dizziness, restlessness, sweating Signs: tachypnoea, hyper and hypoglycaemia, fever, seizures
what investigations should you consider doing for someone presenting with tricyclic antidepressant overdose?
- serum cyclic antidepressant level does not correlate well with severity of toxicity and is a poor predictor of clinical outcome - ABG for evaluation of acidosis or hypoxia - Bloods - ECG: > Sinus tachycardia > Wide QRS complex > PR and QT interval prolonged
what is the diagnostic investigation for acute myeloid and acute lymphblastic leukaemia and what does it show?
Bone marrow biopsy: Presence of blast cells in ≥20% of the bone marrow cells confirms the diagnosis (myeloblasts in AML and lymphoblasts in ALL)
what are some of the features of fibromyalgia?
- chronic pain: at multiple site, sometimes ‘pain all over’ - lethargy - cognitive impairment: ‘fibro fog’ (difficulty with concentration, memory loss or confusion) - sleep disturbance, headaches, dizziness are common - far more common in women than men
what are 2 examples of rate-limiting calcium channel blockers?
diltiazem and verapamil
in what situations should a paracetamol level be taken as soon a patient arrives with paracetamol overdose?
- if the paracetamol was ingested more than 4 hours ago - if the overdose was staggered
what are some hypervolaemic causes of hyponatraemia?
- Cirrhosis - Nephrotic syndrome - Congestive heart failure
what investigations should you consider in a patient presenting with paracetamol overdose?
- Paracetamol level: take paracetamol level four hours post-ingestion, or as soon as the patient arrives if: > Time of overdose is greater than four hours. > Staggered overdose (in staggered overdoses, the level is not interpretable except to confirm ingestion) - U&E, creatinine - to look for renal failure and have a baseline. - LFTs: may be normal if the patient presents early but may rise to ALT >1000 IU/L. This is the enzyme level taken to indicate hepatotoxicity. - Glucose: hypoglycaemia is common in hepatic necrosis and capillary blood glucose should be checked hourly. - Clotting screen: prothrombin time is the best indicator of severity of liver failure and the INR should be checked 12-hourly. - Arterial blood gas: acidosis can occur at a very early stage, even when the patient is asymptomatic. It is seen in up to 10% of patients with ALF
in the context of seizures, what is an ‘aura’ and what kind of seizure does it most commonly precede?
An ‘aura’ is part of the seizure in which the patient is aware, and may precede its other manifestations. The aura may be a gut feeling, or déjà vu, or strange smells etc. It implies a partial (focal) seizure, often, but not necessarily from, the temporal lobe
what can thalidimide be used to help manage?
multiple myeloma
what are some possible causes of mitral regurgitation?
- Coronary artery disease/ post-MI - Mitral valve prolapse - Infective endocarditis - Rheumatic fever - Congenital heart disease - Connective tissue diseases: Marfan’s syndrome, Ehlers-Danlos syndrome
a 12-lead ECG shows tachycardia and a narrow QRS complex, what is this?
supraventricular tachycardia
what gene is ankylosing spondylitis most commonly associated with?
A strong association with HLA-B27 exists, particularly in white western European populations.
what are the 2 categories that tension-type-headaches can be divided into?
- Episodic TTH. This occurs on fewer than 15 days each month. It can evolve into the chronic variety. - Chronic TTH. This occurs on more than 15 days each month and has all the features of the episodic TTH. Chronic type is more likely to be medication-induced and to be associated with comorbidities such as depression
what are some of the causes of acute limb ischaemia?
- Thrombosis (~40%): most cases of leg ischaemia result from the presence of thrombus at sites of atherosclerotic narrowing - Embolism (~38%): for example, left atrial thrombus in patients in atrial fibrillation - Graft/angioplasty occlusion (~15%) - Trauma - Compartment syndrome
what drugs can cause B12 deficiency?
metformin, colchicine, PPIs (these are rare causes)
what ABPI reading would expect in a patient: 1. with no PAD 2. with intermittent claudication 3. with pain at rest 4. with impending gangrene?
- 1 2. 0.6-0.9 3. 0.3-0.6 4. <0.3
how does pseudogout present?
- Presents very similarly to gout, but symptoms are generally milder - Knee is most commonly affected joint, but can affect any joint
describe intermittent claudication
- aching or burning in the leg muscles (can be calf, thigh or buttocks) following walking. Pain comes on more rapidly when walking uphill than on the flat - patients can typically walk for a predictable distance before the symptoms start (should obtain claudication distance in history) - can be present in both legs, but one is usually worse than the other - usually relieved within minutes of stopping - not present at rest (if it is, this indicates critical limb ischaemia!)
how long should a PR interval be on a normal ECG?
Should be 3-5 small squares (0.12-0.2s) (if prolonged, should consider 1st degree heart block)
which valve is most commonly affected by infective endocarditis?
the mitral valve is most commonly affected, followed by the aortic valve
what is neutropenia?
Neutropenia means a low neutrophil count. The normal range for neutrophils is 2.5-7.5 x 109/L. Moderate neutropenia is defined as a neutrophil count of 0.5-1.0 x 109/L. Severe neutropenia is a count of <0.5 x 109/L.
what would an ECG look like of someone in ventricular fibrillation?
ECG shows rapid, bizarre, irregular waves of widely varying amplitude and frequency (basically it’s all over the place)
what is the ‘wearing-off effect’ and ‘on-off effect’ associated with levodopa use?
A major issue with levodopa is the wearing-off effect, where patients symptoms worsen towards the end of the dosage interval. Increasing the dosage/frequency may overcome this, however patients may then start to get dyskinesia at the beginning of a dosage. When this occurs together, it is called the on-off effect.
how long would you expect someone to experience morning stiffness in both: osteoarthritis rheumatoid arthritis
OA: <30 mins (if any) RA: >1 hour
how should someone with suspected metastatic cord compression be managed?
- 16mg IV dexamethasone stat + MRI spine within 1 hour - Consider neurosurgical intervention
briefly describe cardiogenic shock (i.e. the definition)
Cardiogenic shock occurs when there is failure of the pump action of the heart, resulting in a decrease in cardiac output causing reduced end-organ perfusion. This leads to acute hypoperfusion and hypoxia of the tissues and organs, despite the presence of an adequate intravascular volume
how would you expect someone in ACS to present?
- Prolonged (>20mins) central or epigastric chest pain which may radiate to left arm, shoulder, neck or jaw. > Remember that certain patients (e.g. diabetics, elderly) may not have pain (silent MI) - Pain may be described as substernal pressure/crushing pain - Chest pain may be associated with sweating, nausea, vomiting, fatigue, shortness of breath and palpitations - Low-grade fever, pale and cool, clammy skin.
what happens to preload and afterload in: 1. hypovolaemic shock 2. cardiogenic shock 3. neurogenic shock
- preload: decreases, afterload: increases 2. preload: increases, afterload: increases 3. preload: decreases, afterload: decreases
what 4 x-ray changes are classically seen in OA?
- Narrowing of joint space - Osteophytes forming at joint margins - subchondral cysts - subchondral sclerosis
how should B12 deficiency be managed (including dietary advice)?
- Dietary advice: eggs, cereals, meat, fish - Hydroxocobalamin 1g IM injection 3 times a week for 2/52, then 1 mg every 2–3 months (if no neurological involvement)
what are the different doses of adrenaline that are used in anaphylaxis (3 different doses depending on age)?
0-6 years: 150mcg 6-12 years: 300mcg >12: 500mcg
which lobe do the majority of partial seizures arise from?
temporal
what is thrombophilia?
Thrombophilia refers to a predisposition to thromboembolism. In practice, the term is used to describe patients who are at significantly increased long-term risk of venous thromboembolism
if a patient has right-sided homonymous hemianopia, what does this mean and where is the lesion?
the right visual field has been lost in BOTH eyes lesion is at the left optic tract
what is the most important/significant possible complication of AF?
stroke
what are the definitions of persistent and permanent AF?
Persistent: not self-terminating; lasting longer than seven days, or prior cardioversion. Persistent AF may degenerate into permanent AF. Permanent: Long-standing AF (defined as over a year) that is not successfully terminated by cardioversion, when cardioversion is not pursued or has relapsed following termination.
a patient comes in with a possible PE. Their PE Well’s score is 3, how should they be investigated?
do a d-dimer, if positive do an immediate CTPA (if score is 4 or more, do immediate CTPA, is score is less than 4, do d-dimer)
what are some medications that can cause hyperkalaemia?
ACEi, ARBs, NSAIDs, potassium-sparing diuretics (e.g. spironolactone), beta-blockers, heparin, trimethoprim
with what symptoms would you expect someone with rhuematoid arthritis to typically present with?
- Insidious, symmetrical (but occasionally can be asymmetrical) arthritis lasting >6 weeks. - RA can affect any synovial joint but typically affects the small joints of the hands and the feet. More joints are affected with progression of the disease. - Joint changes: heat and sometimes redness, swelling, pain, stiffness (especially in the early morning or after inactivity), progressive joint destruction and loss of joint function - Morning stiffness lasting >1 hour
in which form dementia should acetylcholinesterase inhibitors (E.g. rivastigmine, donepezil etc) be actively avoided?
in frontotemporal dementia- may worsen confusion
when should a AAA be monitored yearly (i.e. have repeat aortic ultrasounds on a yearly basis)?
when it is 3-4.4 cm in size
if a direct coombs test of someone with haemolytic anaemia comes back positive, what does this suggest?
that the cause of the haemolytic anaemia is immune e.g. haemolytic disease of newborn, blood transfusion reaction
chest pain which is classically relieved by sitting forward, and made worse by lying down, is associated with which condition?
pericarditis
If BP is found to be high in clinic, what can be offered to confirm it?
If between 140/90 and 180/120, offer ambulatory blood pressure monitoring (ABPM) to confirm the diagnosis of hypertension. If ABPM is unsuitable or the person is unable to tolerate it, offer home blood pressure monitoring (HBPM) (note that if >180, you should consider whether they need referral for same-day specialist assessment)
what is the most common feature of a focal seizure arising from the occipital lobe?
floaters/flashes
what type of breathing commonly occurs in the early stages of cardiac arrest?
Agonal breathing (occasional, irregular gasps) is common in the early stages of cardiac arrest and is a sign of cardiac arrest and should not be mistaken for a sign of life
what are some of the possible triggers for DIC?
- Sepsis/severe infection, major trauma or burns - Some malignancies (acute myelocytic leukemia or metastatic mucin-secreting adenocarcinoma) - Obstetric disorders (amniotic fluid embolism, eclampsia, abruptio placentae, retained dead fetus syndrome) - Severe organ destruction or failure (severe pancreatitis, acute hepatic failure) - Vascular disorders (Kasabach-Merritt syndrome or giant haemangiomas, large aortic aneurysms) - Severe toxic or immunological reactions (blood transfusion reaction or haemolytic reactions, organ transplant rejection, snake bite).
after a patient with a first presentation of anaphylaxis has been stabilised and is ready for discharge, what should be organised/arranged for long-term management?
- Refer to an allergist or allergy clinic to try to identify the allergen, so that it can be avoided in future. - Organise self-use of pre-loaded pen injections for future attacks (e.g. EpiPen; containing 0.3 mL of 1 in 1000 strength (that is, 300 micrograms) for adults; and for children 0.3 mL of 1 in 2000 (150 micrograms)). This again may be best done in allergy clinics. It is important that the technique for using these auto-injectors should be demonstrated and taught - Give a written self-management plan, information about anaphylaxis and biphasic reactions, and details of the possible signs and symptoms of a severe allergic reaction - Encourage the patient to wear a medical emergency identification bracelet or similar
what are some of the signs/symptoms of right-sided heart failure?
- peripheral oedema - ascites - hepatomegaly - raised JVP
what causes ‘cogwheeling’ in Parkinson’s disease?
a tremor is superimposed on a limb with increased rigidity
which condition is commonly associated with acute mesenteric ischaemia?
AF (other emboli causing conditions are also associated, but AF is classically)
the murmur of which valvular disease most commonly radiates to the carotids?
murmur of aortic stenosis
what ECG features would you see in SVT?
12 lead ECG: will show tachycardia, narrow QRS complex (<0.12s), may have absent P waves
in which people should paracetamol dosages generally be halved?
people <50kg
what are some secondary causes of hypertension?
- Renal disease is the most common cause of secondary hypertension. Causes include: glomerulonephritis, pyelonephritis, adult polycystic kidney disease, renal artery stenosis - Endocrine disease such as: Cushing’s syndrome, Conn’s syndrome, thyroid dysfunction, hyperparathyroidism - Drug causes: steroids, NSAIDs, monoamine oxidase inhibitors - Other causes: pregnancy, coarctation of the aorta
what are rituximab and infliximab examples of and very briefly how do they work?
- they are biological therapies - rituximab= an anti-CD20 monoclonal antibody, results in B-cell depletion - infliximab= a TNF-inhibitor
what are some of the possible causes of complete heart block?
Complete heart block may occur due to: Myocardial fibrosis, previous MI (especially inferior), aortic valve calcification, cardiac surgery/trauma, digoxin toxicity
is the large or small bowel more likely to be obstructed?
80% of bowel obstructions are small bowel
what is the function of the facial nerve?
- Muscles of facial expression - Taste to anterior 2/3rd of tongue - Lacrimation + salivation
which genetic condition is most often associated with bicuspid aortic valve?
Turner’s syndrome
what type of anaemia is associated with gallstones?
haemolytic anaemia- bilirubin stones can develop in patients with persistent haemolysis
how is someone with MS who is experiencing an acute relapse usually treated?
500mg methylprednisolone for 5/7 with gastroprotection (omeprazole 20mg OD) should always discuss with a specialist neurologist first
what age group is most affected by appendicitis?
most common between ages of 10-20, but can occur at any age
which investigation is absolutely contraindicated in a patient with a suspected extradural haematoma?
Lumbar punctures are absolutely contraindicated for extradural haematomas, as they result in a drop in CSF pressure, which may speed up brain herniation
what are some of the features of a headache cause by a increased ICP?
- Headache which is worse in the morning/when lying down - Headache may wake from sleep - Headache may be exacerbated by coughing - Nausea and vomiting - May have visual changes - May have a change in mood e.g. more irritable
what type of haemophilia is more common?
type A is more common than type B
which causative organism is typically associated with pneumonia in alcoholics?
Klebsiella pneumoniae
what would you expect to see in an injury of the superior gluteal nerve?
- paralysis of gluteus medius and minimum resulting in impaired hip abduction - positive Trendelenburg sign (when stood on one leg, pelvis drops on the side of the lifted leg, meaning muscle weakness/paralysis on opposite side)
what is Klumpke’s palsy (not features) and how is it caused?
- Klmupke’s palsy= injury to the lower trunk of the brachial nerve plexus (C8-T1) - caused by hyperabduction of the arm through trauma or excessive traction on the arm during delivery
if a patient becomes haemodynamically unstable due to new-onset AF, how should they be managed?
emergency electrical cardioversion
what are some of the features of a tonic seizure?
sudden, brief stiffening of muscles of whole body, causing person to become rigid and fall. Recovery is swift but injuries may be sustained
with what signs/symptoms might someone with varicose veins present with?
- Visually, dilated + tortuous veins are seen - Patient may also complain of leg pain/ache, leg swelling, leg itching - Possible skin changes include: ulceration, venous eczema, lipodermatosclerosis
what is myasthenia gravis?
Myasthenia gravis (MG) is an autoimmune disorder of neuromuscular transmission, resulting from binding of autoantibodies to components of the neuromuscular junction, most commonly the acetylcholine receptor
what are the reversible causes of cardiac arrest?
- 4 Hs: hypoxia, hypothermia, hypovolaemia, hyperkalaemia (+ hypokalaemia, hypoglycaemia, hypocalcaemia, acidaemia and other metabolic disorders) - 4 Ts: cardiac tamponade, tension pneumothorax, thrombosis (coronary or pulmonary), toxins
how does reactive arthritis usually present?
- Reactive arthritis usually develops 2-4 weeks after a genitourinary or gastrointestinal infection. About 10% of patients do not have a preceding symptomatic infection. - The onset is most often acute, with malaise, fatigue, and fever. - An asymmetrical, predominantly lower extremity, oligoarthritis is the major presenting symptom. - Low back pain often occurs
what is a common metabolic abnormality in someone with ACS?
hyperglycaemia is common in people admitted to hospital with ACS. Hyperglycaemia at the time of admission with ACS is a powerful predictor of poorer survival and increased risk of complications while in hospital, regardless of whether or not the patient has diabetes.
describe the murmur heard in mitral regurg
The murmur heard on auscultation of the chest is typically a pansystolic murmur described as “blowing”. It is heard best at the apex and radiating into the axilla. S1 may be quiet as a result of incomplete closure of the valve. (remember, left-sided murmurs, including mitral regurg, can be heard louder on expiration)
what are the two types of thalassaemia?
alpha and beta (depending on which polypeptide chains in haemoglobin is affected)
which medication is by far most responsible for cases of salicylate poisoning?
aspirin
what are some of the causes of small and large bowel obstruction and what are the most common causes?
Small bowel: adhesions (~75%) from previous surgeries, strangulated hernia, malignancy, foreign body, pseudobstruction Large bowel: colorectal carcinoma (most commonly), constipation, diverticular stricture, sigmoid or caecal volvulus
what, briefly, is coeliac disease?
An immune-mediated, inflammatory systemic disorder in which the gliadin fraction of gluten provokes a damaging immunological response in the proximal small intestinal mucosa, leading to malabsorption of nutrients Malabsorption is due to the death of enterocytes (absorptive cells) and villous atrophy
what monitoring should be done when starting someone on an ACE inhibitor?
do renal function and U&Es 1-2 weeks after starting ACEi, as can cause renal impairment and hyperkalaemia (should recheck 1-2 weeks after any dose changes)
with what features would you expect a DVT to present with?
Calf warmth/tenderness/swelling/erythema/pain, mild fever, pitting oedema Can progress to PE without DVT being clinically apparent
who do haemophilias more commonly affect?
boys (as X-linked recessive)
what is the first-line medication used in the management of primary Raynaud’s?
first-line medication: calcium channel blockers e.g. nifedipine
what exactly are diverticula?
A diverticulum consists of a herniation of mucosa through the thickened colonic muscle
what are the most common fragility fractures?
Fragility fractures occur most commonly in the spine (vertebrae), hip (proximal femur) and wrist (distal radius). They also occur in the humerus, pelvis etc
what condition should be screened for on a new diagnosis of type 1 diabetes?
coeliac disease
briefly described the histopathology in Alzheimer’s dementia
Accumulation of β-amyloid peptide, a degradation product of amyloid precursor protein, results in progressive neuronal damage, neurofibrillary tangles, increased number of amyloid plaques, and loss of the neurotransmitter acetylcholine Cortical atrophy is apparent in the temporal, frontal, and parietal areas
what are some of the features of a tonic-clonic seizure?
loss of consciousness. Limbs stiffen (tonic), then jerk (clonic). Breathing is shallow or temporarily suspended which may cause cyanosis. May be incontinent. May bite tongue. Usually <2mins, followed by post-ictal confusion, drowsiness, headache, soreness.
in RA, what must have been tried before a biological therapy (e.g. rituximab) can be considered?
at least 2 DMARDs (including methotrexate) must have been tried and been unsuccessful
how is thalassaemia inherited?
autosomal recessive inheritance
what is the most common cause of secondary Raynaud’s?
connective tissue disorders, particularly scleroderma, but can also occur in rheumatoid arthritis, SLE etc
what are the 2 main possible complications of pericarditis?
- Pericardial effusion (which may lead to tamponade) - Constrictive pericarditis (thickening/scarring of the pericardium interferes with ventricular filling)
how many types of MND are there, which is the most common, and which carries the worst prognosis?
4 types Amyotrophic lateral sclerosis is the most common type Progressive bulbar palsy carries the worst prognosis
what are the 3 core features of Lewy Body dementia? (of which 2/3 must be present for a diagnosis to be made)
- Fluctuating cognition (attention & alertness) - Spontaneous motor features of Parkinsonism e.g. tremor, rigidity, poverty of facial expression, festinating gait. Occurs in roughly 70% - Visual hallucinations (~70%)
what is the main investigation used to help confirm polymyalgia rheumatica?
ESR, plasma viscosity and/or CRP. Raised inflammatory markers are characteristic laboratory finding in PMR but may be normal (note: USS can also be done if diagnosis is still unclear, typically showing joint effusion/bursitis)
what is the maximum recommended potassium infusion rate via peripheral lines?
10mmol/hour
what is the most common extra-articular manifestation of ankylosing spondylisis?
anterior uveitis (occurs in 20-30% of patients)
how should a haemodynamically stable patient in SVT be managed?
1st line: reflex vagal stimulation e.g. by Valsalva manoeuvre (forced exhalation against a closed airway), immersing the face in ice cold water, or carotid sinus massage 2nd line: IV adenosine (6 milligrams initially, followed by 12 milligrams 1-2 mins later if needed) 3rd line (or if adenosine is contraindicated, e.g. asthmatics): IV verapamil hydrochloride 4th line: direct current cardioversion Recurrent episodes of paroxysmal supraventricular tachycardia can be treated by catheter ablation
what is the normal size of a QRS complex?
0.12s (3 small squares)
how are osteopenia and osteoporosis differentiated using a DEXA scan?
- Osteopenia (low bone mass): hip BMD between 1 and 2.5 SD below the young adult reference mean (T score less than -1 but above -2.5). - Osteoporosis: hip BMD 2.5 SD or more below the young adult reference mean (T score ≤-2.5).
what signs might be found on examination of someone with peripheral arterial disease?
- Diminished or absent foot pulses - Pale and/or cold limb/foot with possible hair loss - There may be poorly healing wounds of the extremities (ulceration or gangrene suggests critical limb ischaemia) - may have positive Buerger’s test in critical limb ischaemia
how are haemophilias inherited?
X-linked recessive manner
what causes reactive arthritis (including examples of organisms and the most common organism)?
reactive arthritis occurs due to a prior (roughly 1 to 6 weeks prior) gastrointestinal or urogenital infection: - Post-enteric: the three most commonly associated enteric pathogens are Campylobacter, Salmonella and Shigella species - Post-venereal: Chlamydia species (most commonly: Chlamydia trachomatis) or human immunodeficiency virus (HIV). Chlamydia species are traditionally thought to be the most common cause of ReA
briefly describe all the different types of heart block (in terms of ECG findings)
First-degree heart block: PR interval > 0.2 seconds Second-degree heart block: - type 1 (Mobitz I, Wenckebach): progressive prolongation of the PR interval until a dropped beat occurs - type 2 (Mobitz II): PR interval is constant but the P wave is often not followed by a QRS complex Third-degree (complete) heart block: there is no association between the P waves and QRS complexes
what would you expect to see on ultrasound of an individual with gallstones? (both cholecystitis and cholangitis)
In cholecystitis, would expect to see a distended gallbladder and/or thickened gallbladder wall (+ stones themselves in gallbladder) In cholangitis, would expect to see a dilated common bile duct (+ stones themselves in duct)
what are some risk factors for infective endocarditis?
valvular heart disease, valve replacement (prosthetic valve), structural congenital heart diseases, previous IE, hypertrophic cardiomyopathy, IVDU
what are some of the possible causes of B12 deficiency?
- pernicious anaemia (80% of cases) 2. Potential after-effects of surgery e.g. gastrectomy or ileal resection. 3. Bacterial overgrowth or parasitic infestation. 4. HIV infection 5. Dietary deficiency, which may occur in strict vegans but, even in them, it is rare 6. Drug-induced deficiency: metformin, colchicine, PPIs
which cancers most commonly cause spinal mets (which may lead to spinal cord compression)?
breast, lung, prostate are most common thyroid and kidney are not unusual
what are bouchard’s and heberden’s nodes?
Bony swelling and deformity seen in OA due to osteophytes - in the fingers this presents as swelling at the distal interphalangeal joints (Heberden’s nodes) or swelling at the proximal interphalangeal joints (Bouchard’s nodes)
